The NHS estate is one of the health service’s most important assets. From hospitals and community facilities to administrative buildings, the environments in which care is delivered have a direct impact on patient safety, staff wellbeing and operational performance. Yet our research suggests many organisations are struggling to maintain their estates in the face of increasing financial and operational pressures.
In March 2026, we surveyed 77 NHS estate leaders to understand the challenges, priorities and opportunities shaping estate maintenance across the NHS. These findings highlight the scale of the challenge many organisations face. Estates teams are being asked to maintain increasingly complex buildings and infrastructure while working within constrained budgets and responding to growing service demands.
In our new guide, Maintaining the NHS Estate, we help you tackle some of the key challenges raised.
You told us your biggest challenges are
63%
ageing infrastructure
53%
budgets/funding
38%
backlog maintenance
32%
workforce shortages
Ageing infrastructure is the biggest challenge
Our research indicated that ageing infrastructure (63%), budgets/funding (53%) and tackling backlog maintenance (38%) were the top three challenges for estate leaders. Workforce shortages and competing organisational priorities also featured prominently.
Compliance and backlog top maintenance priorities
These pressures are also reflected in maintenance priorities. When asked what would most improve estate maintenance, respondents ranked maintaining compliance with legislation and reducing backlog maintenance as their top concerns, ahead of workforce development, data quality improvements and sustainability initiatives. This is no surprise given the increasing amount of legislation, penalties for non-compliance and obvious need to keep our patients and colleagues safe.
Patient safety drives maintenance decisions
Importantly, estate maintenance is not being viewed purely through a facilities management lens. Patient safety was identified as the number one driver of maintenance decisions, followed by compliance and ensuring buildings remain operational.
Respondents overwhelmingly recognised the connection between estate performance and patient experience. The survey found strong agreement that maintenance decisions have a significant impact on patients and that effective maintenance can improve energy efficiency and reduce avoidable waste. This is why developing a robust infrastructure strategy and using it to inform investment decisions is absolutely critical.
Digital ambition limited by data
However, organisations were less confident about their readiness to adopt digital tools such as predictive maintenance technologies, asset management platforms and advanced monitoring systems.
The research suggests that while there is enthusiasm for innovation, many organisations are still grappling with the fundamentals. Respondents highlighted poor-quality asset data, limited integration between systems and concerns that technology investments could fail to deliver value without stronger data foundations in place first.
There was nevertheless strong interest in emerging technologies such as artificial intelligence, analytics and predictive maintenance.
Workforce challenges adding pressure
Unsurprisingly, given recent cost-cutting targets, respondents reported shortages of engineers, technicians and experienced estates leaders, alongside concerns that NHS pay structures are increasingly uncompetitive when compared with the facilities management and construction sectors. Many warned that losing experienced staff not only creates recruitment pressures, but also results in the loss of valuable organisational knowledge.
Funding cycles limiting progress
When asked “What would have the greatest positive impact on estate management?”, respondents consistently pointed to better funding arrangements. Short-term, year-end funding cycles were seen as a particular barrier, making long-term planning difficult and often forcing organisations to prioritise immediate pressures over strategic maintenance and lifecycle replacement programmes.
Backlog maintenance remains a significant challenge
Beyond funding constraints, operational pressures were identified as the biggest barrier to tackling backlog maintenance. Many organisations reported difficulties accessing clinical spaces due to high occupancy rates, limited decant facilities and the need to maintain uninterrupted services.
Procurement challenges ranked second, with respondents citing lengthy procurement timescales, limited specialist expertise and excessive bureaucracy as significant obstacles to delivery. Workforce capacity and capability completed the list of major barriers.
Looking ahead
The message from the research is clear. The condition of the estate is absolutely critical to delivering better patient outcomes. However, ageing infrastructure, constrained funding, workforce shortages and operational pressures continue to limit progress.
Addressing these challenges will require a combination of long-term investment, stronger leadership, improved workforce capacity and better use of data. If these foundations can be put in place, estates teams will be better equipped to move from reactive maintenance towards a more strategic approach that supports safer, more sustainable and more resilient healthcare environments.
