If infrastructure isn’t at the start of your conversation, your strategy is already failing: The NHS boardroom's blind spot

This one might be a bit controversial. In the last couple of blogs, we’ve talked about creativity. We’ve considered what it means in the context of NHS infrastructure, and how we need to think differently to shape something better.

So now we've got the big ideas. The bold thinking. The system perspective.

All essential. All exciting.

But here’s the uncomfortable truth. None of it matters if the infrastructure conversation is happening in the wrong room.

Let's challenge the general belief, and the health system's persistent narrative, that estates is something of a secondary enabler. You could say even it can be a bit of a strategic afterthought.

I’m going to suggest that from today, we’re going to need to START with infrastructure.

The uncomfortable truth

Let’s be honest.

In many systems, infrastructure is overwhelmingly seen as an operational ancillary function. It’s a mere enabling workstream that gets pulled in once the real decisions have already been made.

Estates? That’s the team that manages the lifts. Fixes the heating. Manages the car park. Submits a capital bid that nobody has any money to fund. Talks about the risks of RAAC and complains about the lack of investment. Does a big chunk of the Green Plan for the organisation. Makes teams squeeze into less space. And so on.

Meanwhile, the big-picture conversations about transformation, care models, population health and the future of systems are happening somewhere else.

Somewhere higher up.

In a different building.

With a different language.

With different people.

And that’s a problem. A BIG problem.

Because you can’t build deliverable new models of care on foundations you haven’t even considered.

We’ve got it all mixed up: the wrong starting point

We’re taught that form follows function. That infrastructure enables services. That service always comes first.

And yes, in a ideal world that’s absolutely true. It’s the right approach, and feasible IF you’ve got unlimited time, space, energy, and the capital to finance it all.

We don’t.

So our approach has to evolve.

We need to create different, and far more symbiotic, relationships around infrastructure.

Relationships where infrastructure and service design inform each other from the very beginning.

Relationships where system and service strategy are actively shaped by the real limitations and opportunities of our current infrastructure.  

Where service transformation isn’t imagined in a vacuum, only to be undone when someone later realises - ’damn, we don’t have a space that can do that, and nor do any of our partners’.

This isn’t about restricting ambition.

It’s about enabling it.

And the only way to enable that ambition is by making sure strategy is grounded in deliverable reality from day one.

And that is not just smart.

It is essential.

Infrastructure IS strategy

Every decision about place, space, and design is strategic.

Where a service sits.

Whether a building enables integrated, community-centred care.

How infrastructure aligns with digital systems, workforce planning, climate goals, and wider economic development. Etc.

These aren’t operational issues. They are the foundations of system transformation.

We talk endlessly about the future of the health system - We're designing strategies responding to the 10 year plan to guide the shifts from analogue to digital, sickness to prevention and hospital to community.

Great. Now show me the infrastructure and estate that supports it all over the next 10 years.

Because if infrastructure isn’t part of the early conversation, we'll end up attempting to shoehorn shiny strategy into what we've already got.

If you’re very, VERY lucky, that might just work.

If you’re not, then your plan falls apart before it even begins.

Time to elevate the conversation

So maybe it’s (finally) time to move the infrastructure conversation out of the boiler room and into the boardroom.

Literally, metaphorically and at scale.

This isn’t about a conversation chasing more capital for buildings, or waving backlog maintenance risk registers. It’s far, far deeper than that. Because infrastructure isn’t just a mere enabler - it needs to be viewed as a fundamental part of the system itself.

So,

If we want integrated care, we need integrated planning.

If we want sustainability, we need forward looking, imaginative and realistic estates strategies.

If we want innovation, we need flexible, future-ready infrastructure.

If we want a transformed system, we need to ask ourselves if we actually have the physical foundation to support what we want to achieve?

And if we don’t have, or can’t create the right foundations, let’s be brave enough to say so before we waste months designing services we can’t deliver.

The choice is clear - either we face the reality of our infrastructure limitations upfront, or we continue to plan for a future we can't possibly build.

A shift in mindset and language

And part of the wider change starts with estates teams, and the network of specialists who support them.

Too often, in estates and infrastructure we lead with the detail. The technical. The pressures. The constraints. The money.

And while all of that is valid, it risks making estates and infrastructure specialists sound like blockers. So we need to shift the narrative.

Let’s start speaking the language of people rather than obstacles - Access. Equity. Experience. Sustainability. Resilience. People. Places. Lives. Health.

Ultimately, this is the simple symbiosis we need: Strategy that understands infrastructure. And, infrastructure that speaks the language of strategy.

The ask

This is a call to system leaders - it’s time to take a good look around the table.

Who is truly championing infrastructure in your most strategic conversations? Not after the grand vision is drafted, but right from the very beginning, before the critical decisions are cast in stone?

Do you have that voice in the room that holistically understands the estates space, and really grasps how physical space moulds outcomes, unlocks access and equity, and enables true integration?

Do you have the person who truly connects health infrastructure not just to capital requirements, but to the bigger picture of population health, digital transformation, sustainability, and equity?

Is there someone round your table who genuinely bridges these gaps? Someone who uses a different infrastructure narrative? Someone who can help shape a different future?

If the honest answer is no, then ask yourselves - can you truly afford this oversight?

Unfortunately, the ambitious future you're designing won't materialise on good intentions and clinically-led strategy alone. It demands robust foundations to support those bold ideas.

And we must remember that these foundations aren't accidental in systems that get this right - they're meticulously designed.

So, let's stop relegating infrastructure to an operational afterthought.

Instead, let's elevate it to its rightful strategic place as absolutely core to the system's success.

Because when infrastructure is an early and integral part of the conversation, your strategy moves beyond a well-intentioned document to a powerful, deliverable reality.

So ask yourself, not just who is at your table, but who’s missing.