The power of the messy middle: Why we don’t need to choose a side of the fence
We won’t build the future of healthcare by choosing sides.
We’ll only build it by connecting them.
In the world of health infrastructure, it’s easy to fall into binary thinking. Tradition or innovation. Stability or disruption. Long-term strategy or short-term delivery. Acute or community. Buildings or digital. Creative or technical. And so on.
But the truth is, the future doesn’t live at the edges - it lives in the messy middle.
The messy middle
The messy middle is space where the practical and the possible collide.
It’s where grounded, operational realities meet bold, imaginative thinking.
It’s where digital and physical infrastructure overlap, where estates strategy meets clinical service design, and where systems thinking becomes visible, tangible, and real.
It’s where different people and ways of thinking converge.
Where technical expertise and creative imagination don’t compete - they complement.
Where we focus on BOTH/ AND, not EITHER/OR.
And while this space can feel uncomfortable, uncertain and unstructured, this is exactly where transformation begins.
We just love binaries
We LOVE binaries in estates. Clear lines. Neat plans. Categories we can tick off. Boxes we can fill in a strategy template.
Culturally, it often feels like we have to pick a side when it comes to an ‘estates approach’. Stick with what we know or chase something totally new. Rely on technical rigor or turn to creative exploration. Preserve established systems or break everything to build something different.
The truth is, reality doesn’t conform to simple either/or choices, and the real world rarely fits into neat categories.
So, framing things as binary limits possibility.
In health estates, progress emerges when we shift our focus away from either of the edges - concentrating on the messy and human middle, where systems, people and policies come together.
And when we learn to design and think from that place, we can unlock entirely new ways to build resilience, sustainability, and connection.
Beyond the binary
Instinctively framing challenges as either/or often leads us to questions like:
How do we disrupt the system without breaking everything?
How do we preserve what we have without stagnating change?
Which side of the fence should we be on - tradition or future?
The problem is that these questions reinforce the false binary.
The messy middle asks a different question. How do we do both?
This idea goes way beyond infrastructure culture or philosophies. Binary thinking creeps into the very heart of estates too.
We separate digital systems from physical estate, and spaces for acute care from community care - as if each exists independently. We talk about integration, yet our language continues to assume division.
The untapped power of BOTH/AND
Always looking only at either/or blinds us to the possibilities of BOTH/AND.
BOTH the status-quo systems we inherit AND the ones we dream of creating.
BOTH the rules that guide us AND the space to bend or reimagine them.
BOTH the (sometimes cumbersome) processes that keep everything running AND the experiments that could improve the system.
The future exists between what we know how to do and what we could do. Between the established frameworks that cannot be deconstructed overnight and imagined ideals that push us forward.
“Because creativity without grounding is just fantasy. But without imagination, we’ll never create anything new.” - Emma Ingham, Loxie
Both grounding and imagination are essential.
Living in the messy middle allows us to do both at once.
Why the middle feels so messy
The messy middle isn’t messy because it’s chaotic. It’s messy because it’s human.
It sits between what we know and what we imagine. Somewhere between the proven and the possible. And both sides of these spectrums offer their own kind of safety.
One side feels safe because it’s known - it gives us certainty. It’s been tested, measured, and validated.
The other feels safe because it’s theoretical - an untested ideal that stays comfortable precisely because we don’t have to make it real.
The middle offers no such comfort. It’s the space where things get complex.
This is a space that resists neat categorisation.
It’s where:
Bold ideas coexist with respect for existing systems.
Innovation flows through tradition, not against it.
Creativity becomes a lens to see existing infrastructure differently.
Radical thinking is applied practically.
Here, boldness isn’t about shouting how different you want to be, or destroying what has gone before - it’s about connection and genuine progress.
Living in the messy middle
Living in the messy middle requires a combination of mindsets and approaches:
Visionary pragmatism – You dream big, but allow yourself to start small. Push boundaries, but know when to work within constraints.
Systemic curiosity – You look for hidden patterns, notice overlooked connections, and focus on where the gaps are.
Imperfect action – You start with small iterative interventions that drive progress, without waiting for any form of self-prescribed perfection.
Empowered doing – You give teams permission and space to experiment safely and creativity needs room to breathe.
These approaches turn tension into opportunity. Contradiction becomes productive. Complexity becomes manageable.
Ultimately, a path forward becomes clear.
Why the messy middle matters in health estates
The messy middle is where health infrastructure actually lives everyday.
It’s the space between the old hospital building and the new model of community care. Between policy ambition and operational reality. Between capital investment and lived experience.
Every estate decision sits at the intersection of competing demands:
Balancing capital constraints with the need for innovation
Integrating long-term strategy with short-term adaptability
Enabling local flexibility without losing system-wide coherence
Infrastructure isn’t static bricks and mortar - it’s alive with digital systems, people, workflows, relationships. And they all intersect. When we work intentionally in this space, something powerful happens:
Resilience starts to grow naturally, not through mandates or emergency fixes.
Sustainability is designed-in, rather than retrofitted.
Infrastructure-led prevention emerges, promoting wellbeing through the way the system is built, connected, and experienced.
This is where the NHS becomes more than a provider or property owner.
It becomes an infrastructure connector, a facilitator, and a navigator of complexity.
Take neighbourhood health centres as an example. The temptation is to see them as shiny new, or refurbished, buildings -some sort of tangible evidence of transformation.
But a new health centre, or health hub, isn’t transformative because it exists. It’s transformative because of how it connects into its local ecosystem - of GPs, social care, transport, digital systems, green spaces, and local communities.
The true potential lives in understanding, navigating and maximising the potential of those complex infrastructure connections - in the flows of people, data, and energy between places.
That’s the messy middle.
Why it is so important to live in this place of possibility
The messy middle is everywhere across estates, strategy, and service design. It asks us to embrace possibility, not certainty. To experiment while respecting what exists. To lead boldly without burning everything down. To navigate flexibility and compromise in a world of constant change.
It asks questions like:
Where can the old and new come together?
How can tension become a source of strength rather than conflict?
Which connections are invisible but vital?
How can small interventions ripple system-wide?
Who is missing from the table that could unlock new possibilities?
It’s about seeing infrastructure, policy, and people as a web of possibility rather than a fixed blueprint. In a world of rigid plans and concrete boundaries, this can feel challenging – but it’s achievable when we focus on the connections, flows, and relationships that bring the system to life.
The takeaway
If we embrace both/and instead of obsessing over either/or, we can unlock something rare - a healthcare system that is visionary and practical, bold and considered, innovative and wise.
In a world obsessed with binaries, health infrastructure must embrace the messy middle - where stability and change coexist, where being bold doesn’t mean being extreme, where being creative doesn’t mean starting from scratch, and where innovation doesn’t require abandoning what came before.
We don’t need to choose a side of the fence.
We need to live in the middle.
Because that is where the future waits.
That’s where we actually build something new.
And the first step? Just start.