Nobody has released the clinicians
By webmaster · · 6 min read
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A programme that has not engaged the clinicians who will use the
space will be redesigned, late, at cost. You will hear that at every
healthcare capital event. It is probably true. It is also not evidenced,
and you should know that before saying it to a board.
I looked for published UK evidence quantifying the chain from weak
clinical engagement to redesign to cost on NHS schemes. It is not there.
What surfaces is American consultancy and vendor material, unsourced,
and worth nothing in front of an estates director. So the honest
position is this: there is no published UK figure for
it. Here is what can be shown instead, and it points somewhere
less comfortable.
The
guidance already knows the failure mode, and it is not that nobody
asked
Health Building Note 00-09 sets out a project structure, and among
the roles it names a User panel. Read its definition slowly:
User panel (representatives of each of the relevant service
departments, in each case authorised to define their department’s needs
and to review and agree how those needs are to be met)
The parenthesis is the whole point. The guidance is not asking for
consultation. It is asking for people authorised to define needs
and agree how they are met. A room full of attendees who cannot
commit their department satisfies the meeting and not the
definition.
The same expectation runs elsewhere. HBN 00-01 says that room sizes
and circulation space taken from HBNs and the Activity DataBase “should
be thoroughly reviewed by the clinicians and users, including patients
and the public, together with technical advisers to establish the
organisation’s brief for the spatial requirements”. The standard layout
is a starting point for clinical review, not an answer to it.
And in ventilation, the one area where NHS engineering governance is
codified this tightly, clinicians are not consultees at all. HTM 03-01
Part A 4.5 says the Ventilation Safety Group should typically comprise
an authorising engineer, an infection prevention and control person, the
authorised person, estates staff, “clinicians and specialist departments
(for example, theatres, critical care areas, pharmacy, medical
microbiology, nursing, decontamination)”, and “personnel from the
finance department with accountability for capital and revenue
evaluation”. Clinicians and finance are in the same room by design, as
members.
The
cost mechanism is documented. The frequency is not.
HBN 00-09 2.24 describes a gate and states the consequence of moving
after it:
At the end of each part of the design stage, the project team and the
IPC team will be required to sign-off the information issued and
reviewed. This signifies that the design-brief requirements and changes
agreed during discussions have been incorporated. Any subsequent changes
made after sign-off should be made via a “change protocol”, which can
have significant cost and programme implications for the project.
Paragraph 2.30 adds that changes during construction or after
completion “could have a significant adverse impact on costs and the
building project”.
That is official NHS guidance saying, in terms, that late change
costs money. It is the strongest support the popular claim has. Note
what it is not. It says nothing about how often this happens, or to how
many schemes, or at what value. Anyone quoting these paragraphs for a
percentage is quoting something that is not on the page.
The constraint is
capacity, not consultation
The National Audit Office reported on the New Hospital Programme on
16 January 2026. Its finding on engagement, at paragraph 3.33, is the
most current data point available:
Hospital 2.0 will only result in future benefits if clinicians are
able to work differently in the new hospitals. Securing buy-in from all
clinicians may be challenging. As at October 2025, the risk of delays to
NHS professional engagement with the designs was rated ‘Amber’ due to
pressure on trusts and wider organisational changes in the NHS affecting
their capacity to engage.
Read the stated cause, because it inverts the lazy version of the
thesis. The NAO does not say clinicians were not asked. It says trusts
lack the capacity to engage, because of operational
pressure and reorganisation.
The same report records what DHSC has done: a prototype single bed
hospital room, tested for whether staff can administer care in it, and
15 clinical design briefs produced in collaboration with
clinicians, covering urgent and emergency care, outpatients,
maternity and paediatrics. That is engagement at national scale. The
risk is still Amber.
So the failure is not a failure of intent, and it will not be fixed
by better invitations. If you have not released the clinicians,
you have not engaged them, and sending the drawings out for comment is
not engagement, it is a distribution list. The consultant whose
input your theatre design needs is running the list that pays for the
theatre. Nobody has backfilled her.
The
people you need are named, and they already have jobs
This is not unique to clinicians, and the estate’s own governance
shows the shape of it. HTM 00 sets out a hierarchy: a Designated Person
at board level, an Authorising Engineer who stays independent and audits
annually to that board, a senior operational manager as informed client,
an Authorised Person with operational responsibility, and a Competent
Person doing the work. Paragraph 3.22 is the one worth knowing: the
Competent Person “will be appointed, or authorised to work (if a
contractor), by the AP”.
Not by the project manager. Your contractor’s operative touches a
critical system because a named individual inside the trust authorised
it. That is a real control, and it depends entirely on that individual
having time to exercise it.
NHS England has now applied exactly this logic to one role. Its
letter of 15 April 2026 (PRN02414) introduces a central IHEEM register
and certification for authorising engineers working on NHS
infrastructure in England, with a transition period of three years.
Alongside it, estates and facilities leaders are “encouraged to plan
time and support for applicants through workforce development and
assurance budgets”. Time, planned, with a budget line against it. Nobody
does that for the clinicians.
What this does not settle
The claim at the top of this piece remains a professional judgement
supported by guidance and one dated risk rating. It is not a research
finding, and presenting it as one invents an evidence base.
Three further limits. HBN 00-09 is a 2013 document carrying a 2012
Crown copyright, and it predates the pandemic; its own Appendix 3 states
that “many of the recommendations in this appendix are based on
consensus rather than scientific observation”, which is a candour worth
matching. HTMs and HBNs are guidance, not law, and HBN 00-01 itself
warns that a brief should distinguish mandatory from desirable and that
“blanket statements should be avoided”. And all of the above is England:
Scotland publishes SHTM, whose ventilation standard has a broader stated
scope than the English one, and Wales publishes WHTM where it has
authored one.
None of that changes the practical point. Engagement is not a
communications task with a schedule. It is a resource with a cost, and
if it does not appear in the programme budget as a line, it has not been
planned.
