Root Causes of Maintenance Backlogs in the UK NHS Estates

Healthcare is a critical infrastructure essential for social well-being, providing vital services that directly impact patient safety, operational efficiency, and clinical outcomes. As the UK’s national healthcare provider, the NHS (National Health Service) relies on this infrastructure to deliver high-quality care. Despite its importance, NHS estates face a rapidly escalating £13.8 billion maintenance backlog (2023/24), growing by 13.6% annually. This backlog jeopardises operational integrity and long-term viability of healthcare facilities. Through thematic analysis of seven expert interviews, this study identifies systemic root causes: aging assets and infrastructures, funding and resource constraints, data management & digital transformation, workforce and skills gap, maintenance culture and planning inefficiencies, regulatory and standards compliance, and external and environmental risks. Existing research lacks granularity in addressing these drives. This study offers a novel taxonomy to equip policy makers and NHS leaders with the insights necessary to develop effective strategies for reducing backlog growth and ensuring the delivery of safe, high-quality healthcare services.