On my Sunday morning run, I was listening to one of my favourite podcasts, Acquired. In an episode with Mark Zuckerberg, he talked about what defines a technology company (listen here). Not the product it sells, but where technical competence sits.
His point was straightforward. Many organisations describe themselves as technology companies but are not structured like one. Engineering expertise is often siloed. Boards lack technical representation. Strategic decisions are made without people who understand the underlying systems. When that happens, technology becomes an afterthought rather than a foundation. At Meta, engineers shape strategy, sit across leadership, and influence board-level decisions. Not everyone needs to be an engineer, but without sufficient technical voices at the top, Zuckerberg argues, you are not a technology company.
While Meta and hospitals operate in very different domains, that framing made me stop and think about the NHS.
Hospitals are among the most complex organisations in the country. They are multidisciplinary, large-scale providers operating around the clock in safety-critical conditions. Their purpose is simple to state and hard to deliver. Provide high-quality patient care, reliably and safely.
They are not technology companies. But they are deeply technical organisations.
Clinical care depends on engineering in ways that are largely invisible until something fails. Power, water, ventilation, medical gases, fire safety, digital infrastructure, and the physical condition of buildings are not background services. They are core systems. If they fail, care fails.
Yet most NHS Trusts no longer have Directors of Estates and Facilities, Infrastructure, or Capital Development sitting on their boards.
That raises a difficult question. Why is engineering expertise so often absent from the top table in organisations that depend on it so completely?
One explanation lies in how estates are framed. Too often, they are described as support services. Necessary, but secondary. A cost centre rather than a clinical enabler.
That framing is both historically and practically wrong.
Sanitation alone is widely regarded as the greatest medical advancement of the past 150 years (Guardian article). Clean water, safe buildings, effective waste management, and controlled environments did more to improve population health than many drugs or procedures. Estates are not peripheral to care. They enable it.
When healthcare estates are treated primarily as financial assets to be rationalised or monetised, the consequences are predictable. Patient safety risks increase. Staff effectiveness suffers. System resilience weakens. Short-term savings are prioritised at the expense of long-term capacity, flexibility, and preparedness.
In my PhD research, this tension surfaced repeatedly in interviews with Directors of Estates and Facilities, Heads of EFM, and Authorising Engineers across NHS Trusts.
Some interviewees were candid about the advantages of not being on the board. Fewer meetings. Less bureaucracy. More time spent close to operational reality, dealing with backlog maintenance, net zero pressures, and workforce recruitment and retention.
But almost all raised the same concern. Without direct board access, they depended on whoever represented them. Most often the CFO. Sometimes the COO or CEO. Occasionally the Chief Nurse.
And that dependency mattered.
Over 65% of senior estates leaders and Authorising Engineers in the Delphi study (n=165) described the lack of board-level representation as a critical barrier. Not because of status, but because estates priorities struggled to compete when filtered through other agendas.
As one interviewee put it:
“Considering the costs associated with the Estate, the lack of EFM representation on the board has always been an issue. There is also a conflict of interest as our Director of Estates is also our Finance Director.”
Another was more direct:
“Activity challenges […] such as cancer referral rates […] are always going to be trumping the Estate.”
When estates are represented indirectly, they struggle to compete with more visible and politically salient performance pressures.
This marginalisation is striking when set against Trust strategies.
Guy’s and St Thomas’ NHS FT strategy commits to “modernising our infrastructure” to remain resilient and at the leading edge of healthcare (Source). Cambridge University Hospitals NHS FT prioritises “building for the future” through a safe estate and investment in new facilities (Source). Manchester University NHS Foundation Trust explicitly links value delivery to its “estate and digital infrastructure” (Source).
The rhetoric is clear. Infrastructure is strategic. Estates enable care.
But strategy without governance muscle is fragile. None of these organisations have direct estates and facilities representation on their boards. When trade-offs between clinical activity and infrastructure investment are made, infrastructure priorities are easily deprioritised, particularly in the current financial climate.
I wanted to test this question with something more concrete than anecdotes. I therefore ran a small, exploratory comparison between Trusts with estates represented at executive board level and those without.
I compared Oxford and Buckinghamshire, both with Chief Estates and Facilities Directors sitting on board level, with Guy’s and St Thomas’, Cambridge University Hospitals, and Manchester University NHS Foundation Trust. Using NHS Model Hospital estates and facilities benchmarks, I took a snapshot across costs, productivity, quality (PLACE), and safety.
The picture is mixed. Guy’s and Cambridge both score strongly on PLACE, but also show higher or unusual cost signals. Guy’s pairs very high quality, for example cleanliness, with a high cost base and high finance costs. Cambridge performs well on productivity. Oxford and Buckinghamshire show tighter unit costs on several measures, including lower finance and waste costs, and lower overall resource intensity.
Interpreting these figures is difficult. They are not comparing apples with apples. Trusts differ by scale, estate age and complexity, teaching and research intensity, PFI exposure, accounting treatment, and reporting practice. Safety figures are raw counts rather than normalised indicators.
The only safe conclusion is that drawing meaningful comparisons is hard. If estates performance is genuinely strategic, boards need better ways to measure it.
What should good estates metrics look like?
And how confident are we that the numbers currently in front of boards support the decisions they are being asked to make?
Several interviewees pointed to a practical response, articulated particularly clearly by David Jones in his writing on estates leadership (here).
His argument is that backlog maintenance is not an estates problem. It is a strategic risk and value issue. Boards do not engage with technical tasks. They engage with outcomes.
Executives think in terms of risk, cost, capacity, reputation, and delivery against organisational priorities. Estates challenges need to be translated into those terms. Lost beds. Increased downtime. Safety incidents. Regulatory exposure. Avoidable cost.
When estates leaders frame their challenges this way, they are far more likely to influence decisions.
This leaves a real question for estates leaders across the NHS.
Should Directors of Estates push for board-level presence, on the basis that infrastructure is fundamental to care and deserves direct representation?
Or, given current realities, is the more effective strategy to master the language of the board, communicating estates challenges so clearly in terms of risk, value, and outcomes that influence is achieved without a seat at the table?
Perhaps the answer is not either-or.
But if the NHS is serious about delivering world-class facilities to support world-class care, it cannot afford a continued disconnect between estates strategy and estates governance.
Image: Mark Zuckerberg speaking at the 'Acquired' event. © Heute.at, licensed under Creative Commons Attribution 4.0 (CC BY 4.0). Image cropped for layout.