Extending Lean from Capital Delivery to Operations in England's' Healthcare Estate Management

<ns5:p>Background The National Health Service (NHS) maintenance backlog reached £15.9 billion in 2024/25, exceeding the £14.0 billion annual cost of running the estate for the first time and marking an 189% increase from £5.5 billion in 2016/17. Capital investment is projected to grow by only around 1% per annum in real terms to 2028/29, against a backlog expanding over 15% annually, making incremental capital expenditure insufficient to close the gap. This study examines why Lean principles, despite three decades of policy advocacy from the Latham Report (1994) to the 10 Year Health Plan (2025), have not been systematically extended from capital delivery into operational estate management. Methods Drawing on 16 semi-structured interviews (I01-I16) and an eight-member expert panel (P01-P08), thematic and content analysis was used to identify recurring barriers to Lean lifecycle extension in NHS estate management. Results Four interconnected themes were identified: structural separation of capital and operations budgets; insufficient Lean tool rigour in the operational phase; cultural and informational barriers to extension; and digital enablement as necessary but insufficient Lean practice. BIM adoption now reaches 72.3% across UK (United Kingdom) construction (NBS, 2025), yet only 14% of practitioners had used a digital twin operationally as of 2021 (NBS, 2021), a figure absent from the 2025 survey. Practitioner accounts describe a sector investing in digital infrastructure without the Lean process discipline to convert data into operational value. Conclusions A standards-anchored, maturity-based migration pathway is recommended, integrating ISO 19650-3, Asset Information Modelling, soft landings, and defined Lean key performance indicators. Operational Lean practice, rather than digital investment alone, is the mechanism through which the NHS estate crisis can be addressed at scale.</ns5:p>