Carl-Magnus von Behr, Professor Tim Minshall, and Professor John Clarkson report on research, sponsored by the University of Cambridge and Cambridge University Hospitals NHS Foundation Trust, to identify how knowledge priorities vary among NHS EFM staff across organisational levels. The results highlight knowledge gaps in sustainability and digitalisation, varying skill priorities for managers and directors, and a strong reliance on external expertise. The findings ‘emphasise the importance of aligning organisational structures with evolving knowledge demands’, and targeted training for effective healthcare EFM.
The role of estates and facilities management (EFM) in the healthcare sector is often overlooked, despite its crucial contribution to the efficient delivery of clinical services. The research on which we report here – in which 152 EFM professionals participated – was conducted by a team from the University of Cambridge’s Engineering Design Centre and Institute for Manufacturing, and highlighted the need for tailored communication channels for different knowledge types. This study addressed the gap in understanding the precise knowledge needs of EFM staff at different organisational levels. This lack of clarity limits the ability to develop targeted training and career pathways. By identifying the key knowledge areas essential at various career stages within EFM, the aim of research was to empower the workforce, fostering better performance, and enabling a more sustainable and efficient NHS.
The findings reveal several key points: Firstly, there is a strong reliance on external Authorising Engineers for technical and benchmarking expertise. Secondly, we observed a significant gap in the areas of sustainability and digitalisation, indicating a misalignment between strategy and practice. Thirdly, collaboration skills are crucial for Managers, whereas Directors of EFM prioritise financial management, affecting technology adoption and reliance on legacy systems. The insights gained from the research highlight the importance of aligning organisational structures with evolving knowledge demands, and designing targeted training programmes for effective healthcare EFM management.
Financial constraints and a sizeable backlog
The critical role of EFM in enabling clinical services to be delivered effectively cannot be overstated. However, tasked with managing over 1,200 hospitals and 3,000 treatment facilities,1 EFM professionals face not just financial constraints, but also a significant £11.6 bn maintenance backlog and the goal of achieving Net Zero carbon emissions by 2040.2 These challenges are compounded by workforce issues within EFM – an ageing demographic, high absence rates, and skills gaps.3 Addressing these challenges necessitates leveraging the collective capabilities and skills of the NHS workforce through enhanced collaboration and integration of fragmented services. However, achieving effective collaboration depends on various factors, including the organisational and cultural environment, and requires careful orchestration to foster widespread adoption within the organisation. Studies show that there is a lack of knowledge sharing among NHS Trusts’ EFM teams,4,5 affecting communication and patient safety, especially during COVID-19.6 The literature emphasises the need for strategic alignment, resource integration, and effective communication in healthcare EFM operations.
There are three overarching organisational levels within EFM: (i) directors of EFM at a strategic level – overseeing long-term planning and organisational vision, (ii) heads of EFM and managers at a tactical level – responsible for translating strategies into actionable plans, and (iii) engineers and technicians at an operational management level, focused on the hands-on execution of daily tasks. Each level has unique roles and knowledge requirements, making the flow of precise, coordinated information vital for effective EFM. Knowledge is not just information, but a valuable asset that encompasses experience, values, and expert insight into organisational practices.7 Due to the context-dependency of hospital buildings and operations, it is crucial to differentiate between mere data, and actionable knowledge essential for competent and effective decisionmaking. In this context, knowledge sharing (KS) goes beyond storing and retrieving information. It is about creating a system where knowledge, especially the tacit kind gained through experience, is shared and applied effectively. While technology plays a role in this process, the human element – the insights and experiences of staff – is crucial within the EFM context.5 As a result, individual NHS hospitals require the abilities to access and apply knowledge from other hospitals to solve tasks more effectively, efficiently, and economically.8 This involves not just identifying the right type of knowledge to share,7 but also understanding how it fits into the daily routines of staff, and aligns with the hospital’s goals.
Consider the task’s nature and context of use
In developing effective knowledgesharing systems for NHS EFM, it’s crucial to consider the nature of the task, the context in which knowledge is used, and the individuals involved. This approach ensures that knowledge sharing is not only about transferring information, but also about enhancing the collective expertise within the healthcare environment. There are distinct knowledge areas that are essential for catering to highly regulated healthcare settings. These extend beyond the traditional FM scope due to the critical impact on patient care and safety. In FM literature, there are eight core knowledge areas identified for FM professionals,9 including leadership, people management, and operational know-how. While these also apply to the NHS context, our study aims to extend this set of core knowledge areas to cater for the specific regulatory requirements of hospital EFM.
NHS EFM teams navigate critical issues like staffing, financial limitations, and environmental targets. To tackle these, EFM staff need expertise across various fields, and the success of sharing this knowledge across NHS Trusts depends on tailoring the approach to the specific type of knowledge being shared. We thus evaluated existing FM competencies in the literature,9-11 and aligned them with the specialised needs of NHS EFM, as outlined by various professional bodies and the NHS.12-14 Our study investigated the overarching knowledge areas and subordinate knowledge types crucial for various NHS EFM roles, aiming to underpin effective knowledge management and workforce development within NHS EFM. Through the review of the academic literature and FM guidelines, we identified 15 knowledge areas for NHS EFM, as shown in Figure 1.
Delphi study to engage EFM professionals from different organisational backgrounds
To identify and rank the importance of the key knowledge areas for NHS EFM staff, we conducted a three-round Delphi study, since this data collection method is more suitable for the 24/7 operation of the hospital environment and geographically dispersed staff than traditional in-person methods. After securing ethical approvals from the NHS Health Research Authority (REC: 22/HRA/1079), we distributed online questionnaires via Qualtrics. The process began with an open-ended round to gather insights, followed by two rounds where participants rated the importance of these suggested knowledge areas on a Likert scale from 1 (not important at all) to 5 (extremely important)
Professionals across various EFM roles were invited through NHS England, HefmA, and IHEEM, resulting in 152 participants. To simplify the complex array of job roles and titles in the NHS, while still capturing the diversity of EFM job levels, participants were categorised into five sub-panels based on their NHS Band Level (BL) according to the Career Route Map designed by IHEEM and HefmA.15 The final consensus was formed through a grading system (median >3.5 and interquartile range ≤ 1 among at least one sub-panel), considering the varied perspectives across the different sub-panels. This method ensured that the findings would be reflective of the diverse viewpoints across organisational levels, and applicable for effective knowledge sharing within the NHS EFM domain. The study procedure is illustrated in Figure 2
The study involved three Delphi rounds using Qualtrics surveys. Initially, 129 participants proposed 340 knowledge types, condensed into 70 statements. In the second round, 124 participants rated these statements on importance, using a custom consensus grading system to achieve consensus on 62 statements. The third round had 101 participants re-evaluate the remaining 15 statements, resulting in a final set of 69 knowledge types with consensus. We analysed these 69 statements that achieved at least partial consensus among participants in Rounds 2 and 3, grouping them into overarching knowledge areas, as shown in Figure 1. We analysed these knowledge areas for differences and similarities across the five sub-panels, using the percentage agreement, which is the percentage of participants who rated the knowledge type as ‘very’ or ‘extremely’ important to their job role. We averaged ratings within each knowledge area and used R’s ‘Pheatmap’ library to create the heatmap (see Figure 3), displaying average importance ratings across sub-panels with a colour-coded gradient, and clustering knowledge areas by similarity.
FINDINGS – Shifting knowledge priorities across different organisational levels of NHS EFM
This section identifies the following overarching categories: (i) cross-functional, (ii) regressive, (iii) progressive, and (iv) expert knowledge areas. To enrich the quantitative data and underline the observed trends, we use qualitative comments from participants
Firstly, the study identifies five essential knowledge areas across all organisational levels: Problem-Solving, Legal & Regulatory Knowledge, Resilience & Risk Management, Communication Skills, and Organisational Skills. These areas are deemed very important by over 70% of participants for their daily tasks. Yet, within these, some skills, such as Negotiation (part of Communication Skills) are less prioritised at the operational level, with under half of Technicians rating them as important. Therefore, it is imperative to prioritise ongoing learning, even in fundamental areas such as Communication Skills, as there is room for growth in advanced abilities as EFM staff advance in their careers. The current absence of dedicated training programmes for such skills was underscored by a Director of EFM, who noted that communication skills ‘should be a core skill of any in-house estates manager, [but are] not something taught on surveying/estates-related courses’.
Secondly, we identified five progressive knowledge areas crucial as EFM professionals ascend the organisational hierarchy: Leadership & Team Management, Financial Management, Human Resource Management, Collaborative Proficiency, and Strategic Management & Planning. The importance of these areas was rated highest at the tactical level. For example, Leadership & Team Management is most crucial for Managers, but diminishes in importance towards Director level. This trend might be due to Managers having more immediate supervisory duties compared with heads of EFM. However, a Manager highlighted a lack of preparedness for such responsibilities, saying: ‘I often need to lead without being a line manager… That is an area some people struggle with [and which] needs better understanding.’ In contrast, Human Resource Management is most critical for Directors and Heads of EFM, who handle staffing budgets. While some Managers view HR knowledge as useful, but are reliant on HR specialists for support, a Head of EFM contrasts this by stating: ‘We do HR planning ourselves without HR involvement.’
Importance of interdisciplinary collaboration
Collaborative Proficiency stands out as a vital knowledge area for both Managers and Heads of EFM, reflecting the significance of interdisciplinary and interorganisational collaboration. A Head of EFM reflected that ‘to plan any strategy we need to link with colleagues in other fields not just restricted to ICT, Finance, and HR, but clinical colleagues, too’. Despite this importance, another Head of EFM emphasised that they often feel that collaboration is ‘more important to me than perhaps the team’. Managers, however, expressed challenges, since there is ‘often limited time to network with [peers] and share learning’. This discrepancy becomes more striking at the Director of EFM level, where – surprisingly – there is reduced emphasis on collaboration, despite the NHS’s push for strategic alignment among regional Trusts through Integrated Care Systems (ICSs).
Interestingly, Strategic Management & Planning does not have the highest perceived importance at Director of EFM level, but at the tactical level – something underlined by a Head of EFM highlighting that ‘some top management wouldn’t know how to write [reports], so it’s easy to push responsibility to lower grade staff’. Financial Management stands out as the most important for Directors, aligning with their significant role in budget management, and possibly because many Directors of EFM do not sit on the Trust Board, but report through the Directors of Finance. However, a Director of EFM pointed out that these organisational structures can lead to ‘a conflict of interest, since the Director of EFM is also our Finance Director’. This can impede the ability of EFM teams to advocate for and secure funding for state-of-the-art technologies.
Thirdly, the study found that Data & Information Management is a regressive knowledge area, holding the greatest significance at the operational level, and diminishing in relevance as individuals move from Technician to Manager roles. This change is attributed to reduced responsibilities for manual data recording and organisation at higher levels. Despite this, the NHS Long Term Plan of 2019 emphasises that ‘people, data and technology are crucial to the ongoing evolution of our NHS’.16 To achieve this vision, developing digital skills at senior organisational levels is essential to effectively utilise technology and data in enhancing healthcare services.
Reliance on AEs for specialist knowledge
Fourthly, Professional Development, Technical Expertise & Experience, and Benchmarking & New Technologies, are of highest importance for Authorised Engineers (AEs). A Director of EFM notes that ‘most Directors will have one specialist knowledge from the route they developed through [but they] cannot have operational knowledge of all services’, indicating the reliance on AEs for specialised knowledge. Heads of EFM particularly value AEs’ expertise for compliance and assurance, despite AEs being technically required only for annual audits. In Benchmarking & New Technologies, AEs’ extensive client portfolios enable them to effectively compare NHS Trusts’ performances. However, their role as independent experts presents challenges in advising on future technologies and suppliers. A Manager highlighted a gap in support for exploring new technologies: ‘It is left to my own personal reading – I never see any guidance on [future technologies].’ This reliance on outdated systems carries significant financial risks, as a Government Security analysis projected a potential cost of £13-22 bn over the next five years for the public sector,17 a substantial portion of which affects the NHS, emphasising the crucial role of AEs in navigating technological changes and financial management within the NHS.
Lastly, the study reveals a concerning gap: no Delphi participants suggested any knowledge types in the area of Environmental & Sustainability Awareness, which is alarming given the NHS’s commitment to being the first healthcare system to achieve a Net Zero carbon target. The NHS recognises the need for an ‘upskilled workforce to drive and implement the interventions’ [18, p. 41] for this goal. However, this sustainability agenda seems not to have become a priority for EFM staff yet. The limited guidance from central NHS authorities has contributed to a gap between the NHS’s high-level environmental goals and the day-to-day management focus. This disparity highlights a critical need both for immediate attention, and better strategic alignment in integrating sustainability into the core objectives of the NHS.
SUMMARY – Key knowledge gaps to address in NHS EFM development
The study sheds light on how the importance of different knowledge areas shifts as EFM professionals move through the ranks, with Figure 4 offering a clear visual representation of this dynamic. Figure 4 illustrates how the priorities for different knowledge areas change at different stages of the EFM career path. Additionally, it points out a significant oversight in Environmental & Sustainability Awareness, a key area that has yet to receive due on-the-ground attention within the field. These insights into the knowledge priorities of EFM professionals provide valuable information for those in the field, suggesting areas for development and potential focus in professional training and education.
NHS staff rely significantly on external Authorising Engineers (AEs) for Technical Expertise & Experience and Benchmarking & New Technologies, along with Professional Development. The study uncovers a notable decrease in the prioritisation of Technical Expertise & Experience as EFM professionals move from Head of EFM to Director roles. This trend poses critical questions about the sufficiency of in-house technical knowledge for high-level decisionmaking and advocacy within EFM. The heavy reliance on AEs, particularly for understanding and adopting cutting-edge technology and practices, is concerning, as AEs spend very limited time in the Trusts, and also do not necessarily understand the local building context to the same degree as internal EFM staff. It suggests potential challenges in effectively operating advanced systems, and in making informed decisions about technology investments, especially at the Director level. Enhancing internal technical understanding, and aligning it with organisational needs at the top management levels, are thus essential for strategic and informed allocation of resources and technology adoption within NHS EFM
Collaborative Proficiency emerges as crucial for Managers and Heads of EFM, underlining the necessity of interdisciplinary and inter-organisational collaboration. However, challenges in networking and prioritisation become evident, particularly at the Director of EFM level, despite the NHS’s emphasis on strategic alignment via Integrated Care Systems. This will need to be addressed to turn around the ‘continued failure to embrace integrated care systems’. [19, p.2].
The study reveals that Environmental & Sustainability Awareness is not sufficiently prioritised at any organisational level in NHS EFM, and that there is a notable lack of emphasis on Data & Information Management in senior roles. This misalignment between sustainability goals and on-the-ground focus necessitates a strategic focus on these areas to enhance the EFM workforce’s capabilities. Additionally, these findings align with the gaps in sustainability and digitalisation skills noted in the NHS Workforce Action Plan, underscoring the urgency to develop ‘training programmes to develop […] social, technical and digital skills, for example, Net Zero Carbon skills’ [3, p. 9].
FUTURE – innex.ai: A revolutionary step in NHS infrastructure management
Building on our extensive research, we are transitioning from analysing the current landscape to implementing a tangible solution: innex.ai. This innovative software, developed in collaboration with AI experts at the University of Cambridge, unifies repositories spanning NHS guidance and best practices, and leverages AI technology for fast and reliable access to the latest information. Moreover, it will facilitate connecting to domain experts and peers for best practice knowledge sharing, and assist in policy drafting and grant applications. This innovative tool aims to transform information dissemination and knowledge exchange, boosting productivity in accessing guidance and best practice.
Acknowledgements We are grateful to Karl Redmond from NHS England for his crucial role in refining this paper. His expertise and constructive feedback greatly enhanced our research.
Carl-Magnus von Behr
Carl-Magnus von Behr is a PhD researcher at the Institute for Manufacturing (IfM), University of Cambridge. His research investigates how to enhance knowledge sharing among NHS EFM teams for a more resilient and sustainable delivery of care. Prior to starting his PhD, he obtained an M.Phil. in Industrial Systems, Manufacture and Management from the University of Cambridge, and a BSc in Industrial Engineering and Management from the Technical University Berlin, Germany.
Professor Tim Minshall
Professor Tim Minshall is the inaugural Dr John C Taylor Professor of Innovation at the University of Cambridge, Head of the Institute for Manufacturing (IfM), and Head of the IfM’s Centre for Technology Management (CTM). He is an expert on open innovation, and his research is focused on the links between manufacturing, innovation, and skills, with a key area of his research now addressing the application of innovation management techniques to improve healthcare outcomes.
John Clarkson
John Clarkson is Professor of Engineering Design at the University of Cambridge, and of Healthcare Systems at Delft University of Technology. He leads the Healthcare Design Group at the Cambridge Engineering Design Centre, which researches the role of systems thinking in the UK NHS for the delivery of safe, effective, and affordable care. He is a specialist in engineering design, and particularly the development of design methodologies to address specific design issues such as change management, inclusive design, and systems leadership.
References
1 NHS England, The NHS Premises Assurance Model (NHS PAM). NHS England, April 2023. https://tinyurl.com/ bd84t8tw
2 NHS Digital. Estates Returns Information Collection; Summary page and dataset for ERIC 2022/23. 14 December 2023. http:// tinyurl.com/5dd4h3w9
3 NHS. Estates and Facilities Workforce Action Plan, London, 15 June 2022. https://tinyurl.com/447v2wrm
4 J. G. Barlow JG, Koberle-Gaiser M, Moss R, Noble A, Scher P, Stow D. Adaptability and innovation in healthcare facilities. Lessons from the past for future developments, HaCIRIC, Report, December 2009.
5 Pathirage C, Haigh R, Amaratunga D, Baldry D. Knowledge management practices in facilities organisations: a case study. Journal of Facilities Management, 2008; 6(1): 5–22,
6 HSIB. ‘Oxygen issues during the COVID-19 pandemic’. 15 January 2021.
7 Davenport TH. Putting the Enterprise into the Enterprise System. Harvard Business Review 1 July 1998. https://tinyurl. com/3m7r2ea2
8 Holdt Christensen P. Knowledge sharing: moving away from the obsession with best practices. J of Knowledge Management 2007; 11(1): 36–47.
9 Awang M, Mohammad AH, Sapri M, Rahman SA, Requisite Facilities Management Competencies for Sustainable Development at Higher Education Institutions, vol. 9, 2014.
10 IFMA.
11 Core Competencies of Facility Management, October 2020. https:// tinyurl.com/2f76w5k4 11 Department for Education. Estate management competency framework. Jun. 2023. https://tinyurl.com/4xesd4bu
12 IHEEM and HefmA, Future Leaders – Healthcare Estates & Facilities Management Joint Workforce Strategy, March 2021. https://tinyurl.com/ buhc3zp9
13 NHS. NHS Health Careers: Estates and facilities, Health Careers. https://tinyurl. com/4bkprh9u 14 NHS Employers. National profiles for Estates and Maintenance, 2023. https:// tinyurl.com/3r6mwnns
15 IHEEM Career Route Map, IHEEM. https://www.iheem.org.uk/futureeaders/career-map/
16 The NHS Long Term Plan. NHS, Jan. 2019. https://tinyurl.com/3rspuj2c 17 Cabinet Office. Organising for Digital Delivery.
9 September 2020. https:// tinyurl.com/44zbjm25 18 Delivering a ‘Net Zero’ National Health Service, NHSE/I, London, October 2020. https://tinyurl. com/5n6z6466 19 Stein KV, Goodwin N, Miller R. From Crisis to Coordination: Challenges and Opportunities for Integrated Care posed by the COVID-19 Pandemic. Int J Integr Care 2020; 20:(3).