Table 2. Themes, sub-themes and codes... | Emerald Publishing

Table 2.

Themes, sub-themes and codes derived from analysing barriers and opportunities to existing hospitals to achieve the vision of a future sustainable and climate-resilient hospital

Themes	Sub-themes	Codes	Barriers	Opportunities
Estate management	Estate management strategy	Planning	Short-term, fragmented and reactionary asset management planning Lack of central/government support in strategic planning Hospital infrastructure not adapting quickly to evolving clinical services Carbon assessments unable to support planning	Clinical strategy as an opportunity for long-term estate planning Integrated care delivery frees hospital space and allows for reconfiguration planning
		Targets and KPIs	Current guidelines provide generic and high-level targets Lack of understanding of the carbon footprint targets Net-zero targets based on the 1900 baseline	Defining KPIs can be an opportunity to focus on investments and resources SMART targets would provide the final goal
		Knowledge of the estate	Lack of digital models (2D and 3D) and a BEMS The absence of a central repository for estate information Lack of assessment of vulnerability to overheating due to insufficient temperature monitoring and the absence a BEMS
		Maintenance strategies	Lack of preventative maintenance strategies in acute hospitals The current backlog maintenance The current risk register compilation approach Increased asset maintenance complexity due to the integration of technology	Computer-aided facilities management (CAFM) systems can support the organisation and co-ordination of maintenance interventions Maintenance strategy allows for improvement in the transition journey
	Retrofitting and upgrading the existing estate	Net-zero estate	Existing hospitals unable to achieve net-zero carbon without significant offsetting due to footprint and height constraints and power generation issues Lack of updated standards to support net-zero transitions The capacity of the electrical grid as a potential barrier in the journey to electrify hospitals	Innovative solutions for power generation
	Retrofitting and upgrading the existing estate	Suitability for retrofit	Unsustainability of the existing estate in terms of footprint, layout and building typologies Lack of quality of buildings and environment Ageing buildings and outdated fabric, structure and utility systems unable to meet changing demands Combined heat and power engines unable to meet current demand	Integrated care delivery and digital technology can: reduce the demand for physical assets; allow infrastructure optimisation; and enable to focus budgets on critical improvements
		Climate adaptation of the estate	Lack of long-term adaptation strategies for the estate Climate-induced risks are understood but seldom translated into risk assessments or adaptation strategies Reactionary overheating strategy, lacking long-term interventions The estate is challenging to adapt to future climate and temperatures without repurposing and disposal strategies	Understanding changes in the external climate to plan and save money long-term Simplifying the business continuity plan (BCP) to improve the resilience of the estate Monitoring the existing estate through sensors to understand vulnerabilities to overheating
Financial aspectsFinancial resources managementFunding availability• Lack of funding.• Dependence on political decisions• Clinical services prioritised for funding over estates and facilities• Estates unable to meet changing clinical service requirements without investment in physical assets• Insufficient funds influence the definition of targets for the estate	Financial resources management	Funding availability	Lack of funding Dependence on political choices Clinical services prioritised for funding over estates and facilities Lack of funds influences the definition of targets for the estate
	Financial resources management	Funding sources	Reliance on grants for investments	Private Finance Initiative (PFI)
	Facilities management commercial services	Investment appraisal strategies	Lack of funds leading to business cases focusing solely on initial capital The lengthy approval process for business cases preventing revenue consideration Extended timeline rendering business cases outdated by the time they are implemented	Integrating initial capital, revenue and the life cycle model in business cases is more expensive upfront but can save money in the long term Energy cost analysis can shorten the payback period for investments Incorporating resilience in intervention strategies is more expensive upfront but saves money long term
		Procurement	Procurement process Double- and triple-lock approval Suppliers with sustainable credentials not prioritised due to higher costs
		Contracts and agreements	Inability of trusts to enter into power purchase agreements or energy performance contracts
NHS organisational development	Leadership	Hospital leadership	Short-term planning and focus on decreasing expenditures or minimising costs Dependency of hospital leadership on government policies Prioritisation of clinical needs above estate needs	Changing leadership culture Integrating estate and long-term clinical strategies
		System leadership	Inability of trusts to achieve the net-zero targets without the right resources	Shifting from hospital to system leadership Creating a network of hospital CEOs
		Role of EFM in the leadership structure	Strong sense of disconnection between estate needs and leadership engagement Lack of strategic representation of the WFM team is a barrier Lack of power for the sustainability teams	Better integrating the sustainability teams with the leadership structure
	Estates and facilities within the NHS	Upskilling FM	Upskilling in EFM EFM seen as an unappealing profession	Focused training programmes and a generational shift
		Recruitment	Recruitment into NHS EFM due to better salaries and progression options offered by competitors Recruitment challenges push trust to rely on external contractors	Introducing a pay scale reform for EFM in the NHS, with regionalised salaries reflecting the demand in the area Employing energy managers to support planning and coordinate activities
		Cultural difference	Divergent priorities between clinical staff and EFM staff Clinical teams are reluctant to change service delivery methods and move to community settings

Themes	Sub-themes	Codes	Barriers	Opportunities
Estate management	Estate management strategy	Planning	Short-term, fragmented and reactionary asset management planning Lack of central/government support in strategic planning Hospital infrastructure not adapting quickly to evolving clinical services Carbon assessments unable to support planning	Clinical strategy as an opportunity for long-term estate planning Integrated care delivery frees hospital space and allows for reconfiguration planning
		Targets and KPIs	Current guidelines provide generic and high-level targets Lack of understanding of the carbon footprint targets Net-zero targets based on the 1900 baseline	Defining KPIs can be an opportunity to focus on investments and resources SMART targets would provide the final goal
		Knowledge of the estate	Lack of digital models (2D and 3D) and a BEMS The absence of a central repository for estate information Lack of assessment of vulnerability to overheating due to insufficient temperature monitoring and the absence a BEMS
		Maintenance strategies	Lack of preventative maintenance strategies in acute hospitals The current backlog maintenance The current risk register compilation approach Increased asset maintenance complexity due to the integration of technology	Computer-aided facilities management (CAFM) systems can support the organisation and co-ordination of maintenance interventions Maintenance strategy allows for improvement in the transition journey
	Retrofitting and upgrading the existing estate	Net-zero estate	Existing hospitals unable to achieve net-zero carbon without significant offsetting due to footprint and height constraints and power generation issues Lack of updated standards to support net-zero transitions The capacity of the electrical grid as a potential barrier in the journey to electrify hospitals	Innovative solutions for power generation
	Retrofitting and upgrading the existing estate	Suitability for retrofit	Unsustainability of the existing estate in terms of footprint, layout and building typologies Lack of quality of buildings and environment Ageing buildings and outdated fabric, structure and utility systems unable to meet changing demands Combined heat and power engines unable to meet current demand	Integrated care delivery and digital technology can: reduce the demand for physical assets; allow infrastructure optimisation; and enable to focus budgets on critical improvements
		Climate adaptation of the estate	Lack of long-term adaptation strategies for the estate Climate-induced risks are understood but seldom translated into risk assessments or adaptation strategies Reactionary overheating strategy, lacking long-term interventions The estate is challenging to adapt to future climate and temperatures without repurposing and disposal strategies	Understanding changes in the external climate to plan and save money long-term Simplifying the business continuity plan (BCP) to improve the resilience of the estate Monitoring the existing estate through sensors to understand vulnerabilities to overheating
Financial aspectsFinancial resources managementFunding availability• Lack of funding.• Dependence on political decisions• Clinical services prioritised for funding over estates and facilities• Estates unable to meet changing clinical service requirements without investment in physical assets• Insufficient funds influence the definition of targets for the estate	Financial resources management	Funding availability	Lack of funding Dependence on political choices Clinical services prioritised for funding over estates and facilities Lack of funds influences the definition of targets for the estate
	Financial resources management	Funding sources	Reliance on grants for investments	Private Finance Initiative (PFI)
	Facilities management commercial services	Investment appraisal strategies	Lack of funds leading to business cases focusing solely on initial capital The lengthy approval process for business cases preventing revenue consideration Extended timeline rendering business cases outdated by the time they are implemented	Integrating initial capital, revenue and the life cycle model in business cases is more expensive upfront but can save money in the long term Energy cost analysis can shorten the payback period for investments Incorporating resilience in intervention strategies is more expensive upfront but saves money long term
		Procurement	Procurement process Double- and triple-lock approval Suppliers with sustainable credentials not prioritised due to higher costs
		Contracts and agreements	Inability of trusts to enter into power purchase agreements or energy performance contracts
NHS organisational development	Leadership	Hospital leadership	Short-term planning and focus on decreasing expenditures or minimising costs Dependency of hospital leadership on government policies Prioritisation of clinical needs above estate needs	Changing leadership culture Integrating estate and long-term clinical strategies
		System leadership	Inability of trusts to achieve the net-zero targets without the right resources	Shifting from hospital to system leadership Creating a network of hospital CEOs
		Role of EFM in the leadership structure	Strong sense of disconnection between estate needs and leadership engagement Lack of strategic representation of the WFM team is a barrier Lack of power for the sustainability teams	Better integrating the sustainability teams with the leadership structure
	Estates and facilities within the NHS	Upskilling FM	Upskilling in EFM EFM seen as an unappealing profession	Focused training programmes and a generational shift
		Recruitment	Recruitment into NHS EFM due to better salaries and progression options offered by competitors Recruitment challenges push trust to rely on external contractors	Introducing a pay scale reform for EFM in the NHS, with regionalised salaries reflecting the demand in the area Employing energy managers to support planning and coordinate activities
		Cultural difference	Divergent priorities between clinical staff and EFM staff Clinical teams are reluctant to change service delivery methods and move to community settings

Source(s): Authors’ own work