In the NHS, it is easy to think of health and safety on construction sites as something that sits primarily with contractors.
After all, they run the site, employ the workforce and prepare the risk assessments. However, after more than 25 years of delivering projects in live hospital environments, and through my role as a CIOB Client Champion, I have learned that this view is not only incomplete but also risky.
NHS clients have a critical role in protecting the health and wellbeing of construction workers, patients, staff and visitors during construction works.
This reflects the strong message within the Chartered Institute of Building’s client guidance: responsibility cannot simply be passed down the supply chain.
Our buildings, our patients and our operational pressures fundamentally shape how safe, or unsafe, construction activity becomes.
The reality of construction in healthcare settings
Nearly all NHS construction projects take place in live, operational environments, which immediately sets them apart from most other construction sites.
On an acute hospital site, thousands of people may be present at any one time: patients, relatives, staff under pressure and members of the public moving freely through the estate.
When you add emergency departments, mental health services and critical care areas, the potential for harm increases significantly.
Construction activity introduces noise, dust, vibration, temporary services, hoardings and unfamiliar personnel into that environment.
If it is not planned and managed properly, it threatens not only the wellbeing of construction operatives but also patient safety, staff morale and the hospital’s ability to function. This is precisely why the NHS client role is so important.
Understanding the regulatory landscape, and its limits
Like all clients, NHS organisations must comply with the Construction (Design and Management) Regulations and the Building Regulations, which establish the legal baseline.
Healthcare estates also operate within an additional framework of standards, most notably the Healthcare Technical Memoranda (HTMs).
These documents set out best practices for maintaining patient safety and operational continuity, covering areas such as infection control, ventilation, resilience, testing regimes and acceptable tolerances.
Although HTMs are technically guidance, they are widely regarded as an expected standard of care.
When issues arise during commissioning or post-construction, one of the first questions asked is whether the HTMs were followed.
Managing the overlap, and occasional tension, between statutory regulations and healthcare-specific standards is therefore a core responsibility of the NHS client.
Why the client cannot step back
As NHS clients, we possess knowledge that contractors simply do not have.
We understand how our buildings truly function, how services are interconnected and how clinical operations respond under pressure.
Estate records are often imperfect, particularly in older facilities.
Even with extensive surveys, contractors cannot always see what lies beneath the surface.
Problems frequently arise not because of carelessness but because of missing or incomplete information.
Contractors rely on clients to share critical knowledge and to challenge assumptions so that work can be planned safely around live services and vulnerable users.
Our duty of care also extends beyond the construction workforce to patients, staff and visitors. This responsibility cannot be delegated away.
Planning for wellbeing, not just compliance
Realistic planning is essential. Tight programmes, constrained budgets and pressure to return clinical space to use are constant features of NHS estates work.
However, unrealistic timescales and under-resourced site setups contribute directly to stress, fatigue and unsafe behaviours.
Welfare facilities provide a clear example. Site compounds must be sufficiently sized to deliver appropriate welfare provisions, and value engineering should never compromise these essentials.
If individuals are cold, wet, tired or rushing, the likelihood of accidents increases.
Within procurement processes, HTM compliance must be made explicit, with any derogations subject to formal, multidisciplinary sign-off.
This should involve infection control, engineering, fire safety, health and safety, and clinical leadership to ensure that risk decisions are transparent and properly owned.
Managing interfaces is where most risk lies
In practice, serious incidents most often arise where interfaces are poorly managed: cutting into live services without understanding downstream impacts, excavating in areas with poorly documented buried services, or failing to control dust that may trigger fire alarms or increase infection risks.
Advance notice for service interruptions and excavations is essential. Works should be reviewed and walked through before permits are issued.
While contractors produce risk assessments and method statements, NHS clients must rigorously review these where they interact with operational systems.
For high-risk services such as medical gases, power and water, hospital engineers with detailed estate knowledge must be directly involved.
Contractors must also plan for emergency scenarios, including fires during works or major incidents requiring construction activity to cease.
Leadership on site makes a real difference
Client presence and leadership have a tangible impact. Construction workers quickly recognise when safety is taken seriously.
There have been occasions where I have halted works due to unsafe conditions, despite the resulting programme pressures.
Explaining that such decisions are made to ensure everyone returns home safely often reframes the discussion.
Simple measures can also deliver meaningful improvements. On one refurbishment project, short mandatory cleaning sessions were introduced before lunch and at the end of the day.
These significantly reduced dust, prevented unwanted fire alarms and improved the overall working environment.
A shared responsibility, led by the client
Health, safety and wellbeing during construction works are a shared responsibility. However, NHS clients hold a uniquely influential position due to the complexity and sensitivity of healthcare environments.
We cannot ignore unsafe practices or treat construction activity as separate from patient care, particularly within higher-risk buildings.
Clients frequently identify issues before they escalate, and acting early is both a professional responsibility and a legal duty.
The ultimate objective should be simple: zero harm.
While ambitious, this goal aligns directly with the core purpose of healthcare organisations.
By fully embracing the client role, NHS bodies can help create safer construction sites and safer environments for patients, staff and the public alike.