This thesis originated from a research question created by a focus group of National
Health Service (NHS) senior estates managers, who considered that the systems of
internal control do not give adequate assurance that NHS healthcare building services
engineering day-to-day maintenance activities conform to the national guidance. The
initial aim of this research was to test their concerns against empirical evidence from
NHS Trusts. This was achieved by identifying the gaps within the participating Trusts'
maintenance managerial activities when assessed against national standards. Central to
the methodology used to assess the level of dynamic risk being generated was the
rejection of the NHS national standard 5x5 risk criticality grid in common use throughout
the health service, in favour of a series of specific 'Utility Functions'. This has created
greater transparency and robustness of the risk assessment process. To the
researcher's knowledge, this is the first time that 'Utility Theory' has been used in such
scenarios. The result of this analysis has shown their fear to be correct. And for each of
the 31 NHS Trusts taking part, the multi-professional focus groups composed of their
own senior managers confirmed that there are areas of non-conformance within their
maintenance regime, which were previously unknown. In all cases the organisations
considered that their failings were exposing their patients, staff, public and stakeholders
to substantial/intolerable risk through a 'systematic' failure of the Trusts' governance
The aim of this research then expanded to design techniques that specifically assesses
the resource needs to close these managerial gaps employing industry standard
techniques. Then again employing 'Utility Theory' examined various revenue levels of
directly employed maintenance artisan resource with respect to risk, via a specifically
designed simulation model. This has proved that the historical NHS methodology for
assessing workforce planning to be fundamentally flawed, as it seriously underestimates
the resource need. This research then developed and designed a generic day-to-day
monitoring assurance framework from reference to the research into High Reliability
Organisations, Normal Accident Theory and managerial governance needs.
The overriding recommendation from the research was that NHS Trusts must redesign
their governance systems to ensure that they are aware of their estates department's
non-conformances when assessed against national standards.
A Doctoral Thesis. Submitted in partial fulfillment of the requirements for the award of Doctor of Philosophy of Loughborough University.