Blog #2: How knowledge flows (or doesn’t flow) through the NHS

Healthcare infrastructure isn’t just about policies, procedures, or technical manuals gathering dust on shelves. Often, the knowledge that keeps hospitals (and all other high-risk infrastructure for that matter) running safely and efficiently lives in people's heads - passed down through informal conversations and built through years of experience.
When I started my PhD research into knowledge sharing among NHS Estates and Facilities Management (EFM) teams, I thought that the NHS - being a national healthcare system as opposed to federal, fragmented system in Germany - would be benefitting from large economies of scale through standardisation and efficient coordination and communication channels. However, during countless interviews with EFM professionals across the NHS, I heard variations of the same story: “I don’t have a network of personal contacts from people in my role in other Trusts” or “I don’t know any other engineers outside my Trust”. These weren’t isolated complaints - they revealed a systemic challenge that goes to the heart of how information flows (or doesn’t flow) across the NHS.

The knowledge that really matters

Healthcare systems are heavily focussed on documented knowledge - the regulations, policies, and procedures that fill filing cabinets and intranets. However, the knowledge that really drives day-to-day operations is largely undocumented. It’s the know-how gained from past successes and failures, and the know-who of understanding exactly which colleague, contractor, or Authorising Engineer to call when you’re facing an unfamiliar challenge.

STO framework illustrating levels of management and required information types (2)

The pyramid of organisational hierarchy above shows us why this matters so much. At the operational level, where technicians and engineers work, knowledge needs to be immediate, objective, and highly detailed. At the tactical level, where Heads of EFM operate, it becomes more strategic but still needs to be actionable. At the strategic level, knowledge is more about broad patterns and long-term planning.

Yet, the current knowledge sharing systems are often misaligned with the needs of the operational and tactical staff. Often, they are tasked with extensive documentation while neglecting the human networks that are needed for frontline staff to actually solve problems in a safe, efficient, and cost-effective way.

Three strategies, three challenges

Through my research, I learned about the three overarching communication strategies that organisations use to share both documented and undocumented knowledge: (i) social networks, (ii) personalisation channels, and (iii) codification channels.

Different channels for sharing documented and undocumented knowledge across NHS EFM teams (adapted from Ambrosini and Powell)

Social networks are critical to success but constrained by limited time and budgets

For successful knowledge sharing to take place, trust between both parties is a critical success factor. Hence, the most effective knowledge sharing happens through personal networks - current or former colleagues who can be trusted with a quick phone call or email. This works particularly well for senior staff like Directors of EFM, who often move across NHS organisations throughout their career, building networks of trusted colleagues as they climb up the managerial ladder.

But what about the staff at operational and tactical levels, who lack the extensive social networks early in their career. The only chance for them to meet peers would be on training courses or networking events. However, budget constraints and time pressures mean they can’t attend conferences or networking events. The result? Isolation and reinvention of the wheel across hundreds of NHS Trusts.

Personalisation strategies for peer-to-peer knowledge exchange need strenghtening

To address the limitations of informal social networks, personalisation can be seen as the formalisation of social connections - shifting from relying on who you happen to know, to using structured expert directories or formal networks to identify and reach the right person with the knowledge you need. In the NHS, there are various formal inter-organisational networks. Dozens of professional bodies (IHEEM, HefmA, CIBSE, NAHFO, or CIWM to name a few) organise events and conferences, providing crucial forums for peer-to-peer knowledge sharing. A lot of interviewees during my research highlighted the benefits of professional bodies in sharing knowledge across Trusts - “The HefmA and NAHFO networks really work well in that respect. [...] we share our knowledge”.

The drawback of these networks is that they rely on membership fees that many NHS Trusts do not cover for their staff. Furthermore, staff cannot find time for conference attendance - they are heavily overloaded with multiple responsibilities and there are always more pressing issues at hand. As one Director of Estates told me: “as you get busy, it’s one of the things that drops off. I just cannot find the time to engage with that.”

Authorising Engineers (AEs) act as crucial knowledge brokers across Trusts, managing large portfolios ranging from “between 40-50 major hospitals” to “200 in total, but a wide variety [of sizes]”. Their independent role allows them to share insights confidentially and connect staff across organisations. As one Head of Estates shared, it’s common for AEs to say, “This hospital is considering a new system - can you spare them some time?” And the answer would usually be “Yes”. Peer support is also key among AEs themselves. When faced with unfamiliar issues, they regularly consult one another: “Many problems are ones we’ve seen before - so I’ll speak to other AEs.”

However, the role of the AE faces multiple challenges. Not all AEs go through the formal IHEEM certification process, leading to variability in standards, as shared by an AE: “Some are okay, some I wouldn’t trust.” At the same time, the profession is ageing, with many AEs now in their sixties or seventies and few entering the pipeline - raising concerns about future capacity and continuity.

Codification: The outdated guidance crisis

The third strategy that can be used for knowledge sharing focuses on standardising practice through documented knowledge repositories - a system that should, in theory, provide consistent, up-to-date guidance across all NHS Trusts. This includes everything from national HTMs (Health Technical Memoranda) and HBNs (Health Building Notes) guidance to local policies, procedures, and digital platforms like the National Estates and Facilities Collaboration Hub.

Publication dates of latest HBNs and HTMs, revealing that a majority of guidance documents has not been updated in the past 10 years (analysed in early 2024, source: NHS England)

The data tells a stark story about the state of our guidance systems. Looking at publication dates of HBN and HTM documents, we see massive gaps and inconsistencies. After a flurry of publications in the mid-2010s, updates to these critical guidance documents has become more sporadic. Many guidance documents are years out of date, while others contradict each other or fail to address modern challenges like climate change, digital infrastructure, or post-pandemic infection control requirements. The fragmentation has been exacerbated by various NHS reorganisations and changes in responsibility, making it difficult for NHS England to coordinate nationally. As one NHS England representative admitted, they often "don't know what all the teams around the country are doing."

Digital solutions haven't solved these problems either. The NHS Futures Collaboration Hub, designed to provide "the latest information and policies" and serve as "a platform for discussion with estates colleagues from across the NHS", has struggled to live up to its promise. Rather than becoming a go-to resource, it's become what one interviewee described as a place where "you get lost in the chats", as "the information isn't timely" - essentially a "self-help environment" for day-to-day questions rather than a reliable source of domain-specific knowledge. Similar challenges have been seen previously with the Global Digital Exemplar programme which was designed to create a national learning ecosystem to spread the knowledge. However, participants of the programme felt that shared case studies (so-called 'blueprints') had limited applicability because they failed to address the nuanced local needs that make each Trust unique. This highlights the fundamental limitation of trying to codify and share complex, context-dependent knowledge.

Why this matters now

Senior staff rely on personal networks that younger colleagues lack, professional bodies struggle with engagement due to time and budget constraints, and the documented guidance systems are increasingly outdated and fragmented. The result?

Critical knowledge is trapped in silos just as we need it most. And the COVID-19 pandemic showed us what happens when knowledge systems are tested to their limits. Emergency modifications to medical gas pipeline systems, rapid deployment of temporary facilities, and unprecedented demands on infrastructure all required the kind of tacit knowledge that doesn't appear in any manual. But with 34% of the most experienced NHS EFM professionals approaching retirement age (NHS Estates and Facilities Workforce Action Plan), we're facing a potential exodus of experience and knowledge that could leave the next generation struggling to maintain increasingly complex infrastructure, creating difficulties in addressing crucial questions. For instance, how will they effectively maintain the resilience of electrical systems while integrating intermittent renewable energy sources? And how will they prevent hospital overheating during heatwaves while simultaneously reducing the NHS's carbon footprint?

Looking forward: Interconnecting knowledge strategies

In my opinion, the answer isn’t to choose between codification, personalisation, or social networks, but to understand how these strategies can complement one another. We need systems that actively strengthen the links between them, enabling knowledge to flow more effectively across individuals, teams, and organisations.

A more resilient knowledge sharing system will:

• Connect people with information - helping staff find both the relevant guidance and capture the insights that arise through its use
• Strengthen isolated networks - enabling staff to discover peers with relevant experience across Trusts
• Reduce friction to share knowledge - through intuitive tools that make it easy for staff to share their experiences and best practices
• Create a safe space for honesty - encouraging staff to share not just successes, but also challenges and pain points without fear
• Avoid information overload - by tailoring content streams to individual roles, interests, and needs

This is precisely why we’re building INNEX - not as just another repository, but as a platform purpose-built to address the barriers uncovered in my research. INNEX helps users surface the right knowledge quickly while encouraging peer-to-peer exchange by connecting people in similar roles, contexts, or challenges. By linking people, problems, and insights across Trusts, INNEX not only improves knowledge access but reveals wider patterns and systemic issues that might otherwise remain hidden.

Want to dig into the details of my thesis? Find the full thesis here.

In upcoming posts, I’ll share case studies from the COVID-19 response and introduce the ten personas I identified in my research - ranging from Technicians to Directors of EFM - each with distinct knowledge needs and sharing behaviours.