Mapping the socio-technical causes of overheating risk and unequal thermal burden in hospitals in England: a qualitative systems inquiry using AcciMap

Background

Hospital overheating arising from more frequent heatwaves threatens healthcare staff wellbeing, patient safety and service continuity, but is often managed as an estates or seasonal problem. We examined how interacting organisational, infrastructural and experiential conditions sustain overheating vulnerability and unequal thermal burden in hospitals in the south of England.

Methods

We conducted a six-phase, multi-source qualitative systems inquiry integrating 129 overheating incident reports from two National Health Service (NHS) hospitals in Hampshire, England, six stakeholder interviews, two focus groups with healthcare staff and patients (n=12), and a national stakeholder refinement focus group (n=4). AI-supported thematic analysis was combined with context-mechanism-outcome synthesis and iterative AcciMap construction, to produce an integrated systems explanation.

Results

Twenty themes were consolidated into six interacting explanatory pathways: 1) recognition without durable resilience; 2) hidden visibility; 3) workaround-based resilience; 4) unequal adaptive capacity; 5) underuse of emergency preparedness and business-continuity systems; 6) institutional framing. The analysis indicated that, within the hospital settings investigated, overheating persisted despite recognition because ownership, information, resources and delivery capacity were fragmented across system levels. Frontline workarounds sustained care but could conceal thermal burden and defer structural adaptation. Staff and patients had unequal capacity to regulate exposure because of differences in mobility, autonomy, physiology, clinical dependency and occupational role. Existing preparedness systems offered a route from seasonal reaction to anticipatory action, but overheating was not consistently embedded within them. The AcciMap showed how shared factors connected the six pathways and identified coordinated intervention entry points across monitoring, governance, preparedness, service delivery and infrastructure.

Conclusions

Overheating in hospitals in England is best understood as a socio-technical patient-safety and adaptation challenge, not a single-domain estates problem. Our analysis indicates that durable resilience requires environmental intelligence linked to accountable decisions, support for staff and patient adaptation, activation of preparedness systems and long-term infrastructure change.

Key messages

What is already known on this topic

• Hospitals in England are increasingly exposed to extreme heat, while ageing infrastructure, limited cooling and operational pressures constrain adaptation.

• Systems approaches can reveal contributory factors across organisational levels but have been used mainly to investigate discrete safety incidents rather than recurrent climate-related vulnerability.

What this study adds

• Six interacting pathways explained why recognised overheating risk can persist within hospitals: fragmented delivery capacity, limited visibility, dependence on workarounds, unequal capacity to adapt, underused preparedness systems and institutional framing.

• Continued service delivery can conceal the burden transferred to staff and patients; apparent operational resilience should not be equated with safe or sustainable heat adaptation.

• Combining thematic analysis, explanatory synthesis and AcciMap modelling connected lived experience and operational evidence to system-level intervention entry points for heat adaptation.

How this study might affect research, practice or policy

• Hospitals in England should connect indoor environmental monitoring with staff, patient and operational consequences; embed heat within emergency preparedness and business continuity; and evaluate who can access protective measures.

• Our AcciMap approach provides an avenue for local remapping and development of mechanism-linked interventions to improve hospitals’ heat resilience.