Best foot forward: improving NHS organisations' carbon footprint

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The NHS’s carbon footprint is massive, so what can be done to improve the environmental sustainability of healthcare, asks Chris Naylor.

The NHS in England alone has a carbon footprint that exceeds emissions from all planes departing Heathrow Airport, and produces enough sewage to fill Wembley stadium once every 16 days.

A growing number of organisations are exploring what actions they can take to improve the sustainability of their activities.

Increasingly, a connection is being made between environmental sustainability and the core objectives of the health service. A report from the King’s Fund, Sustainable Health and Social Care: connecting environmental and financial performance, explores the multiple overlaps between sustainability and other system objectives.

Key among these is the connection between sustainability and the quality, innovation, productivity and prevention programme. These agendas are closely related, with both pointing to the necessity of re-focusing on efficiency, value and prevention of avoidable activity.

While many of the quick wins involve operational changes such as adopting energy efficiency measures, a key message of our report is that improving efficiency at this level is unlikely to be sufficient. A more fundamental transformation in service models is needed – for example, with a greater emphasis on prevention, shifting care upstream, and integration across different services.

Clinical decisions made in primary care have significant environmental and financial implications. For example, the use of pharmaceutical products accounts for 22 per cent of the overall NHS carbon footprint. Improved medicines management and prescribing practices could reduce ineffective or wasteful use of drugs.

Primary care will also play an important role in supporting people to manage their own condition. Supported self-management has been found to reduce unplanned hospital admissions among people with long-term conditions. This reduction in demand can be taken as a proxy for avoided environmental damage – provided it is not accompanied by increased demand for other forms of care.

Many acute trusts have made considerable progress over recent years in improving the energy efficiency of their buildings. The challenge now is to spread ownership of the sustainability agenda out of estates departments, so that it becomes seen as a responsibility for medical directors, finance directors and the organisation as a whole.

Service redesign will be needed to ensure patients get maximum value from all resources (financial or natural) invested.

New technologies present opportunities to develop more sustainable models of care. For example, telehealth and telecare tools may reduce emissions related to patient and staff travel. The current focus on integrated care may also help.

If services are provided in such a way that patients experience an efficient journey through the system and receive well-co-ordinated support, this should be more sustainable from both an environmental and a financial perspective.

Public health

The critical importance of improved public health to the long-term affordability of the NHS has been stressed by the Wanless review and elsewhere.

The same applies to environmental sustainability. The most environmentally sustainable approach to health is likely to be one that minimises the system’s use of natural resources by promoting good health in the population and preventing those who become unwell from going on to need resource-intensive care. Local governments will need to take a lead role on this as they take on responsibilities for public health.

By influencing the design of care pathways, commissioners can play an important role in driving many of the service changes described above. Clinical commissioning groups – along with the NHS Commissioning Board – can help to develop a more sustainable system by including environmental requirements in service contracts and holding providers to account for their performance against these.

Commissioners will also need to work with health and wellbeing boards and other local partners to ensure that services in their area are resilient to the various predicted consequences of environmental change, including the increased incidence of extreme weather events in many parts of the country, and rising prices for energy, water and other natural resources.

Regulatory bodies

Regulatory and standard-setting organisations will also play an important role. For example, the role of the National Institute for Health and Clinical Excellence in driving evidence-based care across the system is critical – nothing could be less environmentally sustainable than providing interventions which fail to deliver benefits to patients.

Regulatory bodies will need to consider how they can promote sustainability as a core dimension of quality, akin to cost-effectiveness or equity of care.

The actions above represent some but not all of the opportunities to improve the environmental sustainability of our approach to healthcare. Taken together, this represents a broad set of changes which will require leadership from professionals of all kinds. Leaders will need to build support for change by articulating the opportunities for a focus on sustainability to go hand in hand with quality and productivity improvement.

Priority actions for health and social care organisations

Develop a more detailed local understanding of the problem by measuring the environmental impacts of the organisation’s activities, and assessing the potential impact of environmental change on future care needs and services.
Engage staff with the sustainability agenda, through strong leadership and by empowering staff to take responsibility for reducing the environmental impact of their own activities.
Actively exploit the synergies between environmental sustainability and other objectives – for example, by identifying changes that may bring health or financial benefits as well as environmental ones.
Invest in preventive approaches to reduce demand for formal care, by promoting self-care and self-management, among other strategies.
Explore the opportunities presented by new technologies such as telehealth and telecare, or combined heat and power generation in hospital facilities.
Improve medicines management and prescribing practices to reduce inefficient or wasteful use of pharmaceuticals.
Engage with suppliers and use procurement and commissioning processes to drive sustainable practices in supply chains and service providers.
Engage with patients and the public to build wider support for environmentally sustainable approaches to delivering care.