Chapter 6: The NHS as a leader for environmental sustainability


Why this matters

NHS organisations have a significant impact on the environment and are some of the largest contributors to climate change and air pollution. The NHS alone is responsible for 40% of public sector emissions in England.

Delivering high-quality health and care places numerous demands on natural resources and the environment, such as:

  • use of energy, water and consumables, including plastics
  • waste production and waste management
  • travel, which requires fossil fuels and contributes to air pollution.

In 2017, the health and social care system used 27.1 million tonnes of CO2e and 2.23 billion m3 of water. This includes 589,000 tonnes of waste and 9.5 billion travel miles generated by NHS providers. Indeed, health and care-related travel constitutes around 5% of all road travel in England. Given its large carbon footprint, any action the NHS takes to support responsible consumption and reduce waste can have a significant impact on the environment. This is important not only to reduce the carbon impact, but to support more sustainable utilisation of finite resources overall.

The climate crisis has serious direct and indirect consequences for health. Toxic air pollution is associated with acute and chronic health conditions that cost health and social care £157m in 2017. Exposure to air pollution is estimated to cause the equivalent of 40,000 premature deaths in the UK each year, and more than 2,000 GP practices and 200 hospitals are in areas affected by toxic air., Climate change and air pollution also disproportionately affect disadvantaged and vulnerable populations., These communities are more exposed to climate hazards, more vulnerable to the harms they cause and have relatively fewer resources to cope or recover from their effects, thereby further entrenching inequalities.,, And while improving environmental sustainability will have benefits beyond local populations, it is one of the main ways the NHS has influence as an anchor institution, and can improve the wider determinants of health and support community development. It has the power and responsibility to influence action on a broader scale to reduce its contribution to climate change and protect resources for the health of future generations.

What do anchor environmental sustainability strategies look like in practice?

Adopting sustainable practices within the NHS

  1. Developing leadership and staff buy-in for environmental sustainability

Influencing sustainable practices in the community

  1. Helping shape community environments and behaviours and influencing local suppliers

Policy context

Public sector organisations are legally required to deliver environmental sustainability as outlined in the Climate Change Act 2008, which commits the UK to reducing its carbon emissions by 80% by 2050. The legislation has since been amended to introduce a target to bring all greenhouse gas emissions to net zero by 2050. NHS leaders have enacted several changes to help deliver on these aims. NHS England and Public Health England jointly fund the SDU, which helps NHS organisations with expert advice and guidance on how to support environmental and social sustainability. NHS organisations in England are also required by the NHS Standard Contract to produce an annual Sustainable Development Management Plan that sets out how they will reduce carbon emissions. And as previously discussed, Wales, Scotland and England each have legislation in place to promote the social value of public purchasing, including considerations for broader environmental sustainability.

The NHS Long Term Plan re-emphasised the importance of reducing greenhouse gas emissions and air pollution associated with delivering health care, and acknowledged the need for collective action from all NHS organisations to reach these targets. The NHS has made progress over the past decade by reducing its carbon output by 18.5%, though as one of the world’s biggest organisations with one of the largest carbon footprints in the UK public sector, these improvements could go much further if the NHS embraced and developed its role as an anchor institution.

Learning from practice

Adopting sustainable practices within the NHS

  1. Developing leadership and staff buy-in for environmental sustainability

Reducing the health and care system’s carbon footprint involves taking action in several areas, including improving energy efficiency, supporting more sustainable travel for patients and staff, and reducing waste and water consumption.

As with all complex improvements, changing organisational behaviour to support environmental sustainability needs leadership and commitment from senior leaders., Interviewees told us that responsibility for implementation has often been left to sustainability officers without more senior or board-level support. This has often meant that interventions lack coordination and visibility, and could have a greater impact if they were part of an organisation-wide strategy.

Stakeholders who have managed to get senior leaders on board emphasised the importance of creating a vision that appeals to corporate strategic aims. Clearly linking environmental sustainability to goals around improving health has been helpful for some:

‘I just kept banging my drum (about) the whole 40,000 excess deaths a year in the UK due to air quality. So, that stat always hits home.’

Sustainability lead

Acute trust

There is also a lack of accountability on sustainable development within the system. Despite a strong legal context for action, there are no sanctions or incentives beyond national targets for action on sustainable development, which are insufficient on their own to motivate and drive change. One promising development is that the SDU is developing a dashboard to help organisations understand their baseline, assess their readiness and set individual targets in line with their own goals. This data will amalgamate to STP and ICS level to support greater system accountability and regional planning.

Adopting more sustainable operational practices also relies on staff engagement at all levels, requiring a shift in culture, attitudes and knowledge. Research suggests that staff resistance often comes from feelings of having insufficient knowledge or skills to implement change and not knowing the impact of interventions., Giving teams the tools and resources they need to feel empowered to implement solutions and measure impact is key to supporting the NHS to support environmental sustainability for local communities.

During interviews, senior leaders commented that NHS organisations have often been able to make the greatest progress on reducing local air pollution, partly because this is an area with clearly defined metrics that can more easily demonstrate impact.

There are numerous tools and resources to support teams to reduce pollution. These include the Clean Air Hospital Framework, which offers best practice and guidance on how hospitals can improve outdoor and indoor air quality in key areas like procurement, travel, construction and energy generation. The SDU’s Health Outcomes of Travel Tool supports NHS organisations in measuring the impact of travel and transport, helping to quantify the impact of pollution from different sources and how to reduce them. The SDU is also developing frameworks to support progress in other areas where the NHS can have an impact, including recycling schemes, biodiversity, responsible chemical disposal, responsible construction and conservation.

A number of interviewees felt that action on sustainability has become easier as more staff are aware of the climate crisis and its impact. Organisational champions and communication campaigns have helped build a sense of shared motivation, responsibility and ownership over solutions. The NHS has an important role to play in educating staff about what they can do, both at work and outside of work.

‘When I started here, it was just me and nobody really taking sustainability on… Slowly, got more people on board … After a couple of minutes, you can tell them what it’s about and a lot of people, the light bulb just clicks that it’s just good business; like being efficient and using all your resources whether it be staff, the patients we’re dealing with or the environmental impacts of your actions … The tide turned quite a few years ago.’

Sustainability lead

Acute trust

Examples of action by NHS organisations include promoting use of public transport or walking and cycling to work, monitoring waste generation and recycling rates, and installing more energy efficient heat and power sources. But NHS organisations and local systems could do more to coordinate their efforts. There is also an opportunity for regional and national policymakers and the SDU to share good practice and innovations – something NHS England and NHS Improvement have committed to as part of the NHS Long Term Plan.

Case study 6: University Hospitals of North Midlands NHS Trust and Beat the Cold

University Hospitals of North Midlands NHS Trust has launched an initiative to establish more sustainable and affordable energy sources and reinvest savings in the community. Recognising the links between hospital readmissions during winter and poor heating and living conditions, it worked with residents and the local council to crowdfund for 1,100 solar panels, installed on NHS hospital buildings. By switching to renewable energy, the trust saved nearly £300,000 that was invested into a local charity, Beat the Cold, which tackles cold-related sickness and fuel poverty. This initiative has helped strengthen relationships between the trust and residents. Early evaluation suggests the project has helped achieve savings by reducing the rate of readmissions, particularly among elderly people and other vulnerable groups. Having the support of the chair of the board was essential:

‘It was so important that we had the support of the hospital chairman. On the day we were putting the solar panels up a member of the board tried to stop us… The hospital chairman had to overrule him.’

Business development manager

Beat the Cold

Influencing sustainable practices in the community

  1. Helping shape community environments and behaviours and influencing local suppliers

As an anchor, the NHS can use its voice to push for broader developments that support the environmental health of local communities. For example, some NHS organisations have advocated for more public transport routes and cycling lanes to NHS hospitals, which benefits individuals’ health as well as the environment. This has knock-on benefits for local public transportation, which research has shown can help improve social inclusion and stimulate economic regeneration in deprived areas.

For example, Epsom and St Helier University Hospitals NHS Trust has been working with local councils to improve public transport links to the hospital for staff and the local community. After receiving repeated complaints about the difficulty of getting to the hospital via public transport, the sustainability officer at the trust negotiated with local councils to pilot a new ‘on-demand’ bus service for residents in Surrey, with a designated bus stop on the hospital site. The staff shuttle bus has become a public bus service, and the trust has negotiated with Transport for London to further extend bus services to the hospital.

Purchasing and commissioning can also be harnessed to influence sustainability practices in the community. The supply chain is one of the biggest components of the health and social care system’s carbon footprint, accounting for 57% of its carbon emissions in 2017, with the largest hotspots being medical instruments and equipment, followed by pharmaceuticals., As discussed in the procurement section, the NHS can reduce some of this by working with local suppliers to reduce its carbon output.

For example, as part of its Care without Carbon strategy, Sussex Community NHS Foundation Trust is working with suppliers to reduce carbon emissions, which make up 60%–70% of the trust’s overall carbon footprint. The sustainability team has embedded sustainability criteria and metrics into the tendering process by setting targets for suppliers to reduce their vehicle emissions over the lifetime of the contract.

Improving environmental sustainability in the wider community requires strong partnership working, and much can be achieved by anchors working together – something we explore in the next chapter.

Summary and implications for practice and policy

As one of the largest public sector resource users and polluters, the NHS must take action to reduce its environmental impact. Beyond changing its own organisational practices, the NHS can drive progress within local communities by using its influence at all levels of the system to advocate for broader changes that promote sustainability and improve the wellbeing of communities, particularly for disadvantaged populations who face the highest levels of environmental risk.

For national bodies, this means moving beyond simply setting national targets on narrowly defined areas such as air pollution to supporting the development of metrics, tools and resources across all domains of environmental sustainability and supporting capability at the front line.

At the local system level, organisations can work together to develop shared goals and strategies to improve environmental sustainability and track their impact. The NHS is also well placed to work with other anchors to influence supplier behaviour and make local transport or infrastructure more environmentally sustainable.

NHS organisations need strong leadership to give visibility to strategies, align efforts with other organisational priorities and maximise the influence of the NHS on environmental sustainability within their local area. Understanding which of their practices and activities have an adverse environmental impact is an important first step; securing engagement and buy-in from staff is also essential to finding solutions. Organisations should educate their staff and offer skills, resources and tools so they can take action.

Practical resources to support implementation

Care Without Carbon – our strategy (Sussex Community NHS Foundation Trust)

Clean Air Hospital Framework (Global Action Plan)

Health Outcomes of Travel Tool (Sustainable Development Unit)

†† This includes carbon emissions associated with the extraction, processing, assembly, packaging, transport, storage and handling of products and materials that are directly and indirectly consumed by service providers.

Previous Next