Low-carbon care is consistent with existing health system priorities, such as increasing prevention, moving care out of hospital, improving efficiency and harnessing technology. It is important to recognise and support these synergies where they exist. But progress in these areas is often slow, and net zero care will not simply be delivered as a by-product of existing actions. It will require dedicated effort.
From our research and conversations with people working on sustainable health care, we identified four main areas for action that leaders and policymakers should focus on now to enable the shift to net zero care.
Invest resources to shift to low-carbon care models
Decarbonising care, as with other forms of improvement, will require dedicated time and resources for staff at all levels. The current reliance on volunteerism to progress net zero action is unsustainable and insufficient. Some organisations are leading the way. Newcastle Hospitals NHS Foundation Trust has employed junior doctors in paediatrics, oncology and anaesthetics with half or more of their time dedicated to quality improvement related to environmental sustainability. South-East London ICS has committed to identifying, educating and resourcing clinical staff to work on sustainability in primary care. And some ICSs in England are appointing dedicated clinical fellows as part of the Chief Sustainability Officer’s Clinical Fellow Scheme.
Clinical staff also require knowledge and skills to identify how environmental sustainability relates to their practice, what changes they can make and how best to implement them. There is much more to do to raise awareness: 2022 Health Foundation polling found that awareness of the net zero ambition among NHS staff was still relatively low at 48%. Environmental sustainability needs to be embedded consistently across professional groups through undergraduate and workplace education and training. Work should be done to build on positive moves such as the UK-wide curriculum for environmental sustainability in undergraduate medical education endorsed by the Medical Schools Council.
Building on the concept of sustainability in quality improvement, environmental sustainability should be normalised within thinking about the quality of care, with an expectation that it be integrated into all quality improvement and service-change efforts as well as professional development and clinical guidance. As hospital trusts and systems develop improvement approaches aligned to national models, such as the NHS Impact approach, there is a clear opportunity to integrate a strong focus on environmental sustainability into wider efforts to improve the quality of care. Strengthening the understanding and deployment of quality-improvement approaches will be important in enabling the shift to low-carbon care.
There are key capabilities clinical staff need to deliver more sustainable care. These include carbon mapping the care pathway or service and identifying opportunities for change; co-producing more sustainable approaches to care with patients; implementing these approaches, including seeking guidance and support from sustainability teams and leads; testing and measuring the impact of changes; and sharing approaches and materials across teams and organisations.
Put sustainability at the core of good leadership
Net zero care will only be delivered if organisational leaders place environmental sustainability at the forefront of decision making. This includes clinical leaders, who are in a strong position to design and lead changes to the services they deliver and play a pivotal role in educating and influencing others. Prioritising sustainability, unlocking resources and investing staff time and training in decarbonising care all rest with leaders.
There are many challenges competing for leaders’ attention. The net zero goal must be integrated and balanced with other long-term priorities, such as boosting efficiency, achieving financial sustainability, reducing waiting times, enhancing out-of-hospital care, delivering digital transformation and improving the safety and quality of care through implementation of the new national improvement strategy, NHS Impact. Moreover, these priorities are often aligned and face common strategic and operational challenges – offering opportunities for synergy and mutual reinforcement. For example, by delivering 485,000 outpatient appointments (40% of all appointments) virtually, University College London Hospitals saved over 13 million miles of patient travel and 1,300 tonnes CO2e during 1 year.
Decarbonising care also requires leaders to break out of organisational silos and come together across local health systems. In England, all 42 ICSs have developed green plans that set out strategic approaches to net zero. However, these vary widely in detail and quality and can lack clear implementation plans. Within an ICS, every integrated care board (ICB) is required to have a board-level lead who delivers on the green plan and net zero goals. Differences in the extent to which ICBs have appointed dedicated sustainability leads and individuals with clinical experience are likely to drive variations in how ICBs approach the decarbonisation of care. Further, while a coherent system-wide approach should offer an opportunity to pool the resources and expertise of organisations and avoid duplication, many ICSs lack the shared infrastructure and resources required, and the maturity of environmental sustainability partnerships is variable.
Awareness-raising and capability-building is needed to equip senior leaders with the skills and knowledge to lead in alignment with the NHS’s net zero ambitions. Leaders also require an understanding of the practical measures that can improve the environmental sustainability of care. To meet these needs, leadership training should be delivered at a larger scale, building on programmes developed by the Centre for Sustainable Healthcare and NHS Leadership Academy. Practical support should be given to integrate environmental sustainability within strategy development and decision making, and also focus on bringing leaders together to support collaboration across systems.
Ensure major policy levers are used to drive progress
Care delivery is shaped by a vast array of nationally directed conditions, guidelines and incentives placed on leaders, managers and staff. However, the major approaches used to manage and improve services, deliver national priorities and safeguard quality – such as payment systems, performance targets, regulation of NHS organisations and approval systems for new medicines and technologies – were not designed with net zero in mind.
In recent years, there has been some progress prioritising sustainability within national policies. NHS England has introduced a range of environmental sustainability targets and reporting requirements for NHS organisations. The Care Quality Commission now considers environmental sustainability part of its single assessment framework of health and care providers. In 2021, the Investment and Impact Fund incentivised primary care networks to switch to prescribing lower-carbon inhalers as part of a suite of incentivised targets (though this incentive was short lived and has been removed under the latest primary care plans). Additionally, the National Institute for Health and Care Excellence published a decision aid to support patients and clinicians switching to lower-carbon inhalers, though it has yet to replicate this approach in other relevant areas of clinical practice.
But these developments constitute just a tiny portion of the targets, policies, guidelines and payment systems that influence care delivery. Current national policy will help or hinder progress on the net zero goal in ways that are not yet well understood. To inform more supportive policy, the role of national levers in achieving NHS net zero must be reassessed.
Support research and innovation to enable faster decarbonisation of care
Service changes and care pathway transformation
Evidence is crucial for both policy and practice on sustainability. But there are inherent challenges in building the evidence base due to difficulties measuring the environmental impact of products and pathways and the lack of a standardised measurement and reporting approach. Reducing the environmental impact of care requires understanding the current carbon footprint of services, what changes could be made and what the impact will be on other aspects of care.
We now have a good overall picture of carbon emissions by health care setting and what some of the biggest contributors are. There is work underway – including by NHS England, the Centre for Sustainable Healthcare and the Sustainable Healthcare Coalition – to explore specific specialities and care pathways, such as eye care, surgery and kidney care, to demonstrate how carbon hotspots can be identified and changes targeted. What is less clear is what care pathways, medicines and devices should be prioritised next or how to make the changes required, highlighting the importance of funding more research into sustainable health care. A new UKRI funding programme, which includes a focus on lower-carbon care models, may help here, but further attention and work will be needed.
Innovation also has an important role to play in enabling the transition to lower-carbon care. Several initiatives have already been launched to test and demonstrate new sustainable innovations. For instance, SBRI Healthcare are running a competition to support small and medium-sized enterprises to develop innovations that align with the NHS Suppliers Roadmap and generate carbon reductions in care. Further support for innovation can help things move faster. Given that many innovations only have been implemented on a local level, there is a particular need to identify what innovations should be prioritised for adoption elsewhere and support their spread. New innovative methods of evaluation are also needed, along with a process of consensus-building around acceptable thresholds for evidence standards in this context.