The UK’s National Health Service recently announced an ambitious plan to become net-zero by 2045, the first health system in the world to make such a commitment. Ian Gough reviews the report which sets out how the NHS plans to deliver on this significant goal.

On 1 October the UK’s National Health Service (NHS) became the world’s first health system to commit to delivering a net-zero service, and by an earlier date than the 2050 target set last year by the UK government for the economy as a whole.

In its new net-zero strategy, Delivering a ‘Net Zero’ National Health Service, the NHS Public Board has set two targets:

  • For the emissions controlled directly by the NHS (the ‘NHS carbon footprint’): net-zero by 2040, with an ambition to reach an 80% reduction by 2028–32.
  • For an extended set of emissions including those that they can influence in the supply chain (the ‘NHS carbon footprint plus’): net-zero by 2045, with an ambition to reach an 80% reduction by 2036–39.

This is important because the NHS is the biggest single organisation in the country, with a staff of 1.3 million and accounting for 7.2% of GDP. Its current emissions as conventionally measured contribute about 4% of the UK’s territorial carbon footprint. The NHS has already made considerable progress in reducing its emissions, from 16.2 million tonnes of carbon dioxide equivalent (MtCO2e) in 1990 to 6.1 MtCO2e in 2019, according to the net-zero strategy. However, when including indirect emissions – the ‘carbon footprint plus’ – the total is more than four times greater – estimated to be 24.9 MtCO2e in 2020.

A further issue, central to the NHS, is the feedback effect of greenhouse gas emissions on population health and well-being. Indeed, as the NHS’s net-zero strategy states, “The climate emergency is a health emergency. Climate change threatens the foundations of good health, with direct and immediate consequences for our patients, the public and the NHS.” More heatwaves and rising infectious diseases will increase demands on the health service; on the other hand, improved health prevention and interventions could reduce demand. For example, the document points out that up to one-third of new asthma cases might be avoided as a result of efforts to cut emissions. There are substantial co-benefits between environment and health. Thus a second aim of the strategy is to build adaptive capacity and resilience into the way care is provided.

How did the NHS produce its net-zero route map?

In January 2020, the campaign ‘For a Greener NHS was launched to set an ambitious, evidence-based route map and date for the NHS to reach net-zero. The resultant strategy document describes how a four-step analytical process was followed to establish these trajectories:

1. Baseline: A complete update of the NHS carbon footprint was conducted to provide an estimate of present-day emissions against a 1990 baseline.
2. Projections: A number of scenarios were then modelled to understand the emissions from the NHS over the long term, including a ‘do nothing’ scenario and a ‘committed policies’ scenario.
3. Carbon reductions available across the system: Available reductions for each of the key sources of carbon were estimated, which informed the system-wide targets for net-zero.
4. Net-zero interventions: Drawing on a call for evidence announced in January and external technical input, an extended set of interventions and carbon reductions were modelled, to give confidence in the credibility and ambition of the trajectories.

To estimate NHS emissions, the report applied the 2015 Greenhouse Gas Protocol, to combine: direct emissions from owned or directly controlled on-site sources, indirect emissions from the generation of purchased energy, mostly electricity, and all other indirect emissions including the full supply chain. For the NHS, the supply chain dominates, contributing 62% (see Figure 2 on p13 of the report). The direct carbon footprint of NHS institutions, overwhelmingly of hospitals, accounts for only one quarter of the total. The other major items are pharmaceuticals and anaesthetic gases (20%), medical and non-medical equipment (18%), personal travel of staff, patients and visitors (10%), and ‘other’ supply chain (24%).

To determine how the NHS could move from where it is now to net-zero, the report draws on the NHS Long Term Plan for the 21st century and other recent commitments, together with responses to the call for evidence. The report produces recommendations on: estates and buildings, transport and travel, anaesthetics and inhalers (whose emissions of nitrogen dioxide account for a remarkable 5% of all equivalent emissions) and resource use and substitutions.

How adequate are the report’s proposals for how to reduce emissions?

Emissions from estates, the report states, could be brought down to zero via new build, optimisation of existing estate and onsite generation of energy, all aided by the future decarbonisation of electricity. Travel and transport improvements include Green Travel Plans to encourage active travel, though these contribute relatively small savings – the bulk would derive from electrification of all vehicles. Food and catering look to sourcing more local and healthier food, which would have added co-benefits for health. A drive to minimise the large quantity of single-use material and plastics could save a considerable 1.8 MtCO2e.

But after taking all this into account the majority of indirect emissions remain. The report pins substantial hopes on tackling this residual in two directions: through “research, innovation and offsetting” and “new modes of delivering health care”. The first seems little more than a wish-list, but the second is more developed: building on the NHS Long Term Plan, there would be a combination of moving more healthcare out of hospitals, digital transformation and developing new modes of care. Boosting the availability of out-of-hospital care close to people’s homes would reduce hospital admissions and their associated emissions, and travel costs and their emissions, as well as potentially improving the quality of care. Another component is labelled “empowering people” but the report does not develop this theme, except by calling for improvements in the early detection of disease and improved techniques of treatment, for example in orthopaedics. Smarter digitalisation would permit more remote consultations.

Room for more focus on procurement and prevention

Two elephants remain in the room: procurement and prevention. The first is addressed in the report but sketchily. The NHS procures materials from 80,000 suppliers. While the NHS does not control their emissions directly, it can use its considerable purchasing power to influence change. The report states the aim to extend existing procurement policies to exclude supply firms that do not aim at zero carbon. There is indirect evidence that public provisioning systems for healthcare are indeed better able than market systems to promote and implement national strategies for reducing greenhouse gas emissions: for instance, the per capita carbon footprint of health care in the USA is more than double that in the UK and three and half times greater than in several European countries.

Most surprising is the lack of interest shown in the report in the potential role of preventing ill health – and thereby mitigating emissions through reducing hospital admissions and treatments – save for a brief discussion of the estimated carbon savings associated with an alcohol reduction programme in Nottingham. This is my one major criticism of the report.

The upstream public intervention agenda – to prevent harm before it occurs, usually focusing on whole populations and systems – is missing from the report. When addressing food, catering and diets it mentions improving hospital food, which would have both health and environmental co-benefits, but leaves alone the potential for upstream measures such as traffic lights to highlight harmful foods and regulating additives to improve population health. The advocacy of Green Travel Plans recognises the wider benefits to health of active travel but does not incorporate this into potential savings for the NHS.

Yet these cost savings are well researched. One UK study concludes that a wider shift in transport from driving to walking and cycling could bring about significant reductions in heart disease/stroke, breast cancer, dementia and depression. Similarly, a 30% reduction in livestock production and consumption of red meat would reduce heart disease by 15% (excluding effects on all other obesity-related diseases). It is estimated that the NHS spent £6.1 billion on overweight and obesity-related ill-health alone in 2014 to 2015, equivalent to the annual spend on the police, the fire service and the judicial system combined.

It is perhaps unreasonable to accuse a report on net-zero in the NHS for this neglect of whole health in the population. But given the huge residual emissions that the service faces, an upstream prevention policy could play a major role in achieving net-zero.

This would also chime with a new focus on demand-side climate change mitigation policy, likely to be seen in the next report from the Intergovernmental Panel on Climate Change. This approach, in line with the Sustainable Development Goals, would aim to reduce demand for high-carbon consumption while meeting basic needs. Evidence is growing that a demand-side approach has proven effects in reducing emissions at low cost, avoiding risky reliance on unproven mitigation technologies while at the same time improving non-monetary measures of well-being. These include low-cost behaviour changes such as reducing use of heating and cooling, taking shorter showers, reducing appliance use, shifting from private to public transport, eating less meat and improved recycling.

A genuinely ‘world-leading’ report

Aside from the insufficient space, as I see it, given to prevention, Delivering a ‘Net Zero’ National Health Service is, in an over-used phrase today, a ‘world-leading’ report. The commitment to becoming net-zero by 2045 by a core UK institution is extremely positive. That the institution in question is the NHS, whose goal is to further health and well-being for today’s population, is especially significant: this aim should not and cannot be at the expense of health and well-being of generations to come.

Ian Gough is a Visiting Professor at the Centre for Analysis of Social Exclusion (CASE), LSE, and an Associate of the Grantham Research Institute. The views in this commentary are those of the author and do not necessarily represent those of the Grantham Research Institute.

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