The road to net zero
Business professionals brainstorm a net zero plan in an office

Four years since the NHS pledged to become the world's first net zero health service by 2045, HB looks at what has been achieved

In October 2020, the NHS published the report ‘Delivering a ‘Net Zero’ National Service,’ in which they set two monumental, unprecedented targets: by 2040, to reach net zero on their direct emissions, and by 2045 for those that they influence, making them the world’s first health organisation to strive towards net zero. This came in response to the publication of the NHS Long Term plan in 2019, and the #GreenerNHS campaign in 2021 led by the NHS’s chief sustainability officer Dr Nick Watts, as well as legislation such as the 2015 Paris Agreement, which put pressure on organisations and governments to take action against the climate emergency.

Impact on health

Climate change and health are inextricably linked. The World Health Organisation warns that climate change is the leading threat to global health, and without action, it is estimated that PM2.5 and NO2 pollution alone could result in £5.3 billion worth of treatment costs for strokes, child asthma, coronary heart disease, and lung cancer. As climate change worsens, so do threats of storms, floods, heatwaves, and outbreaks of infectious disease, straining healthcare systems, whose emissions only exacerbate the effects of climate change.

With the NHS responsible for four per cent of emissions, serious action is necessary to incite more sustainable NHS practices that produce fewer emissions, produce less waste, and focus on prevention rather than cure: one seasonal vaccination has an estimated carbon footprint over 14 times smaller than the treatment of one influenza case.

Areas for change

In their 2020 report, the NHS listed eight areas for change, and in 2022, the UK embedded net zero healthcare into their legislation, through the Health and Care Act 2022 which required NHS commissioners to specifically address net zero emission targets, as in line with the Climate Change Act 2008 and the Environment Act 2021.

Progress & achievements

Now four years after the initial publication of the 2020 report, the NHS has made significant progress in each area to target emissions, though pressures still remain for the NHS to do more if it wants to reach net zero by 2045.

Primary care, trust estates, and private finance initiatives comprise 15 per cent of NHS carbon emissions, producing an emission total of 167 ktCO2e in 2019. This has shifted NHS focus to prevention rather than care and treating as many people out of hospital as possible by focussing on ensuring that people interact with services that are the closest to them – including in their own home. This approach is estimated to avoid 8.5 million km of unnecessary travel per year to and from hospitals, with a carbon saving of 1.7ktCO2e per year. Examples of these strategies in practice include delivering consultations and treatment services from community hubs, leading Manchester University NHS Foundation Trust to halve their CO2 emissions from patient travel.

A virtual ward in Leicester saved an estimated 1,100 bed days, £530,000 and 138 tonnes CO2e. Additionally, strategies like Getting It Right First Time (GIRFT) have saved approximately 49,026 less appropriate procedures, 385,493 from reduced length of stay, and 4,967 emergency readmissions, equating to an annual carbon reduction of approximately 26.5 ktCO2e.

In 2020, 62 per cent of NHS carbon emissions were created by medicines, medical equipment, and supply chains, leaving significant room for improvement. In September 2021, a roadmap was approved by the NHS England public board to help suppliers align with the NHS’ net zero ambitions between now and 2030. Ways to make the supply chain more efficient include the more efficient use of supplies, low-carbon substitutions, and ensuring carbon suppliers are decarbonising their own processes. These have been put in practice through campaigns like the Plastic Reduction Pledge and ‘The gloves are off’, as well as focussing efforts on the small amount of medicines that account for a large portion of emissions. Anaesthetic gases and inhalers are the biggest culprits of these, namely desflurane: emissions from one bottle are equivalent to burning 440kg of coal, and account for two per cent of all NHS emissions. Initiatives to make changes include University Hospitals Bristol NHS Foundation Trust saving 360 tonnes CO2e per year using alternatives, with use falling from more than 30 per cent of all anaesthetic gases in 2018-19, to approximately 3 per cent in 2022-23. This has saved an estimated 60,816 tonnes of carbon emissions per year, the equivalent of taking 29,000 cars off the road.

With 3.5 per cent of all road miles in England relating to NHS patients, visitors, staff, and suppliers, and government legislation for all vehicles to be electric by 2035, the NHS is under pressure to decarbonise their fleets. The NHS has pledged that all vehicles purchased or leased are to be low or ultra-low (ULEV), as part of the NHS Long Term Plan commitment that 90 per cent of the NHS fleet use low emission vehicles by 2028.

Transport

Northumbria Healthcare Foundation NHS Trust, for example, have been investing in electric vehicles since 2012, with 79 chargers installed across nine sites by 2020. Other initiatives include the rollout of fully-electric ambulances starting in London this year, Manchester’s electric HGV fleet, electric drones to deliver chemotherapy to the Isle of Wight, and the push to use bikes where possible.

It has been estimated that a mass shift away from cars represents potential savings of approximately 461 kt CO2e per year, thus requiring NHS trusts to have a green travel plan as part of their annual planning and reporting. Manchester University NHS Foundation Trusts’ sustainable travel plan, for example, provides personal travel advice for staff, over 200 additional cycle parking spaces, and shuttle services to encourage the movement towards net zero.

Innovation

Innovation is also a key strategy in NHS’s roadmap to net zero through ensuring that digitisation methods align with ambitions to reach net zero by 2040. In 2013, the then-health secretary Jeremy Hunt challenged the NHS to go paperless by 2018, though the deadline was pushed back several times to March 2025. As of late 2023, 90 per cent of NHS trusts have electronic patient records. Within digitisation, it is still paramount that sustainable practices are in place, as demonstrated by action at Imperial College Healthcare NHS Trust through implementing new software that automatically turns off idle computers overnight. This saves 590 tonnes of carbon and £440,000 without compromising security or user experience.

In their initial report, the NHS pledged to support the construction of 40 new ‘net zero hospitals’ as part of the government’s Infrastructure Plan with a new Net Zero Carbon Hospital Standard.

In 2023, the NHS published the report ‘NHS Net Zero Building Standard’ where clear standards and criteria are outlined in both the construction and operation of NHS buildings.

Operations

Within hospitals, it is also key that practices strive towards decarbonisation as much as possible, such as in surgeries, which account for as much as 25 per cent of hospitals’ carbon emissions.

In May 2022, a team at Solihull Hospital performed the world’s first net zero operation by using reusable PPE, avoiding anaesthetic gases, and implementing a plan for minimising electricity use, among other initiatives. This has been estimated to have reduced carbon output by almost 80 per cent, the equivalent to a diesel car travelling 5,500 miles, with remaining carbon output offset through a variety of projects, such as planting trees.

Sustainable heating and lighting practices are also key to reaching net zero by 2045. In 2021, NHS Property Services managed to secure 100 per cent renewable electricity across the building portfolio, offsetting more than 37,000 tonnes of carbon dioxide a year, and saving around £8.9 million over the first two years. The 2020 report detailed a £50 million NHS Energy Efficient Fund (NEED) that will upgrade lighting across the estate, acting as a pilot for future work and saving £14.3 million and 34 ktCO2e. This exists alongside other grant schemes such as the government’s Public Sector Decarbonisation Scheme, the third phase of which granted Nottingham University Hospitals NHS Trust more than £70 million to decarbonise Queens Medical Centre. Strategies like AI to monitor and control energy, and installation of photovoltaics are both estimated to produce reductions of 2.3 per cent and 1.6 per cent of carbon emissions, respectively. Many hospitals have already started the switch to solar power, such as in Milton Keynes and Hull, and in 2023, one of the country’s first net-zero care centres opened in Devizes, which uses heat pumps and solar panels to generate heat and electricity.

The report’s focus on adaption includes building resilience into the heart of policy, as the NHS needs to adapt to the impacts of climate change that are already happening. The UK Health Security Agency (UKHSA) and NHS England were commissioned by Defra to provide the government with a Third Health and Climate Adaption Report, published in December 2021, which highlights the challenges of building a climate resilient health and care sector, and offers further guidance in effective governance, leadership, and workforce development to adapt to the worsening effects of climate change. A further fourth report was commissioned early this year.

The Third Health and Climate Adaption report details that 82 per cent of participating NHS staff support the development of targeted mitigation and adaption strategies. The 2020 report’s final initiative on values and governance includes thorough training for all NHS England and NHS improvement staff to understand the links between health and climate change, and interventions they can take to reduce emissions, especially relevant as a 2022 Health Foundation poll found that awareness of the net zero ambition among NHS staff was still relatively low at 48 per cent.

Local to national

Furthermore, local initiatives in practice can be scaled up to a national level. Operation TLC (turning off equipment, switching off lights; closing doors) at Barts Health NHS Trust improved patient experience, while also saving carbon and £500,000 from reduced energy consumption. Expanding this model across the NHS could save up to £45 million and 200 ktCO2e per year.

Four years on, progress towards the ambitious target of a net zero NHS by 2045 has been made, but serious efforts are needed to reach a goal with an estimated success rate of 50 per cent. 

The British Medical Association (BMA) emphasises that the government will need to provide additional resources and support if this target is to be met, after their 2021 survey found that 16 per cent of NHS organisations didn’t record their carbon footprint. The Labour government has pledged to reform and decarbonise the NHS through three major shifts (sickness to prevention; hospitals to communities; analogue to digital), and a 2024 publication by The Health Foundation stresses that this goal is unlikely to be achieved without focused government action. In October 20204, the government called upon the general public to help guide the future of the NHS through their Change NHS campaign, which will form the basis of their new 10-Year Health Plan. If it proves to take control of the initiative by offering adequate support, resources, and guidance, there is much hope that the NHS will reach net zero by 2045.