Sustainability is critical for future proofing the NHS

Infrastructure

As one of the world's largest healthcare systems, the NHS faces the critical challenge of aligning its facilities, infrastructure, energy use, and transport approach with sustainability goals across scope 1-3 emissions (fig 1). Presently, NHS infrastructure consists of ageing and modern facilities, with varying degrees of energy efficiency and environmental impact. On average, 76% of the organisation’s energy use is from fossil fuels.50 In facilities with poor sustainability ratings, fossil fuels are the predominant source of energy.

Evidence from various health systems globally indicates that sustainable healthcare facilities can substantially reduce carbon emissions without compromising patient care.5152 Practices such as the use of renewable energy sources, green building design, retrofitting of existing facilities to improve energy efficiency, and waste reduction strategies have proven effective and provide good return on investment owing to energy cost savings. Within the NHS, more could be done to support evidence driven approaches to tackling emissions hot spots. For example, operating rooms are three to six times more energy intensive than other clinical areas of the hospital, primarily because of heating, ventilation and cooling requirements, and the need for tightly controlled heating and humidity conditions.5354 Shutdown checklists and switching off ventilation systems overnight have been shown to be effective strategies for reducing energy use.19 A lead for sustainability, with appropriate training on the impact their decisions have on the wider population's health, should be in place for any areas of procurement or facilities.

The transport system, pivotal for primary and secondary care, is heavily reliant on fossil fuels, contributing substantially to the NHS’s carbon footprint. Transitioning to electric and hybrid vehicles, along with encouraging telemedicine where feasible, has shown a notable decrease in transport related emissions.55 Because almost every person will visit healthcare facilities at some point, the NHS must be an advocate for the wider infrastructure changes and government investment needed to facilitate active travel, as a health co-benefit.

Technology

Reducing supply chain emissions for medical equipment and drugs has the potential to deliver substantial gains in NHS emission reductions. Within the healthcare sector, scope 3 emissions comprise the greatest proportion of emissions; 62% of all emissions in the NHS are attributable to the supply chain.24 The NHS can use its influence as one of the biggest single investors in healthcare goods and services globally to drive the prioritisation of reduced carbon emissions, along with financial cost and quality-safety profile factors, in procurement decisions; Greener NHS has made progress on this by setting targets for suppliers.56 Such an approach could help to bring about a broader health sector wide move towards improved sustainability and reduced carbon emissions. To do this effectively, the NHS should strive for a more cohesive national procurement approach—one means of achieving this would be through setting and enforcing environmental standards for national healthcare procurement. There is also a role for reduced national procurement of the most environmentally harmful drugs and preparations, and their eventual removal from national formularies. This change would require legislation and input from government, NHS leaders, senior clinicians, pharmacists, and organisations parallel to the NHS, such as NICE (National Institute for Health and Care Excellence), MHRA (Medicines and Healthcare products Regulatory Agency), and others. Anaesthetic gases, including nitrous oxide often used for labour analgesia (as Entonox), and metered dose inhalers are particularly polluting—volatile gases constitute 5% of all emissions from acute NHS hospitals34—and contribute directly to global warming.3031 The NHS has recently decommissioned the use of desflurane from 2023-24 because of sizeable emissions where reasonable, less polluting alternatives exist.35

Digital technology is being increasingly used in healthcare delivery to ensure personalisation of care. A move towards a patient centred approach to care can support better patient experiences by giving increased autonomy to patients, along with benefits in terms of sustainability. Tools such as eHealth or mHealth apps have the potential to reduce inappropriate or unnecessary investigations and treatments, reduce the impact of patient transport or travel to the clinic setting, improve health (particularly in patients with complex chronic disease), and decentralise care out of hospitals and into communities and homes.37 Importantly, patient care should not be compromised.

Waste

Waste in the NHS includes “wasteful practices”—the unnecessary use of services and products—and excessive or inappropriate material waste generation. Wasteful practices, which are often overlooked, account for a substantial proportion of inefficiency and waste of resources, personnel, and capacity in the health system. The best way to reduce waste is to minimise unnecessary use, first and foremost by maintaining a healthy population, proactive primary and secondary prevention, accuracy in diagnostics and treatment, and choosing products wisely. An estimated 10% of items dispensed in primary care are overprescribed and 15% of people take five or more drugs a day.57 Around one in five hospital admissions in people aged 65 and older is caused by the adverse effects of drugs. Up to half of all drugs are wasted, costing the NHS up to £300m a year.1858

The NHS produces substantial quantities of material waste. The 156 000 tonnes of waste that are collected as “clinical waste” each year are incinerated at high temperatures—an expensive operation—and disposed of by landfill or an alternative method. Drug waste contributes to landfill, greenhouse gas emissions, and environmental harm as a result of wasted pharmaceuticals entering waterways.1858 A whole system approach is needed, with investment in research to measure the ecological footprint of drugs that enables prescribers and patients to make environmentally informed choices.59 All NHS organisations should have a testing regime in place for surveillance and addressing these issues as a responsibility of the Health and Safety Executive.

Single use plastics and equipment in operating theatres and clinical areas still outnumber use of sterilisable tools and reusable surgical kits. The NHS often does not have accessible recycling bins in office, catering, and ward spaces. Reasons cited for the use of single use surgical gowns and drapes include convenience and misconceptions about clinical safety and infection control. However, reusable gowns have been shown to provide greater protection and durability, a 60–95% reduction in energy use and cost savings, and there is no evidence that reusable personal protective equipment results in higher healthcare associated infection rates.6061

Cradle-to-grave life cycle assessments of products or components of care are increasingly common626364 and must factor in the entire lifetime impact of the product or care assessed. For example, while minimally invasive surgeries produce greater emissions compared with open surgical techniques,65 the often associated shorter length of stay and fewer postoperative complications might balance towards a net environmental benefit.65 Key principles of the circular economy can be applied to keep healthcare products in circulation as long as possible: refusing to use an item, reducing the frequency of use, reusing items when possible (with sterilisation or washing), renewing (through repair or remanufacture), and recycling.19

Food

The food and agriculture sector is responsible for 30% of the world’s greenhouse gas emissions, and the main cause of terrestrial biodiversity loss.66 Five standards have been set by the Department for Health and Social Care for hospital food, one of which is sustainability.676869 A sustainable approach to food and nutrition in the NHS requires thorough consideration of the processes around food provision for inpatients and staff in NHS facilities. Currently one in six meals are left uneaten,70 and nutritional education and advice for the public is needed to drive behaviour change.71

At trust level, simple approaches that benefit both health and environment include NHS sourcing of local, sustainably grown, plant based options; minimising food packaging; and reducing food waste. Hospital trusts that bring catering in-house are more likely to find food of better quality, produced locally, offering better value for money.72 Outsourcing of catering in the NHS, while often chosen as a cost saving tactic, has been linked to poorer health outcomes.72 Health benefits accompany a more sustainable approach to food.

Engaging local staff to highlight specific areas of their practice where improvements could be made would enhance impact and buy-in.73 Successful actions taken by hospitals have included “meatless Mondays”, on-site vegetable and herb gardens, sharing unserved food with community kitchens, and sending food waste to local farms and on-site anaerobic digestion units.

Much more needs to be done across the NHS and wider society to promote the benefits of eating more plant based foods. A public engagement campaign supported by the government with healthcare at the forefront to promote the health and environmental benefits of sustainable diets would help to drive the societal shifts required.

Workforce

The NHS workforce constitutes 1.3 million people, presenting an opportunity to upskill a large number in sustainable practice and climate preparedness. However, many healthcare workers experience barriers that limit their ability to act, including lack of education and training, policies and workplace guidance, and support from their peers.74

Sustainability must be recognised as a core focus of practice that acknowledges the ethical and moral duty of doctors to play their part. Education for Sustainable Healthcare is a mandatory requirement of the medical regulator outcomes for graduates,75 and the Health and Care Professions Council has produced guidance on education for sustainable healthcare for preregistration allied health professionals.76 Medical schools, royal colleges, and other professional training organisations have started to integrate sustainability into their curriculums,77 enabling students and trainees to influence and advocate for green issues within the teams they work in. The 2024 General Medical Council good medical practice guidelines reference the importance of sustainability.78 However, more needs to be done; for example, training on sustainability within healthcare must be made mandatory across the UK, supported by investment and buy-in by national bodies and provider organisations.

Action is required across the workforce. Executive and board level leadership teams could be supported by developing networks of learning and communities of practice that enable staff and wider stakeholders to learn from each other and provide opportunities to improve environmental sustainability and clinical care.79 Healthcare workers, who are recognised to have a trusted voice and impactful messaging when talking about the climate crisis, are increasingly motivated to speak out as part of their professional responsibility to try and prevent a worsening of the climate crisis, and they should be supported in this.748081 Rotational training—wasteful in terms of travel and resources, disruptive to trainees’ lives and of arguable educational benefit—might be an area for reconsideration.82

Nature and the environmental determinants of health

A stable natural environment is critical for limiting the impacts of the climate crisis and achieving the UN’s sustainable development goals. Where the loss of biodiversity on land and water is a major threat to human, animal, and environmental health, repairing this loss is vital for health. A large and growing body of research has shown the positive impacts of more proximal green space for physical and mental health.83 Access to green space results in substantial reductions in all cause mortality,84 obesity,85 cardiovascular disease,86 type 2 diabetes,87 improved pregnancy outcomes,88 and improved immune system functioning.89

In the NHS, nature based interventions have been recognised as valuable strategies for prevention of ill health, supporting patients recovering from illness, and promoting good health and wellbeing.90 Participation in nature based activities is associated with a substantial positive effect on psychological, social, physical, and intellectual outcomes.91 Recent analysis found that nature prescribing programmes could save the NHS £100m per 1.2 million people involved.92 Additionally, access to green space is “equigenic”, meaning it is able to reduce health inequalities93; robust evidence shows that disadvantaged groups gain the most health benefit from improved access to nature,94 and trees and vegetation effectively reduce the urban heat island effect, which predominantly affects socioeconomically deprived communities with higher proportions of marginalised people.95 More broadly, good access to nature for all in England would reduce NHS pressures equivalent to saving £2.1bn in health spending every year.94

As one of the largest landowners in England, the NHS forms an anchor institution in communities across the country, through physical spaces for socialising, learning, recreation and exercise, and where people receive treatment for ill health. Interventions such as the NHS Forest Initiative—planting trees and meadows—offer several benefits to people and biodiversity, with one participant at Mount Vernon Cancer Centre stating, “when I felt like I was being poisoned on the inside with the chemotherapy drugs, it was very helpful to witness living things growing and carrying on in nature. It gave me hope.”83

To mitigate harm and maximise the health co-benefits of action, it is important that policies tackle climate change, biodiversity loss, and other environmental impacts together. Being in balance with the natural environment should be a priority; this means questioning the impact of our current health practices on planetary boundaries,16 and doing what is required to restore the major earth systems to within their identified safe limits. Prioritised government investment and action towards improving access to nature in the most nature deprived communities, in line with the health co-benefits of environmental action, would deliver the most health benefits and cost savings. Achieving health co-benefits can be achieved by integrating health in all policies across all sectors, informed by the social and environmental determinants of health, as well as integrating social prescribing practices, such as green prescribing for mental health.9096