The NHS has embraced the immediate carbon challenge as a starting point for a more ambitious plan to respond to climate change, alter its ways of working and the relationship it has with the resources it consumes. This represents an opportunity for the NHS as local economies move towards greener, more sustainable models, anchored in regeneration and community capability. Across all sectors and regions, it is clear from our State of the provider sector survey that there is appetite to share work on:
- how to make these changes systematically and at scale
- how to bring ingenuity and inclusion to the climate challenge.
Everyone can start somewhere
Given the scale of climate change, and the breadth of interventions needed to tackle it, it can be challenging to know where to start. Some trusts are focusing on areas where change can have the greatest impact, offer clinical and financial benefits and long-term efficiency savings, or achieve 'quick wins', and say this has enabled them to start their journey.
Case Study
Gateshead Health NHS Foundation Trust
Alison Marshall, Chair, Gateshead Health NHS Foundation Trust
Anthony Robson, Managing Director of QE Facilities Ltd
Sarah Medhurst, Sustainability Manager of QE Facilities Ltd
Gateshead Health NHS Foundation Trust, based in the Northeast of England, provides a range of hospital and community health services from its facilities all within Gateshead. As one of the largest employers in Gateshead, the trust has acknowledged the central role it plays in both reducing carbon emissions and supporting its local communities to become more sustainable. It is keen to integrate sustainability into everything it does and is committed to meeting the 80% carbon reduction target by 2028.
Meeting its environmental targets
The trust has set up two biodiesel Combined Heat and Power (CHPs) systems, which power a significant portion of their site, producing around 2M kWh of zero carbon electricity and around 500,000KWh of zero carbon heat annually, with estimated savings of £200,000 per annum. It has also obtained £1.6m through the government's Public Sector Decarbonisation Scheme for solar panels, air source heat pumps, and for improving their building management system (BMS). The projected annual electricity generation from the solar panels is estimated to be over 640,000KWh and the heat moved over to decarbonised technology is estimated to be over 2.6m KWh. This investment will result in significant financial savings long term and carbon savings resulting in seven of the trust's buildings being net zero for energy use. These major investments are paving the way for the trust to meet its net zero ambition by 2030 for the NHS carbon footprint.
Alongside this, the trust's Zero Waste to Landfill work is enabling it to meet its national targets for waste management. For example, the trust has switched from using single use plastic drums and sharps bins to a reusable sharps bin system and board base containers for pharmaceutical waste and pathology waste. It is also exploring a regional reuse scheme and hub across their ICS, so that all the trusts within the ICS can share storage facilities and reuse equipment between them.
The trust is also exploring how it can reduce the length of its supply chains and consolidate deliveries, and recently secured its own manufacturing plant to make personal protective equipment (PPE). Its aim is to eventually produce PPE for the whole northern region, and to source the raw materials within the UK.
The importance of system-wide efforts to reduce carbon emissions
Wider support from the system will be needed to support the trust meet its ambitions to reduce the carbon emissions of its supply chains and the delivery of tests to its specialist pathology centre. It has considered switching to using electric vehicles to transport tests but would need charging points across their wider region to support longer distance travel. Developing this infrastructure will require system wide change, and there is work underway within its ICS to set up the same type and network of charging points at all hospitals within the region.
There is no project too small for sustainability
The trust emphasised the need to start somewhere and that there is no project that is too small for sustainability. The trust has managed to achieve a lot in a few years through its approach, which it sees as more than just achieving net zero.
Engaging with staff across the organisation is also central to driving behavioural change. It has set up a sustainability committee that comprises multiple subgroups that are driving improvement within their departments. For example, the pathology department has established its own sustainability committee, which feeds into the wider work of the organisation. The trust sees partnership working across the ICS region as important for wider system change, but also emphasises the need to start somewhere and embed sustainability into every interaction so that it becomes 'business as usual'.
Changing means embracing digital
The NHS is keen to ensure that the digital transformation agenda is compatible with the trajectory towards a net-zero health service. It sees digitally enabled care models that will significantly reduce the need for travel to healthcare locations as a key element of reducing its environmental impact. Around 3.5% of all road travel in England relates to patients, visitors, staff and suppliers to the NHS, so digitally enabled care can make a difference. Several trusts are embracing this as part of their sustainability journey.
Case Study
Milton Keynes University Hospital NHS Foundation Trust
Joe Harrison, Chief Executive
John Blakesley, Deputy Chief Executive
Anthony Marsh, Estate Service Manager
Milton Keynes University Hospital NHS Foundation Trust is a medium sized district hospital that provides a range of acute hospital services and an increasing number of specialist services to the growing population of Milton Keynes and the surrounding areas. It believes sustainability is central to the future development of the NHS and has been on a journey to reduce its carbon emissions, with the aim of becoming net carbon zero by 2030.
Renewable energy to support digital transformation
Trust leaders at Milton Keynes University Hospital see digital transformation "going hand in hand with the green agenda" and the health and wellbeing of their patients. In line with the 2021/22 NHS operational planning guidance, the trust is on track to deliver 25% of its outpatient activity virtually by March 2022, which will provide greater flexibility for where and how patients have their consultations and help to reduce emissions from unnecessary travel. Digital transformation will also enable it to work more closely with primary care and share patient records across the patch.
Further examples of this digital drive include the introduction of eCARE, the trust's electronic patient record solution and MyCARE, a platform which allows patients to receive outpatient letters and view discharge summaries via an online portal. These projects have helped to reduce the trust's reliance on paper and lowered its onsite data storage requirements, which supports its broader green agenda.
The trust has also been busy reducing its carbon emissions by investing in renewable energy and improving its energy efficiency where possible. This has included smaller scale changes, such as installing LED lights throughout its buildings, to 'bigger ticket' projects, such as investing in the installation of over 2,500 solar panels across the hospital to increase the energy generated on-site. The power generated in a year from its panels is equivalent to the total power used in a year by 200 average homes. This has enabled the trust to save £28,000 in energy bills in less than three months, which it can invest back into sustainability projects. It is also working to decarbonise its buildings by improving insulation, which includes re-roofing its oldest estates, and trialling new highly insulated rendered cladding on its cardiology department building.
Commitment from the organisation is important
There is a lot of other work underway within the trust to reduce its carbon footprint and become more sustainable, such as exploring biodiversity on their site, switching to electric vehicles, and improving waste management. What has really helped the trust gain traction is having a board that is committed to the 'end goal' rather than being too focused on the bottom line and tapping into the enthusiasm that exists within the organisation to drive behavioural change.
The trust recognises that delivering this work is in partnership with stakeholders and organisations outside of the NHS. For example, it intends to align its green plans with its local council's ambitious vision to become net carbon zero by 2030. They are working with the council to explore how best to decarbonise the estate with the potential of a district heating network, which the trust will have a core role in making this investment viable.
Having the numbers to support the changes made, such as how much money it has saved from its solar panels and demonstrating how these changes link back to the health and wellbeing of patients, staff and the wider community, is also hugely beneficial to generating and maintaining interest from staff across the trust.
Data is a key accelerant
Trusts and system leaders need robust data, with clear progress measures in order to understand how effective their interventions on reducing carbon emissions are. Granular information about emissions, such as the impact of switching to renewable energy sources and financial savings generated will enable trusts to measure progress and build board-level confidence in its decarbonisation work. The greener NHS national programme has said that more work is needed to improve the monitoring and data collection capacity of the system.
Case Study
Kent Community NHS Foundation Trust
Natalie Davies, Director of Corporate Services
Dan Wright, Head of Sustainability
Kent Community NHS Foundation Trust provides wide-ranging NHS care in a range of settings including people's own homes; nursing homes; health clinics; community hospitals; minor injury units and in mobile units. It serves a population of about 1.4 million across Kent and 600,000 in East Sussex and London, making it one of the largest community health trusts in England. They are also one of the largest employers in Kent, employing over 5,000 staff across a range of professions. Within this context, the trust has a central role to play in tackling climate change and has recently started work to reduce its carbon footprint.
Sustainability within its communities
For the trust, sustainability isn't just about carbon emissions alone and reducing the bad”, but also about enhancing sustainability within communities and enabling people to make the right choices in their own lives. For example, it is one of a handful of trusts that is subsiding the installation of electric vehicle charging points at its staffs' homes. The trust is also undertaking biodiversity surveys at its sites to inform how they are managed, protecting what is already there and to encourage new flora and fauna into the environment where viable. Additionally, the trust's green spaces are multi-functional, supporting therapeutic outcomes for patients, and providing for its hospital kitchens. This work promises to be hugely beneficial for patients, staff and the communities around its hospitals.
Alongside this work, the trust is transitioning more key sites to be fully owned and managed by the trust, rather than rented. It believes local ownership has a huge positive impact on both sustainability and for addressing the wider determinants of health, as it will enable services to be built around the communities it serves.
The vital importance of data monitoring
The trust sees data as a key driver for making a real change in sustainability, as this will enable it to measure its impact and more effectively identify where it needs to target its resources. For example, it was aware that grey fleets (i.e. employees' vehicles) were one of its biggest sources of carbon emissions, but existing data methodologies lacked the sensitivity to accurately monitor change. The trust has since developed a Python-based tool which merges reported staff mileage with information held by the Department for Transport about the model of vehicle to calculate a more robust emissions footprint. Additionally, the trust is reducing non-essential travel by delivering more training virtually and using a 'digital by default' mindset for initial patient consultations, reducing both staff and patient mileage.
Its work to developing the application of data extends to the trust's estate, here retrofitted high resolution electricity monitoring is being used to optimise management of emissions and engage occupants with how buildings work and how its actions can reduce associated consumption.
Tackling climate change is part of the anchor journey
Trusts' role as anchor institutions means they can contribute to sustainability efforts locally beyond the provision of health and care services. By working with others locally trusts can have a greater impact on wider determinants of health, such as improving access to services by bringing it closer to communities. Trusts across the country are considering their wider role in the community to provide social and environmental benefit.
Case Study
Northamptonshire Healthcare NHS Foundation Trust
Richard Wheeler, Chief Finance Officer
Northamptonshire Healthcare NHS Foundation Trust delivers over one hundred different services to the Northamptonshire community. These include a range of mental health services, community services, sexual health, prison healthcare services and a number of others including specialty services. Services are delivered in a variety of settings, from the more traditional clinical settings to those delivered in the community, in homes, workplaces and in schools.
The trust recognises that health and the environment go hand in hand and is keen to deliver high quality care and improved public health services without exhausting natural resources or causing severe ecological damage.
Connecting sustainability to new ways of working
The trust is considering new ways of working to support its sustainability ambition as services transition through a recovery period following the pandemic. The trust is looking to improve its services and processes from both a public health and a sustainability perspective; empowering staff to work smarter by optimising the technology available to them; promoting diversity and inclusion by providing staff with more options to work flexibly and remotely; and shifting the organisational culture to one that is more outcomes-based, enabling staff to work in more innovative ways.
For non-clinical staff, this means more people are working from home than they were before the pandemic. For clinical staff this shift is enabling them to deliver more services virtually and to design innovative ways to deliver services more effectively and efficiently. For example, the sexual health clinics have set up collection points that give patients the opportunity to access medications or information they need when and where it suits them.
It is also enabling staff to deliver more out-of-hospital care. For example, during the pandemic, mental health services were able to reach young people in outdoor locations where they felt safe, such as in their local parks. The trust sees this as complementary to its work to reduce carbon emissions and its impact on the environment.
The role of its sustainability committee
The trust has set up a sustainability committee which plays a vital role in driving this work across the organisation. Alongside supporting the work to embed new ways of working into the organisation, the committee has set clear environmental targets that it can monitor and report on through its annual Carbon Footprint report. It highlights its internal and external communications as an important driver as this enables engagement from across the organisation with this issue.
Harnessing clinical leadership
Medicines account for 25% of emissions within the NHS. The majority of this is found in the manufacturing and freight involved in supply chains, but 2% of the NHS' emissions can be attributed to the use of anaesthetic gases and 3% to inhalers. The NHS has identified these two contributors as areas for early intervention. The 2021/22 NHS standard contract expects every trust to reduce its use of desflurane, a commonly used anaesthetic gas, to less than 10% of its total volatile anaesthetic gas use. Every ICS will also have to develop plans for clinically appropriate prescribing of lower carbon inhalers. As clinically effective and financially viable lower carbon alternatives exist, trusts have already begun making this switch.
Case Study
University College London Hospitals NHS Foundation Trust
Luke Oshea, Director of Innovation
University College London Hospitals NHS Foundation Trust (UCLH) has committed to reduce its impact on the environment, with a 10-point plan to reach net zero carbon dioxide emissions by 2031. UCLH also recently declared a climate emergency, signalling its commitment to the wider public but also to its staff that it is prioritising the need to address this issue. Last year it agreed an executive-level lead for sustainability to drive this work.
A focus on altering clinical practice
There is a lot of work that needs to be done to deliver a net zero health service, and UCLH recognises that some of its longer-term ambitions, such as fully decarbonising its estates, will require significant capital investment and planning. Another challenge for the trust around decarbonising its estate is that key hospital sites are PFI schemes, meaning changes require complex finance considerations and agreement from multiple parties. UCLH has therefore
decided to start its journey to net zero by focusing on three targeted areas where it can make an impact early, such as altering clinical practice. Its initial focus included:
- reducing the use of the most environmentally harmful anaesthetic gas, which make up five percent of the trus's carbon footprint
- investing £2.7m to install low-energy LED lights across its hospital sites
- reducing patient travel by 50% by expanding the use of virtual clinics, as part of ongoing improvements to outpatient services – the pandemic demonstrated it was possible to successfully deliver virtual appointments, to maximise the clinical, environmental and financial benefits of UCLH's outpatient service
Within three months, UCLH has almost phased out the use of the anaesthetic desflurane and expects low-carbon, intravenous anaesthesia to become standard procedure for most operations in the near future. This 'quick win' is enabling the trust to gain momentum and build confidence at board level to continue its work to reduce its impact on the environment. It has also delivered its ambition on LED lights and expects this to provide a return on investment within three years.
This commitment is also enabling staff to engage with the issue and is empowering them to make changes within their departments. For example, its pharmacies have changed the way they package medications for patients on hospital wards, as they were concerned about the level of unnecessary plastic waste. While changes like this may be smaller in scale, they signal the direction of travel and are visible signs to staff that things are changing for the better.
What is needed to go further and faster?
Focusing on areas where UCLH can quantify the environmental, clinical and financial benefits of its decisions has helped it demonstrate progress to its board and drive further action. Realtime data at a granular level will be needed to enable the trust to identify where it can have the biggest impact to reducing its emissions. UCLH is also keen to see improvements to the wider carbon accounting infrastructure, as well as more tools to standardise best practice across the NHS. While the trust is keen to work with 'greener' suppliers as much as possible, it says that the NHS needs to utilise its purchasing power at a national level to encourage the behavioural change needed across NHS supply chains.
Adapting to climate change and building resilience
The NHS recognises that it needs to support efforts to reduce the severity of climate change, which is reflected its net zero targets. However, it will also need to consider how the impact of climate change on local environments and communities will affect the way they run services, including the impact of the increasing frequency of extreme weather events such as floods, storms and extreme temperatures.
Case Study
Yorkshire Ambulance Service NHS Trust
Alexis Percival, Environmental and Sustainability Manager
Yorkshire Ambulance Service NHS Trust has been leading the way for a number of years now on initiatives to protect the environment. It was the first ambulance service in the world to introduce hydrogen hybrid emergency patient transport vehicles in 2018. This enabled around 35 - 45% of the vehicles' energy to be powered by hydrogen rather than solely diesel. It was also the first ambulance service in the UK to employ an environmental manager 12 years ago, which has enabled the trust to prioritise this issue.
The service covers 6,000 square miles of varied terrain, from isolated moors and dales to urban areas, coastline and inner cities. It serves a population of over five million people across Yorkshire and Humber, and its callouts have increased over the years, strengthening the importance of reducing its carbon footprint and adapt to the impacts of climate change.
The context for ambulance services
Ambulance services across the UK are exploring options to transition over to net zero vehicles that make the best use of green technology. The recent launch of a zero-emission hydrogen and electric ambulance, developed in partnership with ambulance services, the NHS, industry and Innovate UK, will enable zero emission vehicles to travel further before needing to recharge or refuel. However, comprehensive electric charging and hydrogen infrastructure across the NHS is needed to support ambulance services make the shift to zero emission fleets.
Adaptation and climate resilience
Yorkshire Ambulance Service NHS Trust has a number of projects underway to reduce its carbon footprint, such as installing solar panels on its ambulances, improving its waste management, and trialling new technology for a zero-emission rapid response operational ambulance. It is also thinking about building climate resilience and considering how it can adapt to manage the expected rise in sea level and tidal flooding over the next few decades.
With climate resilience in mind, the trust is planning to develop a new ambulance hub that will have solar panels, battery storage, and be made from greener building materials and insulation. The first hub is going to be situated in Hull, which will provide it with an opportunity to test its climate resilience given that the city is already 80cm below sea level and is at high risk of flooding. The trust is also considering opportunities to train frontline staff to deal with the climate changes impacting region from flooding to heatwaves, fires to droughts and how they directly affect the patients that they attend to.
Engagement within organisation is important
Employing someone to lead on this work within the organisation has been important, but engagement across the organisation is key to driving this work forward. For example, replacing Entonox gas with greener alternatives requires engagement from paramedics and clinicians, as well as commitment from the trust's leaders to explore alternatives. Starting with smaller changes and building up has helped to bring people on the journey, alongside communicating progress and improvements internally and externally.
The wider political environment around climate change and sustainability has also helped drive behavioural change and push sustainability and climate change up the agenda. COVID-19 has also shed light on the level of waste produced, for example the consumption of 2.3 billion face masks across the NHS in England. A reusable facemask pilot trial was launched to trial the viability of use of reusables within the ambulance service as well as across the rest of the NHS. This is providing the trust with a visible symbol of its impact and the work that still needs to be done.