Sustainable services: Future trends

• There is increasing pressure for health services to be delivered in ways that are environmentally sustainable
  This will require action in terms of both mitigation (carbon reduction) and adaptation to climate change. Concerns around sustainability will play a growing role in shaping the future of health services.
• Carbon reduction targets will challenge all sectors of the economy, including health care
  The UK as a whole has committed to dramatic reductions in greenhouse gas emissions – by 34% by 2020, and by 80% by 2050.
• The scale of the challenge suggests that a fundamental transformation in service models will be needed
  Although some improvement can be made by increasing efficiency at the operational level (for example, through use of energy-efficient technologies) this alone is unlikely to be sufficient.
• There are close connections between environmental sustainability and other system goals
  For example, both the sustainability and productivity agendas imply the need for a renewed focus on cost-effectiveness, value and prevention of avoidable activity. Environmental sustainability represents an additional impetus for making changes already advocated for on financial and quality grounds.
• The current policy framework creates a number of barriers
  These barriers discourage organisations from developing more sustainable approaches at the local level. Policy-makers will need to make changes to create a more enabling environment, and explore how existing policies can be delivered in the most sustainable way.
• Over time it is likely that sustainability will be seen as an essential dimension of quality
  Sustainability is likely to become a core value akin to equity or accessibility, with mechanisms to monitor and hold the system to account for its environmental performance.

It is highly likely that pressure for health services to be delivered in a sustainable way will increase over time. However, the scale and pace at which this will happen is not clear. It will depend on a number of factors, including:

• the speed at which environmental changes take place
• social and political responses to the threat (and reality) of environmental changes
• the extent to which a business case for environmentally sustainable health services can be constructed, in terms of financial savings and/or health gains.

There is also uncertainty regarding the potential direct health impacts of moving towards a low-carbon society and of climate change itself (for more see our broader determinants of health section).

The NHS is the most significant public sector contributor to climate change, and is under increasing pressure to reduce its carbon footprint.

Carbon footprint of the NHS

The NHS in England is responsible for around 20 million tonnes of carbon dioxide emissions annually (1), and spends over £50 million a year on carbon permits.

The cost of these permits and other environmental policy measures is set to increase over time.

The NHS is currently seen as a world leader in developing a strategic approach towards sustainability, with the establishment of an NHS Sustainable Development Unit and publication of an NHS Carbon Reduction Strategy.

The carbon footprint of the NHS is shaped as much by models of care and clinical behaviours as it is by the buildings and technologies used (1). Substantial changes in service models would be needed to reduce health care-related carbon emissions in line with wider national targets.

59 per cent of NHS carbon emissions are linked to procured goods, 24 per cent to direct energy use in buildings and 17 per cent to patient and staff travel. Pharmaceutical production alone accounts for 22 per cent of NHS emissions (1). More efficient use of pharmaceuticals could deliver financial and environmental benefits, potentially including recycling of unused medicines where clinically safe.

Some forms of care have particularly high environmental costs, eg, one year of kidney dialysis is equivalent to seven return flights between London and New York (2). Highly carbon-intensive interventions and services will become decreasingly cost effective over time as environmental policy tools are strengthened and energy prices rise.

NHS carbon dioxide emissions

Source: Naylor C, Appleby J (2012). Report. Sustainable health and social care: Connecting environmental and financial performance

Changing weather patterns and increasing prices for energy, water and other resources are likely to have direct operational-level consequences for the delivery of services.

Weather patterns in the UK will show greater seasonal variation meaning:

• hotter, drier summers, with more heatwaves and droughts
• wetter winters, with more flooding and severe storms.

There are recent examples of extreme weather events disrupting service delivery in the United Kingdom (1) and these are predicted to become more frequent.

For example, 10 per cent of London's hospitals are at risk of river flooding (3).The Environment Agency’s online flood map shows which areas of the United Kingdom are at increased risk.

Adaptation measures will need to include:

• reducing the vulnerability of health care facilities to flooding
• modifying buildings to remain cool during summer
• reducing water use to improve resilience to drought (4).

Ongoing research (eg, the BIOPICCC project at Durham University) is modelling the resilience of health and social care services and the public infrastructure on which they depend, but as yet, there is limited evidence on specific risks.

The operational consequences of climate change will vary across different areas. Organisations will need to assess the potential local impacts, and take measures to ensure that facilities, supply chains, infrastructure and workforce are resilient to environmental change. Energy security issues may become increasingly important for health care providers, and for the United Kingdom as a whole.

In addition to direct operational-level impacts on health services, climate change will also play a role in shaping the pattern of health needs in the UK. These implications are dealt with separately, in our broader determinants of health section.

Next trend: Economic pressures

1. NHS Sustainable Development Unit (2012). Report. NHS England Carbon Footprint Update
2. Naylor C, Appleby J (2012). Report. Sustainable health and social care: Connecting environmental and financial performance
3. Achour N (2010). Journal article. 'Resilience strategies of healthcare facilities: present and future'. International Journal of Disaster Resilience in the Built Environment, vol 1, pt 3, pp 264–76.
4. London Climate Change Partnership (2011). Report. London's changing climate: In sickness and in health