Picture yourself 20 years older, living in a world that has failed to take sufficient action to avoid global warming. The Arctic is ice-free during the summer, and many parts of the world are under extreme pressure as a result of changed weather patterns. Water scarcity has fed war and unrest in Africa and the Middle East. Growing parts of Bangladesh have become uninhabitable as a result of rising sea levels. Food prices are higher globally. In Europe, debates about how to deal with increasing numbers of ‘climate refugees’ have become heated and divisive.
In this future world, the need to stop further climate change has become ever more urgent. Strictly enforced carbon rationing has been introduced in the UK and other countries, meaning that individuals and organisations of all kinds have to make hard choices about how to live within their permitted limits. The NHS is not exempt from this, and some forms of care – for example, new and highly intensive drug treatments with large carbon footprints – begin to look as unsustainable as flying to New York for a long weekend. What choices would the NHS have to make in this scenario, and how would it weigh human health against environmental harm?
The ethical question in this bleak picture is about the value placed on human lives. Today, that question is answered implicitly by the National Institute for Health and Care Excellence (NICE), the body responsible for assessing the cost-effectiveness of drugs and other treatments. In its assessments, NICE uses a threshold of £20,000 to £30,000 for each year lived in perfect health, and usually rejects treatments that cost more than this. Returning to our climate-troubled world of the future, we can imagine NICE rejecting treatments on carbon-usage as well as financial grounds. In ethical terms, the argument would be that by offering certain treatments, the NHS would be doing unacceptable harm to the health of future generations through further global warming.
The scenario described above is by no means far-fetched, but it is not unavoidable either. The NHS currently accounts for around 4 per cent of all UK greenhouse gas emissions – similar in scale to the airline industry. There are good reasons to believe that, given sufficient time, this carbon footprint could be reduced – even to zero – without undermining the principles and goals of the NHS. If this is going to be achieved, we can make five broad predictions about what will need to happen over the coming years.
First, environmental costs will increasingly be reflected in the financial price paid by the NHS for energy, drugs, food and other resources. As a result, low-carbon forms of care will become increasingly cost-effective relative to carbon-intensive alternatives, and in some cases this could be expected to tip the balance when comparing the merits of different treatment options. For example, social support and psychological interventions generally have a smaller carbon footprint than highly medicalised forms of care and could play a greater role in the treatment of some conditions.
Second, when and how we travel will become an increasing focus of concern. The US-based Institute for Healthcare Improvement has argued that to be fit for the 21st century, health systems should aim to ‘move knowledge, not people’. Though not developed with climate change in mind, this maxim serves well as a design principle for low-carbon health care. Patient and staff travel accounts for around 16 per cent of the NHS carbon footprint. Through increased use of digital technologies, including electronic medical records and innovations in the field of telehealth, health care can increasingly be delivered remotely. When people – whether staff or patients – do need to travel, walking or cycling will be the preferred options, which could serve two ends simultaneously – promoting health while also cutting carbon.
Third, the NHS will need to use its purchasing power much more assertively to drive change in supply chains. More than half of the NHS carbon footprint is attributable to procured goods and services, in particular pharmaceuticals, medical devices and food. Pharmaceutical products cost the NHS more than £15 billion a year and account for one-fifth of the total NHS carbon footprint. While attention is currently focused on the financial savings possible through smarter procurement, in the future we can expect to see this widen so that there is a greater focus on environmental as well as financial costs, with techniques such as life-cycle analysis being routinely used in procurement processes to capture the costs associated with all stages of a product's life, from production to disposal.
Fourth, there will be a continued focus on reducing waste and maximising value for patients, for example, by reducing provision of treatments that are of limited clinical value; preventing unnecessary admissions to hospital; improving communication and co-ordination between different parts of the system; and ensuring that drugs are prescribed appropriately and taken as intended. In short, anything that involves using resources and getting little to show for it means wasted money and unnecessary carbon emissions. To eliminate this waste, a carbon-neutral NHS would have to be smarter and more personalised, both through the use of new technologies and by getting much better at understanding what actually matters to individual patients.
Fifth, the drive to reduce the NHS carbon footprint will be another reason for shifting resources away from cure and towards prevention. Anything that succeeds in reducing demand for health care is also likely to reduce associated carbon emissions (provided that reductions in one part of the system are not undone by increases elsewhere). Some public health measures may also have direct environmental benefits. For example, eating less meat can improve your health while also reducing your carbon footprint – and can also help the NHS if the alternative is vascular surgery. Preventive interventions are not necessarily carbon-free (think of mass prescription of statins, for example) but in general we can predict that a carbon-neutral NHS would need to focus more on keeping people healthy.
If enough progress is made in these areas, the NHS could become carbon neutral without having to undertake more drastic forms of carbon rationing. Top priority should be given to steps that can improve health today as well as in the future. For example, reducing fossil-fuel usage can improve air quality now and also mitigate climate change over the decades to come. There are plenty of opportunities for carbon reduction to go hand-in-hand with efforts to improve the health of the population and increase the efficiency of health services. But seizing these opportunities will mean taking action sooner rather than later.
Progress has been made in recent years. As a result of the 2008 Climate Change Act the UK has a legally binding commitment to reduce greenhouse gas emissions from the whole economy by 80 per cent by 2050, supported by an interim target of 34 per cent reduction by 2020. The NHS in England has pledged to play its part by setting itself the same targets. The NHS published its first carbon reduction strategy in 2009, and in 2015 it surpassed an interim target of reducing emissions by 10 per cent despite significant increases in overall activity.
Meeting the commitments for 2020 and 2050 will be much more challenging, and going fully carbon neutral would be harder still. In a time of rising budget deficits and mounting pressures, climate change might seem to be a distant priority for the NHS. But it is one that will need to be tackled if access to comprehensive health care is to be sustainable in the future: the pain will be greater if we leave it till later.
‘The NHS if’ is a collection of essays published by The King’s Fund that explores hypothetical scenarios and their impact on the future of health and care.
We are asking a small number of experts – some of them members of staff at The King’s Fund and others external experts in their fields – to write short essays that consider ‘what if’ questions about health and care in England. We’ll be publishing these essays on this website throughout 2016.
Our aim is to encourage new thinking and debate about possible future scenarios that could fundamentally change health and care. The essays cover three themes: the NHS and society; medicine, data and technology; and how the NHS works.
In each essay, the author gives their informed but personal view of a possible future. We invite you to let us know what you think and join the debate by adding your comments below the essays or by tweeting using the hashtag #NHSif.
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