Intended for healthcare professionals


We can progress sustainable healthcare by breaking silos and changing behaviours

BMJ 2024; 385 doi: (Published 08 April 2024) Cite this as: BMJ 2024;385:q813
  1. Samantha Holmes, sustainability clinical fellow
  1. The BMJ
  1. @SHolmes_SLT

Sustainable healthcare is more important than ever given the escalating climate crisis. We must break out of silos and encourage behavioural change, or risk continuing to preach to the converted, says Samantha Holmes

I have recently been immersed in the world of sustainable healthcare, after moving from a clinical role to a sustainability fellowship. What has struck me the most is that the world of sustainable healthcare exists in a silo—an echo chamber of people who care about sustainability telling each other about sustainability. There is inspiring work being done in healthcare globally and the NHS in particular. Guidelines are being published to support and push the implementation of sustainable clinical practice, and undeniable progress is being made towards the NHS’s net zero agenda. But we are not yet reaching healthcare professionals outside of these silos in sustainable healthcare. We need to reach further and get there faster, using the principles of behavioural change and implementation science, to bring sustainability in healthcare to a wider audience.

Considering the wealth of robust evidence that already exists, it is an indisputable fact that sustainability matters. Our welfare, lives, and planet depend on people caring about living in a sustainable way that ensures that we do not exceed the finite resources that we have. Healthcare, specifically, is part of the problem—the NHS contributes 4% of England’s carbon footprint1—so it must also be part of the solution.

Sustainable healthcare is synonymous with high quality care—it aims to deliver the best possible health outcomes while minimising financial and environmental costs and adding positive social value. Furthermore, sustainable healthcare is in line with what the public and staff want from their healthcare system.2 We also know that the public and our healthcare workers are concerned about the climate emergency.23 As the NHS strives to reach the goal of net zero by 2040, we are seeing an increasing number of policies and guidelines emerging to bring sustainability to the fore, not only in clinical settings but across all sectors of the NHS. Despite this, a disconnect remains between these directives and coordinated, collaborative change. Why isn’t this work translating into more accelerated change?

Firstly, we must consider the lack of dedicated sustainability roles in the existing NHS workforce. Data from 2023 showed that 8 in 10 NHS workers were concerned about climate change and 9 in 10 had taken action in their professional lives towards the NHS net zero ambition.4 But there is a lack of data as to how many of these healthcare workers have dedicated time in their job plans to act on sustainability initiatives. Without that ringfenced time and focus in their role, how can a healthcare worker justify keeping up to date with the latest evidence on sustainable practice, enrolling in a sustainability focused continuing professional development accreditation, or attending a conference that is purely focused on sustainable healthcare?

Secondly, sustainability is not yet embedded in the clinical landscape of healthcare, and it is still therefore barely a consideration in daily practice across most specialties. The NHS operates under strain, and in my experience most clinicians are dealing with the immediate problems in front of them—the overbooked outpatient clinic, the patient who cannot be discharged to the community owing to a lack of social care provision, or the chronic understaffing of services. This leaves little in the way of mental energy to consider the future of the planet. This is where choice architecture can have a role—the sustainable choice becoming default, rather than an additional burden on staff. This requires system level changes, such as the redesign of clinical care pathways to low carbon models or adding climate literacy and sustainability to mandatory training packages.

Thirdly, policies that embed sustainability in clinical practice and the delivery of healthcare are insufficient tools in isolation to achieve behavioural change at the pace and degree that is required to achieve net zero. There is an urgent need to accelerate our efforts—for the first time, global warming has exceeded 1.5°C across the year.5 And while these policies are necessary, medicine (and, more generally, healthcare) is not simply an exercise in following guidelines. We all recognise the need for evidence based clinical practice, yet we must also acknowledge that it takes on average 17 years for evidence to trickle through into clinical practice.6 Clinicians need to be guided on how to make changes to the way in which clinical care is delivered through appropriate frameworks and policies, but alongside this, behavioural change theory tells us that they must also be convinced that those changes need to be made.

People are motivated by seeing themselves in someone else’s behaviour or hearing something that strikes a chord. Finding that chord when talking about sustainability takes excellent listening skills: tell your story, and then listen carefully—find the part of your story that someone is prepared to connect and engage with. As Maria Neira outlined, someone who is discussing their grandchild’s asthma may then be ready to understand the connection to climate change.7

With the climate crisis accelerating, it is vital that we move sustainability out of its current silos and into broader medical discourse and standard practice. Alongside the push for wider systems change, we need to embed and normalise the concept of living within the limits of our planet, and bring this subject to our meetings, conversations, and conferences. In the words of Renee Salas, “Numbers numb but stories stick.”8 We need professionals from within the sustainability silo to share their personal stories about how and when sustainability began to become important to them. Don’t just tell them why it matters, tell them why it matters to you.


  • Competing interests: None declared.

  • Provenance and peer review: Commissioned; not externally peer reviewed.