Making healthcare and health systems net zero
BMJ 2020; 368 doi: https://doi.org/10.1136/bmj.m970 (Published 30 March 2020) Cite this as: BMJ 2020;368:m970Read our Health in the Anthropocene collection
- 1Medical and Health School, University of Exeter, Exeter, UK
- 2Faculty of Public Health Sustainable Development Special Interest Group, London, UK
- Correspondence to: D Pencheon d.pencheon{at}exeter.ac.uk
The climate emergency that is a key part of the Anthropocene poses substantial risks (and opportunities) for every sector of society, including health systems and professionals. There are three specific ways in which health systems are important. Firstly, patterns of morbidity are already changing across the planet as extreme weather events become more frequent, more severe, and last longer (heatwaves, floods, storms, wildfires, etc). Secondly, the changing climate is compromising how well health services can cope with and respond to both current and future demands. Thirdly, health services are themselves substantial contributors to the causes of climate change in terms of greenhouse gas emissions and avoidable ecological damage. The Anthropocene therefore affects both health and healthcare systems, but healthcare systems are also one of the causes of the Anthropocene.
This article describes how health systems and professionals can and should respond to the health and wider effects of the climate emergency—in particular, what we already know about the likely routes towards health systems that are net zero carbon.1
Avoiding a health crisis
Words are important. Calling the Anthropocene simply an environmental crisis risks compartmentalising it: the environmental crisis is also a health crisis. Health systems and professionals can respond ambitiously and visibly in three ways. We must prepare for the inevitable adverse health consequences of an overheating world (adaptation); we must seize the additional and immediate health benefits of a systematic and rapid move away from fossil fuel dependency, particularly towards more sustainable food systems, better diets,2 cleaner transport systems, cleaner air,3 and reduced pollution (health co-benefits). And we must make sure that health systems no longer contribute to the problem and become carbon neutral (mitigation).
The first step to becoming carbon neutral is to measure the scale of the challenge. This should be done in internationally recognised ways, in absolute amounts, and repeated to generate a time series of data to monitor progress. Studies from the UK,4 US,5 Australia,6 and Japan7 indicate that healthcare’s climate footprint is equivalent to 4.4% of global net emissions.8 The NHS in England is estimated to generate 27.1 million tonnes of greenhouse gas emissions annually, representing 6.3% of England’s emissions overall.4 The proportional greenhouse gas footprint attributed to healthcare in Australia is comparable at 7%, equivalent to the entire carbon emissions of the state of South Australia, the fifth largest of Australia's states and territories by population.6
Reducing avoidable emissions and ecological damage
The next task is to identify the most practical steps to reducing avoidable emissions and environmental damage.
Wider economy
The health system has the potential to contribute significantly to the decarbonisation of the wider economy, particularly in improving supply chains in carbon intensive activities such as buildings, transport, energy procurement (a rapid move to 100% renewable), and food procurement.
Buildings—Being the biggest employer in Europe,9 the NHS oversees one of Europe’s largest infrastructure portfolios (buildings and land). This could be a real obstacle to better health and care.10 Large centralised hospitals are crucial, but should only do the things that cannot be done elsewhere. Large hospitals often inhibit the development of more patient centred and information technology driven services that can help deliver lower carbon, safer, and more convenient care closer to home. Such services can help people develop more confidence, competence, and control over their health. Globally, most healthcare is delivered, and most health gain is achieved, in primary care, where the potential for low carbon, preventive services is much greater. Any patient who is treated in an expensive, carbon intensive hospital when they could be equally well managed in primary care or at home should be considered an example of system failure.
Transport—Almost one in 20 of all road journeys in England are related to the health and care system, producing greenhouse gases, air pollution, road trauma, and noise.4 The air pollution impact can be reduced by 25% by improving facilities for hospital staff to commute through multioccupancy car journeys.11 Health services, usually one of the largest local employers, can promote the building of new sustainable transport infrastructure to increase active, healthy, low carbon commuting.12 In addition, transport infrastructure and vehicle fleets within health services should go electric: hospitals are well placed to lead the rapid roll out of electric vehicle charging points for staff and visitors. Already, at least one ambulance service covering four counties in England has fitted its rapid response vehicles with solar panels to reduce idling of engines, which reduces pollution, greenhouse gas emissions, and expense.13
Energy—Healthcare organisations should rapidly increase their purchase of renewable energy, working towards 100%, and assess the potential to generate as much of this as possible on currently owned land. In 2015, 16 hospitals in seven European countries explored options to become zero carbon with a plan to source at least 50% of their energy needs from renewable energy.14 One of the aims of this EU funded work has been for a 1000 hospitals throughout Europe to be producing at least 20% of their energy needs from renewable energy onsite using photovoltaic and biomass technologies. In Staffordshire, England, a hospital has partnered with a fuel poverty charity and an energy company to use its large roof space to reduce emissions and generate savings for the hospital, the charity, and investors. The £335 000 (€380 000; $420 000) cost of this investment has been entirely funded by members of the public, who receive a 4.5% average rate of return.15 New health service infrastructure should be built (and existing ones re-engineered) to minimise energy use and maximise opportunities for buildings and land to generate clean, healthy, renewable energy.
Food—An animal based diet is both high carbon and less healthy. To reduce carbon emissions and promote healthy diets, the amount of meat (especially beef and lamb) and dairy foods in all catering should be minimised, and vegetable, fruit, nut, and pulse based options made more available. Some hospitals are already taking the lead in local sustainable food systems.16 Many have meat-free days, and in some countries (such as Indonesia) there are hospitals that are almost completely vegetarian.
Procurement—Over 60% of the total carbon footprint of the NHS is attributable to procuring goods and services.17 All goods and services should be sourced preferentially from suppliers who can show that they are taking steps to reduce their carbon emissions (and their supply chains) to zero. As a large and powerful purchaser, a nationally coordinated health service can have substantial influence and help normalise such practices and policies throughout the wider economy.
Within the health service
For health services to become carbon neutral, they must also reduce emissions that are specific to the health system. Pharmaceutical and medical technology are the largest contributors (36%) to the procurement footprint of a health service.4 Such high intensity carbon products therefore need to be used judiciously, minimising waste and promoting reuse of unused medicines where safe and practical. The proportion of drugs manufactured globally that end up having a net positive therapeutic effect has not yet been established, but wasted products are often allowed to pollute the air through incineration or pollute water through careless disposal.
Metered dose inhalers and anaesthetic gases are two examples with great potential to reduce greenhouse gas emissions in the health service. In 2017, they accounted for 3.1% and 1.7% of England’s health and social care emissions, respectively.4 As well as emissions from manufacture and transport (which will be eliminated when the wider economy becomes carbon neutral), both have greenhouse effects in themselves. Eliminating this will require stopping their escape into the atmosphere (perhaps possible for anaesthetic gases), substituting them with products that have equivalent or near equivalent therapeutic effects (such as dry powder inhalers), or finding other forms of prevention and treatment. Switching to dry powder inhalers can save drug related greenhouse gas emissions and financial costs simultaneously.18 In 2017, 70% of all inhalers sold in England were metered dose inhalers compared with 13% in Sweden, where there has been a more rapid transition to dry powder inhalers.19 Guidance from the National Institute for Health and Care Excellence (NICE) in England has already stated that both patient and population health need to be considered when prescribing inhalers.20
System-wide causes of population health and illness
A crucial part of a health service’s journey to net zero carbon is to continue increasing the efficiency of the current models of care: reducing waste, error, and unnecessary care and, crucially, preventing the preventable. High quality care is more sustainable care: clinically, financially, and environmentally.
The route to zero carbon for health services will not be by efficiency alone—some services and models of care will need to transform radically. Hospitals cannot continue to grow in number or size, consuming more resources at the expense of more sustainable approaches to protecting and improving health. Building ever bigger, more centralised hospitals has long been known to be unsustainable financially, and the evidence now suggests such continued growth is unsustainable environmentally too.7 Better systems of prevention and care are more likely to be more effective and more sustainable than more buildings. We may need to shift our focus from bigger, more complex hospitals that deliver most care to smaller, smarter, more adaptable hospitals that coordinate care among multiple providers, particularly patients and their carers, both on-site and in the community.
We may be faced with a future where we have to consider the carbon costs as well as the financial costs of care. Some healthcare interventions with marginal benefit and huge carbon costs may not be justifiable when judged against long term health and fairness (and survival) for the wider population. Carbon related health economic analyses (eg, CO2 equivalent emitted per QALY gained) would be needed to help professionals and the public make better decisions about what is fair and affordable. Serial public surveys have indicated that over 90% of the public in the UK think it is important for the health system to work in a more sustainable way.21
Start with governance and accountability
One powerful way to normalise all these organisational, national, and global actions is to introduce “integrated” reporting. This would mean that clinical, financial, and environmental data can be linked and the multiple benefits more clearly recognised and valued, and that they are reported using the same nationally and globally recognised standards as in other sectors. Carbon reporting, as part of environmental reporting, is a first step for healthcare organisations to reduce emissions and to align themselves with national laws based on the recommendations of the UN Intergovernmental Panel on Climate Change (IPCC).
In England, annual reporting is mandated for health service organisations through the Department of Health’s accounting process.22 This is an opportunity for all healthcare organisations to show their progress and good practice systematically, quantitatively, and comparably. Health systems have an opportunity to show that sustainability in healthcare is a core part of quality and governance.23
Internationally, action by health services is made more possible by the commitment and guidance from global agreements such as the Ostrava declaration on environment and health, led by the World Health Organization and UN Environmental Programme,24 and the global sustainable development goals, all 17 of which have important health implications.25
Although health services need to prepare for the inevitable consequences of climate breakdown, the strategic priority must be mitigation. Adaptation manages the unavoidable; mitigation avoids the unmanageable. Progress is possible: the NHS in England reduced its footprint by 11% between 2007 and 2015 while increasing activity by 18%, resulting in a reduction per unit of activity of 33%. This is on course to meet nationally mandated carbon reduction targets.4
The role of the health systems, health professionals, and patients in the global journey to net-zero carbon soon is important because of their size, reach, trust, and exemplary role. Moreover, the environmental threats we are faced with are health threats. We should live up to our historical commitment and duty of care to do no harm.
Key messages
As well as having to deal with the health consequences of climate breakdown, health systems are major contributors to it
Health systems can both reduce their own carbon impact and influence the wider economy’s emissions
Rigorous measurement of carbon emissions, including emissions from the supply chain, will be necessary to reduce them
Carbon accounting should become a core part of the management of health systems, alongside financial accounting, and built into governance systems.
Footnotes
Competing interests: We have read and understood BMJ policy on declaration of interests and declare that DP is a former director of the NHS England/PHE Sustainable Development Unit. JW is chair of the Faculty of Public Health sustainable development special interest group.
Provenance and peer review: Not commissioned; externally peer reviewed.
This article is part of a series commissioned by The BMJ.