“We live in a world of competing sorrows,” said Daniel Moynihan, the US senator. We also live in a world of competing agendas, and the NHS has to think about saving money, increasing productivity, improving quality and access, and many other issues as well as achieving environmental sustainability. And despite their fine words, the health minister and chief executive of the NHS clearly do not think environmental sustainability that important because neither turned up for the launch of the NHS Sustainable Development Unit’s Routemap for Sustainable Health.

People rightly pay attention to what leaders do rather than what they say, and it was a bad signal that neither turned up. As I listened to the Deputy Chief Executive of the NHS make a speech that he must have put together using magnetic poetry (frontline, lead, change, challenge,  going forward, communicate, opportunity, progress) I began to feel depressed and thought of the Easter Islander who chopped down the last tree and condemned the people to irreversible social decay. Then I felt bad about feeling bad: at a launch the mood should be upbeat and can do, and I think that was the mood of most.

But can the NHS do it? You probably know the figures. The NHS has a carbon footprint of 21 million tonnes of CO2 equivalent and accounts for  25% of all public sector carbon emissions. That’s a bigger carbon footprint than some 120 countries and is twice the footprint of the Sudan, which has a population of 42 million people. It’s because of the scale of carbon consumption of the NHS and other developed world enterprises that we are now using the resources of 2.5 planets.

Survival depends on making drastic changes, and the NHS is supposed to reduce its carbon consumption by 80% by 2050 and by 10% by 2015 from the 2007 baseline. In fact consumption has risen since 2007 despite the recession, and if things don’t start turning round fast then the future targets will look impossible before we’ve even started.

As David Pencheon, director of the NHS Sustainable Development Unit, said at the meeting, there are two broad ways to reduce carbon consumption—by doing what we do now more efficiently and by doing things differently. Doing what we do now more efficiently is unlikely to account for much more than a 10% reduction, so it’s about doing things differently, very differently.

The routemap has a chart that shows many aspects of “transformation” that are needed. We must move from curative and fixing medical care to early intervention and preventative care, from sickness to health and wellbeing, from professional to personal, from buildings to healing environments, from “decision making based on today’s finances” to “an integrated value of the future which accounts for the impacts on society and nature.”

Can this ever happen? I hope it might, but I have my worries. Firstly, the bet that concentrating on prevention and health will lead to less demand is reminiscent of the optimism of the 40s that the new NHS would quickly mop up problems and cost less. Secondly, the brutal reality of the NHS is that it’s a sickness service, most employees spend most of their time dealing with the sick. Surely a service that still employs 1.3 million people and has so many buildings and so much stuff can’t cut its carbon consumption by 80%. And, thirdly, there is no mention of death and how we die. It seems to me that we will need a fundamental shift in how we approach death—not fending it off at huge cost but learning to welcome it, even to the point of assisted suicide.

As Pencheon explained the routemap is not a “how to do it” but a “what to do.” The onus is on the organisations and individuals to find a way and to share their learning. As I’ve heard before, there are three main ways to respond to such a major challenge and threat as climate change: deny it, become a “climate terrorist,” or work at it every day, simultaneously being optimistic and realistic, with all the discomfort that implies. Most opt for denial, but that needs to change, as the routemap says, from climate change being “nobody’s business” to “everybody’s business.”