Sarah Walpole, Jerome Baddley, and Rachel Stancliffe: Lost in transition

Much has been hypothesised, debated, and advocated about NHS reform. Specialists in a range of areas have looked at the impacts on their particular area of work, yet little has been remarked about the impacts of the transition on one of the NHS’s core duties – sustainability. Rising natural resource costs, climate change, and legal obligations make this a critical area of risk for public health and health care delivery.

Health services should contribute to a healthy society by exemplifying fair and sustainable use of finite resources and encouraging individuals and communities to live healthier, more sustainable lifestyles. To achieve this change is needed; but top down restructuring on the basis of no evidence, privatisation, and fragmentation should not be in the equation. A healthy transition would protect core NHS values and actively protects and promotes the health of current and future generations.

The NHS has already set internationally leading aspirations for sustainability through “Saving Carbon, Improving Health(1),” which outlines the national baseline and clear aims to reduce waste, improve efficiency, and cut carbon emissions across all areas of NHS activity. Practical approaches to achieve these aims are gradually being embedded across the UK, but aspects of the proposed reform threaten the development of sustainable health care.

Firstly, reorganisation combined with a squeeze on the public sector budget and job losses is breaking down working relationships, decreasing staff morale, and increasing time pressures. All of these jeopardise efforts to roll out and plan long term investment into what is a relatively new focus for the NHS.

As evidenced in cost calculations by the NHS Sustainable Development Unit (SDU), carbon savings are often money saving (2), therefore sustainability initiatives are an important driver for “efficiency savings” in the health service. However, implementing sustainability initiatives often requires an initial investment of time and money. It takes expertise, local leadership, and coordination to create a board room to boiler house approach and it will take real vision to hold onto this through another structural change.

Secondly, health care commissioning from a range of providers will increase fragmentation, thus reducing continuity between health service providers, and increasing repeat investigations, travel, and associated logistics emissions. For example, in Nottinghamshire carbon emissions have been reduced where Primary Care Trusts coordinate procurement on behalf of health centres, community hospitals, and GPs, which is not possible where an assortment of health providers manage different sites.

Thirdly, a system that allows increased health care provision by private entities will not keep protection of public health (present and future) as a primary objective. Private health care providers treat patients in order to receive payment for the service that they are commissioned to provide. For a profit making company, duty to the shareholder supersedes duty to the patients, and there is no duty to protect public health. Health and health care are not one and the same, and a narrow focus on measured outcomes risks compromising the sustainability and social determinants of health agenda. Air and water pollution are prime examples of negative health effects of resource use that will be seen far beyond the spatial and temporal location in which the health service is provided. While sustainability outcomes could be included in contracts with providers; in reality, developing and assessing a sufficiently comprehensive set of public health and sustainability outcomes to commission may be an impossible task unless this is built in nationally.

Fourthly, strategies to provide human, financial, and organisational capacity for a sustainable health service have not been provided. Whatever shape the future health system takes, it is essential that health service providers, including clinicians, are equipped with the knowledge and skills for their role in providing a high quality, low carbon, risk resilient health service. Those providing (and commissioning) services must be not only motivated, but sustainability literate and numerate.

What would make for sustainable health service reforms?

During this radical rethink of the NHS, sustainability must be prioritised. A successful health service will exploit the fact that health and sustainability can be mutually reinforcing. As sustainability is a relatively new agenda in healthcare, innovation must be supported in both delivery and design of healthcare services. Setting sustainability as a core component of health curricula is crucial to provide the expertise and motivation to design and implement sustainable healthcare now and for the future.

Funding should be earmarked for NHS organisations to research and develop innovative solutions and share best practice to maximise community connections, local partnerships, and activities such as food growing, home energy saving, and cycling. Specifically, this could be achieved through the development and expansion of the NHS’s Sustainable Development Unit.

By integrating sustainability now, the government can shape an NHS fit to provide good quality healthcare for all into the future. Meanwhile, as we work though the shake up, we must ensure that we learn fast from best practice around us, take care to protect existing efforts and allow the innovation and long term thinking required to integrate sustainability across all NHS activities.

1. “Saving Carbon, Improving Health: The NHS Carbon Reduction Strategy for England”, NHS Sustainable Development Unit, 2009, 
2. Marginal Abatement Cost Curves, NHS SDU, accessed 10th June 2011

Sarah Catherine Walpole, F2 doctor, NYEC deanery; co-ordinator and web manager, Climate and Health Council,, curriculum developer and foundation liason, sustainable healthcare education network, E-mail:

Jerome Baddley, Sustainable Energy development manager, The Nottingham Energy Partnership; 

Rachel Stancliffe, director, The Centre for Sustainable Healthcare,

All authors have completed the Unified Competing Interest form at (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; SCW has financial relationships with any organisations that might have an interest in the submitted work in the previous three years. JB is a paid employee of NEP Energy Services, who have been commissioned by a number of NHS trusts and the DoH to conduct carbon foot printing work over the last 36 months. RS is an employee of The Centre for Sustainable Healthcare. SCW works on a voluntary basis for The Climate and Health Council and the Sustainable Healthcare Education network.