The National Health Service has been transformed in the past five months to respond to the covid-19 pandemic, and the social care system has been severely strained. More recently, the UK Government has announced a major restructuring of the public health system to widespread concern from across the health community. There is now much discussion on how the “recovered” health and social care system should look. The pandemic still has some way to go, and SARS-CoV-2 is likely to become endemic, but early recovery planning is critical if we are to get it right and avoid simply returning to all the problems and inequalities of the “old normal.” 
A severe economic recession is beginning and the climate emergency is growing, bringing with it more severe heat waves, floods and storms.  What’s more, the covid-19 pandemic will no doubt at some stage be followed by another pandemic. How we recover from this crisis will shape both health and health inequalities for decades to come, and our resilience (or vulnerability) to all types of future crises.
Our organisations are concerned with tackling the climate emergency, protecting health from its impacts and maximising the benefits to health from responding to it. The health and social care system is responsible for 6% of the UK’s greenhouse gas emissions and one in 20 journeys on the roads. The system is the largest employer in the UK with a combined staff of over three million, and a major purchaser of products and services. The health and social care system can have an important impact on the climate crisis, and the NHS in England has this year committed to reaching net-zero carbon emissions as quickly as possible.  The rest of the health and care system needs to similarly develop a comprehensive and practical plan to stop contributing to the climate crisis, while also building resilience to future shocks by embedding climate adaptation principles and addressing the root causes of vulnerability, including inequalities.
We have discussed the changes in the health and social care system that emerge from the pandemic, and we have prioritised the ones that we think might do the most to help drive a healthy, green and resilient recovery.
1] Promote health not just healthcare
We now know that the UK has had more excess deaths during the pandemic than any other European country.  The pandemic has exposed the difference between health and healthcare and the importance of a complete system of care. There are multiple reasons why the UK has had such a high death rate, including waiting for too long before taking strong enough action, but they undoubtedly include the high levels of structural inequality and deprivation in Britain, including by ethnic group; the poor underlying health of Britons, particularly the number who are obese and diabetic; an inadequate and fragile social care system that is disconnected from the NHS; and the underfunding of public health. 
The NHS is important and much loved in Britain, but the NHS can make only a small contribution to improving health and preventing illness; a fact that’s still not well recognised by politicians and the public. Health depends much more on the environment and social factors such as economic security, equality, meaningful and secure employment, good housing, education, unpolluted air and water, affordable and nutritious food, access to green spaces, and community strength.
These are also key factors which influence communities’ and individuals’ resilience to all kinds of stressors, from viral pandemics to the impacts that climate change will cause (such as floods, heatwaves, air pollution, droughts and impacts on global food prices) in the coming decades. This means that tackling poverty, inequality and their causes—for example through investment in education and skills, high-quality housing and the creation of good green jobs—will both improve health and strengthen community resilience.
Government and local authorities must place emphasis on policies and actions that promote health not simply healthcare. This must include dismantling structural inequalities, strengthening social protections, promoting active transport (walking and cycling) and a healthy diet (more fruit and vegetables and less meat), reducing dependence on motorised transport (and so reducing air pollution), increasing access to green space, and promoting more equitable employment practices. It also means ensuring that the recovery from the covid-19 pandemic reduces pervasive social and economic inequalities and embeds carbon reduction and climate adaptation as top priorities.
2] Re-balance the whole health and social care system
The pandemic exposed the disconnect between health and social care with high death rates in care homes, partly from infected people being discharged from the NHS to care homes.  For an increasingly elderly population social care is as important, if not more important, than health care. Dementia is now the most common cause of death in Britain, and health services can do little for dementia, but social care is crucial.
Politicians in Britain have shied away from reforming social care, putting it in the “too difficult” box for too long. There is not the same demand for more resources for social care that there is for the NHS. But the time has come to better resource social care and integrate the two systems, as well as to recalibrate health spending with more focus on prevention. In the longer term, this should lighten the load on the NHS, reducing carbon emissions. Better funding of social care should be part of a comprehensive plan for the system to reach net-zero carbon emissions as quickly as possible (as is being developed for the NHS in England).
Public health is a crucial part of the health and social care system but it receives less than 3% of the funding of the NHS; and funding per person has fallen by a quarter since 2014.  This neglect will have contributed to Britain’s high rate of excess deaths from covid-19. Increasing long-term funding of public health as well as protecting its independence from politics and better integrating it into the whole system will keep people healthy and reduce health inequalities and improve resilience. It is essential that such major changes reflect a long-term strategy that is underpinned by analysis and consultation across the system, and that in increasing its focus on pandemic preparedness, the government does not overlook or de-prioritise action to increase our resilience to other health threats, including those arising from climate change and extreme weather. 
Re-balancing the system should also include more and better cooperation with communities and civil society, listening to and working with local communities in order to help them address the health issues that matter to them in fair, inclusive and locally-appropriate ways. The NHS and social care system can never be expected to reduce health inequalities and create a healthier environment on their own—though as anchor institutions they can contribute towards these goals—but better (and equal) relationships with communities and civil society can make a difference, reducing inequalities and carbon emissions. 
3] Change the health system from one that does things to patients to one that supports people to stay healthy and manage their conditions
An already large and increasing proportion of healthcare is concerned with people with long-term, often multiple, conditions. How well a patient with meningitis does depends largely on the clinical team, whereas how well a patient with a long-term condition, like type 2 diabetes, does depends primarily on their ability to manage their health needs. This in turn depends on their knowledge and skill, on their environment, resources and the social and clinical support they have access too.
During the pandemic, attendances at NHS facilities for reasons other than covid-19 dropped dramatically. In part this was people caring more for themselves, although part was also caused by people not attending for problems where NHS care was needed.  Lockdown has shown us both the critical importance of patients having the right knowledge and skills to manage their long-term conditions effectively, and just how much can be done to support this when it is prioritised.
Before the pandemic the NHS had tried to follow a mantra of “nothing about me without me,” encouraging “co-production” of care systems with patients and shared decision-making. This approach has been made more challenging by covid-19, but this ethos and practice will remain equally important in the long term, and meaningful inclusion and participation of patients and communities as recovery plans are developed and major changes are made to the public health system is vital. The government and NHS should work with patients to support patients in caring for themselves, increase health literacy, and give people access to all their records from general practice, hospitals, mental health, and social care, in an integrated, secure and accessible form. Consultations by phone or online can also help patients help themselves and reduce journeys to health facilities; perhaps 50% of GP consultations and outpatient visits might happen by phone or online in the future if the choice is routinely open to patients.  Such developments should, in the long term, help to reduce NHS activity and travel to and from health facilities (and so carbon emissions), improve patient experience (for example, by reducing travel time and time patients need to take off from work or other responsibilities) and improve health outcomes.
4] Give more freedom to local parts of the NHS to innovate and learn sustainably
The centre of the NHS has traditionally controlled much of what happens in the NHS. During the pandemic people within the service went beyond their contractual commitments and just “got on and did things” without worrying about what the centre thought—so increasing the capacity for innovation and learning. The different parts of the NHS are different in their needs and giving staff more freedom to innovate and learn—and properly protecting time for staff to engage in meaningful quality improvement work, and adequately resourcing it—will create more responsive and efficient services, so improving health and reducing carbon consumption. In addition, improving sustainability should become a core part of improving quality, building on the Centre for Sustainable Healthcare’s SusQI framework, to harness the motivation of many health professionals to create more sustainable healthcare and to ensure that all future innovation is sustainable. Partnering across sectors has produced valuable tools for measuring environmental impact and this could be built on with new collaborations which “test and learn” and innovate at a local level accelerating progress towards NHS carbon net-zero. 
5] Change the rules of the system to cut carbon emissions
As health and social care plan for recovery we must seize the opportunity to build resilience and embed long-term thinking including the requirement for all organisations to measure and reduce their carbon footprint and adapt to the impact that climate change is already having. A priority for all health and social care organisations is to balance their budgets, but we are already in a world where carbon emissions should matter as much as, if not more than, money. All the organisations might be required to measure and publish their annual carbon footprint together with a plan for reducing it to net-zero as rapidly as possible. The figure should include all that the organisations procure, which means working closely with suppliers whether they be international or local.
Similarly, the National Institute for Health and Care Excellence should consider carbon emissions in its work—when approving drugs and devices for use in the NHS and when developing care pathways. There are already signs of this beginning to happen.
6] Pay more attention to the wellbeing of staff
The pandemic has placed a great load on health and social care staff. Many have become sick and some have died through their work, and the mental health of many has deteriorated. The public has expressed its appreciation of the contribution of health and social care staff through weekly claps and fundraising. But these provide no long-term change.
In addition to improving employment conditions and pay, particularly for those in low-paid roles, measures to promote healthier and more sustainable diets and travel to work can also help to improve the workforce’s wellbeing and show staff that they are valued. The health and social care system should encourage and incentivise active travel and healthier diets (both of which will reduce carbon consumption) for its staff. It should also promote mental health, for example through more flexible employment and training options, providing access to green space and making available Schwartz rounds (structured sessions where staff can share emotional experiences). 
Covid-19 has exposed undervalued strengths of the health service (staff dedication and the capacity to innovate) but also the failures of healthcare. We must learn from this to build a fairer, more resilient system that contributes to a fairer, healthier and greener society.
There are many other changes that the health and social care system can, and needs to, make to promote health and progress towards net-zero carbon emission and improve resilience to future crises, but we have picked out major changes that could have the biggest impact as we start to think about recovery from the pandemic. We hope that the government health and social care system will encourage and support these changes. We will contribute to and monitor progress.
Richard Smith, Chair, UK Health Alliance on Climate Change. Richard Smith is also the Chair of Patients Know Best, a member of the Sustainable Healthcare Coalition.
Rachel Stancliffe, Director, Centre for Sustainable Healthcare.
Will Clark, Healthcare Without Harm Europe.
Fiona Adshead, Chair, Sustainable Healthcare Coalition. The Sustainable Healthcare Coalition’s secretariat endorses the messages in this paper. It may not represent the views of individual members.
Izzy Braithwaite, Member, Health Declares Climate & Ecological Emergency.
Competing interests: None declared.
4] Comparisons of all-cause mortality between European countries and regions