Last week the Climate Change Committee (CCC) reported that the UK government is making poor progress with its aim of achieving carbon net-zero by 2045. The report also showed that the country is doing badly with adaptation to the damage that we know will come from the greenhouse gases that are already in the atmosphere: “Only five of 34 sectors assessed have shown notable progress in the past two years, and no sector is yet scoring highly in lowering its level of risk.” In the same week a leak of the near-final draft of the 2022 report of the Intergovernmental Report on Climate Change made clear that the world is failing to meet the challenge of climate change. The sad truth is that it’s all too easy to make grand promises—as the British prime minister is fond of doing—but hard, very hard to achieve them. It’s against this dismal background that the report on progress the NHS in England is making towards achieving net-zero is to be welcomed.

The NHS in England was the first health system in the world to have a plan to achieve net-zero—by 2040 for the greenhouse gas emissions it controls and by 2045 to include the emissions that arise from all that the NHS procures. The NHS in Wales also now has a plan, and the NHS in Scotland has one in draft. The NHS in Northern Ireland does not yet have either a commitment to reach net-zero or a plan. Most health systems in the world have rising emissions of greenhouse gases, which is absurd when the World Health Organisation says that climate change is the world’s major threat to health. In the US healthcare accounts for 12% of the country’s emissions.

NHS England has a plan because of the commitment of Simon Stevens, who is now stepping down as chief executive of NHS England. One anxiety is whether whoever follows him will have the same commitment because it is the new leader who will have to oversee the harder work of implementing the plan. The plan, which was published in October 2020, builds on ten years’ work by the Sustainable Development Unit, which despite many NHS organisations not seeing the environment as a priority did manage to achieve reductions in the NHS carbon footprint. Stevens proposed the plan before the pandemic began, and the Greener NHS Programme, led by Nick Watts, the chief sustainability officer, has been cautious in promoting the report and its work when NHS staff have been struggling with covid-19.

But every day that passes without action makes it harder to achieve what are already ambitious targets that will not be easy to achieve. Following last week’s report to the NHS Board, a letter is being sent to the leaders of NHS organisations requiring them to have a board-level net-zero lead by 1 October 2021 and a refreshed plan by January 2022. Integrated Care Systems will have to produce a system-wide plan by the end of March 2022. This might sound like boring bureaucracy, but success in reaching net-zero will depend on every part of the NHS making changes. The centre might lead, but the NHS organisations—including community services, many of which like general and dental practices and pharmacies are independent—will have to deliver. Every board needs to have somebody who is knowledgeable about decarbonising just as every board needs people who are expert in finance. One of the challenges is to achieve consistent, reliable, and granular reporting on carbon footprints, and a new net-zero data collection framework has been developed. A report on carbon footprints by region and system is promised for September 2021.

Between July 2021 and September 2021 the Greener NHS programme wants to reach out to all 1.3 million staff with the proposal that they “have something they can personally do to tackle climate change while improving their own health and the health of their patients.” As with everything else the NHS does it ultimately depends on the willingness and capability of the staff to achieve net-zero. It’s perhaps more implicit than explicit in the report that everything has to change, including clinical practice. I chair the UK Health Alliance on Climate Change, which includes most of the royal colleges as well as the BMA, Lancet, and BMJ, and I think it’s fair to say that most of our members did not see responding to climate change as “core business”—but now it is. 

The nature of many endeavours—and certainly achieving net-zero—is that there are quick wins at the beginning, but the task becomes progressively harder. Indeed, nobody knows exactly how to achieve net-zero, and the plan includes research. The plan also includes encouraging prevention, shifting more care into the community, and reducing inequalities—all things that have long been the aim of the NHS, but where progress has been minimal or things have gone backwards. Then the whole notion of net-zero recognises that absolute zero will be impossible and that therefore the carbon that the NHS consumes will have to be offset or sequestered—but how?

Quick wins have included reducing anaesthetic gases (particularly desflurane, which probably wasn’t needed in the first place), increases in digital consultations (largely because of the pandemic), using renewable energy and electric ambulances, and installing LED lighting. One of the challenges to achieving net-zero is the old (and often poor quality) building stock of the NHS, and the NHS has won over £260m from the Government’s Public Sector Decarbonisation Scheme to make improvements. The money will be used to improve energy efficiency, decarbonising heating and lighting systems, improving building fabric, and installing solar panels. No doubt much more money will be needed, which will be a challenge as the government has to repay the huge borrowing necessitated by the pandemic.

Achieving net-zero for the emissions it directly controls will be hard, but still harder will be encouraging all suppliers—many of them multinational companies, for whom Britain is a small part of their market—to achieve net-zero. Two-thirds of the NHS carbon footprint arises from procurement of supplies, and a fifth results from pharmaceuticals. The NHS long ago set up the Sustainable Healthcare Coalition, which brings together the NHS with private suppliers, but now it will introduce a Net Zero International Leadership Group, which will include the leaders of companies such as AstraZeneca, GSK, Biogen, Microsoft, Johnson & Johnson and Unilever together with leaders from the BMJ and the Health Foundation.

We must all hope that the NHS is not yet another body that makes grand promises and then fails to deliver them. The signs are encouraging that the NHS recognises the difficulty of what it needs to achieve, has allocated resources (both staff and money) to making it happen, and introduced systems of monitoring and accountability. The targets of net-zero by 2040 and 2045 will be achieved only with unremitting commitment.

Richard Smith was the editor of The BMJ until 2004.

Competing interest: RS is the unpaid chair of UK Health Alliance and the unpaid chair of Patients Know Best, a digital health company that can help reduce the NHS carbon footprint (he has equity in the company). He sat (unpaid) on the NHS Net-Zero Advisory Committee and is a friend of Simon Stevens, the chief executive of NHS England, Nick Watts, the Chief Sustainability Officer, and David Pencheon, the first director of the NHS Sustainable Development Unit.