The Darzi review highlighted the health imperative to act on climate change, and was unequivocal that ‘the NHS must stick to its net zero ambitions’. This review by a senior clinical leader furthermore set out that environmentally sustainable health care can help improve health and health care, stating: ‘There is no trade-off between climate responsibilities and reducing waiting lists. Indeed, often health and climate are mutually reinforcing goals’. Environmentally sustainable health care can help deliver the government’s ambitions to improve the NHS and should be integral to the forthcoming 10 year plan for health.

What is sustainable health care?  

With projected increases in the population’s health needs, and estimates showing that NHS productivity has not recovered since the pandemic, the long-term financial sustainability and productivity of the NHS are key challenges for the 10-year health plan to address.

Sustainability of health care systems is often understood as the ability to ensure resources needed for quality health care, such as workforce, funding and equipment, meet need for care over the long term. If resources are constrained, this means minimising the need for health care and creating a productive health system which uses resources efficiently to generate better health outcomes.

Environmental sustainability of health care services – delivering care in a way that minimises impact on the environment – rarely features in the conversation about financial sustainability and productivity. However, health care cannot be delivered in the long-term without being environmentally sustainable. Health systems need funding, staff and equipment, but also clean air and water, liveable environmental conditions, and functioning ecosystems on which all supply chains depend. Fundamentally, to deliver care sustainably, the health care system must use resources in ways which do not prejudice future health and wellbeing.

The climate crisis has already disrupted care in the NHS, from care settings overheating and servers in meltdown to flooding, and with stark recent examples of supply chain disruption globally. These, along with health care’s own significant contribution to the climate crisis, demonstrate the urgent need for the NHS to decarbonise to be able to deliver high-quality health care into the future.

Achieving the triple bottom line

Environmentally sustainable healthcare has at its heart ensuring resources for care meet care needs over the long term, through action on both health care need and supply. A core framework for this approach is the principles of sustainable health care. These principles include health creation and patient empowerment to minimise health care need, and making healthcare delivery lean, resource–efficient, and low–carbon. Examples of work across the NHS have demonstrated that more environmentally sustainable care can simultaneously improve health, save costs, and make progress towards the NHS’s net zero goals. Seeking to maximise quality of care while minimising the cost to the ‘triple bottom line’ of health, financial and environmental impacts can help us work towards both environmentally and financially sustainable care.

Prevention, a core focus of our specialities of public health and general practice, encapsulates the triple bottom line approach. Prevention of ill-health was a founding principle of the NHS, and health promotion or preventative approaches often reduce the need for more expensive – and more carbon-intensive – healthcare. Spending on public health has been found to result in greater improvements in health than spending on NHS activity.

Prevention of illness has been a policy priority for many years, but spending on preventative services is small and falling in comparison to secondary care. Figures released by Parliament show that the percentage of Integrated Care Board funding going to general practice has fallen to its lowest rate in nearly a decade despite the cost–effectiveness of primary and community care. Public health teams also provide a range of mandated and additional functions to tackle health harms, but Health Foundation analysis has found a 28% per capita reduction in the central government allocation to local authorities for public health since 2015/16. Health cannot be shaped by the NHS alone, but real terms funding cuts to local authorities over the past 14 years hamper efforts to improve people’s health through planning, housing and transport reform, which can have added environmental co-benefits.

Sexual health services are a good example of how reducing funding on prevention can hamper the environmental and financial sustainability of care. A 40% reduction in spend on sexual health services amidst an increase in attendance of more than a third over the last decade has led to the Local Government Association warning of services at breaking point. Inadequate access to contraception, diagnosis and treatment of sexually transmitted infections has led to health, financial and carbon consequences, including rising rates of infections that are more costly and complex to treat. The new government’s focus on moving from sickness to prevention is much needed, but years of cuts to public health and preventative services will take concerted action to reverse.

Sustainable health care in action

To secure the NHS’s future, health care leaders must make both environmental and financial sustainability part of the core business of delivering high-quality care. They must be united in calling for the 10-year Health Plan to centre environmentally and financially sustainable care but must also build the movement for change locally. Health care leaders must consider the triple bottom line in decision-making in all teams and organisations, strengthen preventative and community-based approaches to care, and build the next generation of leaders to accelerate progress further.  Leadership at all levels in the NHS is essential if we are to achieve the aim of delivering quality care which can be sustained for current and future generations.

Authors

Catriona Callan
Caitríona is a GP registrar and clinical policy fellow at the Health Foundation and co-ordinator of the Greener Practice training form.

Jay Burt
Jay is a clinical fellow to the NHS Chief Sustainability Officer at the Health Foundation.

Lucy Vanes
Lucy is a public health registrar at Manchester City Council.

Declaration of interests
We have read and understood the BMJ Group policy on declaration of interests and declare the following interests: none.