8th April 2025
NHS England, before its abolition was announced, released its updated Green Plan Guidance, which calls on all NHS trusts and Integrated Care Boards to refresh their green plans. There is much to applaud, and the sheer range of activity on display and suggestions on offer is admirable. A range of actions from food waste to heat pumps is addressed.
However, the gravity of the threats to us if we take insufficient action combined with the risks to health mean we need to be increasingly ambitious.
Refreshing plans is no bad thing if it spurs ambition, engagement, activity, and progress. But plans can often have the opposite effect, giving an illusion of progress rather than real progress. Devising plans is much easier than implementing them. Progress will come only with proper accountability of evidence based, meaningful metrics at every organisational level.
We propose nine measures to improve the guidance.
Require each NHS organisation to measure and publish its carbon footprint
Extraordinarily the guidance does not require organisations to measure their carbon footprint. The guidance is sprinkled with guidance on actions that DON’T need to be done: specifying that non-NHS organisations delivering health and care do not need a plan.
Encourage NHS leaders to be bolder and provide them with evidence-based guidance
Leadership is more than simply adhering to the minimum requirements of the wider system. Leadership is more than responding to “we have been asked to…” There needs to be far more about linking the vision of a modern health and care system to the incentives for local organisations, teams, and staff to innovate, to take risks, to have the capacity and competence to experiment without fear. We should do these things because they are difficult. And we need to be more courageous than defaulting only to “no regrets actions”, however important and effective they are.
Board level leads are indeed important, but there should be much more practical and evidence-based guidance about how this is most effectively done; not to concentrate and isolate the responsibility for progress in one part of the organisation but to make it a core and universal part of duty and culture. The NHS has a duty to lead, not a reluctance to follow: Heat network systems? Large hospitals should be the centre of one, not just “connect” to one.
Insist that partnership is essential and point out that there are many examples of outstanding practice to follow
Rarely is anything delivered by solo heroes of teams. In a complex system, partnerships are key to any progress. That means much more than just local government. There are many organisations in the third sector working tirelessly on issues such as increasing the health of food for patients, staff and visitors such as Plant Based Health Professionals. The NHS is one of the largest procurers of food and energy in the country – so is there updated annual guidance about how NHS organisations and networks use their purchasing muscle to change food and energy systems?
The size of the NHS means there are always outstanding examples of good practices, showing not only that they can be done but are being done. Where the NHS excels at sustainable practice, we should make it visible and normal. The health service operates and employs people in every community in the country – a great chance to normalise future behaviour. Perhaps the most important partnership is with patients and the wider public, an area where good research and accessible guidance would be very welcome.
Recognise that guidance on the need to follow the law and that improved regulation are important tools
The NHS has a good record of initiating local innovations. but a poor record of spreading those innovations across the service. Perhaps the most powerful tool we have for spreading local innovations are statutory requirements and environmental targets. Guidance should be constantly updated to include the statutory obligations from the Health and Care Act 2022, the Social Value Act, the Civil Contingencies Act, and the Climate Change Act. Including these should reduce risks to health and improve legal compliance.
The Care Quality Commission should steadily increase the ambition of what is required from the NHS as the threats and opportunities escalate. These requirements are a good way for the NHS to make it clear that much is expected of every part of the service.
Make sustainability one of the core dimensions and measures of quality
Sustainability will never be a truly helpful part of the business of health care until it is treated and measured as a core dimension of quality, alongside effectiveness, efficiency, safety, and equity. It would be helpful to mainstream the excellent work done on this by organisations such as the Centre for Sustainable Healthcare.
Include specific and practical guidance on decarbonising clinical care
The guidance offers help about which clinic areas might be prioritised for decarbonisation. It is right to remind us that it is ultimately how we design and adapt pathways or models of care that determines everything from infrastructure to drug use. But no clinical areas and conditions are immune from opportunities to decarbonise, mainly by eliminating unsafe, unnecessary, and low value care. Guidance needs to be practical and specific: “support work to reduce emissions across patient pathways, spanning primary, secondary and community care and the third sector” is not enough.
Minimise unnecessary interventions and incorporate ideas from evidence-based reports on reducing carbon
As in all health systems there are many unnecessary and low value diagnostic tests and treatments, and minimising these is good for patients and reduces costs and carbon. There are also many reports–like, for example, the Green Surgery report–that include actions that can reduce waste and carbon. These should be implemented.
End of life care often includes unnecessary, medically dominated, and undignified interventions and offers opportunities for reducing suffering, carbon, and cost.
Require NHS organisations to update plans but emphasise the importance of action
This updated guidance stresses the need to update organisational plans. That is often a good thing, but only if it spurs ambition, engagement, activity and genuine progress.
Make environmental sustainability a core business of the NHS
Being the first healthcare service to commit to net-zero is impressive, but it will need much more integration of sustainability into quality, governance and staff development to make health services part of the solution not part of the problem.
A summary list of suggestions, recommendations, and guidance is useful, but the guidance misses the opportunity to make clear that environmental sustainability must be a vital part of the core business of a transformed NHS that delivers “high quality care, now and for future generations, within available resources.”
Without fundamental integration into transforming the system, most of the proposed actions with environmental benefits will appear to be competing with health outcomes and better resource use, not reinforcing them. Environmental sustainability is not simply a convenient and occasional layer of efficiency of the present care system; it is an integral and core part of constant quality improvement.
We will only get one chance at this. The largest organisation in western Europe, with the right leadership, ambition, governance and guidance can make a huge positive difference to both the present and the future.