Sustainability: How ICBs are approaching net zero

Victoria Vaughan: There’s massive pressure in the daily running of the NHS but, above this, is the climate change emergency. Having the chance to focus on this against these well-documented pressures must be a challenge, so how are you progressing towards the Net Zero targets?

Dave Sweeney: The NHS mandate, the legal requirement, was a help in terms of doing that from an ICB perspective cause there’s nothing like a good old mandate or some legal requirements to shake the system up. But more important is the way we went about it. Sack qualifications, sack where you sit in the hierarchy. Identify those people who were absolutely passionate about climate change, about net zero at the heart of those trusts and at the heart of those communities – work with the willing, work with those people who want to make a difference. We call it identifying the sparkly-eyed people. And it’s really worked.

And also, supporting the Trusts to have their own green plans and then generating a system green plan, we followed very tightly the governance of the ICB, and so we’re able to get that signed off at the highest level, and there is your mandate. Now, some were more visionary than others, and you can tell which ones were written by the trusts and which were written externally – they were brilliant but didn’t necessarily capture the heart of what was going on in that community.

Since then, we’ve done some great work baselining our carbon and making sure that we’ve got something that’s very measurable in terms of reducing that carbon footprint. We’ve got a sustainability board, and under that as a number of sub-groups that are doing some fantastic work. For example, in primary care, we’ve got some real, we call them disciples, advocates and ambassadors doing amazing work on things like inhalers.

Identify those people who are absolutely passionate about climate change, about net zero at the heart of those trusts at the heart of those communities, work with the willing – we call it identifying the sparkly-eyed people.
Dave Sweeney

VV: Who have you worked with in primary care?

DS: We’ve worked with a number of pharmacists and we were able to get a little bit of money to bring in a GP to give up the time to work on this for one to two days a week, and it’s that white coat alignment – having a medic speaking to medics is really important, and they bring a different message. When we’re turning from some of these inhalers, there’s a discussion now because the ICB’s strapped and the new carbon-friendly inhalers are actually far more expensive to buy, and then getting through all those GP patient lists to do to a review is a massive piece of work and you do need that medical input.

Isla Wilson is the chair of Cheshire Wirral Partnership and she’s absolutely 100% passionate and committed to net zero and social value. So we asked her to be our ambassador and Isla’s brought a huge amount of clout right at the board level. It’s a tactical, strategic approach to make sure that the leadership and the approach are really solid.

Karen Taylor: That is the way you have to go about it, through identifying your champions – your passionate people who will actually try and convince those naysayers. My role is to take that good practice and share it, to identify what is working and what’s not and why. No organisation can do this on their own because you’re so dependent on all the stakeholders or your suppliers. We know scope three is the really challenging area to reduce the carbon footprint and yet all of your organisations across the NHS will be using the same suppliers. It’s great that you’ve got this partnership across Merseyside and Cheshire. But others are forming them as well and learning how you went about it, and the best way to optimise the impact is where what we do comes in.

VV: Tim, where are things in Bedfordshire, Luton and Milton Keynes ICB?

Tim Simmance: We’ve got the standard things that we were mandated to do through NHS England in place, we got our plans in place and again, there’s also variety of quality across those. But in that process, we’ve uncovered a lot of individuals doing great things anyway, people who were just cracking on with things.

So we undertook a piece of work locally with a very bright and dedicated public health registrar to come work for us around the health impact of sustainability and look at our green plan and green plans across our patch to see if we were to enact this, what would the health benefit be or if we weren’t to do it, what would the health risk be?

My job is to help improve health. So it’s looking at it in terms of patient quality of care. If you had a pill that could reduce the risk of diabetes by 20%, we’d be going for it. Well, we do. It’s a low-carb diet. Similarly, if we could reduce strokes by 27%, we would do something about it. Well, we can, it’s about improving our air quality, getting air pollution down to World Health Organisation levels, that would enact that health improvement and suddenly people are switched on to it. People are saying actually, you know, this isn’t just some sustainability bod’s job, this is my job.

Going to our primary care practices and saying come and talk about environmental sustainability, they say they are too busy. If you go to them and say we can help you address your budgets, we can help you improve your quality of care for your patients, and we can help you improve your staff morale and your recruitment retention – suddenly they’re all ears.

Becky Jones: If you can provide that overarching framework that captures all of the work that’s already taken place, it enables people to come together and share best practice, but also then provides that evidence so you can really show – this is what we said we’re going to do, this is how we’re delivering it and this is our evidence. Then it links into the accountability and leadership. If you’re not accountable for anything, nothing’s going change or make a difference. By having that, it’s very much about co-producing. It’s not just about saying, ‘You will do this’. It’s about saying, ‘How do we all want to come together?’

I think Cheshire and Merseyside, where I work with Dave, is the first in the country to have an Anchor Assembly, which is chaired by the ICB chair, and it says you’ve signed up to this commitment as an anchor institution. You’ve agreed to pay the living wage, you’ve agreed to commit to delivering carbon zero, and you’ve agreed to use the NHS estate in the best way possible. So now tell us how you’re doing against that? And that’s accountability.

 There’s no point in us battling away with video consultations to reduce travel if our patients don’t like it, haven’t bought into it and aren’t engaged with it.
Tim Simmance

TS: The evidence piece is absolutely critical. You know, we talk about prevention being the panacea of all ills, and yet we need to see the evidence in order to show it. The ability to do that at local level is important, people have to measure their own improvement then find that ability to share that outwards and other people can then just pick and lift and then test out in their own system.

There has to be room for that testing, that engagement with industry, with people who’ve got those product ideas to get that evidence base to say it works, this is what it does. This is the carbon reduction, this is the financial benefit, this is the quality benefit.

And there’s co-production. There is a real role for our residents and our populations in achieving the net zero goal. There’s no point in us battling away with video consultations to reduce travel if our patients don’t like it, haven’t bought into it and aren’t engaged with it. Similarly, with inhalers, you know, you hear varying anecdotes of people saying it’s brilliant because it’s helping the environment and other people saying, I don’t like it because it’s a change, and I’ve not been engaged in that change. We really need to engage our populations and say this is not just about us trying to save money. This is not just about us trying to prop up a healthcare system. This is about you, your environment, your kids and your kids’ futures.

VV: What kind of barriers do you come up against when trying to progress on the sustainability agenda?

DS: In terms of some of the barriers that people may come across, there’s finance. The finance people in the NHS at the minute are trying to sort out the bottom right-hand corner, which is adrift. So there’s tactics. Our chair is talking about increasing the prevention spend, which is currently about 4% up to 10% over the next couple of years. We’ve got to think big picture in terms of how we do that. One of the things we were talking about is a carbon currency. When you say carbon currency to finance directors, all of a sudden, they listen. Evidence does show that if you save a gargantuan amount of carbon and energy, there is a fiscal value to that. But the bravery is that’s not just soaked up into trusts, soaked up into savings across the board. That’s an accumulation of potential prevention spend. That’s accumulation of social value that can plant trees that can do more in the communities. That’s where the leadership and the bravery is.

When you say carbon currency to finance directors, all of a sudden, they listen. Evidence does show that if you save a gargantuan amount of carbon and energy, there is a fiscal value to that
Dave Sweeney

TS: There’s a follow-on point here. Dave’s talking about internal arguments around the finance side of things in the carbon currency. But actually, and this points to what Karen’s been looking at in terms of that supply chain piece, there’s a danger that we look at this in a sort of transactional way. But we really should do it in that co-production way with our supply chains and say this is the direction we’re going, this is what we will want to be doing. There’s the road map from NHS England looking at this and, over time, we’ll move to a point where we won’t be purchasing stuff from organisations that aren’t also aligned to net zero goals. But we need to support our organisations in our supply chains to do that and look at that, and a carbon currency is one way of looking at that. One way of helping is to encourage people to think about that and starting to say, well, what is your footprint? At some point, we won’t be buying from people whose footprint is above a certain level.

VV: In Delivering Net Zero , medicines and chemicals in primary care are a big area of carbon emissions. What are you looking at doing in this area?

KT: The report we published was global because the pharma industry is global, and many of the big pharma companies who’ve made very ambitious declarations about becoming net zero by various dates – and they all have different dates – they are trying to do it globally.

One of the things that we do include in that report is the fact that the NHS has said it wants to be the first net zero healthcare system, and it will be stopping doing business with people who are not aligned with them, who don’t share their same ambitions and who can’t demonstrate what they’re doing to reduce their carbon footprint. It’s actually quite an incentive because it might be the first one to have declared that as a system, but many big healthcare providers are saying the same things. There is an initiative of the international hospitals to also drive this agenda. There’s momentum building at a bigger level than even just the UK. It’s about getting together, sharing, understanding, trying to take each other along, because the gains will be ultimately for the public and the health of the populations. Using those levers that you know can work.

When it comes to medicines, there are initiatives like Sustainable Medicines Partnership that are bringing together companies, governments, industry leaders and others together to try and help recognise and drive this agenda. And there’s a very big social element to that as well that a lot of medicines have a sell-by date on them that actually isn’t a real sell-by date. It’s a bit like the food that we eat. And if you look at the medicines, they are still very, very viable, but they get destroyed. At the moment, there’s a process whereby these are then actually shipped to developing countries where they can’t access the medicines, and it’s a sort of a tick in the box for accessing improving access to medicines. Now there’s suspicion around that, but it actually can be done in a very green and safe way. And so that’s just one small example of how you can not destroy all these medicines, which is adding to the carbon footprint, but use them for longer because we understand better how sustainable they can be for longer.

But the whole production of medicines takes a long time. You’ll be familiar with how long it takes to go through drug discovery and clinical trials – the average is about 10 to 12 years. There are now some initiatives like using AI in drug discovery that is speeding up that process very quickly, so enabling the pharma companies to reduce their carbon footprint by speeding up that process where they’re trial and error, that adds to the carbon footprint.

Having said that, though, many of the drugs on the market today will have been developed 12 years ago and, therefore, will have an associated carbon footprint that maybe today you can change easily by using green chemistry, green labs and green manufacturing processes. But it’s that shift, and it’s a very expensive shift for companies to actually engage in. And you’ve got to take your regulators alongside.

The NHS has said it wants to be the first net zero healthcare system, and it will be stopping doing business with people who are not aligned with them, who don’t share their same ambitions and who can’t demonstrate what they’re doing to reduce their carbon footprint. It’s actually quite an incentive.
Karen Taylor

BJ: In order to make the decisions in terms of procurement and what we buy from the supply chain, you need to start at the beginning, and I think the NHS always goes to the endpoint. If you have an ethical framework across the system and there’s something that’s coming in, and it’s more expensive but it’s got a lower carbon footprint, and it is within the ethical framework to make those decisions, then that will start to change the way people purchase.

NHS England looks at social value through procurement, the Procurment Policy Notice 6/20, and it’s very much at the end of when you’re working with people. How are you going to measure how they deliver on their contracts if you, as a system, don’t know what your social value is? How on earth are you going to expect people to deliver on their contracts as a part of that? We need to stop looking at the endpoint and look at having those ethical frameworks, those definitions in place. And so I’m working in the Social Value Network doing that.

VV: What projects are happening on the ground in your ICB area that you can tell us about? Do you have a fleet of electric ambulances?

TS:  You mentioned electric vehicles – they’re not electric ambulances, but we have electric bikes. We’re part of Making cycling e-asier. We’ve got one of our hospitals trialling e-bikes for stuff. It’s helping people think, actually, I can do active travel, I can change my behaviour around this. So I think those sorts of initiatives are the poster child of what we’re doing.

There’s also a similar project going on in one of our other acute hospitals in Milton Keynes around bringing to people’s awareness the energy use of a building right down to what’s happening in a particular room. Milton Keynes hospital is able to show a digital twin of their building so that people can see and realise the impact their behaviour changes have on energy use.

It’s those things that are really going to drive the behaviour changes that we need. Yes, there’s big amounts of carbon locked up in building decarbonisation, in supply chain, in travel and transport. But the reason we’ve got those in the first place is people were unaware of the impact when those things were put in place. Whereas now, if you get people aware of those embodied carbon things now, our future developments will avoid embodying that carbon in our process.

From April this year, we have net zero mandatory training that’s built in our ICB and I understand it’s being shared more widely across the NHS
Dave Sweeney

DS: Going back to Tim’s early point, there’s a vast amount of local projects that are going on without people necessarily knowing about it. We’re trying to harness all those kinds of things. One of the things that I was really proud of this year was making the case for mandatory training right across NHS Cheshire and Merseyside, and it was 100% signed off. From April this year, we have net zero mandatory training that’s built in our ICB, and I understand it’s being shared more widely across the NHS. It was a huge step forward for us in terms of getting that message out.

As part of the sustainability group, we have trusts buying into clean vending machines and proactive work around that. We do have the first electric ambulance – Steve Rotheram, our Metro Mayor, went to see that –  and there’s more to come.

There’s a big clinical waste project that’s being driven by one of our hospitals. The amount of waste that can be recycled and used effectively in other areas is massive. That’s one leader in one trust who’s been working with people in the private industry that are coming up with these great technical modifications, and we’ve bid for the money to pilot it, and if it does what it promises to do, it’ll be a gargantuan step forward for us.

Some of the targets are massive. If you look at the net zero 2040/2045 targets, it’s really scary for people, so you’ve got to set milestones. We said we’re going to be 100% LED by the end of 2024. And within that, there’s a potential for a massive procurement. It’s only lighting but with the potential of a 10-15% social value weighting across that mass scale. So people are signing up to these smaller milestones.

VV: We have mentioned finance and a carbon currency – making that case for the economic benefit of sustainability work. Do you feel that there needs to be more channelled towards this?

DS: It’s very poignant at the minute. As soon as any funding comes out, the likes of me, Tim, Becky and the whole world bid for it, and it’s just a nonsense. It’s a waste of our time. It’s a waste of everybody’s energy when, realistically, we know exactly where it’s already going. It is just a waste of time, and I would stand up in front of any minister and say that. If you want to do something, call it levelling up, I don’t care what you call it – whatever the capital is for innovation and testing methodologies and testing new tech, it has to come with some kind of financial incentive. We know there is waste, but everything we do is on a sixpence. We beg, borrow, steal from anywhere, but that big national dangling of the carrot for X amount of million is a waste of time because it goes absolutely nowhere when you filter it out across the patch. Let’s pick areas and really test these methodologies. Put some money in innovation and tech, test and roll out. If it saves a huge amount of money, and it’s brilliant for the environment, roll it out, mandate it, but the dangling of the carrot and the waste of people’s time in terms of putting huge bids in, I don’t think he’s helpful at all.

That big national dangling of the carrot for X amount of million is a waste of time because it goes absolutely nowhere when you filter it out across the patch
Dave Sweeney

TS: I have a nuanced version of that – what we do is we reward the people who’ve either got something readymade, or you’re rewarding people who’ve got really good bidding teams. If you look at the whole of the UK – where are we going to make the biggest dent for the smallest amount of money, relatively, in our national footprint from a sustainability point of view, not just the carbon point of view? I think that would be a more useful approach to avoid those risks of people feeling it’s been channelled down to a favourite location, a place that always seems to get in the news rather than those backwaters.

There is something about that long-term costing out of what we think this is going to cost, and how do we then, as a country, finance that over time? Because otherwise, we’ve just got our fingers crossed that there will be money available. We don’t know, we haven’t got a clue. When you come up against arguments saying we don’t have the money to do that or we’re focusing on efficiencies this year, go away and come back again next year, you kind of think, well, is the same going to happen next year? We need that long-term plan and finance plan for us to feel like this is definitely achievable.

BJ: I wanted to speak up on something around the finances but from a slightly different perspective. I used to work in local government, which used to and still does long-term planning. But it’s not about the finances; it’s about the people, and you know it’s always short-termism, and if you get it wrong, your job is gone. The culture in the NHS is set up from that perspective – it’s very much last-minute decisions, and everything has to be done in a rush. You don’t get the time to do that long-term planning.

VV: Can the NHS achieve its target? Will it achieve its target, and what might get in the way?

BJ: Will we achieve it by 2040? No, I don’t realistically think so because there needs to be fundamental change made in how systems and processes are delivered from a people perspective because the people run the processes. If you can do that, if we can make these fundamental changes, if we can allow people to look long-term rather than having these short-term consequences, that’s how I think it will be possible. By working together, system working, putting frameworks in place for all of the best practice that’s taking place and allowing people to innovate and to do things differently.

Will we achieve it by 2040? No, I don’t realistically think so because there needs to be a fundamental change made in how systems and processes are delivered from a people perspective because the people run the processes
Becky Jones

DS:  It can. And it will. I’m coming from this positively. I understand Becky’s points, culture and leadership and that short-termism is what will get in the way. But I’m seeing a crack. I’m seeing a bit of the old Dementors and the mood Hoovers and the tyre-kickers moving to one side. Young, energetic people like Becky are coming through and really challenging the Zeitgeist and the old ways of working. In the next five years, we may have a change of government – who knows?  I think there will be a seismic change. So that’s why I think we will. If we don’t have that seismic change, we won’t. But I can see a revolution coming.

KT: I think it can. It’s not just the one initiative. All the time we’ve been talking, I’ve been thinking if we could only expedite and accelerate the digital transformation of the NHS and get that data layer where you know what’s being spent, where it’s being spent, how much things are costing, how much your operating theatres are costing you at the moment and having that really act good data, you can accelerate a lot of these things because you can demonstrate the real improvements that are made.
And the benefits cut across so many different areas, and it’s harnessing all of those minds that are working towards the same end but through different means and trying to get them aligned. I think it can, but there is a cultural issue, but there are the millennials and Gen Z who are really committed and believe in this whole movement, and they’re the ones to harness.

TS: So can it? It can? It’s possible? Will it? I think we will be close. If we don’t achieve it, I think we’ll get pretty close. And I think the bit that’s been alluded to is that cultural piece. But wider than that, it’s a fundamental societal shift. If I take the example of electric vehicles, that’s a like-for-like switch that doesn’t address our environmental sustainability and allows us to continue working and living in exactly the same way, just with a slightly cleaner conscience, and I think there needs to be a fundamental shift in the way that we deliver. Digital transformation is one way that we need to be thinking about this, you know?

Not over-medicalising everything from a public point of view is also important – seeing that I have a fundamental duty as a person to look after myself. Those things are going to be needed to be part of our cultural shift as a society. But the link between environmental sustainability, health and finance is starting to creep into people’s conversation. It’s not just people with beards and long hair that do stuff on sustainability anymore. It is coming. We’re at the peak of something, and we’re suddenly going to shoot down the roller coaster.