Climate change is a health emergency and along with challenges around workforce, health inequalities and winter pressures, system leaders must also work to meet the net zero target by 2040. Healthcare Leader provides an overview of the current state of play
The NHS has done major work on reducing its impact on climate change but achieving net zero by 2040 is still a stretching target. Now the sustainable and efficient use of resources is one of the triple aims of ICBs. So, as they start work, what does that mean for primary care in terms of the environmental impact of the NHS?
The NHS is a major contributor to England’s carbon footprint. In 2021, research published in The Lancet estimated it was responsible for 7% of the UK’s carbon emissions total for 2019.
The health service is making progress; that’s a reduction of 26% since 1990.
But NHS England’s Greener NHS programme estimates that the health service is still responsible for 40% of public sector emissions.
Sarah Walter, Director of the NHS Confederation’s Integrated Care Systems (ICS) Network says: ‘The climate emergency is a health emergency and system leaders recognise that they have a significant role to play. They will be doing everything they can to support NHS England’s ambition of becoming the world’s first carbon net zero health system.’
The national targets include reducing the NHS carbon footprint, for the emissions the NHS controls directly, to net zero by 2040 and reaching net zero by 2045 for emissions the NHS can influence or what’s termed the NHS carbon footprint plus. This chiefly covers energy generation and the supply chain. Interim targets call for an 80% reduction in directly-controlled emissions (the NHS carbon footprint) by 2028 to 2032. For emissions the NHS can influence (the footprint plus) it’s an 80% reduction by 2036 to 2039.
Ms Walter says: ‘Sustainability is a key priority for Integrated Care Boards (ICBs), who are taking a whole systems approach and working with local partners including primary care colleagues across a range of areas, from making the supply chain greener to reducing the environmental impact of services by utilising new technologies such as remote consultations to reduce the carbon footprint of patients.’
King’s Fund senior fellow Chris Naylor says, although the NHS is an international leader in having a net zero commitment and plan, ‘My fear would be that at this moment, when the NHS is really struggling to recover services post-pandemic, the net zero commitments, although in theory they’re a national priority, they’re not going to be one of the things that are really prioritised.’
‘Real progress on net zero requires national leaders continually ‘reinforcing the message’ and giving ICBs the tools they need to do the job,’ he adds.
‘ICBs need more training and support on carbon measurement and carbon reporting so that they can track the progress they’re making. There needs to be training and support for clinical leaders and service managers closer to the frontline,’ Mr Naylor says.
‘Some of this is about giving frontline staff the permission and the skills that they need to make changes to the way they go about their work and then measure the impact of that in terms of sustainability, as well as in terms of quality and cost of care.’
The 2020 Delivering a Net Zero NHS report revealed primary care’s biggest footprint is in medicines and chemicals, then buildings, medical equipment, business services, patient and visitor travel and staff commuting.
Ms Walter said: ‘One area, where progress is already being made is on reducing carbon emissions from the prescription of inhalers, a significant contributor to overall NHS carbon emissions.’
Metered dose inhalers represent 3% of the total. Dr Aarti Bansal, founder of the Greener Practice network, a grassroots group that supports sustainable primary care, says: ‘In the UK, we’re an outlier, using far more metered dose inhalers than the rest of Europe. They contain very powerful greenhouse gases [hydrofluorocarbons] used as propellants to deliver the medication. And there are alternatives, dry powder inhalers that don’t contain these propellants. Their carbon footprint is much lower.’
That’s why many ICBs see improving asthma care as a potential big win for cutting emissions. In Suffolk & North East Essex, the medicines management team has changed the formulary to favour dry powder inhalers.
Andrew Urquhart, Suffolk and North East Essex ICB sustainability lead, says over the past few months training sessions have run evey week, so that every practice understands the change. ‘The next stage now is rollout to the general public, with leaflets and public facing material. We’ve discussed that with some of the patient groups to get their opinion: is the language right?’
It’s important to work with patients and practices. ‘What we mustn’t do is to send everyone a letter saying right, we’re switching your inhaler. The way to do this is to be clinically led in terms of patient reviews,’ he says.
But it’s not just about cutting carbon, he adds. ‘The greenest inhaler for patients is the one that they’re best at using. That’s about checking their technique, checking are they willing to swap? It’s very much a two way discussion.’ Community pharmacies provide a new medicines service, so patients can go and have their technique assessed and understand how best to use their inhalers. They are developing a safe disposal scheme to avoid releasing the propellant.
Dr Bansal, also net zero GP lead for Humber and North Yorkshire ICS, says: ‘There are lots of good clinical reasons why somebody might prefer a dry powder inhaler because they don’t require plastic spacer devices which people find cumbersome to use.”
She adds: ‘In the UK we have some of the worst asthma mortality in Europe. Some of that is because patients are over-relying on the reliever medication that they take when they have symptoms.’ Encouraging people to take their inhaled steroid correctly would improve asthma control as well as cutting emissions.
Grassroots action is important. But working towards net zero also demands leadership. Yet sustainability leads are not one of the mandated ICB board roles.
The Greener NHS programme states that ‘trusts and integrated care boards (ICBs) will meet this new duty [to hit net zero] through the delivery of their localised Green Plans, and every trust and ICB in the country now having a board-level lead.’ But that doesn’t mean a dedicated sustainbility role; in South Yorkshire, the director of strategy and partnerships has the board-level responsibility, while the sustainability lead is a programme director.
Healthcare Leader found a mixture on the ground. Some ICBs had identified sustainability leads. Some wrapped sustainability in with other responsibilities, such as the assistant director, communities. Others referred to ICS sustainability leads; Hertfordshire & West Essex pointed to their ICS chief finance officer.
Some are yet to appoint: a spokesperson for NHS Lincolnshire ICB said they had interim arrangements, were not able to confirm a name currently, but were taking ‘a system approach with partners across the system’.
Clearly, it’s early days. But sustainability leads say that, in any case, the role has to be about enabling, rather than enforcing. South Yorkshire ICB’s Katrina Cleary, Sustainability Programme Director, says: ‘Our role is very much to support and facilitate. It’s not for us to say what you must do, we want to know what you’re doing and we’re going to performance manage it.’
Mr Urquhart, Suffolk and North East Essex ICB sustainability lead, agrees. He wants people to see net zero as part of their own roles. ‘Everyone’s busy. You don’t want them to think, we’ve got a sustainability officer, job done.’ His job is to support people to incorporate sustainability into every every activity.
‘That starts right from day one for new ICB staff. Sustainability features in the induction, outlining the net zero targets. But there’s also work going on to include sustainability in objectives. For someone in IT, that could be related to ‘how do we reduce our digital footprint?’, Mr Urquhart says. Perhaps contributing to a campaign to encourage people to turn their laptops off overnight, working with the communications team. That could double the life of the devices.
It’s not just joiners. There is mandatory training for existing employees; an online course from Health Education England and the Centre for Sustainable Health Care, which takes just 40 minutes.
Commissioning is a key focus. The ICB is working on a sustainability impact assessment for procurement, ‘which means that the concept of net zero and social value is more formally involved at the beginning of a project’. Mr Urqhart is working with the procurement team on the assessments, to live up to the central NHS England requirement for 10% of the weighting for procurement to be on net zero and social value The assessments should be ready for October. But he’s keen to stress that 10% is a minimum.
Management of existing contracts is also important: ‘The green plan will be looking for year-on-year performance improvement. In the past people may have bid for a contract and said, we’ve got a great [green] plan. Actually, does anyone drill into that? Where’s the accountability? What’s the impact of that plan?’
South Yorkshire ICB’s board is looking at the sustainability three-year plan and annual delivery plans at the September board meeting. Inhaler use is a priority here, too. Ms Cleary says: ‘We’ll be expecting every practice to make an improvement from last year.’
There are a wide range of projects. ‘We are piloting a number of specific initiatives with practices and PCNs which ranges from inhaler technique to engaging with patients in communities to use local allotments to plant vegetables.’
Nine schemes, including weekly practice health walks, will be evaluated in September. ‘We then want to share that widely across all the practices, to increase enthusiasm and demonstrate that actually we’re making it easy for these folks to do the right thing.’ The projects were funded by a small pot of £5,000 each, to free up clinical time.
Ms Cleary says to engage clinicians, ‘it’s important that we make clinical sense, that we demonstrate an evidence base’.
She wants to demonstrate working towards net zero doesn’t have to be a burden: ‘I appreciate that you don’t want me adding to your daily grind. I need to be showing you that the alternative is a better working option, or certainly not a worse working option.’
PCNs in Sheffield are exploring community activation – working with a company to help them act in partnership with their communities to understand what’s important to them and engage them in wellness, rather than merely illness.
Ms Cleary says: ‘We want to explore how that could be a model, moving forward with all our 31 PCNs. We need to recognise that it is not going to be one size fits all. In our most multicultural commmities, we might need to engage with different community leaders like faith leaders and different charity organisations than if we were working in one of the more leafy suburbs in our patch.’
The ICB is also keen to work with the Greener Practice Network to promote its asthma toolkit. This provides step-by-step QI projects for improving asthma care, with downloadable resources, educational videos, templates and patient information.
Another area of interest is shared medical appointments for long term conditions. A group of patients with a common diagnosis coming together. It frees up appointment slots, promotes education and peer support and shared learning. Shared appointments can happen online, cutting down on travel.
ICBs may be keen to tackle carbon emissions. But Ms Waters says they need support. ‘Climate change is a crisis and system leaders are addressing this as a key priority. However, not everything is in the NHS’s own hands: ICB leaders still need the tools to go further and faster. Modernising NHS estate, in primary care as well as other settings, will play an essential part in reducing the NHS’s carbon emissions – a much needed increase in capital funding would go a long way to enabling system leaders to deliver the change that is needed.’
As so often, good intentions need to be underpinned by sufficient funding. It remains to be seen whether that will be possible, in a world where primary care is often overshadowed by the acute sector.