Chapter 3: Increasing the efficiency of NHS estates

To meet its ambition of becoming the world’s first net-zero health service by 2040, the NHS must decarbonise its many buildings, reaching an 80% reduction in emissions between 2028 and 2032.

According to the NHS’s sustainability plan, Delivering a ‘Net Zero’ National Health Service, the NHS estate and its supporting facilities services – including primary care, trust estates and private finance initiatives – comprises 15% of the total carbon emissions profile.

At the time of the report’s publication, there were approximately 7,000 GP practices in England, spread over some 9,000 buildings. Total emissions for the primary care estate were 167 ktCO₂e in 2019.

Developing a consistent plan for decarbonisation is no small challenge; the NHS estate comprises 217 trusts all with their own individual green plans, while many independent contractor GPs own their premises or rent them from private landlords. The May 2022 Fuller Stocktake reported that only 14% of premises are owned by NHS Property Services (which also has a Green Plan), with the majority owned by GPs and the rest by third parties.

NHS strategy suggests that reducing emissions from the primary care estate will involve new and upgraded buildings; optimisation of building usage; onsite generation of renewable energy and heat; national electricity carbonisation, and research, innovation and offsetting.

It suggests rather vaguely that ‘additional resource will be required to support older primary care buildings across England to become more energy efficient’.

Specifically, the Net Zero report calculates that:

• engineering interventions such as improved building insulation, lighting and heating could save 59 ktCO₂e annually.
• improvements to building instrumentation and energy management could save 34ktCO₂e annually.
• the installation of photovoltaics and heat pumps could save 7ktCO₂e annually.

An estimated 40% of primary care’s emissions footprint is due to non-clinical carbon from the running of the practice including energy use, which is a major emissions hotspot.

Financial and carbon savings

Funding streams for secondary care decarbonisation include a £50 million NHS Energy Efficiency Fund to upgrade lighting across the NHS estate, and an upfront investment of £259 million for socio-technical interventions to optimise the way the health service uses its buildings. Trusts also have access to national public sector decarbonisation schemes.

Significant investment can result in impressive results. For example, a £105.9m investment by Greater Manchester Mental Health will result in the country’s first all-electric mental health unit later this year. [See case study]

Many carbon reduction measures also create substantial savings and rapid paybacks. But when it comes to GP-owned premises in primary care, few of the pledged decarbonisation actions are within the NHS’s direct control or budgets. Here, the role for ICBs is to encourage and enable GPs to make decarbonisation a priority and to invest in their own premises.

Engaging general practice

Indirect motivation for GPs to do so may come from the increased emphasis being put on sustainability by both the Care Quality Commission, which has added environmental sustainability as a new area of assessment, and the GMC. In Good medical practice 2024, the latter sets a specific duty that medical professionals should choose sustainable solutions, providing these don’t compromise care standards.

However, by way of practical help for current practices, Delivering Net Zero simply signposts free support in the form of the Green Impact for Health Toolkit, produced by the RCGP and the educational charity SOS-UK; this provides comprehensive guidance on available emissions reductions interventions.

Its latest iteration was relaunched in February 2023, and by December, 852 practices were registered users. Since the initial tool’s development in 2014, more than 21,000 positive impacts have been undertaken general practice teams.

A key resource is the toolkit’s RCGP Net Zero Hub which contains practical resources for general practice, covering all elements of sustainability. Estates-related offerings include a free guide to decarbonising general practice net zero action plan for non-clinical emissions and related e-learning that has been used by more than 700 people since its launch.

In addition, the toolkit’s Net Zero service matches practices with a trained adviser who will work closely with its team to develop a decarbonisation plan; however this comes at a cost of several thousand pounds which may deter some practices from using it.

Concerns around costs are understandable, but may be short-sighted warns retired GP (and former RCGP president) Dr Terry Kemple, who leads on the Impact toolkit: ‘If you think net zero’s going to cost you lots of money, it just means you’re not doing it properly,’ he says. ‘If you cut down on waste, overuse and so on, you’ll save money.’

Free decarbonisation plans

In light of the cost issues for GPs, Allison Sathiyanathan, net-zero project manager for Lancashire and South Cumbria ICB, has tapped into local funding to provide practices in Lancashire with a valuable service.

She discovered that independent contractor GPs, as small private businesses, can access a Chamber of Commerce (CoC) scheme which provides eligible organisations with tailored carbon reduction plans. The initiative is funded by Lancashire’s district council making it free of charge for recipients.

This benefits both the CoC, which needs to make contact with local businesses, and the ICB, supporting its decarbonisation efforts. ‘There must be 150 GPs as well as the pharmacist, dentists and ophthalmologists and I am able to connect them,’ says Sathiyanathan.

The process will begin in May with practices invited to awareness sessions. At these, they will be able to sign up for a free decarbonisation plan, involving a visit from specialists who have been briefed on the elements that differentiate practices from other businesses. Preparation will be required in advance of the audit to get the most out of the visit; for example, scrutinising bills and surveying staff about their work-related travel.

‘They’ll be looking at the standard things such as energy and waste, but also at inhalers and working with our medicines management team,’ explains Sathiyanathan.

The resulting ‘stocktake’ will reveal practices’ current carbon footprint, broken down by all the different aspects, and provide a carbon reduction plan, including tailored guidance. ‘For example, it might say that your building needs insulation or would benefit from solar panels; these are your particular options for getting to net zero,’ explains Sathiyanathan.

‘We’ve got four practices doing the pilot this month to make sure that the audit is sufficiently specific for GPs. These participants can then spread the word to their peers.’

A follow-up visit a year on will evidence each practice’s carbon reductions (or for those too busy to accommodate this, there will be a tool to help them measure progress themselves). The ICB will also receive an overview report, helping it to highlight where it should focus its efforts over the coming year.

The kind of green interventions the audit may prompt include practical ways to save energy; for example, through installing LED lighting, insulation and solar panels.

While GPs may opt to invest in these themselves, support from other sources may be available to them as private businesses. In Somerset, for example, Frome Renewable Energy CoOp installed 560 solar panels (equating to 150kw) on the roof at Frome Medical Practice free of charge. ‘It’s a collaborative, community approach,’ says GP, Dr Helen Kingston. ‘We then pay them for the electricity that’s generated. We are able to use as much as we need and the rest gets exported.’

Sathiyanathan is always on the lookout for national and local funding opportunities across sectors.

‘Our trusts won £1 million in LED funding through National Energy Efficiency Funding,’ she says. ‘I fed them the opportunity through the newsletter and they applied. However, she adds that public sector funding is often vastly oversubscribed.

Meanwhile, ‘for local funding you need to look locally so that’s why it’s important to link up with anchor organisations and resources like Lancashire Climate Action Network,’ she continues. ‘That’s what my job is all about.’

Help can even be found closer to home. Sathiyanathan explains: ‘One of our ICB tech colleagues has designed a training package for GPs that advises on things such as switching screens off, not charging your laptop unnecessarily, and even sending links instead of attachments; they use up data and that uses energy.’

Simple behavioural changes

Small behavioural changes, in line with the energy hierarchy, can have an important overall impact on decarbonisation. This urges us to be leaner (use less energy), keener (use it efficiently), greener (choose renewable) and cleaner (opt for low-emission energy) – in that order. ‘Meaner’ (high-emission energy) should be a last resort.

For example, in secondary care, operation TLC (‘Turning off equipment, Switching off lights, and Closing doors) reduced carbon and saved £500,000 at Barts Health NHS Trust. It’s estimated that expanding this model across the NHS could save up to £45 million and 200 ktCO₂e per year.

‘Make every kilowatt hour count,’ agrees former GP, Dr Matthew Sawyer, who runs an environmental sustainability consultancy, advising on issues facing healthcare. He has worked with the Centre for Sustainable Healthcare and Greener Practice to deliver a green plan for primary care for South East London ICS – one of very few that focus directly on the sector. His book, outlining practical ways for primary care to approach sustainability, is due to be published later this year.

‘I did an energy survey at a practice which had five fridges, each worth about 5% of the practice’s annual electricity bill,’ he recalls.

‘One was only used by two secretaries who were happy to put their lunch in the downstairs fridge. The practice also had three drugs fridges: one empty, another containing two small things and a third half full. During flu season, they need all three fridges running, but for the rest of the year, they could consolidate it down to one.

‘There are many simple things you can do to reduce energy,’ he continues. ‘Walk around your surgery and see how many printers are on 24 hours a day; check how many lightbulbs you’ve got; turn radiators down in the corridors.’ He adds that moving to a supplier that uses renewable energy sources may save carbon and costs.

‘With all these actions you’ve saved money rather than spending it,’ says Dr Sawyer – advising GPs to put these savings into a green practice investment fund to finance further sustainability efforts.

Meanwhile, for practices that don’t pay their energy bills directly, he would like to see landlords incentivising GPs to reduce their energy; ‘for example, for every £100 you save on energy, we’ll reduce your service charge.’

Developing green spaces

While energy is a clear priority for decarbonisation activity, better use of outside areas is an opportunity for practices to increase useable space, improve climate resilience and enhance biodiversity. This is also part of the wider strategy for NHS Property Services in its own Green Plan.

Again, simple, inexpensive interventions can have outstanding results. For example, in Yorkshire, Dr Sawyer explains that a nearby practice turned an ‘unloved bit of concrete’ into community asset for the kingly sum of £100. Staff and family helped clear the area, sourced reject plants going cheap at the supermarket and added a picnic bench.

Suffolk and North East Essex ICS has been working with NHS Property Services and Community Voluntary Services Tendring to develop a community garden at the Kennedy Way Medical Centre in Clacton. This is part of the NHSPS’s national Social Prescribing Programme.

Sustainability lead Andrew Urquhart says: ‘The project was created by my colleague Jane Taylor and the [resulting] green space, with raised beds, a men’s shed and vegetable growing is a fantastic example of what can be done relatively inexpensively. It’s about nature and biodiversity, and we’ve interlinked it with our estates strategy. We’re replicating it now; a second GP practice in Abbey Field, Colchester, has done a similar thing. 

‘The catalyst there is that the practice manager could see the value of it. We’ve got those passionate individuals who can make a difference. My ambition would be to have one of those in every GP practice across the land.’

He emphasises the value of forging partnerships, harnessing enthusiasm, creating case studies and supporting replication to get healthcare sustainability projects of all kinds underway.

‘Tap into the path of least resistance; some people will trailblaze and inspire others. Our green champions are talking to practices they know across our patch and we’re starting to see that domino effect.’

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