When you consider the impact of the NHS on the environment, ‘travel and transport’ may not be a contributing factor that immediately springs to mind.
But official statistics show there are more than 9.5 billion NHS-related road miles per year in England which makes up around 3.5% of all road travel, contributing some 14% of the health service’s total carbon emissions.
Staff, visitor and patient travel also negatively impacts on air quality, and an economic impact figure of £345 million has been estimated for the potential mortality effects and costs to society of air pollution from NHS-related travel. Approximately 4% of the NHS’s emissions relate to business travel and fleet transport, 5% to patient travel, 4% for staff commutes and 1% for visitor travel.
Specific ways to address these emissions range from practising increased preventive medicine and reducing health inequalities – so that many chronic illnesses can be avoided altogether – to running zero-emissions ambulances and electrifying the rest of the NHS fleet.
When it comes to vehicles that are directly owned and leased by the NHS and its staff, emissions total 1,000 ktCO2e per year. In its Net Zero travel and transport strategy, published in October 2023, the health service pledged to decarbonise its full fleet by 2035, with its ambulances following in 2040. It also promised that, by 2033, staff travel emissions would be reduced by 50% through shifts to more sustainable forms of travel and the electrification of personal vehicles.
Its strategies emphasise that adopting active transport can have health co-benefits for staff. Shifting away from cars and towards cycling, walking and public transport decreases air pollution, improves physical activity and increases access to care for patients. This represents potential savings of around 461 ktCO2e per year across the NHS.
And changing where healthcare is delivered through providing consultations by phone or online can also reduce ‘care miles’ and therefore a reduction in the emissions associated with patient travel.
Practical interventions that individual employers might make, include promoting and enabling active travel for their staff (and patients), providing e-bikes and related apps, installing cycle racks and facilities for showering, and giving car-parking priority for those who are car-pooling. Patients might be offered digital appointments where appropriate and even shared appointments.
Collaborative working
As with most of the sustainability work set out in NHS decarbonisation strategies, the majority of the guidance and funding around travel and transport initiatives is targeted at secondary care. Progress in primary care relies on ICBs’ ability to motivate and support GPs and other primary care professionals to initiate and pay for specific interventions, as well as building strategic partnerships with a wide range of local and national authorities.
After all, creating cycle lanes or improving public transport can only be achieved in collaboration with other bodies – from local councils to the Department of Transport.
The complexity of the situation is highlighted by Frank Swinton, a consultant anaesthetist and climate change lead for West Yorkshire Health & Care Partnership. He stresses that regional, cross-boundary working – where sustainability is treated as a strategic issue to be built into all decision-making – is essential to achieving the NHS’s net zero targets. And managing this is slow and challenging.
‘We’re doing a lot of work with the local authorities and the combined (mayoral) authority here in Yorkshire to look at how we manage that together,’ he explains.
‘So, for example, we invested some money for GP surgeries to install bicycle parking to try and promote active travel, but very few people travel this way because they feel the roads are too dangerous.
‘And then there’s a piece around “are the roads actually too dangerous? Is that real or perceived? Are there things we can to do make the roads better? Are there things we can do around driver awareness? Are there things we can do in terms of hard infrastructure?”.’
‘All of those things are happening. But because it’s so complex, it’s not easy to give little nuggets of “we’ve done this; and cracked this”.’
He adds that while it’s mandated that the directly owned NHS fleet should be moving to electric, this raises issues around the cost of related infrastructure.
‘Who’s going to pay for charging infrastructure? And where is that going to be? Each motorway-style rapid charger is around £100,000 and needs a 350kw supply.
‘Also, many hospitals around here are at capacity for their electricity supply, so in order to put in extra chargers at 350kw you’d need new bigger bore copper wires from the grid and that’s millions of pounds as an infrastructure investment. And the smaller GP practices and pharmacies don’t have anything like that bandwidth of power supply.
‘So there’s a whole other complex nightmare around that; which great people are working on locally and nationally.’
Nudging behaviour change
When it comes to addressing travel and transport issues with primary care staff and patients, the approach should also be collaborative – encouraging people to change their behaviours, and then striving to accommodate their preferences.
As former GP and environmental consultant Dr Matthew Sawyer explains: ‘It’s an influencing role in many cases, rather than having any direct control, but there are things you can do such as creating space for bike racks, and so on.
‘However, would I put in bike racks without asking anyone first? No. Ask people the question “how would you like to travel” And then think “what can we do as can practice or ICB to encourage and enable that behaviour?”. Just by nudging people, you can make a difference.’
Dr Sawyer points to Hull’s People’s Panel, which, in July 2021, asked participants: ‘How do you currently travel to your GP practice’
‘Almost half (44%) said they drive,’ reports Dr Sawyer. ‘They then asked how they’d like to travel. The number who wanted to drive fell by 25%. So, how can we enable that?’
As with so many sustainability interventions, very simple things can help.
‘If you go onto a practice website and type in “how to find us”, at the top, it will inevitably give details about where the car park is situated; it may not even mention buses, bikes or walking. Just swapping those details around can make a difference.
‘For example, saying, “most of our patients walk and this is how long it takes to walk from the bus stop or town centre”; or pointing out that there are bicycle racks for patients, adding, right at the bottom, that you have a certain amount of limited car parking space.’
Where staff and patients do indicate that they would like to take up active travel options, local funding can sometimes be identified to support this.
For example, Allison Sathiyanathan, NHS Net Zero project manager for Lancashire and South Cumbria ICB, sourced local funding for EV chargers. ‘I had to find that myself and recognise that, as small businesses, practices are eligible to apply,’ she says.
She also identified funding for practices through Active West Lancashire, run by Lancashire County Council, signposting the opportunity to GPs through the ICB’s newsletter and website.
‘It was relatively easy to access and totalled £32,000 between nine practices,’ she explains. ‘That’s gone towards encouraging practice staff and the public to use alternative transport to get to the surgeries; some health centres have provided shower facilities to encourage people to cycle. It’s about trying to get people enthusiastic about these things so that they replicate the initiatives.’
For example, the grant has enabled the Tarleton Group Practice in Preston to buy two e-bikes for doctors to use on home visits. ‘We’re doing our bit to reduce our carbon footprint and the traffic congestion in the village, and at the same time providing much needed fresh air and exercise to our clinical team – give us a wave if you see us!’ the practice posted on Facebook.
Digital appointments
Cycling or walking to health centres is much better for the planet than some of the carbon-guzzling alternatives; but digital communication sits at the top of healthcare’s sustainable transport hierarchy. This is followed by walking and wheeling; cycling; public and shared transport; electric vehicles and car sharing, and ICE vehicles and car-sharing.
It should be understood, though, that digital is only the best option where it is also most appropriate for patients.
‘And there is still a footprint from digital; it’s just far less,’ points out Dr Sawyer. ‘Its use is all about appropriateness. I don’t think digital is suitable for everybody, all of the time. We need to be looking at what’s better for patients and patient outcomes as well as for practices.’
He predicts, however, that workload pressures in primary are likely to open the door to increased use of digital – including artificial intelligence for differentiating problems: ‘The question to ask is “how do we design a service for those who suffer the most inequalities?” If we get it right for that group, we get it right for everybody else. A third of people in the third quintile don’t have a car. So, we should be providing a service that doesn’t need to be driven to.’
Patient-centred care
Digital exclusion is an important issue that needs to be factored into transport-related decisions; a point that has been recognised by Andrew Urquhart, sustainability lead for Suffolk and North East Essex ICS.
‘About two years ago, we commissioned Health Watch in Suffolk and in Essex to do two big bits of work on digital exclusion for patients; that’s been the bedrock of digitalising appointments and deciding what we may or may not do,’ he explains.
But he attests that where tech is used appropriately, it can have some highly positive outcomes on multiple levels.
‘We’ve been doing a teledermatology project with primary care where the output wasn’t around carbon reduction but the best outcome for the patient. It involves using a mobile phone app; an individual takes a picture of their skin lesion, the GP looks at it, and it’s used to triage the patient through the system.’
While he acknowledges that digital care models can be a thorny issue – ‘and are not going to be right for everyone’ – they can improve care for patients.
‘With the dermatology initiative, we halved the number of patient journeys, reduced the number of road miles and sped up the patient through-put. But our focus was ‘what’s best for the patient’. We actually found that people don’t want to be travelling back and forth to appointments; they find that stressful.
‘We’ve done other work using remote monitoring for atrial fibrillation and, in acute care, we did a project with Macmillan and a couple of providers in one of our hospitals around the ‘prehabilitation’ of cancer,’ continues Urquhart.
‘Once a patient has received a cancer diagnosis, they can use an AI-generated digital app to encourage them to keep active and exercising while they’re having their treatment. The findings from that reducing intensive care stays are remarkable.’
Preventing chronic disease
Of course, preventing ill-health in the first place is the very best way to avoid carbon emissions in healthcare, including those caused by travel and transport to appointments.
But by taking action to protect the planet and our environment we will also be implementing measures that improve people’s health.
As Dr Sawyer explains: ‘If we were trying to design a healthcare service that had low environmental impact, great health outcomes, lots of health creation (for example, through access to healthy diets and opportunities for activity), a happy workforce and that was also financially viable… I think we could do that. But I don’t think it would look the way it does at the moment.
‘It would have very local services to serve small populations who then wouldn’t have to drive to reach appointments; it wouldn’t have as much ill-health due to the health creation; just imagine how much of the health service you could free up if you didn’t have chronic disease.
‘I think we could achieve that by looking at things through an environmental or net zero lens.’
While there is a lot to achieve to meet the NHS’s net zero targets – and the challenges are substantial – these goals are only tip of the iceberg adds Swinton, whose ICS aspires to be a leader in its response to climate change.
‘Net zero is important but insufficient in order for us to attain sustainability,’ he asserts. ‘There are really good reasons why the NHS Greener team has focused on the net carbon zero target; not least because it’s the legally binding target we’re all aiming for in the UK. There are also a lot of low-hanging fruit there. But, in and off itself, it’s insufficient.’
