Public services are more sustainable: the NHS example

Planned emissions reductions by the UK National Health Service (NHS) in 2020-21 are on target to reach 1,260 kt of CO2 equivalent. The news comes in the first annual progress report on Delivering a Net-Zero NHS. This is equivalent to a reduction of 1.7 million flights from London to New York.

A major argument for collective provision of several basic services is that it is more sustainable than dispersed private production and purchase. Public and other collective bodies have the potential to pursue low carbon and other ecologically sustainable practices. We have known this for some time in the health service field. The figure below compares the annual per capita carbon footprint of health care in various countries. The footprint in the more market-oriented and decentralised USA is between two and a half and three and a half times greater than in European countries.

Now we have more detailed evidence from the NHS on how this superior sustainability is achieved. On October 1st 2020 the NHS became the world’s first health system to commit to delivering a ‘net zero health service’ by 2040 or 2045 (depending on the degree of control the NHS can exert on emissions).

The NHS net zero plan

The 2020 plan committed to delivering a net zero health service:

  • For the emissions controlled directly by the NHS (the NHS Carbon Footprint): net zero by 2040, with an ambition to reach an 80% reduction by 2028 to 2032.

  • For an extended set of emissions including those that they can influence in the supply chain (the NHS Carbon Footprint Plus): net zero by 2045, with an ambition to reach an 80% reduction by 2036 to 2039.

The NHS is the biggest single organisation in the country employing 1.3 million staff and accounting for 7.2% of GDP. Its current emissions as conventionally measured account for about 4% of the UK’s territorial carbon footprint. Considerable progress had already been made in cutting the NHS carbon footprint in the three decades before this pledge, from 16.2 MtCO2e in 1990 to 6.1 MtCO2e in 2019. But the total including indirect emissions in 2019 were more than four times greater – 24.9 MtCO2e. This illustrates one of the issues in calculating the emissions of a single sector of the economy.

The 2020 Report pledged to do several things. First to provide a complete update of the NHS carbon, shown in Figure 2. The supply chain dominates; the direct carbon footprint of NHS institutions, overwhelmingly of hospitals, accounts for only one quarter of the total. The other major items are pharmaceuticals and anaesthetic gases (20%), medical and non-medical equipment (18%), personal travel of staff, patients and visitors (10%), and other supply chain (24%).

Second, the report modelled various emission scenarios over the long-term, from a ‘do nothing’ scenario and a ‘committed policies’ scenario. This enabled it to determine options for moving from where it is now to net zero. Drawing on the NHS Long Term Plan and other recent commitments, together with responses to a call for evidence, it announced recommendations on: estates and buildings, transport and travel, anaesthetics and inhalers (whose emissions of NO2 account for a remarkable 5% of all equivalent emissions) and resource use and substitutions.

But after taking all this into account the majority of indirect emissions remain. The report pins substantial hopes in tackling this residual in two directions: ‘research, innovation and offsetting’ and ‘new modes of delivering health care’. More about this below.

Progress in the first year

The dramatic reduction of 1260kt was achieved in a year of unprecedented activity and reorganization caused by the Covid pandemic. It resulted from numerous changes:

  • Models of Care: In 2020, a large proportion of outpatient and primary care appointments shifted to being digital-first in response to COVID. This has saved 176 ktCO2e while increasing patient choice.

  • Medicines: A shift away from high-carbon inhalers and anaesthetics will more or less eliminate these emissions over the next three years.

  • Capital Investments: Decarbonise of the NHS estate continued, coupled with every NHS Trust shifting to purchasing 100% renewable energy.

  • Travel and Transport: New contracts are encouraging a shift to ultra-low emission and then zero emission vehicles within the next 10 years.

  • Procurement: Each year, the NHS purchases almost £60 billion worth of medicines, hospital consumables, and other items from over 80,000 suppliers. A new regulatory framework from 2023 onwards will require all contracts over £5 million per year to align with the net zero trajectory.

This illustrates the ability of a collective service to implement a more holistic strategy. However, a publicly owned and funded model may not always be necessary. Social licensing agreements could achieve similar results in parts of the foundational economy dominated by private suppliers, such as housebuilding and renovation, transport or supermarkets.

A critique: where is prevention?

There is a surprising lack of interest in ‘upstream prevention’ in the Report.

When addressing food, catering and diets it mentions improving hospital food that would have both health and environmental co-benefits, but leaves alone the potential for upstream measures, such as traffic lights for harmful foods and regulating additives, to improve population health. The advocacy of Green Travel Plans recognises the wider benefits to health of active travel but does not incorporate this into potential savings for the NHS. This seems to reflect, as I have noted elsewhere, an economic orthodoxy that ‘powerfully constrains preventive public policy’.

A new focus on demand-side policy will figure in the next IPCC Report by Working Group III on options for climate mitigation. This aims to reduce demand for harmful forms of consumption, notably in rich countries. Evidence is growing that a demand-side approach has proven effects in reducing emissions at low cost, avoiding risky reliance on unproven mitigation technologies, such as bioenergy with carbon capture and storage (BECCS), whilst at the same improving non-monetary measures of wellbeing. The recent Akenji Report details (in chapter 5) the substantial co-benefits that a comprehensive prevention strategy could achieve.


This is my one major criticism of a report that is genuinely, in an over-used phrase today, ‘world-leading’. The commitment to net zero by 2045 by a core UK institution is extremely positive. That it is by the NHS whose goal is to further health and wellbeing for today’s population is especially significant: this aim should not and cannot be at the expense of health and wellbeing of generations to come.

A second issue, central to the NHS and other basic public services, is the feedback effect of GHG emissions on population health and wellbeing. ‘The climate emergency is a health emergency. Climate change threatens the foundations of good health, with direct and immediate consequences for our patients, the public and the NHS’. More heatwaves and rising infectious diseases will increase demands on the health service; on the other hand, improved health prevention and interventions could reduce demand. For example, up to one-third of new asthma cases might be avoided as a result of efforts to cut emissions. There are substantial co-benefits between environment and health. Thus a second aim of this strategy is to build adaptive capacity and resilience into the way care is provided.

Ian Gough is Visiting Professor in Centre for the Analysis of Social Exclusion and an Associate of the Grantham Research Institute on Climate Change and the Environment, both at the London School of Economics.