Giving the opening presentation at the half-day online conference, titled ‘The next steps for Net Zero and sustainability in the NHS’, Dr Pinto was introduced by the Chair for the first half of the event, MP for Crewe & Nantwich, Dr Kieran Mullan — who before being elected as an MP in 2019, was an Emergency Medicine Doctor and Clinical lead for Outcomes Publication at the Healthcare Quality Improvement Partnership. He also previously worked at the Patients Association. In 2023 he published a review on the opportunities for Deep Geothermal technology in the UK for Prime Minister, Rishi Sunak, and is a Co-Chair of the All Party Parliamentary Group on Deep Geothermal. Before welcoming Dr Pinto, Dr Mullan gave a brief scene-setting introduction.
Thanking attendees for joining, he said the event brought together a topic that ‘dominated the news agenda’ — climate change, and Net Zero, ‘with an issue that perhaps doesn’t get the attention it deserves — estates and buildings management in the NHS’. He said: “As an MP I have lobbied and campaigned for new buildings, and in fact a new hospital, visited sites in construction, and attended official openings. However, I can’t say I’ve ever heard of an MP being asked to visit a ward or clinical area due to close, but that the Estates team has managed to keep in use.” Dr Mullan continued: “From my time as a clinician, I know what a difference the working environment and fit-for-purpose buildings can make, and the hard work that goes in all year round to try and make that happen — so I want to thank you all for your work; you really are unsung heroes in the NHS. Now you are being asked to do even more heroic stuff, delivering a major programme of decarbonisation alongside your existing challenges. This morning,” he continued, “the BBC published research identifying big (healthcare estates) backlogs, and the impact on patient care. The NHS Confederation is asking for an increase from £7.7 bn to £14.1 bn for NHS capital spending. We know there’s funding for decarbonisation via the Public Sector Decarbonisation Fund, but also know that it is heavily oversubscribed. Not only do you have a stretching target of Net Zero by 2040 in the NHS, but you’re dealing with the stickier end of the wicket.”
Challenge of heating buildings
Dr Mullen noted that the Climate Change Committee recognises heating buildings as ‘one of, if not the biggest, challenge’. He said: “And you’ve got almost 1000 hospitals to heat just as a starting point. That leaves you facing this challenge of Net Zero by 2040 without the money you might want or need to do it. I’ve developed my own interest in this field — working with the Carbon and Energy Fund to explore how deep geothermal technology can deliver solutions for the NHS. It’s a tried and tested source of clean heat being utilised across Europe, including in healthcare settings, and has great potential in the UK.” He continued: “While I’ve talked a lot about buildings and heat, these aren’t the only challenges we face. It’s also about healthcare products, transport, and waste management, and our speakers today will cover the whole range. I hope you find some ideas, and perhaps some inspiration, for solutions you can put to use. So, without further delay, I’m delighted to introduce Dr Hayley Pinto, who has a clinical background as a consultant psychiatrist. She is going to remind us all of the importance and scale of the challenge, and share her perspective on where we are, and where we need to focus next.”
Dr Hayley Pinto, a former lead consultant addiction psychiatrist, had gained nearly 30 years’ experience in the NHS and publicly funded services before joining The Centre for Sustainable Healthcare as its Education and Training lead in 2021. Throughout her career she has been involved in medical education, and was a senior honorary lecturer at the University of East Anglia. She has a Psychology degree, and early in her career completed general practice training before pursuing a psychiatry career. She has been involved in climate education, outreach, and activism for many years.
Climate change and the ‘collapse of nature’
Dr Pinto explained that she had been asked to speak on progress on sustainable healthcare delivery, and priorities for meeting the Net Zero targets. She said: “We know from a wealth of evidence that climate change and the collapse of nature are the biggest threats to human health. The Lancet Countdown reports demonstrate that this is not just a problem for the future; already, extreme heat, drought, wildfires, air pollution, floods, storms, the spread of vector and waterborne diseases, increased pandemic risk, and threats to water and food security, are damaging the health and wellbeing of millions of people in every region of the globe. We know there is injustice in the distribution of these impacts, and that those least responsible are bearing the brunt. Even here in the UK,” she continued, “it’s our most deprived communities that are most exposed to air pollution, heat, flooding, and rising food prices, due to climate-related impacts on crop yields. We also face challenges in maintaining safe delivery of healthcare. Our infrastructure is vulnerable; the 2022 heatwaves saw over 5000 reported incidents of overheating in clinical areas, affecting both patients and staff.”
Working at high temperatures can — it is acknowledged — impact cognitive functioning — ‘not ideal when making life and death decisions’. Dr Pinto added: “Hospitals struggled with overheating of scanners and IT systems, and safe medication storage temperatures. Between April 2021 and March 2022, there were 176 flooding incidents at NHS sites, with 10% of our hospitals at risk of flooding. Additionally, the complex global supply chains on which our systems depend are highly vulnerable to incidents elsewhere. The IPCC’s 1.5 degrees report demonstrated that these impacts increase significantly as we move from 1.5 towards 2 °C — which is why the national 2050 Net Zero targets are based on the IPCC pathway to remain below 1.5 °C. This pathway offers only a 50/50 chance of achieving that — not odds we’d consider acceptable for safety and clinical practice.” Against this backdrop, Dr Pinto said the UK could be proud that the NHS has set more ambitious targets of 2040 for our direct emissions, and 2045 for those we can influence. “However,” she warned, “even 2045 can seem a long way off, which can mean us taking our foot off the pedal when there are competing priorities.”
“So,” she asked, “how can we maintain focus? Firstly, to remain on this pathway and not spend our carbon budget in the next few years, we need to halve our emissions by 2030. The NHS pathway calls for an 80% reduction in that time period — and that’s only six years away. Last year global temperatures leapt up 1.45 °C, and we’re much closer than we thought to breaching the crucial 1.5 °C threshold, so we must accelerate our efforts.” Adding that in 2014, the planet was 0.8 °C degree warmer than pre-industrial levels, but that this had nearly doubled in 10 years, she asked what this meant for the future of our children; 88% of the health impacts of climate change are apparently falling on children under five. Dr Pinto said: “We could consider that our collective failure to tackle climate change is a safeguarding issue for an entire generation.”
Despite a recent rise in public awareness of climate change, she said most people still didn’t really properly grasp the issue. She told attendees: “Recent surveys show that less than half the UK population understand the term ‘Net Zero’, and just a quarter the terms ‘green’ or ‘sustainable’.” She cited a quote from a clinician from a recent evaluation of The Centre for Sustainable Healthcare’s ‘Green Team’ competition: “Depending on what consultants are in that meeting, they’ll just skip it and say, ‘Oh yeah, we all love the dolphins and skip it.’ ” Dr Pinto said: “The fact that a highly trained NHS healthcare professional still doesn’t get this epitomises the catastrophic failure of communication that surrounds the defining issue of our time.”
Moving to ‘briefly outline where we are now, and what we need to do next’, she said: “The latest NHS Annual Report shows that — against all odds — we are on track with emissions reductions, which is encouraging news, but we must keep in mind that the first steps are often the easier ones, and progress is starting to stall.” Showing a pie chart, Sources of carbon emissions by proportion of NHS Carbon Footprint Plus, taken from page 14 of the October 2020 report, Delivering a ‘Net Zero’ National Health Service, she said many providers had to date been quite focused on building and energy projects. She said: “If we are to continue making progress on this, cash-strapped provider Trusts must be able to access funding for the ‘invest to save’ projects which bring down emissions and reduce bills.”
Pharmaceuticals and medical supplies
She pointed out, however, that 35% of the emissions in the NHS Carbon Footprint Plus originate from pharmaceuticals and medical supplies, before even considering that clinical pathways determine ‘how much we travel, use buildings, consume water, and produce waste’. She said: “In primary care, where most patient contact occurs, 65% of admissions are due to clinical activity. The bottom line is we cannot achieve Net Zero without clinical transformation.” How we do this had been the focus of the work of the Centre for Sustainable Healthcare over the past 15 years. She explained: “One of the tools we’ve developed is Sustainability in Quality Improvement (SusQi). This embeds sustainability into clinical innovation using existing quality improvement teams and frameworks.” This ‘holistic approach’ ‘assesses outcomes using the concept of sustainable value, which broadens the focus beyond simply cost effectiveness to measure and value both environmental and social impacts, while also considering the impact of our activities on the health of the population, being mindful that patients are members of the population, not a competing group’. Dr Pinto said: “This is not intended to be a mathematical equation to be solved, but an approach to decision making at any level — from individual care to care pathway design, to business case and funding allocations.”
The Centre also bases its work around the principles of sustainable healthcare — ‘the most effective way to reduce healthcare’s impact being to reduce healthcare activity — ideally through increased focus on prevention, and empowering people to take a greater role in managing their own health, maintaining awareness of their capabilities, and the barriers they may face to making healthy choices’. Dr Pinto said: “Lean pathways mean stripping out activities that are not only low value, but potentially harmful, such as over-investigation and overprescribing. For the activities we need to continue, we must consider how we do so with the least environmental impact.”
Prevention was, she said, ‘the first principle’ — because it had the greatest potential. She added: “Focusing on prevention forces us to break out of our silos; to use the trusted health voice and our status as anchor institutions to work across our communities, advocating for those policy and planning decisions that not only help tackle the climate and nature crisis, but also have enormous potential benefits for population health.”
Chronic diseases causing widespread suffering
She next showed a graphic, on the right of which were chronic diseases causing widespread suffering and increasing demands on healthcare, adding that more and more patients were presenting today with multiple conditions to pathways designed to treat single conditions. Dr Pinto said: “This list covers the six groups of conditions identified in the Government’s Major Conditions Strategy that account for over 60% of mortality and morbidity in England. On the left, you’ll see the things we need to do to tackle climate change.” She pointed out that by rapidly transitioning from burning fossil fuels to renewable energy sources, and reducing our car dependency, we would improve air quality. She said: “We saw the immediate benefits of this with respiratory conditions like asthma during lockdown. Air pollution can exacerbate or cause almost any condition — including many mental health disorders, particularly dementia. By transitioning to active and public transport we also increase physical activity, which is strongly linked to physical and mental health. Currently, half of children and around a third of adults are not active enough for good health. By reducing car-related infrastructure, we free up urban space for nature, and improve access to green space — which has wide-ranging physical and mental health benefits, while reducing flood risk and temperatures during heatwaves.”
By reducing meat and dairy intake, meanwhile, there was the opportunity to reduce cardiovascular disease, some cancers, and — coupled with increased activity levels — ‘the epidemic of obesity and diabetes’. Dr Pinto told delegates: “Retrofitting homes helps ensure people don’t have to choose between heating and eating, are not living in cold, damp, mouldy conditions, or overheating during heatwaves.” Those to benefit most were the most deprived communities. ‘If done well’, she added, tackling climate change should not be a burden for those already struggling in our society, and has the potential to reduce health and social inequality, and improve everyone’s quality of life.
Emphasising that sustainable care was ‘not in conflict with good care’, she said that it was in fact high, and possibly higher quality, care that ‘aligns with, and can help to deliver on, what people might consider competing agendas’ — social value, personalised care, and addressing health inequality. Stripping out waste and reducing demand can ‘help balance budgets’, while ‘almost invariably’, SusQI projects were either cost-neutral, or saved money. She said: “We found, even working with quite burnt-out staff, that this approach motivates and inspires — I think because so many people are worried about the climate crisis, and are making changes at home. Some then feel those values have to be left at the door when they come to work. Being able to live your values at work energises teams, and supports staff wellbeing.”
The Centre for Sustainable Healthcare’s case study library was ‘full of examples’ of successful SusQI projects. Dr Pinto’s next slide showed an example, titled ‘Eliminating low value appointments from the patient care pathway’, which illustrated how — by eliminating just one routine appointment that had become unnecessary due to improved effectiveness and tolerability of treatment, a clinical team saved emissions equivalent to around 75,000 miles of driving and nearly £45,000 annually, and freed up staff to spend time with those who actually need them. While such successful projects showed what is possible, if they remained as individual projects, ‘they will not move the dial’. With ‘evidence of what works’, and multiple case studies, the need was to develop more effective frameworks to scale them up. Additionally, the speaker added, there were a wide range of NHS initiatives ongoing with sustainability potential ‘for prevention, empowerment, lean pathways, and low carbon alternatives’, but ‘almost universally’, they were not explicitly incorporating sustainability. This was ‘a huge missed opportunity to maximise the potential of these initiatives’.
Good work going on but you have to ‘hunt for it’
Dr Pinto said that while there was also ‘a lot of good work’ going on to provide guidance and training across major health institutions, one needed to ‘hunt for it’. She explained: “What I hear from NHS Boards is that they get lists of priorities and targets, but that sustainability is nowhere to be seen. If we’re not modelling embedding sustainability at the top, then how can we expect embattled provider Trusts to do so? Working with NHS organisations, we often see sustainability still being a side issue left to solitary Sustainability leads and a few passionate individuals trying to fit it in around their day jobs. This was noted in a Health Foundation report last year, which described the reliance on volunteerism, and highlighted the need for dedicated time and resources for staff working on this.” From her experience, Dr Pinto said she would add training to the overall formula.
She said: “Without training on how to identify hotspots, and where the biggest impacts can be achieved, what you get is recycling projects.” While recycling was important, the speaker stressed that the overwhelming majority of environmental impacts occur before the point of use, adding: “We cannot recycle our way out of this.” She added: “So, we don’t know everything about how to achieve Net Zero in healthcare, but we do know enough to progress a lot faster. Missing at a national and local level are clear, consistent, visible leadership and prioritisation.”
Dr Pinto said the priority was ‘to communicate more effectively — outlining honestly the risks we face, but also sharing a positive vision of how sustainability can improve our health and quality of life, linking explicitly to the issues people care about’. With the NHS employing around 1.3 million people, it should, she said, be possible to mobilise ideas and expertise, and to ‘make a big difference’. She added: “Secondly, we must embed sustainability in a highly visible way from top to bottom. It should be embedded in our accounting, our decision making performance, and in staff training and appraisal. The Royal Navy is making climate change training mandatory. Why aren’t we?”
Key, Dr Pinto added, was to properly support people to work on sustainability — giving them dedicated time, resources, and training. She told delegates: “We need to develop frameworks, networks, and perhaps even national targets, to scale and spread what we know works to accelerate progress. We’ve done this with desflurane, but people ask me why we can still prescribe the most damaging metered dose inhalers when there are simple sustainable switches? For larger scale capital projects, we need to unlock funding, but much can be done towards clinical transformation by embedding approaches like SusQI that can save money. And finally,” she said, “we need to raise the health voice to advocate at national and local levels for measures that tackle the climate crisis and also improve health at a population level.”
Session Chair, Dr Mullan here thanked the speaker, who he said had ‘really framed the crisis from a broader perspective’. He then invited questions, beginning with one of his own, by asking Dr Pinto — given the scale of the actions that need to be taken across the NHS — how she approaches meetings on sustainability with NHS teams, and how she encourages staff either to ‘start with that bigger picture, or think about breaking it down?’
Dr Pinto replied: “As a doctor I work within the framework of informed consent, and am honest with people about the risks we’re facing, but it’s also so important to paint that picture of sustainability’s benefits. I think that’s been a missed opportunity — we don’t talk enough about what sustainability looks like, but instead focus on what we need people to not do, and not the opportunities this offers.”
The speaker feels ‘people need something to work towards’. One key action she would take — given a longer time period — would be to ‘acknowledge the reality of eco distress, how this affects us, and what we can do about that’. She said: “One of the most effective ways to manage this is to take action, but also to recognise that as one individual, you can’t fix the whole thing; this is a planetary-sized problem. What you can do is tackle a piece of the jigsaw that’s in front of you, and engage others to do the same. It’s about breaking it down to work within your sphere of influence.”
Examples of successful projects
Asked about other examples of relatively straightforward measures — such as eliminating a single routine appointment that had become unnecessary due to improved effectiveness and tolerability of treatment that she had earlier mentioned, Dr Pinto said there were ‘hundreds of examples of excellent SusQI studies’. A key priority seen in many studies had been the importance of engaging with allied healthcare professionals, and ‘how they can make a difference’. She said: “There’s a great study on mobilising people early on CICU units, which reduces their time there, and their time being ventilated. They get home quicker, with better outcomes, and over the first year it saved over a million pounds, due to how expensive those beds are.”
There was also ‘lots of work ongoing around inhalers in primary care’, and on looking at pathways and stripping out some elements. She said: “We still use process mapping in the same way you would with a QI project, but it’s about stripping out the unnecessary steps — things that look small that are repeated many times — such as dropping one blood test or appointment; switching to more virtual delivery of medicine, and being aware of some of the issues around digital exclusion and how to address them.”
Dr Pinto explained here that the Centre for Sustainable Healthcare is a charity set up 15 years ago, which has since been working on this. She encouraged attendees and others to visit its website, and link to its free-to-join networks. She explained: “The Sustainable Healthcare Networks Platform hosts our resource and case study library, so you can search for pretty much anything there and hopefully find a similar project. Let’s not ‘re-invent the wheel’, but rather look for case studies that people have already done in your area, and see if you can replicate them”.
Another attendee asked Dr Pinto if she had seen Board leads or senior NHS Trust personnel going through the work being done and trying to find sustainability opportunities. She said: “Yes, definitely. We are just about to do our Net Zero leadership training for Boards. For instance, one organisation we have worked with in London has very demonstrably been pulling out case studies and seeing how they can replicate them. You need a team in charge of this, which focuses on what’s happening nationally and internationally, and then prioritises which actions to implement.”
Another delegate asked how the NHS can best strike a balance between cost-effectiveness and maintaining high standards of patient care. Dr Pinto said: “With clinical transformation, you are almost invariably saving money, because you’re genuinely streamlining pathways. Much of what we do around sustainability is actions we need to take anyway — around streamlining, reducing costs, managing capacity, personalisation of care, and making it more effective. Prevention isn’t just out there in the community; there’s quaternary prevention as well — which is about not harming people through what we do.” The speaker said this revolved around aspects such as over-investigation, overprescribing, and overdiagnosis.
An attendee from Roche Diagnostics acknowledged Dr Pinto’s point about ‘overinvestigation’ of medical conditions, but said there were also many cases of under-investigating patients, which he feels have a negative impact on climate. He elaborated: “There are cases in particular of heart failure where a lack of investigation at the early stages is leading to heavy reliance on secondary care services, and picking up disease at a very late stage, by which time it’s actually more carbon-intensive to treat the patient.” He added: “I think we need to look more at how diagnostic pathway innovation can help meet sustainability targets.”
Looking at specific pathways
Dr Pinto agreed. She said: “Our courses cover that; there’s real potential for accurate diagnosis. When we discuss prevention, we talk about different levels, so indeed secondary prevention, and early identification. It’s about getting it right, which is a bit more nuanced. It takes looking at specific pathways. One example we use is a new diagnostic test that identifies pre-eclampsia in pregnancy. This has significantly reduced the number of people being admitted and outpatient appointments, because it’s more accurate. So there are many examples. I definitely agree with you. We need to be taking a ‘getting it right first time approach’, and that is why we need to make it explicit that this is actually a sustainability agenda.”