Greener NHS, clearer accountability: What this means for health system leaders

A new report argues that NHS sustainability goals will only be delivered if accountability is strengthened and embedded in mainstream decision-making. We look at what this means for Trusts, Integrated Care Boards and system leaders.

Last month the King’s Fund and the Centre for Sustainable Healthcare published a hard-hitting report, commissioned by The Health Foundation, entitled Environmental Sustainability in the NHS – a new approach to national leadership and accountability.

On the one hand they can see that the NHS 10-year health plan envisages an NHS “fit for the future”, but on the other they can see that health services can be “highly profligate” in their use of natural resources. They quote research showing that a typical maternity unit throws away tens of thousands of plastic baby bottles a year – each used a single time before being disposed of.

Report overview

In terms of the environmental impact of the NHS they state:

• The NHS is responsible for 4-5% of the UK’s carbon dioxide emissions and around 40% of public sector emissions, with:
  • 62% coming from the NHS’ supply chain.
  • 14% coming from travel related emissions.
  • 11% coming from energy use.
• The sector is also a major contributor to pharmaceutical pollution and plastic waste.
• Providing the same care in more energy efficient buildings will not be sufficient to solve the problem – environmental sustainability must involve clinical transformation and new approaches to care.

They note the wider benefits of environmentally sustainable healthcare with, for example, the Department for Energy Security and Net Zero reporting that commitments on solar power are expected to save the NHS around £325m in lifetime energy costs.

Their research found that, despite the existence of statutory environmental requirements (in the Health and Care Act 2022 and the Health and Social Care Act 2012), accountability for meeting these requirements is not sufficiently strong in practice because sustainability is often deprioritised compared with other NHS goals. The example they give is that while Trusts and Integrated Care Boards (ICBs) must appoint a board-level sustainability lead, responsibility is often delegated to colleagues with insufficient influence, authority or resources to drive change within their organisations.

The details of the accountability mechanisms at present are set out in Chapter 3 at pages 11 and 12.  

In Chapter 4, they flag the risk of Judicial Review noting that the inclusion of environmental duties in the Health and Care Act 2022 means that NHS organisations have legal responsibilities in relation to sustainability and could be subject to judicial review if a claimant argues that these responsibilities are not being fulfilled. They also highlight that documents, such as the recently updated green plan guidance (NHS England 2025b), have the status of being statutory guidance, meaning that Trusts and ICBs are legally required to act on it so could be subject to judicial review for not doing so.

Funding is noted to play a critical role. They give the example of reimbursement for Primary Care Networks the through the Investment and Impact Fund encouraging and supporting GPs to adopt greener forms of inhalers in 2021/22 and 2022/23.

In terms of funding from outside DHSC they given examples of:

• More than £1.4 billion from the Public Sector Decarbonisation Scheme.
• Additional solar and battery funding from Great British Energy.
• Substantial support from the Office for Zero Emission Vehicles.

Appendix 1 contains other examples of how sustainable healthcare saves money.

A key issue running through their findings has been the relationship between accountability and prioritisation. Table 3 on pages 17-19 set out the limitations with the current accountability arrangements.

What participants had to say

There are many interesting quotes from those who participated in the research:

• “I’m pretty convinced that there’s no chief exec in our setup that’s going to get sacked because they don’t have a green plan. They might get sacked if they don’t meet their financial targets and various other targets, but no one’s going to get called for not having a green plan.”
• “We get kudos and promotions because we’ve stamped out fires. The longer-term planning for [preventing] a fire in the first place isn’t really [in] lots of people’s psyches.”
• “NHS financial recovery means doing more, when some of us think sustainability requires us to do less and different.”
• “People in my team are hearing from trusts that actually they prefer more of a strong steer because it allows them to go to their chief exec and say, actually, NHS England are expecting us to do this around our estates, our travel and transport, our medicines, whatever it is.”
• “I hate a strategy, and I hate a target. But that is the only thing that generates action.”
• “It’s more effective when it’s part of [a broader organisational framework] than when we are reporting it [separately] from a sustainability perspective.”
• “I don’t think we need to have a separate thing. I think we need to build it into stuff that are already important mechanisms for how organisations work.”
• “The region are monitoring us all on outpatient transformation, like reducing our follow-ups. That could also contribute to carbon savings, but we’re never asked about that. Sustainability is always separate, whereas actually it should just be part of our conversations about the “left shift” [to prevention], performance, all of that.”
• “The NHS is going to save money, so why is the government not taking responsibility for funding solar throughout the entire estate? There are pockets of funding, it’s true. You can apply to get a few solar panels and if you’re lucky you might get it. But it should be across the board. Where there’s a clear benefit, that should just be centrally funded and centrally supported.”

The authors are of the view that ICB leaders have an important and distinct role to play in driving sustainability across the health and care system.

Recommendations for policy makers

They propose a twin-track approach to ensure accountability arrangements drive action at the scale and pace required:

1. Accountability mechanisms designed specifically for sustainability need to be strengthened.
2. Environmental sustainability needs to be embedded throughout broader national and regional accountability and performance management processes so it becomes part of routine decision-making.

They then made 10 recommendations for national policy makers:

1. Build on and reinforce the work of the Greener NHS programme, including through a new statutory duty for the Secretary of State for Health and Social Care.
2. Define clearer responsibilities for board-level leaders in Trusts and ICBs.
3. Introduce annual sustainability performance checks led by regional leads.
4. Make as much performance data as possible publicly available in a consistent and accessible format, to strengthen public accountability.
5. Identify a small set of high-impact priorities and use these to create energy and focus at the local level.
6. Work towards having organisation-specific carbon reduction trajectories for each Trust and ICB.
7. Embed sustainability in wider performance management processes at the regional level.
8. Ensure national accountability mechanisms used for other priorities drive changes that are aligned with sustainability.
9. Ensure CQC’s new assessment frameworks leads to greater prioritisation of sustainability in providers.
10. Make sustainability part of the national vision for a high-quality NHS by communicating the benefits for patients, staff and public finances.

A lot of calls to action!

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