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The NHS Sustainable Development Unit was established because it was felt by both central government and the NHS at large, that: climate change is the predominant health threat we face today; the health service itself risks being more part of the problem than part of the solution; and the NHS is so large and already making progress on this agenda, but in rather isolated areas and places.


It was acknowledged that there is a massive opportunity here to adopt a consistent and systematic approach, understanding that although climate change is an huge threat, sustainability is a very big opportunity.


There is an opportunity for financial savings - both directly in terms of energy, but also in terms of better compliance with carbon taxation, in line with the carbon budgets and the carbon reduction commitment coming into play.


Moreover, the NHS has a duty to comply with the legal framework and because the NHS is so large, it also has an exemplary role here; if the NHS is not seen to be taking this agenda seriously, then it makes it much more difficult for everyone else.


Defining the prerequisites for success is essential to fulfilling this exemplary mandate.


The most interesting and important prerequisite to success is cultivating a sufficiently large number of leaders in the NHS - Chief Executives of hospitals, Presidents of Royal Colleges -  who realise that by taking action on sustainability and taking action on climate change there are far more wins than there are trade-offs.


In the past, the excuse was that we could not afford to take sustainability seriously because we are too busy doing the day job, which is too important to trade off for any rather spurious long-term gains.


However, now people realise that by taking the long-term opportunities seriously, there are also many immediate gains as well, be they financial, reputational, or health related. The key is internalising carbon reduction as a core function of the health service, rather than merely appointing a sustainability officer for example.


Secondly, we need good research and cost-evaluated business case studies to take the more sceptical and cynical down that long journey; to showcase an example of very immediate wins that you cannot afford to ignore and that if you adopt this agenda early, there is much more to be gained.


The health service is, by necessity, focused on today, on emergencies, critical events happening now, dealing with aspects in a reactive way. Consequently, there is a large awareness-raising process to conduct for those people who think that this is absolutely not part of the health service agenda, or that it is someone else's agenda. This is not just about ‘can you afford to do it'; it is a case of ‘can you afford not to do it'.


Another prerequisite is addressing the cultural barriers. Many people in the health service would rationalise our present poor progress on this agenda by saying that we do enough in the health service already, we are saving patients and now you are asking us to save the planet! This is an interesting, almost sociological phenomenon, in that we will try to find excuses for not doing the things we know we probably should, since we know we struggle with them.


Broadly speaking, the challenges we face are not really technical. We are not an organisation that traditionally takes seriously elements, such as energy, travel and transport, sustainable procurement etc - there are many individuals and teams who have progressed on this agenda, but we have not done this well as a national service.


There is a catch 22 here. There is a very important dynamic between the centre and the field, especially in the health service, where there is this culture of letting a 1,000 flowers bloom, of encouraging diversity and local independence. If central government wants us to take this seriously, then they have to acknowledge that in the central targets they set.


However, it is a matter of doing this smartly, so individuals understand the messages that are sent out. There is a big difference between performance-related management of Government bodies in the field, such as the NHS or schools, where individuals get performance assessed within public league tables, and the rhetoric of ministers, who say we take our responsibility for sustainability and the low carbon economy seriously.


We must translate the rhetoric of a low carbon economy into the reality, the vision of a 21st Century health service, education service or prison service. We need to remind people that there can be a win-win for the future, but it requires up-front investment.


So it is just a question of being slightly more visionary, and understanding that anything that is incompatible with a low carbon economy is probably a dumb thing to do. It will come back and bite you, either financially, reputational or legally.


Unfortunately, the health service is not generally a big risk-taking organisation; we are risk averse, taking patient safety very seriously. But actually, innovation and success needs courage, and an air of courage and leadership is risk taking - managed risk taking. Inevitably mistakes will be made, because that always happens with progress.


The NHS ‘Saving Carbon, Improving Health' outlines our strategy going forward and much of the background research that we have done has evolved around carbon. I know carbon does not equate to sustainability, but it is a good matrix that oversees much of the sustainability agenda.


We have completed an overall carbon footprint for the NHS and the next stage of that is to work on a methodology for local organisations and economies in order to enable them to work out their carbon footprint, the priority areas to address, and understanding how to manage this.


A crucial part of building the infrastructure for this involves instilling carbon management and carbon governance into the culture of the NHS in the same way that we instill financial governance, patient safety and clinical governance.


Secondly, not necessarily relying on our own targets, but building on the targets and the incentives that come across government. So, for example, the opportunities and threats to come from taxation - budgeting systems like the carbon reduction commitment and carbon budgets. That is something that finance managers will pick up on immediately and say we must get a handle on this because of the potential financial loss, or the possible financial gain.


Of course, legislation that comes across government is always more powerful than legislation or regulation that comes from within a particular state department, because we have no choice, it affects everybody.


Thirdly, regulatory levels are set quite high in the health service in order to embed these into the overall performance management system of the health care service. In the health service, we will be monitored on our carbon impact year on year.


Initially, there were targets for 2000 to 2010, so the next set of targets we have instituted or encouraged people to adopt, are those from 2007 to 2015: a 10 per cent reduction in direct car emissions, giving local people the opportunity to at least start measuring what their carbon impact and energy usage is, in the direct sense. This is building culture, structure and matrix - those are the three pillars that underpin this.


Real innovation is the key here and this is not about what we do today slightly more efficiently, real innovation is about doing things we do today differently, and sometimes not at all.


One of the most difficult areas for the health service is to stop doing things. Unless we think that radically, this simply is not going to happen; we will not achieve the 80 per cent reduction or more required.


This agenda is tailor-made for genuine innovation in the health service, it is transformational. However, there is a danger that individuals will get locked into incremental change and achieve a false sense of security and progress; when in reality they need the courage, the air cover,  the support and incentives, legislation, the regulation, to bite the bullet and make transformational changes.


There is great practice out there, but it is not systematic, consistent or disseminated and it is not routine.


The challenges going forward, therefore, involve: raising awareness of the strength of the science, both in terms of the threats and the opportunities. Secondly, it requires vision and the courage in a service, which is very much focused on today. We have to live to today's agenda, but we have to do it in a way that does not risk our ability to live for tomorrow. Thirdly, reminding leaders that this is happening on our watch and it will ultimately be our legacy.


The latest guidance from the NHS Sustainable Development Unit is available from the document 'Fit for the Future'published on the 10th September 2009.  For more information, please contact: Karl Heidel on This e-mail address is being protected from spambots. You need JavaScript enabled to view it , or visit the website: Dr. David Pencheon spoke at Govtoday's Heat & Energy '09 - Leading the Shift to a Low Carbon Economy Conference on the 22nd September 2009.

GovToday invite you to comment on any of the issues raised in the above article.

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Written by David Pencheon   
Thursday, 01 April 2010 00:00
Last Updated on Thursday, 03 March 2011 16:47


0 #1 Ian Tait, Director of Estates and Facilities
NHS Wiltshire
The article is a good summary of where we are today. I fully support the SDU direction of travel.

The culture change required within the community health providers means moving out of older buildings. we need to find ways or working either from home or from a 'hot desk' facility in a Local Authority or other public service building. Then we can close some inefficient old buildings.


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