Greening the NHS 1: tackling the climate crisis and aiming for net zero

Introduction

In 2020, the NHS declared the climate crisis a “health emergency” and set ambitious targets to achieve net zero for those emissions under its direct control by 2040, with an 80% reduction by 2032 (NHS, 2020). Net zero can be described as “a state in which the greenhouse gases going into the atmosphere are balanced by [their] removal out of the atmosphere” (Net Zero Climate, 2023).

In 2021, NHS Scotland committed to being a net-zero greenhouse-gas emitter by 2045, acknowledging that unprecedented changes would be needed to achieve this (NHS Scotland, 2021), and the Royal College of Nursing (RCN) has committed to tackling climate change as a health emergency (RCN, 2021). So what has this got to do with nurses as health professionals? Are we doing enough to tackle this problem? Are we even aware of the climate emergency and net-zero targets? How do these relate to us and our nursing roles?

How climate change affects health

Climate change poses a great risk to public health, threatening to undermine the gains made over the past 50 years (NHS, 2020). Its impact is predicted to be catastrophic, far outweighing that of the Covid-19 pandemic or the current economic crisis. Climate change mainly affects those who have a much lower carbon footprint and contribute least to the problem, but who are the least resilient and do not have the resources to deal with its effects – this is known as ‘climate injustice’.

Healthcare is responsible for around 5% of global greenhouse gas emissions and, if we carry on as now, emissions from healthcare could triple by 2050 (Smith, 2022). If it were a country, healthcare would be the fifth largest polluter in the world (Health Care Without Harm, 2019). With NHS emissions equating to those from the whole of Denmark (Cameron et al, 2021), healthcare not only deals with the consequences of climate change, but also plays a significant part in creating the problem.

Climate change has far-reaching negative outcomes affecting many areas of public health from physical injury and disease to social and psychological problems. These are exacerbated as a direct result of increasing global temperatures and extreme weather events (World Health Organization, 2021), and avoidable deaths are happening now, with millions more predicted (NHS England, 2020a). As nurses, we need to act now – we are encouraged to promote safety and to preserve professionalism and trust as part of the Nursing and Midwifery Council’s (2018) code of conduct. But what, specifically, can we do?

“Climate change poses a great risk to public health, threatening to undermine the health gains made over the past 50 years”

Nurses as green champions

Nurses can play a pivotal role in tackling the climate crisis. To have any hope of reaching net-zero targets, we need to play our part, both as individuals and as a profession. The RCN (2021) expressed huge concerns about the worsening health inequalities brought about by climate change and urged nurses to proactively protect and improve public health, and demand stronger action to deal with the problem.

As part of what was voted the most trusted profession for the 21st consecutive year (Brenan, 2023), nurses are in an influential position and ideally placed to:

• Champion the green cause;
• Deliver clear messages;
• Act as role models to influence change with our patients, colleagues, managers, educators, unions and politicians.

The climate crisis should be an agenda item for every departmental meeting. It is vital that the climate emergency is discussed, like an emergency, at every opportunity so that sustainable thinking and practice will be embedded into all roles and responsibilities. I would urge nurses to request that sustainability be added as part of their performance reviews to encourage targeted development in this area. Every decision a nurse takes should consider the environmental impact of that choice and nurses should be encouraged to use greener alternatives, where feasible, to bring about change and improvement.

Nurses can introduce and support changes in all settings in the clinical field to result in more-sustainable ways of delivering care. There are many examples of innovative sustainable healthcare delivery, led by organisations such as the Centre for Sustainable Healthcare (CSH), as well as organisations that promote education and development in this field, such as e-learning for healthcare.

Opportunities around prescribing

Asthma inhalers

Inhaler prescribing is a key item on the green agenda, particularly in primary care, to promote environmental benefits and improvements in care for patients with asthma (Primary Care Respiratory Society, nd). The metered dose inhaler with a propellant is a real carbon hotspot, making up around 13% of the total carbon footprint of primary care, and accounting for around 70% of all prescribed inhalers (Green Inhaler, nd). With each of these inhalers having a carbon footprint equivalent to travelling 175 miles in an average petrol/diesel car, their use has an impact on emissions.

In addition, to be effective, this type of inhaler requires a specific technique and, often, the user must use aids to optimise administration and the uptake of medication. The ability to judge whether the inhaler is empty is also sometimes difficult, which can result in patients using inhalers that are empty or discarding those that are not.

Switching to a dry-powder alternative with a counter, which is often much easier to use, leads to a much lower carbon footprint (equivalent to around four miles driven in an average petrol/diesel car) (Green Inhaler, nd). Research has shown that switching just 10% of metered-dose inhalers to more environmentally friendly alternatives could save up to 58 kilotonnes of carbon emissions and £8.2m for the NHS annually (Baker, 2019). Most importantly, patients can expect better asthma control without the negative implications on planetary health (Green Inhaler, nd). With such improvements in respiratory health, patients require less medical input from their GPs and other health professionals, which reduces costs and places less demand on a stretched service.

As well as encouraging a switch to greener inhalers, nurses can advise patients – and other staff – on how to dispose of used inhalers correctly to minimise further leakage of the environmentally damaging gases. Empty inhalers should not be discarded in normal household rubbish collections but returned to pharmacies, preferably for recycling or, if that is not available, incineration (Green Inhaler, nd), thereby minimising the detrimental environmental effects.

Medicines

NHS England (nda) states that “medicines account for about 25% of emissions within the NHS in England” and reducing pharmaceutical waste is a key aim of the Greener NHS programme. Nurses who are non-medical prescribers can use their prescribing practice to reduce pharmaceutical waste and bring about improvements to patients’ health and the environment. Patients often report amassing supplies of medications in their homes – medications they no longer use or have accumulated over time. As non-medical prescribers, nurses can ensure patients’ medications and supplies are regularly reviewed to assess their effectiveness and whether they are still needed.

Minimising medications, where feasible, reduces adverse effects and risks associated with polypharmacy, particularly with older people or patients who are frail, who are most vulnerable. In addition, there is growing evidence to suggest that our waters and rivers are contaminated by pharmaceutical waste (Shelton et al, 2022) so changes to nurses’ prescribing practice may result in real costs and environmental improvements (Robinson and Breed, 2019).

Social prescribing

Social prescribing and community-based support is a key component in personalised care that brings many benefits to patients and the environment (NHS, 2020), and it is growing in popularity in the UK. Health professionals connect patients to activities, groups and local services to support and meet their practical, social and emotional needs. The idea of inspiring patients to improve their overall health through such initiatives is seen as a sustainable way to provide collaborative community-based care (Office for Health Improvement and Disparities, 2022) and minimises the need for prescribing drugs to remedy problems. It is hoped that large numbers of patients can benefit from this approach and, consequently, demand on care services will reduce.

An example of a social prescription might be a patient who has an exercise regime ‘prescribed’ to encourage them to be more active. With recognised benefits and psychological advantages of exercise and access to green spaces, the approach is expected to bring about improvements to patients’ health and wellbeing, with significant cost savings (MIND, 2021). With reduced reliance on medications, we would also expect to reap environmental rewards.

Sustainable care models

An increasing number of climate-conscious health professionals are beginning to challenge the more traditional ways of working and introduce new, greener ways to deliver care, as part of sustainable care models and sustainable quality improvement pathways. Often, these can result in social improvements – perhaps patient benefits or reduced staff workload – and are promoted in case studies by the CSH. The next two articles in this series will consider such initiatives.

Glove use

The Gloves are Off campaign, launched by Great Ormond Street Hospital (GOSH), is one example of a sustainable care model in which staff were encouraged to use gloves appropriately to reduce the use of plastic and costs, without compromising patient or staff safety. The campaign promoted the use of proper hand-washing techniques to reduce infection, with the associated benefits of real skin contact for patients and reduced risks of contact dermatitis for staff.

The environmental impact was huge during this project, demonstrating a staggering 21-tonne reduction in plastic waste (GOSH, 2019). The participants equated this to 3.5 times the weight of a Tyrannosaurus rex, which became part of the branding used for the campaign.

“If we have any hope of reaching net-zero targets, we need to play our part, both as individuals and as a profession”

Personal protective equipment

GOSH’s work has inspired other organisations to look at their own working practices. Northampton General Hospital undertook a similar project, called Be PPE Free, in which its infection control team reduced inappropriate use of personal protective equipment (PPE) by 20% (CSH, 2022).

It acknowledged over-use in areas, such as making beds, taking observations or transferring patients, and recognised that staff wore PPE inappropriately or did not change it when they ought to – wearing the same PPE between patients, and when collecting clean linen, writing notes or answering the phone were examples given (CSH, 2022). By the time the project was completed, it was able to demonstrate savings of around 53,221kgCO2e – equivalent to 225.4 return trips between Northampton and Glasgow, and more than £71,500 in costs (CSH, 2022).

Remote consultations

When the Covid-19 pandemic struck, NHS staff were forced to think differently and quickly change the way care was delivered to patients in and out of hospital settings. Teams changed systems to allow patients to be reviewed over the telephone or via video links. These remote consultations cut down unnecessary car journeys and often made things easier and more convenient for patients, who did not have to attend appointments in person (NHS England, 2020b). Remote/telephone consultations have continued at The Christie NHS Foundation Trust and become the normal way of reviewing patients.

Travel

Continuing with novel ways of working is a sustainable way forward, and one that Sussex Community NHS Foundation Trust proved by implementing e-bikes to undertake some of its patient reviews. The trust estimated that, although reviews were an essential part of its service, travel contributed to around 5.5% of its carbon footprint. Once implemented, its e-bikes covered around 8,000 miles, and saved around two tonnes of carbon dioxide (CO2) (NHS England, ndb). The project also demonstrated clear improvement to staff wellbeing, with staff avoiding spending time stuck in heavy traffic and looking for parking spaces; patients also fed back their approval, saying how much they loved seeing their nurses arriving on a bike (NHS England, ndb).

Such projects could inspire other teams in acute and community settings to consider what green ideas they could adopt that may have similar outcomes.

Driving a green agenda

Nurses do not need to have formal sustainability training to drive the green agenda in their organisations. There is a wealth of information to support those wanting to progress, and networks regionally, nationally and internationally are springing up to inspire and encourage nurses to work in greener ways; some of these are outlined in Box 1.

We are facing a climate emergency, with far-reaching consequences on global health. Nurses need to drive the green agenda, from both a personal perspective and professionally at work, to identify wasteful practice in their own field and consider more-sustainable alternatives.

The Health and Care Act 2022 demands that healthcare organisations have a Green Plan in place, and a net-zero lead at board level to work towards achieving the targets (NHS Providers, 2022). However, nurses of any grade, in any speciality, can influence change, both in their own sphere of practice and beyond, and can galvanise others to do the same. The only requirement is that they have the passion, enthusiasm and drive to make things better. By being committed to these improvements and by being persistent, nurses can pass on the climate crisis message to people, with real ripple effects so it grows and grows.

Start small

Nurses who are new to sustainability can start with very simple actions, including:

• Everyday things, such as turning off devices (computers, lights, air conditioning) when not in use at work and at home;
• Considering commutes and exploring car-sharing opportunities.

Not only will these actions benefit the environment, but they will also bring about cost savings. If we all do little things, together they can have a big impact and, by setting good examples, we will encourage others to follow our lead.

As experts in our field, nurses will be able to see opportunities where things can be done differently to reduce time, waste, costs and carbon. By joining green nurse networks, we can make contacts with like-minded people who may be farther along the green journey. We can inspire and learn from each other.

The involvement of quality improvement teams might make the job less daunting, so it is worth exploring these when starting projects. Understanding the current baseline is also a good idea to ensure any successes can be clearly demonstrated and shared. Procurement teams may be able to help with this – it is helpful to network with these key players to maximise your chances of success.

Personal lives

Nurses can also consider their own personal carbon footprint, to see if things can be altered to reduce it. By introducing green changes, nurses may see personal health and cost benefits. Researchers at Oxford University found that cutting down on meat and dairy consumption is the most effective way a person can reduce their own carbon footprint – by up to 70% (Petter, 2020) – and such a diet can also bring health benefits. Meat substitutes are improving all the time, and choices are increasing as more people opt for these.

Reducing unnecessary car journeys, and choosing to walk or cycle can improve nurses’ own fitness and may encourage others to follow suit. Fewer cars on the road will lead to cleaner, less-polluted air and the environmental and health benefits that go with that.

Changing holiday habits to reduce flying will drastically improve our personal carbon footprint too. In addition, we should limit any flights to educational events and conferences – we can opt for more-sustainable ways to travel or virtual platforms when available. Many hospital trusts are discouraging less-sustainable travel options among employees – The Christie NHS Foundation Trust, where I work, is taking this stance. Nurses should also advise those hosting events of such environmental concerns, and perhaps even boycott events to put pressure on organisers to make improvements.

Conclusion

Nurses are trusted and often have well-developed communication skills. As a profession, we are listened to and respected by others, and we should not underestimate the influence we can have on people across a wide spectrum. As nurses, we can use our voices individually or collectively in networks and committees – and if they do not exist, we should create them. Greener ways of living and working bring overall benefits that are huge. The recurring message is that by being green, and promoting health, we can drive down costs and care demands. Being green just seems better, in general, in all ways.

Nurses need to be proactive to help drive the green agenda. Who knows where our green crusade will lead? With >300,000 nurses working in the NHS around the UK, imagine the impact we could have, if we all did something.