Action to Decarbonize the U.S. Health Care System: Lessons from the U.K.’s National Health Service

The United Kingdom’s National Health Service (NHS) is the world’s first health care system to commit to achieving net-zero carbon emissions. Here we examine the history and status of the NHS efforts and identify lessons for the U.S. health care system. As the former Director of Strategy for the NHS in England, the lead author helped develop the NHS’s net-zero plan and create the Greener NHS program that is now delivering on the plan’s commitments.

Introduction

The impact of climate change on health and the contribution of health care systems to climate change have been well documented. Intensifying weather events have already resulted in the deaths of millions of people worldwide and thousands of people in the United States alone. Increasing costs, growing inequities in already at-risk communities, and declining quality due to hospital overcrowding and disruptions to the medical supply chain are the dire realities of a health care system impacted by climate change.¹ Globally, the health care sector itself is responsible for as much as 4.6 percent of total greenhouse gas emissions — carbon dioxide, methane, and ozone, among others. In the United States, the share is 8.5 percent.²

Health systems around the world are taking note of these crises and beginning to respond. In 2021, as part of the United Nations Climate Change Conference (COP26), 60 countries, including the United States, committed to creating climate-resilient, low-carbon, sustainable health systems, with 20 countries committing to net-zero health care system emissions by 2050.³ Health systems that adopt a net-zero approach focus on removing carbon as quickly as possible, only as a last resort turning to mechanisms that “offset” remaining emissions that can’t be removed through other means.

The NHS was the world’s first health care system to commit to net-zero carbon emissions.⁴ Like many health systems around the world, the NHS is responsible for large portions of the nation’s overall carbon emissions (4%) and public-sector emissions (40%).⁵ As global recognition of climate change as a health emergency has grown, the NHS launched its Greener NHS program to review NHS progress to date and develop a delivery plan for getting to net zero.⁶ That plan, released in October 2020, offers a roadmap of actions the NHS is already taking and will take to cut its emissions.⁷ It established two target dates for achieving net-zero emissions: by 2040 for emissions the NHS controls directly, and by 2045 for wider emissions it only influences.

The United States has set targets to lower carbon emissions for certain health-related government facilities (like Indian Health Service facilities and Veterans Affairs hospitals), and general government service buildings are set to achieve net-zero emissions by 2045. But there is still much the U.S. health system could learn from the NHS.⁸ In this brief, we describe how the NHS developed and began implementing its net-zero plan and what the U.S. health system could learn as it seeks to mitigate the impact of climate change and reduce its own carbon footprint.

Developing the NHS Net-Zero Plan

As a first step, the NHS sought to determine its total greenhouse gas emissions since 1990.⁹ To do this, analysts gathered calculations of carbon emissions across NHS’s major areas of emissions, including the supply chain, staff and patient travel and transport, building and energy use, and high-emitting drugs used in anesthetics and inhalers. NHS analysts projected future carbon emissions in a “no change” scenario based on recent trends in health care and transport use, as well as U.K. government forecasts.

Next, in 2020, NHS England launched a global call for evidence-based policies and actions that can reduce health care emissions. The Greener NHS team reviewed these initiatives based on their potential impact and their deliverability within the NHS, with input from a panel of experts across the fields of health care and climate change. Selected interventions were modeled against a “no change” scenario to determine their impact on future emissions and remaining gaps.

The analytical method used to develop NHS’s carbon footprint was published in 2021 to support other global health systems seeking to map their own emissions.¹⁰

Action to Decarbonize Health Care

The NHS net-zero plan describes actions the NHS will take to reduce its emissions over the coming years. It also discusses the steps the NHS is already taking to decarbonize (see box).

The areas below are where the NHS identified known best practices or policy actions that can help drive decarbonization.

Inhalers and anesthetics. Medicines account for 25 percent of emissions within the NHS, but a small number of medicines account for a large portion of those emissions. Inhalers (3% of emissions) and anesthetic gases (2% of emissions) are two of the highest emitters.

Inhalers. In the United States, 25 million people have asthma, and 12 million people have some form of chronic obstructive pulmonary disease (COPD). Many get their medicine through metered-dose inhalers that tend to use high-carbon propellants. Inhaler emissions can be reduced by encouraging greater use of dry-powder inhalers that are clinically equivalent to metered-dose inhalers but have much lower carbon emissions. The NHS is supporting this effort by incentivizing primary care providers to report high-carbon inhaler prescriptions and work with pharmaceutical companies to develop lower-carbon propellants or alternatives. It is also working to promote greener disposal of used inhalers.¹⁶

Anesthetics. It is possible to reduce emissions from anesthetic gases by switching to lower-carbon but medically equivalent gases and improving the capture and destruction of gases. For example, the lower-carbon gas sevoflurane, when used for an hour, is the equivalent of driving 18 miles, while an hour of high-emitting desflurane produces emissions equivalent to 200 to 400 miles.

Hospital buildings and facilities. After drugs, hospital buildings are one of the greatest contributors to the health care sector’s carbon footprint. Building new hospitals provides an opportunity to design facilities that are carbon-neutral, or even carbon-negative. However, many improvements can be made to existing buildings, from a switch to LED lighting to the installation of intelligent, real-time emergency monitoring and control systems.

Travel and transport. In England, around 3.5 percent of all road traffic can be linked to the NHS. NHS organizations are transitioning their fleet to low- or no-emission vehicles (including staff-leased vehicles) and testing the world’s first zero-emissions ambulance.¹⁷ Decarbonizing the whole NHS ambulance fleet could reduce emissions equivalent to roughly 730,000 car trips from Washington, D.C., to Detroit.

Medicines and the purchasing and supply chains. While the health care sector does not have direct control of its supply chain, hospitals hold significant purchasing power to influence those chains. Beginning in April 2022, NHS England is requiring all NHS purchases to consider both the NHS net-zero plan and wider goals aimed at tackling social, economic, climate, and health inequities as part of their purchasing process.¹⁸ This is expected to affect supplier actions and could benefit the global market, especially if the United States introduces similar requirements.

New care models and preventive medicine. The NHS is also planning to deliver less carbon-intensive care in the long term.¹⁹ The process of redesigning services is likely to include consideration of ways to reduce waste and emissions. However, the best way to shrink the carbon footprint of the health care sector will be to reduce the need for health services altogether — a need that is growing as climate change accelerates.

Research, innovation, and offsetting. Even with all the actions described above, there will be gaps to fill. The NHS is investing in innovations that might further close these gaps, maximizing every available opportunity to reduce emissions before considering the offsetting of any residual carbon emissions through investment in carbon storage or making reductions elsewhere.²⁰

Although we are unable to undertake a detailed exploration of the equity implications of the NHS’s work here, it should be noted that the NHS recognizes that the health impacts of climate change do not affect people equally. Equity issues, including the disproportionate impact high levels of air pollution and reduced access to green space has on low-income communities, were considered as part of a health inequalities impact assessment completed for the NHS plan.²¹

Lessons for the U.S. Health Care System

While the U.S. government has committed to creating a sustainable health sector, it has not yet committed to a net-zero goal. There are several actions the government could take, drawing on lessons from the NHS, to begin reducing the health sector’s carbon footprint.

Establish baseline carbon footprint for the U.S. health care system and determine the primary sources of emissions. The new Office of Climate Change and Health Equity within the U.S. Department of Health and Human Services (HHS) has committed to establishing clear metrics for assessing greenhouse gas emissions and to developing measures for supply chain emissions. The office will implement data collection strategies that do not place an undue burden on providers. New policies could incentivize gathering data for these metrics, and reporting on them, to help establish how the U.S. health system contributes to emissions. The new office will likely require dedicated funding, however, to pursue this effort.²²

Set targets for reducing emissions. Targets should be set at both the federal and state levels and come with clear milestones and incentives or regulatory requirements. In April 2022, HHS and the White House called on health care stakeholders to voluntarily pledge to reduce emissions by 50 percent by 2030 and to zero by 2050. The intention is to publicly report progress toward these targets.

While this is a positive first step, setting more specific targets will help ensure meaningful progress. Examples from the NHS include setting specific, measurable targets for particular areas, including anesthetic gas, inhalers, transport, energy, and procurement.

Introduce regulations and incentives to decarbonize the wider supply chain. Measures to persuade health system stakeholders to tackle indirect emissions will be essential. As part of HHS’s voluntary pledge, the agency is asking stakeholders to complete an inventory of supply chain emissions by 2024. This will help identify areas where action is most needed.

Share best practice and innovations that can be implemented now. Health care systems can create and share tools and frameworks, like the NHS guide for producing a green plan, for developing and implementing their own net-zero plans.²³ As interventions, tools, and frameworks are identified in the United States or internationally, they should be made publicly available and shared widely to enable systems decarbonize as soon as they can.

International best practices will require review and modification, of course, before they can be implemented in the United States. One immediate action all stakeholders can take is to respond to HHS’s voluntary pledge by designating an executive lead who can direct local implementation of best practices. To support this, HHS is exploring how to integrate climate change into its own agencies, like the Quality Improvement Organizations program²⁴ within the Centers for Medicare and Medicaid Services (CMS). HHS is also partnering with the National Academy of Medicine on the Action Collaborative on Decarbonizing the U.S. Health Sector, which brings together leaders of public and private health systems to explore ways to decarbonize U.S. health care.²⁵

Engage the health and care workforce. Approximately 22 million people work in U.S. health care. Educating, convincing, and motivating them will be essential to achieving net-zero emissions. Staff campaigns could help engage people and support individual and workplace changes that will contribute to decarbonization.²⁶ Training programs and fellowships could also help identify champions to help lead these efforts.²⁷

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Committing to net-zero carbon emissions and reaching that goal are hard work. In the U.S., the task will likely be much more difficult, given the country’s size, geographic diversity, fragmented health care system, and increasing political polarization. Addressing these challenges will require significant commitments and tangible actions at the federal, state, and local levels, supported by financial resources and visionary leadership. But as the NHS experience shows, with a systematic plan for implementation, progress is indeed possible.