Comment / Staying green and out of the red

By Chris Naylor

The headline figures on the environmental impacts of healthcare are striking. The NHS in England alone has a carbon footprint that exceeds emissions from all planes departing Heathrow airport and produces enough sewage to fill Wembley stadium to the brim once every 16 days. There is a growing momentum behind tackling this, with an increasing number of organisations taking action to improve the sustainability of their operations.

But can improving environmental sustainability be reconciled with the financial reality facing the NHS? A King's Fund report, Sustainable health and social care: connecting environmental and financial performance, looks at the link between economic and environmental sustainability and explores the service changes needed to develop an approach that is sustainable in terms of both financial and natural resources.

There is a clear conceptual connection between sustainability and the QIPP programme - both agendas call for a re-focusing on efficiency, value and prevention of avoidable activity.  Modelling by the NHS Sustainable Development Unit suggests there are approaches that could generate cost savings and a growing number of case studies indicate that some of these predicted benefits can be realised in practice.

Many of the quick wins involve operational moves such as adopting energy efficiency measures, installing combined heat and power generators and cutting travel via teleconferencing. Such measures can deliver a significant financial return on investment in a relatively short time. In some cases financing options are available that reduce upfront costs and bring forward anticipated future savings.

But improving efficiency at the day-to-day operational level will not be enough. A fundamental transformation in service models is needed, with a greater emphasis on prevention, shifting care upstream, integration across services and a relentless focus on maximising value. If services are provided so patients experience an efficient journey through the system, get maximum value from every contact with professionals and receive co-ordinated support for their needs, this should be more sustainable from an environmental and financial perspective.

To some extent, then, the changes needed to improve environmental sustainability are the same as those needed to improve quality and productivity. But these are complex issues and there are barriers.  For example, financial and environmental benefits premised on the possibility of reducing bed use in secondary care can only be realised if capacity can be taken out of the system. This shows the need for local action to be supported by changes to the national policy framework - for example, to remove perverse incentives in the reimbursement system and allow hospital reconfiguration to take place as needed.

Finance staff can play a key role in championing sustainability and engaging the wider workforce. Given the broad transformative agenda it represents, sustainability should extend beyond estates and facilities directorates and be a concern for whole organisations - linked closely to the finance function.
There are important implications for skills and capabilities within finance teams. If sustainability is to become a core part of standard business processes, it will be necessary to understand how to value environmental costs and benefits appropriately - and how to weigh these against financial and quality costs and benefits where trade-offs arise. Environmental accounting tools from other sectors must be adapted and refined so they can be applied to health settings.

Leading the sustainability agenda in the current climate will be challenging. But there are overlaps with changes that already need to be made for financial and quality reasons and opportunities to pursue multiple objectives simultaneously. With the right approach it should be possible not only to improve the environmental sustainability of health, but to build a system that delivers better value and improved quality of care for patients.

Chris Naylor is a fellow at the King's Fund