The FHJ debate: Sustainable healthcare should be the responsibility of every physician

Proposition: Sustainable healthcare should be the responsibility of every physician

Thomas Daniels

‘First do no harm’ is perhaps the most famous of medical aphorisms.¹ The World Health Organization (WHO) has described the climate emergency as the ‘single biggest threat to human health’.² Globally, 2024 was the hottest year on record, and 2022 smashed the record for the hottest day in the UK. It is estimated that this caused over 61,000 excess death across Europe that year.³ In the UK there were over 3,400 excess deaths, the equivalent of over seven A380-plane loads of passengers, due to this climate change-fuelled disaster. In addition, despite 29 ‘Conferences of the Parties’ (COPs) over nearly three decades, there is evidence to suggest that global warming is not just continuing unchecked, but accelerating.⁴ Between 2024 and 2050 the World Economic Forum estimates that there are likely to be 14.5 million extra deaths due to the climate emergency, not to mention associated morbidity and climate refugees.⁵ Yet healthcare as an industry makes an outsized contribution to that very same global warming: if healthcare was a country, it would be the fifth largest contributor to emissions in the world.⁶ Medicines account for about 25% of the NHS’s climate impact, putting physicians at the forefront of this negative impact and in prime position to make a significant difference. Without dramatic action, and without a ‘liveable’ planet, the framework to provide any sort of healthcare at all will have disappeared. ‘There is no health on a dead planet’.⁷

The push for physicians is not just an ethical, albeit self-interested, one. In almost every action taken that improves the environmental sustainability of healthcare, the intervention also provides better care for patients: whether that is targeting patients with asthma who use high quantities of reliever medication, preventing over-prescribing for older people or reducing unnecessary blood tests, all are both better for patients and better for environmental sustainability. Better patient care and more sustainable care are two sides of the same coin.

Nor is a choice to increase the focus on environmentally sustainable care in conflict with the need to reduce costs in a cash-strapped NHS. Current health secretary Wes Streeting has said that we are facing the ‘collapse of the NHS’,⁸ which has had increased investment but is seeing diminishing efficiency gains partly due to increased need for healthcare. The OECD has estimated that around one fifth of healthcare spending makes no or minimal contribution to good health outcomes.⁹ The NHS budget in 2024–2025 is likely to be around £192 billion, of which about £120 billion is allocated to secondary care. And yet environmentally sustainable care and financially efficient care are not just compatible with each other, but mutually reinforcing. The UK National Overprescribing Review¹⁰ estimates that around 10% of prescriptions are likely to be unnecessary or not appropriate, while as many as 16% of unplanned hospital admissions were due to adverse drug reactions. By targeting overprescribing, perhaps using the Royal College of Physicians’ latest acute care toolkit (17)¹¹ for example, physicians can make patient care better, reduce the impact of healthcare on global warming and reduce costs on the NHS.

Another national priority is over-use of antibiotics, and specifically intravenous (IV) antibiotics. Physicians are responsible for the majority of antibiotics in secondary care, whose over-use is associated with an increased risk of anti-microbial resistance (AMR). AMR is already thought to be responsible for over 1.2 million deaths per year, and could increase to 10 million deaths per year by 2050.¹² Reducing IV antibiotic use in hospital has even been an NHS England CQUIN target. Despite the obvious benefits of reducing AMR, the sustainability benefits of this initiative are also very significant,¹³ with IV antibiotic doses using 60 times more (single use) plastic than oral medications. On top of this, oral antibiotics are associated with shorter length of stay, fewer blood tests and better patient experience. And it is physicians, on ward rounds every day and in every hospital, who hold the prescribing pen to change this practice. Reducing over-prescribing is better for patients, better for the planet and better for NHS finances.

Beyond the examples given above, there are many other examples of co-benefits from sustainability actions. These include unnecessary testing, single-use equipment and empowering shared decision making, all of which do far more than improve environmental sustainability, be it reducing side effects from unnecessary venepuncture, reducing the barriers to smooth inpatient flow or improving patient satisfaction.

But is it the duty of a physician to consider the climate emergency in the course of the care they deliver? Even if we are to take the stomach-churning step of leaving aside the existential threat to humanity that the climate emergency poses and focus just on the more narrow professional responsibilities of physicians, what does the GMC say? In ‘Good Medical Practice’,¹⁴ the GMC states that doctors ‘have a duty to the health of the wider community’, ‘should make good use of resources … taking account of [their] responsibilities to patients and the wider community’, and also ‘must tackle discrimination where it arises’. To this last point it is worth noting that the impacts of the climate emergency are highly discriminatory, in that they generally affect those in the poorest and most deprived parts of the country and the world much more than those in the more developed and wealthier parts.¹⁵ Given the climate emergency definitely affects the ‘wider community’ (however that is defined), it is clear that the GMC expects doctors to practise in a way that minimises the negative impacts of that care of the wider community, be that a local community or a global community, while not negatively impacting on individual patient care. Thus, physicians have a responsibility to consider and act on the climate emergency for the benefit of the patient in front of us, for patients of the future, for the global community and for the NHS.

Opposition: Sustainable healthcare should not be the responsibility of every physician

Linford Fernandes

Sustainable healthcare is broadly defined as maintaining and improving health outcomes for the population, while minimising the environmental impact of healthcare delivery and interventions. This is done through disease prevention, patient and public empowerment, systems optimisation, and low carbon strategies. While some aspects of sustainable healthcare should be considered by every physician, especially as outlined by Good Medical Practice, the proposition that it should be the responsibility of every physician is unrealistic and inefficient.¹⁴

A closer look at the NHS carbon footprint demonstrates that the biggest contribution to healthcare-associated emissions arises from the procurement and supply of medicines and devices. A second major contributor is the energy spent sustaining the physical infrastructure of healthcare institutions.¹⁶ The decisions made on these options and whether they are environmentally sustainable are far removed from the remit of most physicians unless they are in the senior operational or management positions in their trusts or integrated care boards. On a national level, the National Institute for Health and Care Excellence (NICE) is responsible via its health technology appraisal process for the licensing of medicines and medical devices for use in the NHS. Although NICE has outlined its strategy in addressing environmental sustainability, it has needed encouragement to make progress on these objectives.^17,18 It would be unreasonable to expect physicians to make choices on the medicines and devices they use, when NICE itself has yet to make meaningful improvements to the approvals process. Other major NHS carbon contributors like vehicle travel to and from institutions by healthcare staff is influenced by limited public transport links and cycling routes in smaller towns and rural areas. This is once again beyond the remit and responsibility of most physicians, where unsociable working hours make it impracticable to rely on public transport provisions.

There are aspects of sustainable healthcare that are in the remit and therefore responsibility of healthcare professionals. The RCP’s green physician toolkit provides some areas where sustainability can be prioritised, like reducing unnecessary blood testing or imaging.¹⁹ However, these measures are already practised by physicians during their clinical duties. In a publicly funded healthcare system with finite resources, prioritising investigations and reducing waste helps provide best-value care for the population. I would surmise the fact that this practice can concurrently aid with sustainability is a secondary consideration.

Sustainable healthcare requires investment of time, resources and expertise as well as measurable outcomes. The current physician workforce is stretched with recruitment and retention not meeting the requirements of the population. Tasked with the delivery of healthcare and the training of future healthcare professionals, there is little time for the physician to focus on sustainability practices. At the individual level, the little time in job plans available for continuous professional development is also spent on governance, audit, teaching, appraisal and revalidation. To develop and embed sustainable practice in departmental pathways and protocols, physicians require significantly more time and resource investment.

At the institutional level, there are several barriers in the NHS that further prevent sustainable practices from being embedded in clinical practice, not limited to the lack of organisational memory once practices are put in place, lack of cross-departmental and -site working and lack of measurable outcomes on environmental impact.²⁰ There is significant heterogeneity in the parameters that healthcare institutions use to evaluate progress on achieving environmental sustainability.²¹ Greenhouse gas emissions, energy usage and waste production are a few of the parameters commonly quoted and just looking at these outcomes, physicians have no insight into how their clinical practice impacts on these measures. There needs to be agreement at the level of policy makers and leaders as to how sustainable healthcare is measured at all levels from individual to institutional practice and this should not be the responsibility of the physician. Until consensus measures of environmental sustainability are agreed and adopted, physicians cannot be expected to institute changes in practice based on surrogate markers with little evidence.

Perhaps the most difficult principle of sustainable healthcare to implement is the use of green alternative medicines and devices. National guidance on medicines and procedures across the medical specialties make little to no mention of the environmental impact of their guidance. The first responsibility of the physician is to their patient and hence it would follow that the most cost-effective and efficacious medicines and devices should be implemented regardless of their environmental impact, most of which is had during its production.

In the current healthcare system, the attention of physicians should be concentrated on delivering a high standard of healthcare to their population. While a basic understanding of sustainable healthcare principles is important, for example, the promotion of good health, other aspects of sustainable healthcare should be the responsibility of healthcare leaders and policy makers. Embedding sustainable healthcare practices in the NHS requires institutional and regional action and only then will we see a meaningful and measurable change of our impact on the environment.

What do you think? Vote at https://forms.office.com/e/RdQQsWKg24 until 9 June 2025. Do you like the debate feature? Send us your thoughts to fhj@rcp.ac.uk.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

CRediT authorship contribution statement

Thomas Daniels: Writing – original draft, Writing – review & editing. Linford Fernandes: Writing – original draft, Writing – review & editing.

Declaration of competing interest

The authors declare the following financial interests/personal relationships which may be considered as potential competing interests:

Thomas Daniels is on the Royal College of Physicians' sustainability in healthcare and climate change advisory group.

Linford Fernandes is an editorial board member for the Future Healthcare Journal. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported.