What health services could do about climate change

Advocates for action on climate change face two main challenges. The first is to make everyone aware of the enormity of the problem. The second is to persuade anyone that anything can be done about it. Ignorance is bad enough, but inertia—induced by despair, denial, or the hope of a miraculous technical fix—is even more dangerous.

Climate change, as Robin Stott argues in this week's BMJ,¹ poses grave risks to health.² It threatens the essentials of life. It brings drought, floods, storms, and extremes of heat and cold that can lead to famine, homelessness, dislocation, destruction of communities, the spread of disease, and even mass migrations and armed conflict as people vie with each other for land, water, food, and energy. And let's not forget the effects on mental health of anxiety, insecurity, and a sense of powerlessness as we watch the grass wither and the ice-caps melt.

If medicine is about saving lives, not just by last ditch interventions but by trying to avert illness, then working to alter patterns of behaviour that contribute to climate change could arguably become a priority for clinicians—as an urgent preventive measure. Debating the health implications of climate change may also be the best way to get the general public to take the problem seriously. Concepts such as “sustainable development” and “global warming” can strike the average person as either too daunting to consider or too distant to concern them. But we can all relate to the idea of risks to health that may affect ourselves, our children, and grandchildren. So there are good reasons to put climate change at the heart of the health agenda.

Likewise, the climate change debate belongs at the heart of health service management. The institutions of health care have enormous power to do good or harm to the natural environment and to increase or diminish carbon emissions. This applies particularly to the NHS, with its sheer bulk—still growing year on year. In 2006-7 the annual NHS budget in England is expected to be £83bn (€121bn, $156bn), with a total UK health expenditure of £97bn.^w1 NHS purchasing power is estimated at £17bn a year.^w2 It is one of the largest employers in the world, beaten only by the likes of Wal-Mart and the Chinese army. It employs more than 1.3 million people^w3 and runs 259 NHS trusts.^w4

Consider the huge amounts of food; furniture; medical, cleaning, and office equipment; road vehicles; and building materials the NHS has to buy—directly or indirectly—to keep itself going. Consider the great expanses of land it occupies, the vast amounts of energy and water it consumes, and the mountains of waste it produces every year. Ideally, an organisation committed to safeguarding health would deploy its powers and resources in ways that help reduce carbon emissions. In truth, most decisions are made with scarcely a nod to the needs of the natural environment. The Royal Society for Nature Conservation has assembled the evidence on the NHS's consumption of energy, materials, and water; generation of waste; and travel (see details on bmj.com).^{w5 w6}

There are some exceptions. For example, hospitals in Cornwall have set up a project to purchase food from local suppliers; Addenbrooke's Hospital in Cambridge has a “green travel plan” that encourages walking, cycling, and using public transport; a trust in North Glamorgan has cut carbon emissions and saved money by creative energy management. Such examples are chronicled in a web based guide on good corporate citizenship recently launched by the Department of Health to help doctors and managers in the NHS use their resources more wisely.³,⁴

But good practice still depends on highly committed individuals innovating against the odds. Mean-while, the largest capital development programme in the history of the NHS has brought on a rash of largely unsustainable building. By 2010, more than £11bn is expected to have been spent on 100 new hospitals and more than £1bn on new primary care buildings.^{w7 w8} Most of the new hospitals will have large car parks and energy intensive air conditioning, heating, and lighting. They will often involve costly demolitions of buildings that might have been adapted at less cost in financial and environmental terms. Many will encroach on green field sites beyond urban centres, where access depends heavily on private cars. They will routinely use construction materials from unrenewable sources. They will produce almost unimaginable amounts of waste. And they may not ultimately be necessary, as demographic, technological, and policy changes alter the patterns of health care.^w9

The truth is that, despite an impressive array of official guidance,^w10-w12 incentives in the NHS run in the opposite direction. “Efficiency” is what matters most, and it is still defined as what works best for the financial bottom line. “Value for money” is a limited concept that does not yet recognise virtue in farsightedness. NHS targets are geared towards improving clinical performance and cutting waiting times. No one gets fired for failing to reduce the carbon footprint of a hospital or clinic.

And so, in the name of health care, gargantuan sums of public money continue to be spent in ways that are careless of the physical and mental wellbeing of future generations. A longer term perspective suggests that this makes poor sense, not only for population health, but also for the business of running a national health service.