Holding on to hope

In a light-filled room in south London, a group of health workers gather around a man in a space suit with ‘anti-cynicism coating and disbelief suspenders’. He invites them to travel forward in time to the 2036 they long to see.

Imaginings of green spaces, birdsong, quiet, a more relaxed pace, fill the space.

Their time-travelling guide for the day, environmental activist Rob Hopkins, issues a bold challenge: reframe the climate crisis as an opportunity, let imagination lead as they rethink the future of healthcare.

Rob Hopkins (pictured above, centre), best known for co-founding the Transition Network, contends that climate activism has spelled out the problem but not communicated the ‘delicious opportunities’ available if the focus shifts to the ‘what ifs’.

‘Longing on a large scale is what makes history,’ he says, quoting from Don DeLillo’s novel, Underworld.

His audience know all about longing: some know quite a bit about boldness. They’ve all committed two days to a creative workshop asking, ‘Is a sustainable healthcare system possible?’ Some have been in court for their climate activism.

Early in the workshop, there is a stark recorded message from Professor Julia Steinberger, a UN IPCC (Intergovernmental Panel on Climate Change) report author. Unless we achieve global net-zero carbon dioxide emissions by 2070, temperatures will not stay in the ‘safe’ zone of within 2°C of pre-industrial levels. ‘We are all that stands between our world and utter irreparable destruction,’ she says.

But the tone quickly shifts to the what ifs, to exploration and vision-casting, with much use of flipcharts, collage and greenery from the courtyard at the Jamyang London Buddhist Centre.

Rob Hopkins invites the group to envisage a future where investment in social infrastructure helps build health. He shows futuristic images of pop-up parks, de-paving movements and people swimming to work – then reveals these are already happening somewhere in the world.

Utrecht has 261 miles of bike lanes and its central station has a 13,500-space bike park, for example. Bhutan has famously moved beyond measuring GDP to prioritising wellbeing.

‘It’s not lack of innovation that’s the issue, it’s lack of ability to do things at scale,’ he says.

After a vegan lunch, participants are invited to reinvent the NHS.

Their ideas, written on paper slips, are wide-ranging and far-reaching – and run the length of the room. Many chime with the NHS England 10-year health plan and its focus on shifting ‘from hospital to community’ and ‘from sickness to prevention’.

Others are more radical: deprescribing clinics, free public transport, hospital food grown on site, living-wall gardens, an ‘NHS imagination centre’.

The thrust is towards systems-thinking that prioritises a kinder, more creative, more equal health system rooted in communities which care for people as well as the environment.

What if healthcare was depoliticised and health teams had more autonomy to make decisions? What if there was more time for staff wellbeing and creative thinking to problem-solve?

What if continuity of care was prioritised above all? What if food and nutrition became more part of health conversations? What if the NHS ended all relationship with fossil fuels?

Small groups unpack a handful of these ‘what ifs’, to see if ambitious goals might spawn practical outworkings. There is talk of creating ‘pop-up gardens’ around health settings, for nature connection and wellbeing. There is an idea about creating an exhibition of what a future hospital might look, feel and smell like. There is a strong commitment to share and learn from current examples of sustainable practice as ‘positive stories from the future’.

Yet, harsh realities such as over-busy lives and managers with other priorities threaten to derail the optimism.

‘Moral injury’ is mentioned more than once: these health professionals are painfully aware of being part of a system whose emissions are damaging patient health. Many feel at odds with the system, disempowered, isolated. ‘I’ve not spoken to anyone in my workplace about this stuff in a year,’ says one.

Organiser Alice Clack (pictured top, third from left), a consultant obstetrician and gynaecologist, urges people to connect with like-minded others: ‘It can sometimes be unbearable, being aware of the unfolding climate and ecological emergency while continuing to work in a blinkered and unsustainable health system. But maybe we need to acknowledge the pain of “what is” to take our first steps to “what next”.

‘We are not supposed to deal with these realities on our own and building communities of support is essential.’

They will go on, in the second day, to unpack some of these ideas and discuss which they might move forward.

At the centre of a final flipchart brainstorm are the words: ‘We need to be brave!’

Four days later, at a Westminster Health Forum conference on ‘Next steps for net-zero and sustainability in the NHS’, the talk is high-level and technical, deeply mired in costings and targets.

Sustainability champions from across NHS England, health trusts and other sectors have gathered online to discuss what it will take for the NHS to shrink its carbon footprint.

NHS official voices are cautiously, determinedly optimistic; other voices strain with frustration, at the lack of funding, infrastructure, innovation needed to bring change at scale. What cuts through are individuals’ passion and individual success stories.

Chris Gormley, chief sustainability officer at NHS England, celebrates a 14 per cent reduction in NHS direct emissions since 2019-20, including a 33 per cent reduction in emissions from high-carbon medicines such as anaesthetic gases.

Yet, cutting emissions is proving much harder in an ageing NHS estate in England with an annual energy bill of £1.4bn. Investment in renewable energy has led to a 10 per cent reduction in estate emissions but emissions from the use of gas have dropped by just 1 per cent.

Meanwhile, travel and transport emissions have risen slightly since 2019/20: electrifying the fleet is a priority.

The three shifts in the NHS England 10-year plan, towards community, digital and prevention, are all expected to support net-zero ambitions. But achieving the interim target of an 80 per cent reduction in direct emissions by 2032 ‘is going to be really, really tricky’, says Mr Gormley.

Perhaps an even tougher challenge is reducing the NHS’s indirect emissions, including decarbonising its purchased goods and services, says Heidi Barnard, head of sustainability at NHS Supply Chain.

She explains how suppliers are being encouraged to be more sustainable, including through a requirement for carbon reduction plans and continuing progress assessment via the Evergreen platform. NHS procurement strategies such as Design for Life are prioritising circular solutions and reuse. But challenges remain, including scaling up on success.

‘Net zero cannot be seen as a separate agenda to everything else,’ she says. ‘It absolutely is part of the NHS long-term plan … Progress depends on partnership, early engagement and willingness to challenge established ways of working.’

Many speakers agree on the need for lateral thinking.

Jonathan Guppy, head of sustainability at SCAS (South Central Ambulance Service NHS Foundation Trust), describes the unconventional route his trust is taking to ready its 23 ambulance resource centres for charging electric vehicles.

To install on-site substations, the traditional route would have involved a DNO (distribution network operator) such as a UK Power Networks, taken years and been prohibitively expensive.

Instead, SCAS is using an independent connection provider for most of the work, then an independent DNO will adopt the substation and make SCAS an upfront ‘asset value’ payment. Work began in April, just three months after funding was secured, and the first substation is expected to cost a third of what it would have done through the DNO route.

Peter Leighton-Jones, head of sustainability at Mid Yorkshire Teaching NHS Trust, makes a strong case for ending the current moratorium on new private finance in the NHS – especially since the Public Sector Decarbonisation Scheme and its grants were scrapped last year.

Capital costs to achieve net zero at his trust would be £75bn, he says, but it hasn’t received ‘anywhere near that amount’.

Lucy Symons-Jones, net-zero director of professional services consultancy WSP, echoes the call for new approaches: ‘We need to welcome commercial and entrepreneurial expertise.’

The example of current works at Wythenshawe Hospital in Manchester to switch to geothermal energy, made possible through the Green Heat Network Fund and private finance, makes the point.

The discussion often circles back to the need for longer-term systems-thinking and collaboration.

Alex Forrest of sustainability consultancy Eunomia says that reuse will only become widespread in the NHS with the right policy and systems in place, from inventory management to repair and recertification systems. Innovation needs support, such as ‘forward commitment procurement’ whereby the public sector signals an unmet need for sustainable products and pledges to buy solutions once they’re developed.

Jay Burt, clinical policy fellow at The Health Foundation, underlines the need for leadership engagement and stronger accountability embedded in policy.

Not surprisingly but noticeably, this forum gives less attention to what individuals can do. Mr Gormley suggests health workers passionate about sustainability might look at their trusts’ or integrated care boards’ green plans and speak to leadership about helping with ‘particular deliverables’.

He adds: ‘The healthcare sector is really driven and dedicated to delivering these targets. That doesn't mean they have lots of time to do it … For the NHS, which is the right way to prioritise, our patients obviously come first.’

Yet, for senior house officer in paediatrics Matthew Lee, patient care is indivisible from climate action – and health workers’ ‘educating and empowering’ patients is central to accelerating the pace of change.

Dr Lee, who is involved in promoting screenings of the People’s Emergency Briefing film in healthcare settings, is shocked some colleagues still ask why the climate crisis is a health issue.

‘What if we had the entirety of the NHS workforce, or 1.6 million staff, some of the most trusted professionals in the UK, having discussions about climate change with their patients and their colleagues every single day and taking action collectively at home and in their workplaces?’ asks Dr Lee.

‘The NHS can and arguably should be the epicentre of climate action in the UK.’

Here, there’s an echo of the revolutionary charge of the workshop four days earlier.

Its organiser, Dr Clack, holds out a challenge to NHS sustainability leads. ‘They can see that what we are doing isn't working, or working quickly enough, and the health system is incredibly vulnerable to collapse.

‘Is it time to refuse to participate in incremental change and insist on radical transformation and adaptation? Where is the realistic emergency plan? Where is the attempt at patient education?

‘We should be screening the People’s Emergency Briefing film everywhere and offering a vision of a public health-based response as our “what if”. What would our health service look like if we just started again?’