WIREDGOV

Why sustainability matters for the NHS 

Climate change is the biggest risk to health in the 21st century and the NHS is the largest public sector contributor to UK carbon emissions. Climate modelling indicates that rapid decarbonisation is needed this decade to avoid the need for more costly action in future. The NHS has played a leading role internationally in championing the need for more sustainable approaches to health and care, and this work now needs to be accelerated. 

The financial and environmental sustainability challenges facing the NHS are closely connected. Both require achieving the best-possible outcomes from the resources invested, minimising activities that are of limited value to patients and prioritising prevention and early intervention. 

Improving the environmental sustainability of the NHS delivers benefits for patients, staff and taxpayers. Examples in this report illustrate that, by reducing waste and improving the efficiency of care, sustainability initiatives can save money and improve services. Sustainability interventions also strengthen the resilience of the NHS to cope with climate-related threats, such as extreme heat, flooding and supply chain disruption. 

What this research aimed to understand 

This research examined accountability arrangements for environmental sustainability in the NHS in England, focusing on the mechanisms and practices used to hold trusts and integrated care boards to account. We aimed to understand the strengths and limitations of existing arrangements and how these could be improved. 

What the research found 

Progress to date

Progress has been made over the past five years as part of NHS England’s Greener NHS programme, which has introduced a number of accountability mechanisms. This has included legal duties regarding carbon reduction for the NHS as a whole, and various statutory requirements for trusts and integrated care boards, including the obligation to produce ‘green plans’ setting out how sustainability goals will be met. 

Limitations in current accountability arrangements

Despite the existence of statutory environmental requirements, accountability for meeting these requirements is not sufficiently strong in practice because sustainability is often deprioritised compared with other NHS goals. For example, trusts and integrated care boards must appoint a board-level sustainability lead, but responsibility is often delegated to colleagues with insufficient influence, authority or resources to drive change within their organisations. 

Alignment with wider national NHS goals

The focus of the 10 Year Health Plan for England (Department of Health and Social Care 2025b) – on a more preventive approach to health that reduces the need for resource-intensive hospital care, shifts care from hospitals to the community and makes better use of technology – is potentially highly aligned with environmental sustainability. If implemented successfully, these changes could help to decarbonise the NHS and protect vital natural resources. However, sustainability needs to be an explicit goal in the reforms to ensure that the mechanisms used to hold NHS organisations to account for delivering these shifts also create environmental benefits. 

The role of leadership and narrative

Accountability mechanisms will achieve little unless visible leadership and prioritisation at the highest levels accompany them. Senior NHS leaders and politicians need to communicate the importance of sustainability for the NHS, conveying the benefits for patients and staff in a compelling way, and ensuring that long-term and short-term priorities are balanced appropriately. The government has emphasised the need to reform the NHS to make it ‘fit for the future’. Environmental sustainability and resilience should now become part of that narrative. 

What needs to change? 

We propose a twin-track approach to ensure accountability arrangements drive action at the scale and pace required. 

First, accountability mechanisms designed specifically for sustainability need to be strengthened. 

Second, environmental sustainability needs to be embedded throughout broader national and regional accountability and performance management processes so it becomes part of routine decision-making.