Fresh thinking on healthcare will drive the decarbonisation agenda

Reaching net zero targets currently feels like an insurmountable challenge for NHS leaders.

But modernising healthcare provision will - in addition to the primary aim of improving patient care - reduce the environmental impacts of an NHS that needs to prepare for changing demands and approaches to patient care for decades to come.

Mark Walker, healthcare sector lead for Hydrock, now Stantec, explores the importance of thinking more broadly about how to decarbonise the NHS.

There's no avoiding the fact that the NHS is a high energy user. In England alone, it's responsible for 40% of the public sector's emissions ^[1], and according to the BMA ^[2], 38% of the 237 NHS organisations responding to a freedom of information request made in December 2021, stated that their use of fossil fuels had increased since the start of 2020.

Industry sentiment is that whilst the NHS carbon footprint is reducing, progress has slowed. The quick wins, such as installing LED lighting and improved fleet management, have been achieved. Set against the pressures of waiting lists, staff retention and deteriorating facilities, the effort required to maintain focus and commitment to decarbonisation is proving too much.

To be net zero by 2040 for carbon emissions that the NHS directly controls, and net zero by 2045 for carbon emissions that the NHS can influence, are targets that currently feel unachievable.

More lateral thinking is required on how the NHS both reduces its environmental impacts, and improves patient care and employee working conditions.

To the NHS' credit, there is both awareness and vision of what the future holds for a modernised approach to healthcare delivery in the UK.

It's a vision that transcends the understandable review of the 'New Hospital Programme' announced by the Chancellor within 30 days of the new Labour government coming to power.

The direction of travel is led by 'lift and shift' - the movement of less acute service provision to more localised, community settings. This makes care more accessible to patients and reduces the burden on over-crowded hospitals.

Within hospitals, expect to see increased focus on efficiency, such as investment in autonomous robots to move kit, and streamlined processes to reduce packaging and manage waste.

Interestingly, these examples aren't specifically about the design of buildings to reduce carbon impacts. They are about process efficiencies which have positive impacts on the overall state of the NHS, including emissions.

There is no dispute that crumbling facilities need addressing. It affects employee morale, and puts patients at risk. But how this is addressed is also part of the overall holistic approach to modernising the NHS. According to Estates Return Information Collection (ERIC) data returns for 2022/23, backlog maintenance stands at £11.6bn, a 13.6% increase on 2021/22. Of this, £6.6bn is classified as high risk or critical maintenance, and mental health facilities are especially at risk and frequently overlooked in budget allocations.

An estates-led approach to decarbonisation will help tackle backlog maintenance. New and more energy efficient MEP services and equipment will lower emissions and reduce maintenance demands. It will also ensure the programme of works addresses fire standards and meets the Building Safety Act regulations.

Nevertheless, with advances in medical technology, and increasing digitisation on how to access care, it begs the question on where attention most needs to be placed. We need to shape the infrastructure for an NHS estate that is relevant for 2050 and beyond. Tough decisions are needed between a focus on fixing the roof - literally - or right-sizing and re-imagining the estate. A combination is needed, but embracing a modernised, healthcare system will reduce environmental impacts and meet net zero targets in ways beyond what can be achieved by a more traditional approach to decarbonisation.

Scale-up community-based healthcare delivery: This was set in motion by central government's investment in community diagnostic centres from 2021, and is now a core part of Labour's plans, defined as neighbourhood health centres. The drive is to take a significant amount of healthcare delivery back to communities.

The social and environmental benefits are clear:

• Access to diagnostics and healthcare support that's closer to home for patients.
• Increased opportunity to use public transport to access care, reducing vehicular movement and emissions.
• Re-use of existing redundant facilities in town centres, communities, and shopping malls, generating footfall and social engagement.
• More appropriate working conditions for NHS staff whose role is not related to delivering acute and emergency care.
• Reduction of demand-stress placed on hospitals, allowing more space to be used for acute needs.
• Opportunity to integrate care provision into localised, community facilities, to make better use of the space and transition patients through the system to recovery.
• Easier inclusion of gyms and wellbeing centres at these facilities, to promote healthier and active lifestyles.

The opportunities and challenges from repurposing retail for healthcare were dissected in our recent roundtable, with guests from the NHS and the real estate community - detailed here.

Evidence exists to demonstrate the positive reduction in carbon emissions from this approach. Manchester University NHS Foundation Trust, for example, halved CO2 emissions from patient travel for specialist macular eye treatment by utilising community hubs, whilst improving accessibility to care for patients ^[3].

While not without its challenges, a strategy to bring inter-linked health services firmly into community settings will have far-reaching positive impacts.

Embrace temporary modular wards: Witnessed at the height of the COVID-19 pandemic, the ability to site and use temporary, modular-designed wards to deliver patient care on hospital sites is a legitimate approach to tackling crumbling hospitals.

The key to success is the quality of design of modular pop-up wards that can stand the test of time - sometimes decades - so either appropriate retrofit work can take place, or new facilities be designed with the future in mind.

If the demand on hospitals can be reduced through community delivery and improvements to healthy living, then an argument exists that the sheer scale of new hospital construction required is reduced. This in turn lowers overall carbon emissions including embodied and operational carbon.

But equally, recognising how medical treatment is changing completely, it might even lead to estate rationalisation. Instead of pouring money into failing buildings, the use of modern, modular temporary wards creates the time and space to invest in the appropriate design and construction of new facilities that are as close to future-proof as possible.

Create a holistic energy strategy: The 2022/23 ERIC data returns suggest 35% of NHS Trusts don't have a heat decarbonisation strategy, whilst total energy usage from all energy sources is decreasing by a fraction.

The opportunity to take a site-wide view on energy use and energy provision is a huge opportunity for Trusts given the size of their estates and energy consumption.

Our own work with Mid Cheshire Hospitals NHS Foundation Trust has demonstrated the value of truly understanding the power requirements for a new facility, including the long-term demand from EV charging and the revenue generation this brings for the Trust.

For Mid Cheshire, we've modelled the feasibility and energy provision that can be secured from deep and shallow bore geothermal heat extraction and storage, a private-wire connection to a local authority owned solar farm, on-site renewable energy generation and storage, and the use of air-source heating.

A hospital as a power station is a concept to be lauded. Energy resilience will always be paramount, but the opportunity to generate and combine power from different sources, and support EV charging, is an important step in reducing costs and emissions, and reaching net zero, whilst leaving hospital buildings to be modelled to deliver the best outcomes for patients.

The ultimate step in a holistic energy strategy is to capture heat from a hospital estate and connect it to a local district energy network. The opportunity to address fuel poverty, especially in low-income neighbourhoods, results in the NHS expanding its role in improving health outcomes, as a low-cost energy provider.

Invest in societal change to improve attitudes towards health: If we all lead more healthy lives, quite simply we reduce the burden on the NHS, its estate and associated emissions.

Better housing, placemaking, safe and easy access to sustainable travel options, more investment in sport, and integrated community health provision - as detailed above - will all contribute.

Society's goal must be for the NHS to be a place for genuine care for non-preventable illness or accidents, and not a means to repair a population unable to look after itself. A mindset change is needed to see the NHS as a 'healer', a promotor of healthy lifestyles, and even an energy provider.

Improve our attitudes to health, and we reduce the stress on the NHS, and the energy - literal and metaphorical - required to meet current demand.

Decarbonisation has become a challenging concept for the NHS, faced by so many other challenges. However, if we take a more holistic view on adapting our healthcare provision for the second half of the 21st century, opportunities open up to make the NHS more sustainable, low carbon, and relevant to patient and employee needs.

References:

1. Greener NHS blog

2. More support needed to help the NHS reach net zero

3. MFT-Green-Plan_V1.0.pdf