Key points

  • With the NHS aiming to become the world’s first ‘net zero’ emissions health care system, understanding the views of the public will support the development and implementation of policies to successfully transition to net zero.
  • This long read explores public perceptions of climate change, health and the NHS. It highlights key findings from a nationally representative survey of 1,858 UK adults, conducted by Ipsos MORI in July 2021. 
  • The public are concerned about the health impacts of climate change – globally and in the UK. People consider climate change to be as big a threat to their own health as accidents/injuries and mental health problems. But the NHS’s role as a major contributor of emissions is not well recognised. Only around a quarter (26%) of people surveyed believe the NHS is contributing to climate change.
  • The net zero NHS ambition has the public’s backing. Despite the public being largely unaware of NHS net zero commitments, once explained to them, the majority support the net zero ambition and just 6% oppose it. However, addressing climate change is low down the public’s priorities for the NHS, highlighting the need to emphasise how the sustainability agenda interacts with and supports other health system priorities.
  • There is broad public support for a range of measures to reduce the NHS’s carbon footprint. The public are also willing to make changes to their behaviour (for example, more than nine in ten would return unused medications). Public support falls for proposals that impact individual treatment decisions and care, such as encouraging patients to manage their conditions at home. Patient engagement will be needed to resolve any tensions with individual needs and preferences.
  • The NHS workforce is key to implementing the changes needed to achieve net zero. Only 27% of NHS staff surveyed knew about net zero ambitions, so building staff awareness and knowledge around sustainability is essential.
 

Introduction

Human activity has unequivocally caused climate change. The effects can be seen across every habitable region of the globe and are occurring at an unprecedented rate. Some changes are now irreversible.

The NHS is taking its responsibility to address climate change seriously. In October 2020, the NHS in England published a major new climate change plan, announcing an ambition to become the world’s first ‘net zero’ health care system by 2045. This target requires a substantial reduction in emissions from all sources that the NHS influences – supply chains, buildings, clinical practice, and more – with any remaining emissions ‘offset’ by schemes to remove equivalent emissions from the atmosphere.

NHS commitments to environmental sustainability are not new – the new plan builds on more than 10 years of policy and progress in developing sustainable health care practices (see box below). But the aim to achieve net zero marks a step-change in the level of ambition and investment put into the cause.

With the NHS producing roughly the same emissions as Denmark, the task of getting to net zero is daunting. The transformation to a net zero NHS must also occur during the most challenging period in the history of the NHS – alongside responding to the pandemic, tackling the backlog of care, and meeting rising demand. Action needs to be driven by a workforce that is already understaffed and overworked, against a backdrop of wider system reorganisation.

With NHS net zero commitments already made, does it matter what the public think? And with the waiting list hitting record highs, do the public care about the NHS’s plan for net zero anyway? Understanding public views will support a successful transition to net zero for three reasons:

  • First, the NHS belongs to the people. Public opinion drives policy decisions, and the NHS net zero agenda must be properly prioritised and resourced if it is to succeed.
  • Second, the net zero agenda affects everyone. The shift to net zero will mean changes for how the NHS delivers care, with implications for every patient coming into contact with the service.
  • Third, a net zero NHS depends on changing public behaviour – for example, how patients travel to appointments and make decisions about their care. Listening to and involving the public in decisions increases the likelihood of making policy choices that will work.

To explore these issues, the Health Foundation commissioned a nationally representative survey of 1,858 UK adults about their views on climate change, health and sustainable health care. The survey was conducted between 22 and 28 July 2021 using Ipsos MORI’s KnowledgePanel UK – an online random probability panel. This long read highlights key findings from the research and considers their implications. The full survey findings can be found in this downloadable slide deck.

NHS England’s plan Delivering a Net Zero National Health Service builds on more than 10 years of environmental sustainability policy initiatives in health and social care. Below we provide a brief overview of key policies and progress related to both sides of the climate change response: mitigation (reducing climate change) and adaptation (responding to climate change’s effects).

Climate change mitigation

Mitigation is the action taken to reduce climate change by minimising and ultimately eliminating carbon emissions. In 2008, the UK became the first country to enshrine mitigation targets into law through the Climate Change Act. That same year, the NHS in England committed to the Climate Change Act timeline, becoming the world’s first health care system to set net zero emissions targets. In 2008, the Sustainable Development Unit (SDU, now Greener NHS) was created as a national unit to support and oversee progress towards meeting the targets. The SDU’s first task was to develop a methodology for measuring the carbon footprint of the whole NHS. This was followed by the first national strategy for reducing NHS emissions.

Around the same time, environmental sustainability practices in social care were emerging (see for example the Social Care Institute for Excellence’s sustainability programme in 2009–2012). In 2013, the SDU expanded its remit to include social care and produced a sustainability strategy for the whole of the NHS, public health and social care system in England.

In 2019, the NHS Long Term Plan restated commitments the Climate Change Act targets, alongside new commitments to improve air quality and reduce single use plastics. In 2020, action on environmental sustainability was, for the first time, stipulated in the NHS standard contract and planning guidance. NHS providers were instructed to produce a ‘green plan’, take ‘all reasonable steps’ to minimise their environmental impact, and report on progress annually. The 2020/21 GP contract also included a target for practices to shift towards prescribing lower-carbon inhalers.

The NHS in England has made some good progress towards reducing its carbon footprint, lowering its emissions by 26% between 1990 and 2019. A year on from the publication of Delivering a net zero NHS, the NHS is on track with its planned trajectory to net zero. Carbon reductions have been reported in areas including carbon-intensive anaesthetic gases (reducing from 23.1% of usage to 10.3% between 2018/19 and 2020/21) and patient and staff travel (137 million virtual GP appointments were delivered between June 2020 and June 2021) – though emissions from travel are expected to rise after the pandemic. Additionally, all NHS trusts have been asked to purchase renewable energy as soon as possible, a prototype zero emission ambulance is in development, and engagement has begun with major suppliers to reduce carbon associated with procurement.

Momentum is also building across the wider health system. Arms-length bodies are starting to develop their roles in supporting sustainable health care. For example, the National Institute for Health and Care Excellence have committed to considering the environmental impact of new technologies, and to working with the Care Quality Commission on an environmental agenda. Royal colleges and individual NHS trusts are declaring climate emergencies and developing plans. There are also increasing numbers of advocacy groups challenging the health system on its environmental commitments.

Climate change adaptation

Adaptation is the action taken to prepare for the effects of a changing climate. Adaptation is necessary (in addition to mitigation) because a certain amount of climate change is already inevitable. This means preparing for the health impacts of climate change, such as changes to patterns of illness, and ensuring that health and care infrastructure is resilient enough to withstand weather extremes and can remain operational during climate-induced disruptions and emergencies. The UK Health Security Agency (formerly Public Health England) leads much of the adaptation planning for health at a national level, such as planning for extreme weather. NHS organisations and local authorities also have responsibilities for adaptation under the Civil Contingencies Act (2004) – the legislative framework for emergency preparations.

Assessments of NHS and social care adaptation planning suggest it needs to be strengthened. The SDU’s Adaptation report for the healthcare system 2015 found that while there were areas of excellent practice, this was not systematic at any level. In 2020, the Environmental Audit Committee concluded that the NHS was not adequately prepared to deal with the effects of climate change. Risks around overheating in NHS and social care facilities were raised by the Climate Change Committee in 2019 and 2021 (for example, it is estimated that 90% of hospital wards are vulnerable to overheating). The extent of overheating risks in social care are unknown, but research has identified barriers to effective heat management in care homes, including building design, inconsistent overheating criteria and lack of staff awareness. Greener NHS is currently producing a report on health and care adaptation to feed into the UK’s national adaptation programme.

 

1. Public perceptions of the links between climate change, health and the NHS and social care

Climate change is a major concern for the UK public, with four in five people agreeing that it is a global emergency. Our polling explored public perceptions of the links between climate change and health in three areas: climate change as a threat to health; the health benefits of climate action; and the NHS and social care contribution to climate change.

Climate change as a threat to health

Climate change is a global health emergency, threatening the lives and livelihoods of millions of people around the world. In the UK, the greatest direct risks to health come from the increasing frequency and intensity of extreme weather events. For example, heat-related deaths are projected to more than triple to 7,000 a year by the 2050s. Warmer temperatures risk new vector-borne diseases emerging. And flooding events harm physical and mental health. Like COVID-19, the effects of climate change will not be felt equally, and will likely be shaped by pre-existing inequalities.

The public understand that climate change and health go hand-in-hand. Our polling found a widespread acceptance that climate change threatens the health of people globally (86%) and in the UK (73%). Almost half (48%) think that climate change threatens the health of people in the UK right now. A quarter of people surveyed see climate change as one of the biggest threats to their own health – a smaller threat than chronic diseases (47%), COVID-19 (42%) and lifestyle choices (34%), but as big a threat as accidents/injuries (27%) and mental health problems (25%). Younger people and those from minority ethnic groups are more likely to believe that climate change poses a health risk to themselves and their families, while people living in more deprived areas are more likely to be concerned about the health risk to themselves specifically.

The health benefits of action on climate change

While public debate tends to focus on the economic and social costs of acting, many of the actions that reduce climate change will also bring improvements to health. These health ‘co-benefits’ are realised through mechanisms such as reductions in air pollution (which currently contributes to around 36,000 deaths every year), increased physical activity, improved diet, and better quality housing and green space.

More than half (60%) of the public believe that actions to address climate change will improve the health of people in the UK. But more than a third (37%) think they will not improve health very much, or not at all. Given the value that the public places on health, this suggests there is scope to strengthen support for climate action by framing the climate change response as a health opportunity.

The NHS and social care’s contribution to climate change

The health and social care system is associated with significant use of resources and carbon emissions, comprising around 4–5% of England’s total carbon footprint. But the public does not see the NHS as contributing to the climate problem. Only about a quarter (26%) believe the NHS is contributing to climate change, while nearly a fifth (19%) disagree that the NHS is contributing to climate change – the majority neither agree nor disagree (46%) or don’t know (9%). Less than half (44%) believe that the NHS has a responsibility to reduce its impact on climate change. For social care the picture is similar, although slightly more people (49%) believe that social care has a responsibility to reduce its impact on climate change.

Given the high level of public concern around climate change overall, it is surprising that the majority of the public do not see the NHS and social care as having a responsibility to act. In the long term, reducing emissions from health and social care will help to minimise the health risks of climate change that our polling shows are of public concern. The NHS and social care sector must continue to make the case to the public for why reducing its emissions is a key part of the climate change solution.

 

2. Public perceptions of an NHS net zero ambition

The NHS in England has a target for reaching net zero:

  • by 2040 for the emissions directly controlled by the NHS
  • by 2045 for the emissions the NHS influences but does not directly control.

We asked the public about their awareness of and support for these NHS net zero commitments. While our survey asked about the specific commitments made by NHS England, NHS Wales and NHS Scotland have similar ambitions: NHS Wales has a plan to reach net zero by 2030 and NHS Scotland has a net zero plan in development.

The public are largely unaware of NHS net zero ambitions, with only 13% indicating awareness. But this is not necessarily a barrier to support. Once explained, 70% support the net zero ambition and just 6% oppose it. It doesn’t seem to be an issue that divides public opinion.

A potentially more significant barrier to achieving net zero is low awareness among NHS staff. While we would expect those working in the NHS to have a higher level of awareness than the general public, only 27% of the 121 people surveyed who personally work in the NHS were aware of the net zero ambition. A fully engaged NHS workforce is critical to achieving net zero, so building staff awareness of the ambition and the actions needed to deliver it will be essential.

Prioritisation of climate action and environmental sustainability

While the public generally supports the net zero ambition, it does not feature high on the list of priorities for the NHS, as shown in Figure 1. People ranked ‘reducing waiting times’, ‘hiring additional staff’ and ‘improving staff morale and reducing burnout’ as their top three priorities for the next 10 years (a MaxDiff prioritisation exercise was used – see the slidedeck for further details). Minimising the impact on climate change and the environment was ranked second least important of the 15 priorities considered.

However, unmitigated climate change will have a considerable impact on the public’s top priorities. Limiting climate change helps protect the aspects of the NHS that are most important to people. For example, adverse weather and emergency incidents caused by climate change are increasingly likely to disrupt care delivery and put more pressure on emergency departments, with consequences for staff workload and waiting times. Emphasising how environmental sustainability interacts with and supports other health system priorities – such as waiting times and prevention (see below) – will be important for gaining public support.

Figure 1

Shifting the NHS towards prevention

Our polling suggests that the public support an NHS that prioritises prevention, with ‘shifting services towards disease prevention rather than treatment’ ranked as the fourth highest priority for the NHS over the next 10 years.

Preventing illness so that people do not need carbon-intensive treatments in the first place is a necessary feature of a net zero NHS. Around half (52%) of people surveyed support the NHS focusing more on preventing illnesses in order to achieve net zero emissions, even if this may mean less funding for hospitals. Only 17% oppose this, with 27% remaining neutral. As far as we are aware, this is the first time the public have been polled on prevention as a measure to achieve a net zero NHS.

The moderate support and little opposition for a shift in resources away from acute care suggests that the NHS can be bold in its prevention ambitions. But it is not clear whether this broad support for prevention will translate into support for local service changes – and our polling identified some resistance among the public for measures that impact on individual treatment (see section 3). NHS organisations will need to work closely with public health and local authorities to allocate resources to improve population health while minimising environmental impact.

 

3. Public perceptions of sustainable health care measures

The NHS is adopting a wide range of measures to achieve net zero. We asked the public about their support for different measures with hypothetical trade-offs – some are current or planned practice, while others are not (yet) but were included to test public acceptability. The results are shown in Figure 2.

Providing more environmentally friendly food in hospitals (65% support), switching to low-emission ambulances (63% support) and building new hospitals to net zero standards (60% support) are the measures with the most support.

There is less support for proposals affecting the delivery of health care more directly. For example, more people oppose (35%) than support (30%) the NHS considering environmental impact when deciding what treatments to offer. The public are also divided in their support for the NHS encouraging patients to manage their conditions at home. Older people and people who would vote Conservative were more likely to oppose these measures.

Figure 2

We then tested the public’s willingness to personally make changes to support a net zero NHS (Figure 3). Overall, the majority of people surveyed are personally willing to take each action we suggested – this demonstrates broad public support for environmental action in the context of individual health care.

Figure 3

However, people are more willing to consider some behaviour changes than others. More than nine in ten (91%) would return unused medications and 85% would accept reusable equipment. The public are least willing to take an environmentally-friendly medicine if the NHS had to pay more (65%) or to consider environmental impact when deciding on their treatment (64%).

Support falls when the behaviour change would more directly impact on individual patient care. For example, 30% of people would not be willing to consider the environmental impact of their treatment, with opposition increasing to 34% for people older than 65. Likewise, 30% would not opt for a remote GP consultation (to reduce travel, rather than seeing a doctor in person), increasing to 40% for those aged 55 and older.

 

Conclusion

Climate change is a major concern for the public and is recognised as a direct risk to the health of people in the UK. But the public do not clearly recognise the NHS’s role as a contributor to these risks.

People support the net zero NHS ambition, even if they were not aware of it beforehand. A range of measures to reduce the NHS’s carbon footprint also have clear public backing, such as investing in greener buildings and vehicles, even if this costs the taxpayer more. The public are also willing to play a supporting role, for example by returning, reusing and recycling medications. This knowledge – which proposals have strongest support and can be enabled by public behaviour change – should inform and facilitate the implementation of net zero plans.

People appear less supportive of measures that could directly impact their individual treatment decisions and the delivery of care. The expansion of remote consultations and monitoring as part of a wider shift to digitally-enabled care is factored into net zero plans, but patient engagement will be needed to help resolve tensions with clinical need and individual preferences. Some measures we asked about are not current (or planned) practice, but may need to be considered in the future as the NHS looks at more options to reduce emissions.

People who work within the NHS are key to implementing the changes needed to achieve net zero. As the point of contact for patients, staff will need to communicate environmental issues and any implications for care – for example, by explaining to patients the relative environmental impact of different medicines as part of shared decision making. We found only 27% of NHS staff surveyed were aware of net zero ambitions. Building the workforce’s knowledge about sustainability will be necessary to drive net zero plans – and raising awareness of the net zero agenda from its current low base will be an important first step.

The NHS is facing many challenges and the public see bigger priorities for the next 10 years than addressing climate change. Aligning net zero plans to wider NHS objectives should help to maintain focus on the essential task of honouring vital environmental sustainability commitments.

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