Can an experiential future catalyse action on the NHS net zero goal?

In response to the health threats from climate change the NHS in England has adopted a legally binding target to achieve net zero by 2040 for the emissions it controls and 2045 for the emissions it influences. With just 15 years to reach net zero – and 7 years to cut directly controlled emissions by 80% (versus 1990 levels) – there is no time to lose. But what would a desirable net zero NHS look like, and how can the health service achieve the change needed? 

In 2024, the Health Foundation and The Liminal Space showcased an immersive future scenario of an imagined NHS in 2036 to offer insight and stimulate action on the NHS net zero challenge. The fictional scenario – brought to life through built sets, artefacts and films – aimed to spark imagination and debate about what the most desirable net zero future looks like and how to get there. It was first created as an installation for people working across the health system to experience in person. Now anyone can explore the scenario using our online interactive feature and workshop guide. 

Here we reflect on what we’ve learned so far by using this novel approach, with the aim of supporting others to use the scenario to start their own conversations on the future of net zero health care. To date, over 500 people have experienced our scenario in person through workshops and events, including three half-day workshops in early 2024 with 58 people from the NHS, academia, charities, government, and those with lived experience. The insights below are primarily captured from in-depth discussions at these events, though we also draw on many other conversations the scenario has prompted.

Long-term thinking in policymaking is notoriously hard. Yet the dynamics of climate change, where inaction now makes the impacts worse and more complicated to tackle in the future, make it imperative that the NHS considers the long-term implications of its decisions. As such, environmental considerations need to be integrated into the forthcoming 10-Year Health Plan. As an organisation producing carbon emissions equivalent to a small country, the NHS must take its responsibility to act on climate change seriously.

Achieving net zero requires a large-scale shift to prevention and better management of disease to keep people well; reducing the use of carbon-intensive treatments and settings; eliminating waste and unnecessary interventions; and switching to low-carbon medicines, treatments and products. While not easy to deliver, sustainable health care also brings immediate and long-term benefits for patients and the health system, such as optimising treatment to keep people well for longer. 

While achieving this transformation requires concerted effort from policymakers and leaders, bandwidth and resources within government and among NHS leadership can be in short supply when faced with an immediate crisis in services and severe financial pressures. When less than half of people think the NHS has a responsibility to reduce its impact on climate change, public pressure to prioritise net zero is also limited. Practical approaches are needed to help break out of near-term thinking and engage in the long-term changes needed. ‘Futures thinking’ – a set of structured techniques and tools including scenarios – can support this.

Scenarios are imagined stories about potential futures; a tool to explore possibilities and the implications for policies, plans and organisations today. However, when scenarios are presented (as they often are) as high-level narrative descriptions, it can be hard to connect to the story. 

This is where the ‘experiential futures’ approach comes in. Described as ‘the design of situations and stuff from the future to catalyse insight and change’, they bring the future to life using media as varied as graphics, videos, artefacts and games. Experiences allow people to interact with the future in a tangible and personal way, enabling deeper engagement. 

Our experiential future is a fictional scenario of an NHS approaching net zero. The scenario is set in June 2036 – soon enough to be relatable, but distant enough that the NHS could be radically different to today. Its three scenes take place during 1 day, with the audience experiencing the scenario from three perspectives: as a patient, hospital leader and member of the public. 

The Health Foundation and The Liminal Space developed the scenario iteratively, engaging with experts in sustainable health care, clinicians, leaders and people with lived experience. First, The Liminal Space conducted interviews and hosted focus groups to gather expert views on what a future net zero NHS could look like. It used the themes from these discussions to identify future possibilities, questions and tensions around the net zero transition that the scenario could explore. For example: 

• When should patients be involved in conversations about climate change and the environmental impact of their care?
• How does the country shift from over-treatment, specialisation and over-medicalisation to a more preventative, community-based model of care?
• How do you address public disconnection from the issue?
• What should be the NHS’s role in addressing the wider determinants of health?

Drawing on the themes, the two organisations co-developed three stories representing different levels where change is needed: the personal (‘home appointment’), organisational (‘the hospital boardroom’), and the societal (‘the public debate’). We spoke to a further 15 experts to test and refine our ideas and discussed draft scenarios with the Health Foundation’s Inclusion Panel to understand better the implications for patients and people. The Liminal Space brought the final scenario to life through intricately designed built sets, artefacts and films.

The scenario considers the complex interactions between a net zero NHS and the wider changes occurring in society and health care over the next 15 years. For example, the adoption of data- and technology-driven care delivery; rising numbers of people living with multiple conditions; progress towards net zero in other sectors, such as housing and transport; and more severe and frequent weather events. The scenario is not a vision or prediction. It purposefully balances desirable with less desirable and plausible with less plausible elements. This balance aimed to stimulate thinking around the challenges without causing despair, and to motivate attendees to consider the changes needed to achieve the future they want.

People from the NHS, academia, charities, think tanks, government, and those with lived experience encountered the scenario in workshops. These encouraged participants to confront the futures they do and don’t want, and the actions and decisions needed. Here we summarise the themes from these discussions.

Involving patients in decisions about the sustainability of their care

The scenario prompted discussion around the implications of the net zero goal for the health care professional and patient relationship. Participants’ thought the experience depicted in the patient consultation, in which the professional unilaterally changed medications for sustainability reasons, was undesirable: there was concern about the lack of patient involvement in decisions affecting their care. Attendees emphasised the importance of shared decision making (based on clinical, patient preference and sustainability considerations) but noted that clinicians need guidance to do this well. 

However, some raised concerns about focusing decisions at the patient level. For instance, would an individualised approach achieve emissions reductions at the scale required? Does including sustainability considerations in treatment decisions place an unfair burden on patients and staff? Some suggested that sustainability should be integrated in decisions taken by national bodies on behalf of professionals and patients (for example, in health technology assessments, clinical guidance, and procurement). They proposed making sustainable models of care the default, with a parallel drawn with existing directives to prescribe the most cost-effective medicines.

Using top-down directives to drive progress

Participants reflected that the top-down performance targets (the ‘carbon budgets’) depicted in the scenario could be an effective tool for prioritising sustainability and strengthening accountability for delivery. Some reflected that the speed of transformation needed to achieve net zero necessitates robust central command and control. However, participants also identified a risk that targets based on narrow metrics of carbon emissions could risk incentivising short-term thinking – as the scenario shows. Another concern was that carbon targets could deprioritise action on other important environmental goals impacting or impacted by health care, such as adaptation to climate change or pharmaceutical pollution. Ultimately, views varied on the optimal balance between central direction and local autonomy to achieve net zero. 

The workforce culture and capability needed

The behaviour changes required among the health and care workforce were a focus of discussions. These spanned behaviours of individual staff members, to embedding environmental considerations in the strategic decisions taken by leaders. Building staff capability in sustainable care delivery – such as through developing carbon literacy and knowledge of sustainable quality improvement approaches – was seen as an essential and urgent step, with the timeline to net zero requiring a mass upskilling of staff at all levels, not just trainees. It was recognised that not everyone needs to be an expert, but all staff should have a basic understanding of sustainable practices and why they matter to minimise resistance to change. But to realise the impact from increasing staff capability, it was stressed that staff also need to have the capacity, including time and support from management, to deliver sustainable transformation. 

Participants emphasised that the NHS cannot rely on individual action: leaders must demonstrate that net zero care is a priority in health system transformation to drive progress. The environment staff are working in must change too. For example, while the scenario showed posters aimed at changing staff recycling habits, participants reflected that, by 2036, making choices in line with a circular economy should be the default option rather than a conscious decision. Behavioural insights approaches were also seen to have a role here in subconsciously ‘nudging’ staff towards taking sustainable actions.

The role of health creation and prevention

Participants saw promoting health and preventing the need for health care as a major priority to achieve net zero. To many, the depiction in the scenario that health leaders in 2036 were still debating how to shift the focus of health care from hospitals to more preventative approaches was frustrating but plausible. However, views diverged on whether the addition of a net zero framing to longstanding arguments for greater prevention and out-of-hospital care would help to move the focus in the intervening years.

Many felt positively about the scenario’s depiction of health promotion embedded within NHS care, with social prescribing practices the norm. However, there was also a strong recognition that the NHS plays only one part in health creation and responsibility also lies elsewhere. It was felt that the NHS taking a greater role in addressing the wider determinants of health in the future should not medicalise social issues or reduce the focus on the wider public policy interventions needed to improve health and health equity. Participants debated the role of the NHS and its workforce in advocating for climate action beyond health care. 

The interaction between technology and net zero

Participants noted that many of the technologies in the scenario (eg drone delivery of medication and an AI chatbot for clinical advice) could soon be in use widely. Some highlighted the opportunities of the seamless sharing of health and wellbeing data to personalise approaches to health and to motivate and empower patients in managing their own health. This could reduce the need for carbon-intensive treatments. However, they raised concerns around the potential adverse impacts on health equity and social isolation. Participants noted that the groups most likely to be excluded by technology could also be those more vulnerable to the effects of climate change, compounding inequity. 

The environmental impact of AI and the potential for this to undermine progress towards net zero was another cause for concern. To avoid this, participants argued that the deployment of new technologies should be targeted at areas where there are clear co-benefits for maximising health and reducing emissions, such as reducing unnecessary testing. Participants also highlighted the increasing risk of disruption caused by technological failure during extreme weather events, as shown in the scenario, and stressed the need for adaptation measures.

Building public understanding and support

The scenario’s depiction of net zero becoming a politically charged and polarising issue was felt to be a deeply undesirable but plausible future, despite clear evidence that every fraction of a degree of warming averted benefits human health. Progress towards net zero in other sectors, and public attitudes towards this, were seen as having an important influence on how people will view decarbonisation efforts in the NHS; if the health service were perceived as going ‘too far too fast’, this could provoke a backlash. Participants stressed the importance of framing a net zero NHS positively to build public support. This means focusing messaging on the benefits of sustainable health care for patients and the health system, such as improving people’s health and NHS efficiency. Others questioned whether it was helpful or necessary to promote the net zero NHS agenda to the public at all, suggesting that it could be progressed behind the scenes as part of wider strategies for delivering high-quality care. 

Co-creating a vision for sustainable health care with patients and the public was suggested to build consensus and support. Some emphasised the need to be transparent about the potential trade-offs and suggested engagement approaches such as citizens’ assemblies to help with deliberation on policy options. However, a tension was identified between meaningful public engagement and the rapid change demanded by the urgency of the climate crisis, given that seeking consensus at every step could cause paralysis and delay.

The complexity and urgency of achieving a net zero NHS requires long-term thinking and concerted action today. Our immersive scenario provides a tool to help people working in the health system to connect and engage with this challenge and identify immediate actions. 

We found that the immersive approach helps to provide a common entry point for people from diverse backgrounds to collectively consider the possibilities of a net zero NHS, including those who are new to the issue. The scenario can also help to stimulate big-picture thinking, allowing participants to explore the individual, organisational and societal implications of net zero and how these interact with other long-term changes. 

People’s reactions to the scenario varied: the elements of the future that people found desirable and undesirable were not always the same (for example, on the role of health technologies and data). Participants also recognised the trade-offs that may be required, provoking discussion about the vision for the best possible version of high-quality, low-carbon care and how to make it a reality. 

You can use the online interactive version of the scenario to support discussions in your team, organisation or more widely. When planning these discussions, consider: 

• who to involve, based on your aims. The scenario can be used to bring together people from different organisations and backgrounds to realise their role in achieving change in collaboration. It can also be used by single organisations or teams to explore implications for your policies and plans.
• careful scene-setting and introduction to the scenario. Ensure people understand that it is a possible future, not a prediction nor a vision. Unpacking different views on what is desirable and undesirable can start a conversation about the vision for the best possible net zero NHS.
• at what level is it useful to have your conversations, given your aims: for example, high-level exploration or detailed planning. Our workshop guide gives ideas for how to move from big-picture thinking to generating tangible next steps. Many solutions to achieving a net zero NHS lie beyond health care, so facilitation is needed to help people identify actions within their own sphere of influence. 

We hope you find the interactive scenario and workshop guide useful to help you start your conversations about the net zero future you want and the steps needed. We also hope it provides insights into using an immersive scenario-based approach that can be applied to other long-term and complex challenges for future health and health care.