Policy levers for a net zero NHS: four priorities for the future

The NHS in England has a legally binding commitment to achieve net zero by 2040 for its direct carbon emissions and 2045 for the emissions it influences. Doing so is essential to respond to the health emergency of climate change but will require major transformation of services over the next 20 years to low-carbon health care.  

We have previously set out what low-carbon health care looks like and how it supports other health system priorities such as prevention, quality and efficiency, with examples of where this is already happening in the NHS today. Low-carbon health care:  

• prevents ill health and reduces the need for health care to begin with 
• improves the management of disease and moves care out of carbon-intensive hospital settings 
• eliminates avoidable waste of resources and unnecessary interventions, and 
• uses lower carbon medicines, treatments and products.  

While there is consensus on the features of low-carbon care, it is far less clear how to bring about these changes at the scale and speed needed to meet the net zero target.  

The Labour government has promised fundamental reforms of the NHS through three key shifts: from sickness to prevention; hospitals to communities; and analogue to digital. These shifts need to support the transition to a net zero NHS, but are insufficient on their own to drive progress at the scale and speed required. The government’s plans will be set out in a 10-Year Health Plan for the NHS. With the next decade critical for meeting NHS decarbonisation targets (emissions need to reduce by 80% by 2036–2039), sustainability considerations must be embedded into long-term reforms and  ensure that the new government’s policies are driving rather than detracting from progress. 

National policy needs to steer the health system towards this objective. However, the major national policy levers currently used to drive change in the NHS in England – such as financial incentives, regulation and performance targets – were not designed with environmental sustainability in mind. This may be helping or hindering progress towards net zero in ways not currently known. While many countries now have national commitments to decarbonise their health systems, with approaches varying and progress generally at an early stage, relatively little is understood about how national policy can meet this complex goal. 

Here, we assess how major national policy levers currently used in the NHS in England could be supporting or blocking progress towards net zero. We then suggest four areas of focus for national policymakers to ensure progress is maintained. Our findings are informed by a review of relevant policy documents and literature, conversations with 21 expert stakeholders and a roundtable in August 2024 to test and refine our findings (organisations in attendance are listed in Box 3). We focus on understanding the role of national NHS policy in decarbonising health care delivery, recognising progress will also depend on effective policy to improve prevention, for which many of the policy levers lie beyond health care.  

We define national policy levers in the NHS in England as factors influencing health system performance that can be adjusted by government or NHS England. We draw on a World Health Organization framework to classify major policy levers in four broad categories: governance and oversight; funding; stewardship of resources; and shaping service delivery. 

We undertook desk research to identify policy levers in these categories that explicitly reference environmental sustainability as an objective. We supplemented this by speaking to expert stakeholders to identify other policy levers influencing the transition to net zero care, assess the impact and identify priorities for progress. This approach identified policy levers with indirect impact as well as those that explicitly consider sustainability, although this is inherently influenced by the perspectives of stakeholders interviewed and may not be comprehensive. We sought to mitigate these limitations by interviewing stakeholders from a broad range of organisations and testing our findings in the roundtable discussion (Box 3).  

1. Governance and oversight  

Governance and oversight levers include legislation and regulation, strategy and vision, systems of accountability (eg targets) and the collection, analysis and monitoring of performance data. These levers can drive change by enforcing standards, rewarding progress on defined goals and providing consequences for underperformance or non-compliance. 

The government and NHS have introduced a mix of governance and oversight mechanisms in recent years with the aim of driving progress on the net zero target. The Health and Care Act 2022 requires NHS organisations to have due regard to net zero and environmental targets, and gives NHS England power to publish statutory guidance for the transition to net zero. Adding a new NHS value on ‘environmental responsibilities’ is one of the proposed changes to the NHS constitution, with results of the consultation awaited. NHS emissions at national level are reported publicly in the NHS annual report. 

Regionally and locally, all integrated care systems (ICSs) and NHS trusts are required to publish ‘green plans’ for how the targets will be achieved, and to provide an annual summary of progress on delivery, covering actions taken and planned, with quantitative progress data within their annual report. Environmental sustainability has also been included in the Care Quality Commission’s single assessment framework, meaning that the quality regulator considers a provider’s approach to sustainability as part of its ‘well led’ assessment (Box 1). Trusts and integrated care boards (ICBs) return data used to calculate national NHS emissions, and while many trusts and ICBs have calculated and reported their own emissions, they are not required to do so. However, stakeholders felt that oversight and accountability on net zero could be strengthened. For example, these mechanisms tend to focus on strategy and reporting, with the consequences for lack of progress towards net zero carbon emissions unclear. 

Further, these accountability mechanisms are separate from the NHS’s overall approach to the oversight of ICSs and NHS trusts, set out in the NHS oversight framework. This separation was considered a major risk to delivery as it may mean that sustainable care is deprioritised compared with goals accompanied by more robust accountability mechanisms. While other levers setting system priorities and expectations, such as operational planning and guidance, have on occasion included environmentally focused goals (including in 2020–21 and 2024–25) and aligned goals such as prevention, environmental impacts or sustainability co-benefits of these priorities are often not explicitly considered. 

Our assessment of how far policy levers in the NHS are supporting the transition to low-carbon care in England suggests four areas of focus for future policy.   

1. Strengthen existing accountability for net zero  

Stakeholders felt that progress on sustainable care can be accelerated by strengthening the accountability policy levers that are already in place. This would be relatively straightforward  as it builds on existing governance, measurement and reporting systems.  

As the NHS net zero ambition moves from strategy to implementation, accountability for delivery becomes increasingly important. Previous work has shown that robust accountability systems are essential for progress towards similarly cross-cutting and long-term system priorities, such as health inequalities. Without strong accountability there is the risk of sustainability, like health inequalities, being crowded out by other priorities such as reducing hospital waiting lists.    

Three main areas for action were suggested in our stakeholder interviews and roundtable discussion:  

• Strengthen performance management with clearer expectations and support. Existing levers for NHS organisations such as CQC guidance, NHS standard contract conditions and green plan guidance could be strengthened by setting out consistent minimum expectations for sustainable care delivery and embedding expectations of continuous improvement over time. Providing greater clarity on lines of accountability and mandating senior responsibility for delivery were also suggested.  
• Improve data collection and reporting. Stakeholders identified missed opportunities to collect more meaningful data from providers aligned with long-term priorities. Making local data publicly available could also highlight high and low performing areas, increasing accountability for progress and supporting action to reduce variation.  
• Integrate sustainability with existing oversight mechanisms. Major forms of accountability in the NHS, such as the oversight framework, should demonstrate to health leaders that net zero care is a priority alongside other goals through closer alignment with net zero NHS strategy.

2. Systematically consider environmental impacts when reforming policy levers  

Our assessment identified policy levers for other objectives that may be indirectly supporting the drive to net zero by promoting good management of disease and reducing demand for more resource-intensive care. For example, NICE clinical guidelines aim to optimise quality and cost-effectiveness of care. However, not explicitly considering net zero and its interaction with other goals, such as quality and efficiency, could mean that opportunities are missed to both highlight and maximise health and climate co-benefits.  

Conversely, some levers that do not consider environmental impacts may be hindering progress – such as the payment by results system in secondary care. It is important to identify and understand these potential tensions so that informed decisions can be taken on the trade-offs and risks mitigated where possible. For example, low-carbon models of surgical care could be embedded in strategies to increase elective activity; or sustainability built into financial incentives as quality is for CQUINS.  

The consensus view among stakeholders was that policymakers should systematically consider impacts on the sustainability of care when designing and reviewing policies and evaluating their effects. This would identify opportunities to maximise co-benefits, avoid unintended consequences and build knowledge of what good looks like. This is especially important for policy areas such as payment mechanisms where it is not yet clear – from either the NHS experience or internationally – what financial levers would effectively drive high quality and low-carbon care. 

3. Coordinate and maintain focus around agreed priorities  

No single policy lever can bring about system transformation. Coordinating levers around agreed areas of focus is key. Activity has previously been targeted on carbon hotspots areas of clinical practice, such as anaesthetic gases. But, as decarbonisation of the NHS progresses, new priorities will be harder to find.  

Potential approaches to identifying and coordinating shared priorities suggested by stakeholders included:   

• Aligning policy action with existing system priorities. Stakeholders suggested identifying priorities for sustainable care that maximise co-benefits for other health system goals, such as quality, health inequalities and productivity. Net zero priority-setting could dock into existing priority setting approaches, such as those for identifying areas for improving quality and efficiency (such as the GIRFT programme) and reducing health inequalities (such as the clinical pathways and population groups identified in NHS England’s CORE20PLUS5 approach).  
• Developing new methods to identify priorities. For example, bodies involved in health technologies, innovation and research could undertake horizon scanning to identify and prioritise new opportunities and challenges for the transition to sustainable care. Another suggestion was to build on the GIRFT methodology to identify drivers of unwarranted variation in the sustainability of care to target action on. 
• Maintaining focus on agreed priorities is also crucial. The start-stop use of financial levers to shape inhaler prescribing, with improvements falling short of stated aims, has shown the importance of both coordination and consistency to bring about large-scale change in clinical practice (Box 2). 

4. Address key policy gaps  

Policy areas prioritised by a number of stakeholders as needing more action included:  

• Capital investment. Suggestions included cost-neutral approaches, such as introducing longer term funding cycles or allowing greater capital spend that improves return on investment or reduces resource use and costs over time. Other suggested approaches included allowing NHS organisations to borrow from the Treasury’s National Wealth Fund, as local authorities can, to decarbonise the NHS estate; and requiring large public sector capital investments to assess their carbon impact.  
• Health technology regulation, appraisal and innovation. As new health technologies such as diagnostics or treatments emerge, we need to understand how they influence the environmental impact of care pathways. Stakeholders saw a role for regulators, health technology evaluators and others in the innovation space, such as MHRA, NICE and HINs, to start collecting environmental data about health technologies’ environmental impacts now. This can set the groundwork for using environmental data in decision making, such as in technology assessments, procurement, and prioritising innovations for adoption and spread longer term.   
• Staff capacity and capability building. Upskilling the workforce to improve the sustainability of care as part of quality improvement was seen by many stakeholders as a priority. However, many of the levers to support this currently sit outside the NHS – from third-sector provided courses and programmes on Sustainable Quality Improvement, to training offers by some Royal Colleges for their members. Embedding sustainable quality improvement in national NHS-led approaches to improvement would help drive sustainable practices at the scale required.  

Major and rapid transformation towards low-carbon care is required for the NHS in England to reach net zero by 2045 for all of its emissions, direct and indirect. For this to happen, national policy levers must align with and drive forward these changes. However, the extent to which current policy levers in the NHS are supporting the net zero goal is mixed.  

The new government is embarking on an ambitious 10-year reform programme for the NHS in England. This is likely to require reviewing and adapting major policy levers to achieve its priorities – many of which align well with sustainability principles. To improve progress on net zero in the critical years ahead, national policymakers should first strengthen and build on existing accountability for net zero. Second, systematically consider net zero when designing and reviewing policy levers for other goals. Third, coordinate and maintain the focus of new policy for net zero around agreed priorities. And lastly, focus on addressing key gaps where there are levers with untapped potential to help drive lower carbon care.  

Without focused government action on these priorities there is unlikely to be progress on net zero at the pace needed to meet the legally binding targets. This could leave the NHS unprepared to deal with the escalating health harms and care disruptions caused by the climate emergency. But by building consideration of the net zero goal into long-term reforms, rather than seeing them as separate, there is a real opportunity to improve health and health care now and ensure quality care is sustained into the future.