An uncomfortable truth

Authors: Mark Britnell 

Publication date:  20 Mar 2012

The NHS has a leading role to play in the fight over climate change and sustainability

Twenty years ago the Rio Earth Summit put climate change and sustainable development firmly on the political map. The global financial crisis has rightly occupied policy makers recently, but the forthcoming Rio+20 Summit in June 2012 will refocus their efforts on climate control, emissions, and sustainability. Although climate change has a profound effect on the health of individuals and communities, it’s also an uncomfortable truth that the health sector needs to do more to help global sustainability. For example, in the United States the health sector accounts for 8% of total greenhouse gas emissions, making it the second most energy intensive industry after fast food, while in the European Union the health sector creates 5% of total emissions, the equivalent of the region’s aviation and shipping industries combined. There is considerable room for improvement in healthcare’s environmental footprint.

In the past 20 years globalisation has shifted the balance of power from the industrialised world to the emerging markets. The world’s population has grown enormously (by 1.5 billion to 7 billion), and most people live in cities—with an estimated migration rate to cities of over 130 000 people a day. Hundreds of millions have moved out of extreme poverty, and similar numbers have joined the middle class. By 2030 the world’s middle class, with more resource intensive lifestyles, will grow from an estimated 1.8 billion to 4.9 billion, and the total global population will grow to 8.4 billion. The mean global temperature rise by 2030 is forecast to be 1%, while 39% of the world’s population is projected to be under “water stress.” Poorer countries will feel the most direct consequences of these changes.

Business must take a lead

A recent global business leaders’ event on climate change and sustainability sponsored by KPMG drew over 500 leaders from the corporate world, who heard speeches by Ban Ki-moon, Bill Clinton, and Michael Bloomberg, mayor of New York city. Their message was clear: governments cannot solve the sustainability crisis on their own, and business needs to take a lead. In short, the fight against climate change and to boost sustainability should be good for business and good for the planet. It was clear that the health industry needs to play a more prominent role in leading this change.

We have identified 10 global sustainability “mega-forces” (climate change, energy, resource scarcity, water scarcity, population growth, urbanisation, wealth, food security, ecosystem decline, and deforestation) that are interconnected and important in health outcomes. A seminal publication in the Lancet in 2009 stated that the “effects of climate change will affect most populations in the next decades and put the lives and wellbeing of billions of people at increased risk” and concluded that “climate change is potentially the biggest global health threat in the 21st century.”[1] Most health systems in the world have not shouldered their fair share of responsibility, nor have they fully realised their leadership potential. The NHS has a wonderful Sustainability Development Unit, but its impact across the NHS is limited. Simply put, not enough policy makers, practitioners, and managers see sustainability as a high priority. As a former chief executive of a large teaching hospital, I fully appreciate that clinical quality, financial performance, and waiting lists command most of the attention. As the world’s fourth largest employer and one of the most energy hungry organisations, the NHS, I believe, has an excellent opportunity to step up to reduce emissions, create new jobs, and provide a global example of what health can do. I’ll illustrate with just three examples.

How the NHS can help

Energy production, consumption, and distribution are highly fragmented across the NHS. The large number of hospitals, ambulance services, and other NHS trusts act independently of each other, and this produces energy and cost inefficiencies. For example, new combined heat and power generators and distribution services have vastly superior energy efficiency and dramatically reduce costs. With sufficient will and vision, the NHS could develop one of the largest public-private sector movements in the world, raising substantial investment sums, creating thousands of jobs, and reducing millions of emissions. A national network of leading edge combined heat and power plants with green waste management facilities would transform performance.

Secondly, the distribution chain between drugs and healthcare is antiquated and costly. Currently, drug companies have fragmented supply chains to hospitals, general practices, and retail outlets, with millions of vehicle movements across the United Kingdom. They are facing greater pressure on profitability and return to shareholders, while the NHS faces a large efficiency challenge. By working together the NHS and life sciences sectors can streamline the order, receipt, and distribution processes, thereby reducing the number of deliveries, the amount of packaging, and the cost. The giant US retail firm Walmart has shown remarkable results in transforming its distribution and packaging business, and lessons need to be learnt.

Finally, we need to redesign the way care is delivered. There are millions of hospital outpatient visits each day, and many are vital. The NHS has been slow to adopt new technologies, but the latest developments in e-health, telehealth, and telecare (devices that remotely monitor health status) offer us a glimpse of what could be. To its credit, the Department of Health for England launched the largest randomised controlled trial in the world of such technologies, and its three year evaluation has just been published. With a stunning reduction in mortality levels of 45%, emergency admissions of 20%, and costs of 8% the NHS has shown the rest of the world what is possible. More telecare can reduce emissions and improve health. A truly innovative NHS would help create more health, wealth, and sustainability. It could export this knowhow to the rest of the world.

As our government looks for new ideas for economic growth and job creation, and Rio+20 looks for a greater commitment to sustainability, the NHS can truly lead the world in advanced energy systems, in lean delivery systems, and in new technologies. New public-private partnerships could raise substantial investment, create thousands of jobs, and make a small but important contribution to saving our planet. We just need to innovate, be creative, and have the courage to act at scale and with speed.

Competing interests: None declared.


  1. Costello A, Abbas M, Allen A, Ball S, Bell, S, Bellamy R, et al. Managing the effects of climate change. Lancet  2009;373:1693-733.

Mark Britnell chairman, Global Health Practice, KPMG LLP, London, UK


Cite this as BMJ Careers ; doi: