A three-stranded plan for how to build sustainability in to the NHS can be used from local to national level as a spur to action, writes Sonia Roschnik.

During times of rapid reform and change, it is crucial that the fundamental values of the system are reasserted and maintained. Now is the time to ensure that our actions are sustainable, economically, environmentally and socially. We should not get obsessed with just the detail of categorising functions into new structures; we need also to reaffirm the fundamental values and objectives by taking a strategic and systems approach to health and healthcare.

The NHS SDU launched a Route Map for Sustainable Health on 1 February 2011 which gives insight to the breadth of issues at stake to truly address sustainability as a core part of health.

As the biggest industry in the UK, and with health threatened if we were to take an unsustainable approach, the health sector should lead on this agenda, highlighting all the benefits in an unprecedented way for the health and wellbeing of all.

This article describes the process of developing a route map for a core agenda such as sustainability. It highlights learning points and describes how to develop the concept further. This paper summarises what is included in the route map and how we might monitor future progress.

Why a Route Map?

Globally, we are currently at an important juncture where the demand for oil will soon outstrip its supply, where the requirement to significantly cut carbon and where the economic situation means we need to very rapidly develop more for a lot less, not just through improvements in efficiency but often through radical and transformative ways in which we live and organise our lives. To take on such an important, ambitious and interconnected agenda effectively will need clear vision, strong leadership, and profound collaboration to develop the benefits of economic, environmental and social sustainability. This will require change in almost every aspect of our lives. Individual and communities will only be able to take on these changes if leaders embody the nature of these changes in their visions and policies.

We are therefore embarking on many large scale transformations; and although we do not always know exactly how and where this journey will take us, we must make sure we are not asking the same questions next year and beyond.

Progress can be made without always knowing all the exact details of the journey. We must not use uncertainty as an excuse to paralyse action. The vision and principles are becoming increasingly clear for a low carbon world with quality health and healthcare for all; even if all the exact details and components that need to be addressed are less well defined.

Early steps on the journey

For the health care system in England, the Route Map was not the starting point. The journey began with important and ground breaking research by doing the largest, scope 1,2, and 3 carbon footprint of a sector ever conducted. This NHS carbon footprint for the NHS in England was calculated to set a baseline and to quantify the size of the challenge and the opportunity. We now know this footprint to be 21MT of Co2e and growing. This represents approx 25% of the public sector emissions in England. The methodology means that scope 1,2 and 3 emissions were included and gives a broader picture than carbon footprints generated around energy only. The UK government targets linked to the Climate Change Act are to reduce energy related emissions by 34% by 2020 and to 80% by 2050.

The NHS consulted widely in 2008 on the need for the health service to exploit the benefits of developing sustainably and the need to tackle climate change. Of the 432 organisations within the NHS in England at the time, 66% responded to this non mandatory exercise with 95% confirming support of the NHS being a leader in this field. A mandate for action was clearly important to establish the level of commitment to develop further research, and strategies to deal with climate change.

The resulting Carbon Reduction Strategy based on this research addresses the first five years with well recognised for action.  However, although we know this is necessary, we also know it is not sufficient:  the rate of carbon growth within the health sector means that we need to consider more ambitious and transformational healthcare scenarios; focussing only on improving the efficiency of current models of healthcare will not be sufficient.

These first pieces of quantities and qualitative research suggested we needed to think carefully about how the scale and ambition of what a future proof health service might look like and how it how it might develop accordingly – the level of change required to ensure the health service developed on a sustainable trajectory.

A carefully engineered process of generating societal scenarios enabled consideration of the future impact on health and how health provision can support an improved outcome for all. It has became clear that this can only be done if the health system re-visits and re-affirms its core business. Crucially, for instance, is the health service using limited resources to provide healthcare for the ill, or are we trying to maintain and improve the health of the population so there is less demand for healthcare and more wellbeing?

Other organisations have developed route maps in relation to their business. The world business council for sustainable development based in Geneva developed a roadmap to a sustainable world with key categories from people’s values and mobility to agriculture, and many others. Health is not explicitly mentioned and the NHS SDU decided that a route map specifically developed for health systems would help give us a framework to use over time and to anchor action.

How the route map was developed

A route map identifies the different components that are required in a journey over time.  In this case, we need to identify the important shifts that will be needed to truly start addressing sustainability within a health system.  Obviously strong leadership and a broad collaborative effort across a wide range of influencers are essential, but so are the many other operational areas.  Anyone should be able to look at a route map and be able to identify where their most important contribution might be in the overall scheme.  Put another way, we are all leaders in such an important, wide reaching transition. The Route Map for sustainable health engaged with over 70 organisations in the development process and subsequently securing support from over 200? organisations.

Building on the evidence available, a forecasting exercise was carried out to establish the challenges that a health system will have to face over the coming decades. A PESTLE (Political, Economical, Social, Technological, Legal and Environmental factors) analysis identified five main challenges:

  • Demographics: Potential population increase of 10 million in England
  • Carbon: Carbon reduction of 80% from 1990 levels required to meet the UK government targets
  • Climate: Extreme weather events such as the summer of 2003 are a likely regular occurrence
  • Economics: Funding for the health system is likely to be very challenging; with an ageing population, a higher dependence on state resources and a smaller tax base to fund it. 
  • Technology: The role of networks, communication and technology will be significant.

Groups explored what a health system would need to deliver in ways which acknowledged these challenges and opportunities. The forecasting process considered the elements that would be required over time and categorised in domains such as research and innovation, organisational resilience and public opinion.

After the forecasting came the backcasting: to develop a vision of a future health system (circa 2050) and what would be key timeframes in order to ensure its viability.  The vision describes a system that will maximise the effect on human health whilst minimising its impact on the environment.

Groups then identified actions and milestones around six different aspects to populate the chart:

  • Governance: The systems that would be required to ensure the vision is implemented and embedded
  • Models of care: The core business of health systems
  • Societal attitudes: Society’s behaviours and its contribution to supporting the way forward.
  • Individual attitudes: Our own behaviours and contribution to supporting the way forward
  • Technology: What is needed to support the vision
  • Use of resources: All types of resources including energy, natural resources and people’s time

The themes were developed explicitly on a real time wall chart layer by layer and further critiqued and discussed with the following questions in mind:

  • Is anything missing?
  • Where and what are the linkages?
  • Where are the priority areas for action/research?
  • What are the urgent areas for action/research?

Differences of opinion were integrated into the map.  For example, should we assume that genetic medicine will have a significant impact in 2020 or only later in 2050? Or what is the likely level of devolution of services by then?  This process effectively combined the information coming from fore-casting with back-casting.

Themes quickly emerged.  For example, it is highly likely that healthcare will shift from being an institution led service to a broader health & social care system as part of community development; and that all waste will need to shift from being perceived as a cost to a resource.

Further analysis revealed a simple workable grid that could be used as a framework to ensure action is taken forward.  Crucially it had both intuitive and operational relevance to the contributors: simple enough to remember, and sophisticated enough to capture the breadth of issues. This is the Route Map For Sustainable Health.

What does the Route Map for Sustainable Health cover?

Three core strands are identified – each tackling a different aspect of the challenge: Behaviours, Standards and Innovation:


For a sustainable health system to be plausible, it will require every one of us to shift our thinking, attitudes and behaviours. Indeed society as a whole needs to progress to a post industrial economic model, away from a “growth at all costs” model. (Ref: Tim Jackson?) This means we will need to re-appraise not only our individual behaviours but also the purposes and values of the services we provide for each other.

Standards – use of resources and system governance

Our natural environment has limits that need to be respected.  This requires a mechanism for valuing all forms of resources – beyond the monetary face value (we so often arbitrarily assign) so that human time, wellbeing, and fulfilment are considered as laudable, meaningful and measurable as other objectives. Sustainability needs to be embedded in every decision making and service modelling mechanism and form part of organisation’s public reporting.


Innovation in our models of care and technology will support the transition to a sustainable health system.  Products and technologies with minimal environmental impact and delivering a reduction in health inequalities are essential. Products should be recyclable or used as a form of further resource e.g. clinical waste re-used as building boards or hospital beds transformed into re-usable nappies.

How to make it live?

Our experience has been that this Route Map makes sense as a framework that brings plans and implementation to life, and helps identify where each of us can and should take action.  It can be used in many ways for all leaders, from planning at the organisational level to eliciting and testing a wider consensus of effort nationally.

The SDU website invites organisations to sign up to the framework and for participation in the delivery and shaping of six work streams. This is enabling a wider participative and transparent process.

The framework can be used to map out an organisational approach, their strategy, business plans and progress over time. A blank version is available to support this process and an example is developed to highlight the contribution the SDU can make to this agenda in England.

The map can also help ensure coverage of elements amongst stakeholders and system wide interventions.

How do we know we are making progress on the way?

We need to be able to ascertain progress being made, as it is not clear which levers will develop most effectively and in which order: Examples include:

  • Patients starting to ask, and expect health service providers to understand their impact on the environment, as part of the “care footprint”
  • Business cases, risk and impact assessments should include values for environmental and societal as well as financial values.

Learnings and musings along the way

This process has been peppered with learning points along the entire journey and will continue to do so.

  • Transformational leadership is crucial and will test every one of us en route.
  • It is crucial to have a mandate for action and evidence to get started - a nationwide consultation and an NHS carbon footprint. It is useful to ensure that some unit or body ensures that the mandate and the evidence are updated and monitored on a regular basis.
  • There is no room for defensiveness but a need for openness about how to improve, for instance the exploration of alternative calculation methodologies or learning emerging from other sectors.
  • The need to achieve a balance between specificity within a changing context and the advantage of making such learning and action more generalisable. The Route Map has tried to extract the principles behind the actions that matter.
  • The importance and value of well conducted stakeholder engagement – the process can really make the picture emerge in a more acceptable way and with a more acceptable result.  It will always be stronger than any pre-empted process.
  • This is all new territory for most of us. We have much to learn from a wide scan of horizons about large scale change in general and not just about sustainability and climate change.
  • Be cautious about specific reductions and be wary of including timelines. We do not need to be precisely accurate to understand the sorts of actions that are needed now.

Transforming our health and social services to sustainable systems for health is fundamentally about strategy change and requires strong and visionary leadership to see through the transition from vision and strategy to change and implementation/operationalisation. The route map provides a framework to help take this forward for all organisations and individuals to use, engage with and monitor progress against. This is an exciting journey that requires our sense of legacy and justice in a rapidly changing world to shine through so we do deliver an improved system for today and for future generations.

Find out more



NHS Carbon Reduction Strategy for England: Saving Carbon, Improving Health, 2009. Cambridge: NHS Sustainable Development Unit


Climate change Act 2008 c27, 2008. London: HM Government


Saving Carbon, Improving Health: Update, NHS Carbon Reduction Strategy 2010. Cambridge: NHS Sustainable Development Unit

Climate Futures, 2008. London: Forum for the Future

Fit For The Future: Scenarios for low-carbon healthcare 2030, 2009. Cambridge: NHS Sustainable Development Unit


Vision 2050: The new agenda for business, 2009. Geneva: World Business Council For Sustainable Development

The Marmot Review: Fair Society, Healthy Lives, 2010. London: the Marmot Review


With thanks to Professor Dame Sandra Dawson and David Pencheon.