An organisation the size of the NHS has a huge responsibility to the environment and communities. But are trusts ready to do their bit? Kaye McIntosh investigates

It is not often you hear hard-pressed NHS managers or health professionals argue for even more government targets. But for those pushing for proactive sustainable development in the NHS, that is exactly what is needed.

Almost no-one would dispute the importance of tackling global warming. And the facts clearly show the NHS has a key role: one of the largest organisations in the world, with a vast estate pumping out carbon dioxide. It is responsible for one in 20 journeys in the UK, 83 per cent of them by car or van. Staff, patients and visitors clock up 25 million passenger kilometres a year.

Yet despite encouragement from health ministers, sustainable development has been treated as an aspiration rather than a 'must do'. It does not yet register on the radar of all but the most enlightened chief executives.

'People don't get fired if they don't do it,' points out Sustainable Development Commission lead health commissioner Anna Coote. That could explain why just 20 per cent of acute and 13 per cent of primary care trusts have signed up to use the good corporate citizenship model, the Department of Health-backed tool for assessing commitment to sustainable development.

'Climate change is supposed to be a number one priority for all the leaders of political parties, but that hasn't filtered down to chief executives,' says Helen Ross, public health development manager at Nottingham City teaching PCT. 'If you don't have targets for a very important piece of work like this, people just do it here and there as goodwill, instead of a priority.'

Ms Ross argues that as long as national targets focus on the bottom line, 'the cheapest is best', it is much harder to put wider considerations into the frame. But if you do look more broadly at the impact of your decisions, he says, you can make a difference.

Nottingham City led the way by helping to pilot the good corporate citizen assessment tool. This translated into projects such as setting up a cafe as a social enterprise, rather than going to a big company. The cafe, in a local improvement finance trust centre housing a GP surgery and council services, aims to use local food, employ local people and promote healthy eating.

Few and far between

But good practice such as this is patchy and depends on local enthusiasts, despite the fact that ministers are generally signed up to sustainable development. The government's 2005 strategy document Securing the Future set a target for the NHS to be a leader 'in sustainable procurement across EU member states by 2009'.

The DoH launched the corporate citizenship tool with the SDC a year ago, to encourage trusts and strategic health authorities to work out how well they are doing and where they need to improve. It covers six areas: procurement; transport; employment; community engagement; facilities management; and new buildings.

And there is a clear target for reducing carbon emissions: the NHS has to achieve 15 per cent energy efficiency savings from 2000-10. All trusts are required to report energy consumption data to the DoH every year. In January, the DoH announced a£100m fund to help trusts hit these targets. And there is progress, with seven out of 10 trusts reportedly already meeting them.

Yet Ms Coote says the case for sustainable development always struggles against the 'irresistible pull to an agenda that outweighs everything else - money, targets, the media'. It is easy for hard-pressed managers to overlook the benefits of the long-term agenda of sustainability.

'There is a health dividend for this stuff,' argues Ms Coote. 'All the things that are good for sustainable development have, directly or indirectly, a positive impact on human health or efficiency savings. But these are long-term effects, not medium-term.'

She welcomes the fact that health ministers have backed sustainability. 'It's a good start. But we need to translate that into powerful, purposeful action in the NHS.'

There is good practice on the ground, but we are a long way from being able to say every hospital has a sustainable development strategy and is acting on it, she adds.

If ministers really want behaviour to change, they need to give clear leadership and expectations, build capacity and make sustainable development part of performance management. 'You need all those things working in the same direction to make it happen without the system buckling under the strain,' Ms Coote says.

Positive perspective

But some managers in forward-looking trusts are more positive. Gloucestershire Hospitals foundation trust director of clinical strategy Dr Sally Pearson says: 'The DoH's support for the SDC and the sustainable development framework has reassured us that this a reasonable thing for an NHS organisation to contribute to.'

She is against the idea of top-down targets across the NHS. 'The reality is this can't and shouldn't be the highest priority, as you have to have reached a level of confidence before you can devote resources. You have to get the basics right.'

It was the road to foundation trust status that encouraged Gloucestershire to look at sustainable development. The trust has a corporate citizenship committee. Service leads from all six priority areas in the good corporate citizenship model, from procurement and transport to facilities and employment, sit on the committee, alongside two foundation trust governors representing the public and staff. This is not just a talking shop.

Dr Pearson describes the committee as a powerful means of networking and identifying good practice. It also helps the trust build relationships with other concerned organisations, such as the local strategic partnership or Jobcentre Plus.

The trust now has a park and ride scheme for staff and patients and plans for a free shuttle bus service between sites. The accident and emergency department at Gloucestershire Royal Hospital was designed with energy efficiency in mind - it has deflectors at the windows to ensure rooms do not overheat in summer and a water recycling scheme, for example.

Mike Burne, the trust's general manager for catering services, is working with producers and suppliers to increase the proportion of locally sourced food. To date the trust has managed 30 per cent, but he wants to reach 35 per cent in two years. National contracts for hospital food limit the room for manoeuvre but a lot can be done at the margins.

The trust uses local suppliers for bread rolls, fruit juice and vending machines. 'It's just good communication with local suppliers,' says Mr Burne. Simply encouraging small companies to think about dealing with the NHS is a start.

At the other end of the scale, Derbyshire Mental Health Services trust is just starting out. A workshop on sustainable development last September attracted 40 people - staff, union representatives and service users.

Now a steering group has been set up and the trust plans to use the good corporate citizenship model to measure performance every year. The board has agreed a cycle to work scheme.

The work here grew from a few enthusiasts working as part of the move to foundation status - showing that a bottom-up approach can be just as powerful as orders from the top. But organisational development co-ordinator Sue Flynn says: 'We are at the very early stages of looking at what we can do.' It helped that the team had 'gained credibility' by delivering on previous projects around issues such as Improving Working Lives.

A bright future

Taking a lead on sustainability is not just a must-do for moral reasons, say enthusiasts. It has positive, practical benefits for the NHS and its people. Dr Pearson says: 'It's exciting. Every day you find something else that with little effort means you can start to make an impact on other organisations.'

And at strategic level, DoH insiders say it recognises it could do more to encourage sustainable development.

The terms of reference and final membership are not yet established but the group will consider 'how to build sustainable development into future performance regimes', a DoH spokesperson told HSJ. This could mean the Healthcare Commission assessing all trusts on sustainable development as part of the annual healthcheck. It is clear that sustainability will loom larger on the agenda of every trust, rather than being left to a few enthusiasts. This issue is not going to go away. -

For more information on the Sustainable Development Commission's work with the NHS visit www.corporatecitizen.nhs.uk. The commission is the sponsor of the Good Corporate Citizenship category in the HSJ Awards, e-mail claire.snarey@emap.com for more information.

The Sustainable Communities Awards, run by HSJ and Local Government Chronicle, will be held on 28 March (www.sca2007.com).

Case study: Barnsley goes green

Recycling paper, furniture and clinical waste has saved Barnsley Hospital foundation trust£29,000 in a year.

The project began in January 2005, when estates and facilities director John Petty took a proposal to the senior management team for a recycling officer who would pay for their own salary in savings.

He admits the motivation was 'very selfish - we had an escalating cost in terms of waste disposal - but it also benefited the environment'.

Mark Wilson was appointed in April. Mr Petty says: 'Mark is the catalyst. He does all the legwork, collects all the waste with trolleys. He went all around the departments and encouraged them. You're pushing against an open door. It makes people feel good.'

The hospital began with paper. This includes office documents and large quantities of rubbish. The paper is placed in a skip and collected by a specialist company.

Since Mr Wilson's appointment, 100 tonnes of paper and cardboard have been recycled, saving the hospital£14,000, through cutting landfill fees and selling the paper on.

There used to be two bins by every hospital bed - one for clinical waste, one for household. An investigation found that 60 per cent of what went into the clinical waste bin was ordinary waste. Now this has been removed and nurses are asked to take clinical waste to a bin reserved only for that purpose.

Another£15,000 has been saved through recycling furniture. Used items are kept in a 'green room' so when a department needs a new desk or filing cabinet, the recycling officer can source one.

He works out what the item would have cost new, asks for a£20 contribution to the waste budget, and the difference is counted as a saving.

Barnsley Hospital has a fairly green track record - it has held an energy efficiency accreditation from the Energy Institute since 1997 - and the recycling drive helps improve its carbon footprint further.

But the efficiency angle is the one grabbing the most attention. The total saving is£29,000 minus Mr Wilson's salary - he is a grade-three porter - and John says the hospital is now making a profit.

John adds: 'That's what you would have been throwing away, putting in the dustbin. It's real money, back into the system.'

Varya Shaw

Case study: cutting out cars

Cambridge University Hospitals foundation trust is reported to be the largest single generator of traffic in the whole county, responsible for over 18,000 journeys a day.

But the trust is tackling car dependency among patients and staff. Richard Howe, director of estates and facilities at the trust, says the impetus for change was very practical: when the trust wanted to obtain planning permission for new buildings, the local authority made it conditional on a traffic strategy. The trust's Addenbrooke's Hospital took up the gauntlet.

At the time, 94 per cent of employees drove to work. Now, more than a decade later, 61 per cent of staff journeys are on public transport and bikes.

Every hour, 60 buses serve the hospital. A hospital shuttle bus costs the trust£70,000 a year, raised from parking charges. It will be handed over to a bus operator once it is commercially viable.

The trust and bus companies jointly subsidise staff travel, saving them 20 per cent on the full ticket price. But public transport is not always available at antisocial hours so people on early and late shifts are allowed to park on site - an important concession to win support.

The travel plan is entirely funded by parking charges, but these are set at a reasonable level. Patients pay£2 to park as long as they need, for instance, with concessions for those who have to make frequent visits such as chemotherapy patients.

Mr Howe admits that at first 'there was a lot of hostility about staff having to pay to come to work'.

What made the difference was being able to show that every penny would be invested in better transport such as cheap bus tickets, but also well-maintained car parks for the occasions when people must drive.