The NHS emits a million tonnes of carbon a year, but it must cut this figure drastically. Helen Crump asks whether trusts are giving this issue the priority it requires and highlights some innovative ideas.

As the daily battle to hit targets is fought in trusts across the country, one longer term directive has been creeping up quietly. Trusts have less than 20 months to meet an ambitious target to slash NHS carbon emissions by 15 per cent.

The NHS sustainable development unit put a draft carbon reduction strategy, Saving Carbon, Improving Health, out to consultation at the end of May. It sparked such debate among managers that the consultation period has been extended to the end of September.

Statistics on NHS action on sustainability are hard to come by and the information available presents a very mixed picture. Roughly half of English trusts - 207 - have signed up to the Sustainable Development Commission "good corporate citizen" scheme, which includes sustainability. Six Welsh, five Scottish and four Northern Irish trusts have also joined.

Regional variations are striking. In the North West, 84 per cent of trusts have registered; in London it is just 32 per cent. Acute trusts with large estates are leading the way, with 67 signed up.

There are 65 primary care trusts and 40 foundation trusts taking part, as well as mental health trusts, care trusts and ambulance trusts. Only five out of the 10 strategic health authorities are on board.

But take-up of a scheme specifically focused on carbon reduction is lower - the Carbon Trust is working with 48 NHS trusts on a carbon management programme that requires them to commit dedicated resources, including one staff member giving two days a week over 10 months.

Poorly performing trusts will have to catch up before the Department of Health's 2010 target comes into force - a survey this year showed that four in 10 managers had not yet begun to develop carbon reduction plans.

Sustainable development

The NHS spends around£400m on energy and emits one million tonnes of carbon each year. It must shave off 150,000 tonnes of carbon emissions.

Only 20 per cent of the NHS's carbon footprint stems from energy: 60 per cent is from procurement and 20 per cent from travel, presenting trusts with a set of challenges wider than simply investing in a token amount of renewable technology.

Carbon Trust NHS public sector manager Tom Cumberlege says: "The message is: this isn't about covering your hospital in solar photovoltaic [panels], it's about finding what's the most appropriate business approach towards reducing carbon impact and prioritising this."

Mr Cumberlege says the first two phases of the carbon management programme identified£14m of savings across 30 organisations.

"What we don't want to do is simply to provide trusts with an external consultant's opinion. We want this to be sustainable - we want to build them up internally."

Taking on the challenge

NHS sustainable development unit director David Pencheon says the consultation has exposed chief executives' desire for more information about the way to tackle the challenge of carbon reduction.

He is keen to stress the work will be service-led, not driven by the DH. One of the most exciting outcomes so far, he says, has been chief executives coming forward and acknowledging the scale of the task.

Some have said they are willing to rise to the challenge, provided they receive some support from the centre and are able to operate on a "level playing field".

Sonia Cointet, operational director at the unit, predicts carbon awareness will affect models of care, with services provided in the community through polyclinics or local facilities, cutting car use and promoting walking and cycling.

But there will also need to be less use of disposable goods, potentially putting policy in conflict with infection control.

"It may be that we have to be more creative - often in the NHS we aren't allowed to have competing priorities. But I believe we are creative enough to find solutions."

To date, most NHS sustainability work has taken the form of local schemes designed to address specific problems. One example is in Cornwall, where in 2001 the NHS began sourcing as much of its food locally as possible.

Carbon footprints

Mike Pearson, head of hotel services for Cornwall Healthcare Estates and Support Services, which covers three Cornish trusts, says the initiative came about after managers realised they were taking delivery of sandwiches made as far away as Oxford. The trusts now procure food from Cornish suppliers with 41 per cent of annual spending going to local producers. Mr Pearson estimates this has reduced food miles by 67 per cent, as well as providing a public health benefit by improving the quality of food provided to patients, for instance using fresh rather than frozen fish.

The costs are sometimes higher, but Mr Pearson says: "They actually get eaten. Nutritionally, the patients are gaining and I've got less food waste. If you can get people fed quicker and out of hospital, you can get more people in hospital."

The trust hopes to send sustainable development manager Roy Heath, whose post is part-funded by the Soil Association, out to other NHS organisations to explain how they can follow suit.

"We'd love to spread what we see as almost like a gospel," Mr Pearson says. "You can do this anywhere if you've got the willingness and commitment of your trust."

Antrim Area Hospital in Northern Ireland installed a 40ft wind turbine in 2005, cutting its energy bill by£90,000 a year.

Going mainstream

West Hertfordshire Hospitals trust chief executive Jan Filochowski has planning permission for a£200m private finance initiative health campus as part of a sustainable development in Watford.

The plans, in conjunction with the local authority and partners including Watford football club, include piping rainwater off the hospital roof to water the pitch, and building a combined heat and power plant. All facilities are being set a target of exceeding the current highest efficiency targets for their type of use.

The trust, which is working on a research project on naturally heated and ventilated hospitals with Cambridge University, hopes to cut its energy consumption by 27 per cent. He says: "[Sustainability] probably isn't mainstream enough yet, but one has the sense that it's moving from the anorak end to being something we've all got to do and that's a very important move."

But for every trailblazing trust, there are others where the message is yet to hit home. Mr Filochowski says while more chief executives are attending sustainability events than a year ago, the issue needs to be boosted still further. Trusts must give it greater priority, he says.

"With targets this is going to be a business necessity. I don't think many trusts and their leaders really understand the impact that is going to have. They will get a nasty jolt at least as large as when we were first told about 18 weeks."

Green schemes

Andrew Way, chief executive of the Royal Free Hampstead trust, which is pushing ahead with green transport schemes and replacing its old boilers, agrees that some trusts may have prioritised sustainability below more immediate objectives.

"If you're struggling with meeting the 18-week target and the MRSA target, inevitably they impact much more closely on patients and you'll treat those as a priority."

But he says rising energy prices are driving an improvement in trusts' sustainability credentials: "Once that starts to hit your bottom line, it will start to change the way organisations profile it."

Mr Way has mixed feelings about whether targets are necessary but believes that in the absence of drivers such as financial or clinical outcomes, the NHS may wish to consider how to "penalise or promote proxies for sustainability".

Lord Darzi's emphasis on localism could have a flipside, he says. "If you're looking at doing things locally, what do you do with the space that's heated, lit and provided that's going to be vacated by the service that will be provided locally?

"There's a growing environment that's being provided for patients so inevitably there will be a growing carbon footprint unless you close things down - and I don't see any people having that dialogue.

Increasing patient choice could also have a detrimental effect, he says. "Will patients choose to travel further for services they feel are well established rather than using them locally?"

Commissioning role

But there is consensus on the potential for improvement. There is a strong feeling that commissioners have a role to play.

This could be by insisting suppliers use less packaging or - at a national level - drawing up procurement contracts that include carbon management criteria.

Mr Pencheon says sustainability, currently languishing in the operating framework's third tier, must be given a more prominent and enforceable position.

"Evidence suggests that sustainability and climate change are increasingly important and the NHS has a huge part to play. There's a case to be made for promoting that target from tier three."

Trusts have a last chance to contribute before the consultation closes on 30 September. A final report is expected this year.

Mr Pencheon sees this as a chance for the NHS to shape its own policy on carbon reduction and also to tell the Department of Health how it can best assist in making carbon reduction a reality. He says: "The department is minded to start making this a big policy issue - but only when it's got a mandate from the NHS because of the 'no new targets' issue."

HSJ's Sustainable Healthcare Buildings conference is in London on 11 September, www.hsj-sustainablebuildings.co.uk

MODEL TRUSTS

Percentage of trusts within SHA areas registered on NHS assessment model for the Good Corporate Citizen scheme

  • North West: 84

  • West Midlands: 73

  • South West: 54

  • Yorkshire and Humber: 46

  • North East: 46

  • East of England: 44

  • East Midlands: 38

  • South East Coast: 37

  • South Central: 36

  • London: 32

MEET THE CHALLENGE

Saving Carbon, Improving Health's top 10 challenges:

  • Create "NHS carbon model" to measure progress

  • Carbon management strategy for all NHS organisations by 2009

  • Extend Department of Health's£100m energy fund to help trusts

  • All new buildings to be low carbon by 2015 and zero carbon by 2018

  • All NHS bodies to have sustainable travel plan by 2010

  • Hit waste management targets

  • Improve procurement

  • Price carbon at appropriate level

  • Develop and implement effective sustainable development policies

  • All NHS organisations to report annually on a metric as part of a performance scorecard

See this week's leader for more.