Extreme climate changes are posing a major challenge for the NHS. Can it cope, asks Lynn Eaton

Floods, storms, malaria and death by overheating. A melodramatic picture - or a description of the real threats hovering over a 21st-century NHS?

This Armageddon scenario was spelt out by chief medical officer Professor Liam Donaldson at the launch of the Department of Health review, Health Effects of Climate Change in the UK.

Prime minister Tony Blair has made clear his desire to build an NHS fit for the 21st century. But the service may be facing quite different challenges in 50 years, when the climate in the UK could be warm enough for malaria to become indigenous again. In 2050, tick-borne diseases, including Lyme disease and encephalitis, could be a health risk.

Extra money may be needed for information campaigns to ensure the UK population is aware of the increased risks. Patterns of hospital admissions may change. And, aside from the public health issues, are NHS buildings going to be able to cope with the changes?

Before Christmas, staff and patients at Uckfield Community Hospital in East Sussex had to wade in through a flooded access road, which was impassable to anything other than four-wheel drive vehicles. Ambulances could not return to base, which was in the building.

'We carry a stock of things like dried food and frozen meals for emergencies like this, ' says Barrie Collins, professional head of nursing. 'But it makes you think. '

Two GP surgeries in Lewes town centre were flooded and had to move temporarily to a community hospital.

Worcester Royal Infirmary, a 250-year-old building in the city centre, had to be closed and patients were transferred to other hospitals in the area, including Hereford.

'The hospital is due for closure anyway, ' says a health authority spokesperson. 'The new hospital is on a hill. There is no risk of flood up there. '

Hereford County Hospital is regularly cut off by flood water and sometimes the basement is flooded. Dr Janet Stevens, director of operations and nursing with the trust, estimates that it lost 1,000 outpatient appointments in November and December last year as a combined result of the flooding and fuel crisis.

At such times 'staff call in and we attempt to pick them up and get them through the water, ' says Dr Stevens. 'We have a four-by-four vehicle, which runs on gas as well as petrol. We also run a silver control with police, the local authority and ambulance service so we know what each other is doing. '

What planning there is for floods has been 'relatively low key', says Professor Donaldson's report.

The health sector has not been drawn into a comprehensive disaster planning process, it warns.

High winds and gales are another threat. The report recommends an audit of buildings, particularly hospitals, to check that roofs and chimneys will cope with gales of 100mph. Emergency staff should be trained to drive in hazardous conditions, it recommends, and A&E staff should know how to deal with injuries caused by falling debris.

The experts offer one ray of hope, though. In a worst-case scenario, if there were a windstorm in the late afternoon in London and the south-east, causing hundreds of deaths and injuries, the NHS should be able to cope - provided there is not a flu crisis at the time. The impact would be spread over several hospitals, they predict.

Although the report does not go as far as suggesting air conditioning on hospital wards to cope with hotter summers, it says much can be done to reduce the threat of global warming if public buildings, including hospitals, improved energy efficiency.

St Mary's Hospital on the Isle of Wight, for example, managed to reduce its energy consumption by 50 per cent within three years of opening its low-energy buildings in 1992. The stainless steel-clad building has thick layers of insulation, 2. 5m square roof windows to allow natural light and small, double-glazed windows elsewhere with solar blinds.

'We haven't planned for air conditioning on the wards yet, ' says Roger Manison, director of the estates development programme with the Isle of Wight Healthcare trust. 'Obviously there is a cost to that. Probably this report is something that will trigger the Department of Health to set up a working party to look into it. '

Even one of the 'greener' private finance initiative projects, the Great Western Hospital in Swindon, has no intention of including air-conditioned wards.

The hospital building, which will be completed next year, aims to take account of changing climate over the next 25 years.

'We have made an estimate - it is a guess - that the temperatures will rise by something like 3 degrees over 25 years, ' says Jim Haines, mechanical and engineering project manager for the new site, which is owned by Carillion.

'If you say you are going to design this to be totally air-conditioned, you could be talking about trebling the cost for something that may not occur. '

The flat roof has been built to withstand 100 times the strength of wind that has ever been experienced in the area. As for flooding, they have thought of that too: a balance pond is being built alongside the hospital to take any excess water, which will then be pumped away.