Getting to Net Zero: One Health System Fights Climate Change

SHANOOR SEERVAI: What impact do health systems have on our climate? Headlines about climate change from fires to floods, heat waves to hurricanes are ubiquitous, and these disasters take a huge toll on our physical and mental health. But health care itself is one of the most carbon-intensive sectors in the world, responsible for four and a half percent of greenhouse gas emissions.

One country, the United Kingdom, has assigned itself some ambitious goals to mitigate the publicly funded health care system’s carbon footprint. How is the National Health Service, or NHS, doing in meeting those goals, and is this replicable in other countries? We’re going to talk about all this and more on today’s episode of The Dose with my guest, Nick Watts, chief sustainability officer at the NHS.

Nick, welcome to the show.

NICK WATTS: Hi, hi. Thanks for having me. I’m so glad to be here.

SHANOOR SEERVAI: Alright. So, let’s get started with some context for our listeners. Lots of industries are starting to walk the walk after talk about getting to net zero, but the NHS has been very intentional about this for years. So, tell me about the initial commitment, how that might have been tied to the NHS’s core mission, which is health and wellness. I mean, adding to emissions as consequences.

NICK WATTS: Yeah. So, it’s very simple. In fact, just outside the room I’m in, there’s a big poster, it tells you the core mission of the NHS, that’s been there since the NHS burst into existence: “Provide high-quality care for all, now and for future generations.” The science is incredibly clear. You cannot do that — by definition a health system cannot provide high quality care for all now and for future generations, unless you respond to climate change. It is just not possible.

Climate change undermines the foundations of good health, those broad social environmental determinants of health. Everywhere you look, you see that when we built these health care systems, we didn’t think the environment was going to be moving so quickly. We didn’t think temperatures were going to shift so quickly. We didn’t think floods and storms, infectious disease, shifts in water availability and food security across the world were going to change.

And to be frank, health care systems aren’t ready for that. We have to hold our hands up a little bit as health professionals. We have been a little bit slow around the world to respond to climate change. The rest of the world has started to reduce its emissions a little bit ahead of us. I think just in the last couple of years we are starting to see the health profession, not just in the United Kingdom, but all the way around the world really start to stand up. And we’ve seen in the last 12 months, 24 months, when the health profession gets its act together, it can move mountains to protect the health of its patients and the public. And that I think is what we’re starting to see when it comes to the public health response to climate change.

SHANOOR SEERVAI: So, how did you get started? What was the fire behind that initial commitment?

NICK WATTS: The fire is exactly that. It is an understanding that the NHS exists to protect the health of our patients. We know that climate change impacts on their health. And we know that health starts and ends outside of the four walls of the hospital. And so we have a responsibility to act on that. We have seen that, we’ve seen the health impacts of climate change across the United Kingdom, not in 2050, not a long way away, but today.

And so, to that end the NHS has cared about this for 10 years or so. We have been reducing our emissions slowly, actually, just ahead of the general economy in the United Kingdom. 2020 was a bit of a watershed moment. If the climate crisis really is a health crisis, then we as health professionals should respond to it as though it is a health crisis.

And we’ve seen that we know how to do that. And so October 2020, the NHS became the first health system in the world to make a net-zero commitment. Net zero for the emissions we control directly by 2040. And again like I say, we understand health extends out of the four walls of a hospital or a clinic. And so, we take account and responsibility for our entire global footprint. That is tough. And so 2045 — you get an extra five years because you’re not just in direct control of those emissions, you have to work with partners and friends and colleagues across the world.

SHANOOR SEERVAI: So, let’s talk about those partners and friends. How did it go selling something like this internally to the highest-ranking executives, the people who control the money? For some people maybe this was urgent, but for others maybe not such a pressing concern.

NICK WATTS: The answer might surprise you. I came in just as the new net-zero commitment was put into place, tasked with shifting from planning into delivery, from strategy into delivery.

Never once since I have been here — and this has been in the middle of COVID-19, in the middle of a response to an unprecedented pandemic — never once has anyone ever said, “Nick, now is not the right time.” No one has ever said, “Could we do this later? Could we go a little bit slower?” In fact, quite the opposite.

I get pulled into the door saying, “Oh my god, the climate crisis is a health crisis. We need to respond and act. As such, can’t this happen sooner? Can’t we respond in a bigger way. Is this adequate?” That comes partly from the science we were just talking about. It comes partly from an understanding that we go out every single year and poll health professionals across the United Kingdom, 1.4 million health professionals in the U.K. that work for the NHS. Every year we ask them, “What do you care about? What do you really, really want to see the NHS tackle next?” Every year nine out of 10 of them shout back at us, “I want to see the NHS tackle climate change. I want to work for a health system that is living and breathing my values.”

So, part of it, we don’t get those barriers because there is such overwhelming support for the response. You talk about the finances of that. Surely this is going to cost a lot of money and surely someone is going to get grumpy at you when you say we need to develop a net-zero health care system. The answer when you actually go and look — and we spent a proper year with some of the world’s best experts looking — is that it doesn’t cost that much. The answer is you can act on the vast majority, about 80 percent of your emissions, at almost cost neutral. For the remaining 20 percent, yes, there will be an upfront, initial capital investment, but as a total package, the ROI on that investment pays back in three and a half years is our best estimate.

SHANOOR SEERVAI: Oh wow.

NICK WATTS: And that’s because it’s just energy efficiency. It’s just common sense, good health care. It’s making sure that we are delivering care in a way that is better for our patients. It’s being more efficient, it’s being better with the way that we run the health service. And so, I think everyone recognizes that. I think everyone recognizes that new world you’re talking about, that low-carbon health care system, it’s actually just a good health care system.

SHANOOR SEERVAI: So there’s a value case and there’s a business case. And so, then when you actually get to putting it into practice, how did you develop targets like net-zero emissions by 2040? And then, how do you map out what to prioritize as you get there?

NICK WATTS: Well, step one, know how big you are, know what your problem is. So, first you need to have a carbon footprint in a sense of where your emissions hotspots are throughout the health care system. Once you know that, you need to look at the signs and go, “How quickly do I need to need to reduce my emissions?” And the answer is almost invariably going to be, “Faster.” The answer is always going to be, “Listen we’ve sat on our hands for 30 years or so, right? Climate change has been a big issue since the early ‘90s and to be honest before then.” And so you are running up against two things on the one hand, the practical feasibility of . . . God, it’s really quite difficult to shift an entire system, hundreds of billions of pounds, 1.4 million staff, the practicality against the urgency of climate change. And that’s how you land somewhere in the middle. Our targets are set at 2040. Are they fast enough? Probably not. Will they come forward? Yeah, we think they probably will. We think we can demonstrate that we’re going to be able to move those forward. But we didn’t want to say something that we didn’t think was actually feasible, was actually deliverable, because that’s ultimately what matters more.

You asked a little bit about the net part of this as well. There are negative emissions —offsets — attached to the NHS targets. And whenever anyone doesn’t tell you precisely what they mean by that, you should be incredibly skeptical. The idea has to be you reduce emissions, then you reduce them a little bit more. Then you go and you look in your back pocket and you go, “Is there anything else I could do? Is there anything I haven’t done?” And only then do you get to think about the negative, the offsetting, side. Six percent is the total amount that we are looking to offer. It’s incredibly low. And to be honest, anything higher than 10 percent, I think you no longer have ticket to entry in this discussion.

SHANOOR SEERVAI: Well, let’s just back up a little bit and talk about those hotspots that you mentioned. Not unlike, for example, a university system, the NHS is incredibly complex. So, for example, you could start with your real estate. You could start with patient-facing services, you could start with internal operations. Where were your hotspots?

NICK WATTS: So, that’s the other thing. When you go and look at your entire emissions profile for a health care system and you say, “Okay, what do we need to act on?” The answer, if your target is ambitious as something like net zero by 2040, is everything. You don’t get to just do the top 20 things. You are at some point going to act on every single emission throughout the entire system. So, the question of what do you start on first, I often think is almost where can you get going tomorrow? There are some emissions that are going to have to wait because they just have a long lead time. Some of those pathway-to-pathways where we depend on technology coming down the line, where we depend on new capital investment before we can then start to act on those . . . for us, the early easy wins, you can see them in our supply chain.

And we have made it clear to our suppliers within the decade the NHS will no longer purchase from any supplier, full stop, that does not meet or exceed our commitments on climate change, on net zero. You could look at your fleet, you could look at the ambulances, the rapid response vehicles, the patient transport vehicles. And we’ve done that. We’ve got a commitment that we’re going to electrify them. Not some of them, not the ones that are convenient, but all of them, every single one of the vehicles in the NHS. I think we are the third-largest fleet in the country. And that’s not nothing: we’re behind British Telecom and Royal Mail.

And then you go and look at a couple of those medications that are particularly high carbon that don’t need to be. And we see some of those in meter dose inhalers, in certain inhalers where the accelerant, not the drug, but the accelerant within that, is just unnecessarily bad for the environment. Similarly, certain anesthetics: desflurane is something we’ve got our sights set on at the moment. One vial of that is responsible for somewhere between 300 to 350 kilograms of coal, roughly the same equivalent. And so those are the things we start on, right? The big-ticket items and the stuff that you can do tomorrow.

SHANOOR SEERVAI: So, those are the low-hanging fruit. What are you reaching for when you’re really stretching?

NICK WATTS: Once you’ve done all of those easy things, and I shouldn’t say easy because they’re not easy. Once you’ve done some of that, then you need to turn and go, innovation time. How do we start to think not about what is the health care system like today, but what could the health care system be like five years from now, 10 years from now? Cause we’re not just talking about tinkering around the edges here. We’re talking about transforming what it means to be a hospital, what it means to be a health care system. So we’re talking about aligning the sustainability agenda with . . . in the United Kingdom we would talk about hospitals as anchor institutions within a community that recognize they have a responsibility beyond just their four walls and start to engage with the broader public and community health and well-being.

We talk about digital-first hospitals. And we had some really impressive targets that the NHS was chasing after for remote health care, providing better access, providing better choice to our patients. We blew those out of the water, I’m sure you can imagine last year and the year before with the pandemic, the individual productions there are really quite significant and the access improvements are really quite significant. It’s those sorts of things, it’s starting to think less about what is the carbon in my material concrete or in my vehicle and more about how am I delivering care? How am I shifting the models of care towards a lower carbon?

SHANOOR SEERVAI: So, in some ways the pandemic is making your work easier?

NICK WATTS: There’s a very precise technical answer to that, which is no. We have looked at this in great detail, a whole bunch of things in COVID-19 have reduced emissions. And we talked about one of them there with remote health care and reduced travel, absolutely. A whole bunch of things have increased as well, right? Health care has become quite intensive as we have been dealing with more intensive and more acute issues. There’s been problems with single-use plastics, PPE, and there’s a lot that has to be done there. Very, very, roughly it more or less evens out. We’ve had huge emissions reductions, huge emissions increases. It’s more or less broken even. What we need to do is hold onto the things that have reduced emissions and find ways around the things that have increased emissions.

SHANOOR SEERVAI: So, I want to go back to what you said about your staff being really enthusiastic about this. Was it always this way or, how did you make that connection first for health care workers between climate change and health and wellness?

NICK WATTS: I think a lot of that interest, where I look at the real areas where people are getting really excited, I think a lot of it comes down to someone identifying that I have control over that unique piece of carbon. No one else can access that, no one else is making that clinical decision or making that health care decision that is resulting in the emissions. I’m empowered to do something about it. So, we talked about the emissions from anesthetics, from desflurane. Look, there’s a really, really simple switch. Sevoflurane works very, very well. Its emissions profile is significantly lower. In fact, good anesthetic medicine is moving to TIVA, it’s moving to total intravenous anesthesia anyway.

And what we’ve seen is when you make that obvious, when you develop the science and when you communicate that science clearly, when it’s communicated by the health profession for the health profession, they act on it. Anesthetists across the United Kingdom have acted on that and reduced the proportion of desflurane that we consume in the NHS down well below the target we were aiming for. We were aiming for 10 percent. I think we hit 8, 7, 6 percent just recently. To the point where, when we said, “Well, how about for next year we aim for 5 percent?” The response back from the Royal College of Anesthetists, from the anesthetic community, was, “We think you can go further. Why don’t we eliminate this thing altogether?”

SHANOOR SEERVAI: So, this is all good news. Now let’s look at some of the challenges that lie ahead. How are you hoping to close gaps and push forward in, say, the next year and then maybe the next five years?

NICK WATTS: Sure. So, this will get harder. The NHS we are really, really proud to be able to say that in our first year, since that net-zero commitment, we actually hit our reduction targets. We did that despite the pandemic and it was not easy, but we managed to get there. Next year, year two, that’s going to be tougher. Year three, even harder, year four, even harder. This is . . . there’s a steep curve here and it doesn’t get easier, it gets a bit tougher, although hopefully you have built up a bit of steam of momentum, right? You have started to increase the number of people in the system that are working on this, that are acting on it.

The two things I think we need going forward, next one year, next five years are help, and help from two communities. One, we need help from clinicians across the country. And so what we are starting to do is look at different ways we can unlock good ideas. If you have a good idea for low-carbon health care, we’re going to put into place a few new grants across the entire system for hospitals, for NHS trusts, for regions, to say that idea looks really great, it looks scalable. How about we scatter it across the country? See what works, see what doesn’t. We’re going to be very happy to get things wrong. But unlocking that ingenuity, innovation, passion from clinicians is going to be critical for us.

The other thing we need is help from other countries. The NHS at the moment is not the only health care system in the world to have a net-zero commitment. So we were in October 2020. About 12 months later, 10, 15 countries up in Glasgow at the U.N. climate summit came out and said, yes, okay. The world shifted, and we understand that this is the direction of travel that health care systems, that good health care systems are heading in. That was really exciting. It was a really positive moment. What we need to see now is that commitment turn into tangible emissions reductions. We need to see that commitment turn into tangible strategies that are actionable. If we can get that over the next one year, two years, five years, I will be so much more excited, energized, happy to confidently say yes, absolutely the NHS can do this. There’s something that I spent a little bit of time talking about back when we were developing the strategy, which should be clear, but we need to remind ourselves: the NHS is not an island. It can’t get to net zero by itself. It just isn’t possible. It can only get there if we all move there together.

SHANOOR SEERVAI: Right. So, let’s come back and talk about not being an island, because there are so many vendors that you work with. For example, how are you going to work with global pharmaceutical companies? You’re competing with other countries in the E.U., with other countries around the world to buy drugs. How are you going to push those companies to reduce their emissions?

NICK WATTS: It’s a good question. So, number one, let’s be clear about the direction of travel and let’s be unwavering about the direction of travel. Within the decade, the NHS will no longer purchase from any company — full stop — that does not meet or exceed its commitments, our commitments, on net zero. I’m going to repeat that as often as I possibly can, because that signal is very, very important. I also know that we will not be alone. I know that health care systems all the way around the world will move at that pace, will probably move faster than the NHS. So I know that this is the direction that the global health care market is moving.

Number two, we’re going to have to work very closely with those companies, with our suppliers. They are our partners in delivering health care, at tech companies, pharmaceutical companies. And we have a whole range of innovation competitions where we work with some of these companies to come up with some of the answers. Everyone broadly is on board with the direction of travel. It’s when you get down to the nitty gritty of . . . okay, interesting. Insulin is a big part of our markets say, Novo Nordisk very, very interested in seeing how we might decarbonize that. But cold chains are challenging and decarbonizing, finding a net-zero way of running a fleet of cold chains. We don’t have a problem with it, but we’re interested in discovering how we can work together on that. I think the other piece that we need there, you got to have some clear long-term targets. You got to have some good collaboration with the industry.

The third thing is you got to have some interim targets. It can’t just be a cliff edge that we find ourselves at towards the end of the decade. And so to be clear, for the NHS, all of our tenders going out in a month or two will start to include 10 percent weighting for net zero into absolutely everything we purchase. That’s the first thing we’re doing. April 2023 we expect all of our partners, every single one of the companies we purchase from, to have scope one and scope two. These are the narrower scopes of their emissions, publicly available, talking about how they’re going to reduce their emissions. We want to know that we’re doing business with people that are heading in the same direction as us.

SHANOOR SEERVAI: When you say you’re doing business, do you have to make the business case for these companies or are they bought in?

NICK WATTS: I would say they are bought in. I would say the broad direction of travel, we know everyone is broadly happy with, especially for some of the larger companies that we work with. I think everyone accepts this is the direction that the German, that the French, that the American, British health care systems are heading in. A good example of that, we made some of those big commitments I was talking about a year ago up in Glasgow at the U.N. climate summit. Fifteen of our largest suppliers came out and publicly together said, “This looks really tough, but we’re going to get there. We know that we are going to get there.” And they offered their support, in fact, out to the rest of the industry, out to the others that are going to have to get there together. Because it is not possible for the NHS to get to net zero by itself. It’s also not possible for any one pharmaceutical company to get to net zero by itself.

SHANOOR SEERVAI: You listed some other countries and I can’t help but ask: the NHS is a national health service, publicly funded, very different from the health system we have here in the United States. So, can other countries really achieve what you are doing? Can they scale the way you are?

NICK WATTS: Unequivocally yes. And I hear this a fair bit: “We couldn’t possibly do this. We aren’t a monolith like the NHS. God, come and work here.” We don’t feel like a monolith. We are 220 trusts, we are independent, we are delivering high-quality health care, but in incredibly different ways all across the country. The same I suspect will be true in the United States, as it is in France, in Australia, in India. Can people get to net zero, can a health care system get to net zero, could the United States and its private and its public parts of its health care system get to net zero? Absolutely, without question. Will it do it in the same way as the NHS? No, of course not. And so, it will do some things better, it will do some things different, and we will hopefully learn from each other. It probably won’t be able to run the same sort of structure and response that the NHS has, but that’s okay. The health care system itself doesn’t function that way. It doesn’t mean that it can’t act on its own emissions.

SHANOOR SEERVAI: And do you see your health care system as a model potentially for other industries that are carbon intensive? Are there lessons that others can learn from you?

NICK WATTS: Yes. There are many more lessons we can learn from others, though. And indeed, when you go and look at some of the things that we in the NHS are doing . . . we were really excited, we have the world’s first zero-emission ambulance. Fully electric and electric hydrogen hybrid. Go and look at some of the technology there. Listen, it was produced in the United Kingdom, but a lot of the learning that we took from that about how this might operate, we got from Germany.

If you go and look at the policies we have, the new national policies we have to reduce emissions and improve asthma care from our inhalers. We got a lot of those ideas from France, we got them from Scandinavia. You go and look at some of the analytics behind the NHS’s carbon footprint and our strategy. That came from academic expertise from some of the world’s best experts across in the United States.

There’s a lot we can learn from each other here, because it’s worth saying: No one knows with absolute clarity what a net-zero health care system looks like in 2040 or 2045. We are going to make this up together. And so we’re going to have to be open to some of that innovation, some of that shared learning.

SHANOOR SEERVAI: Nick Watts, thank you so much for joining me today.

NICK WATTS: Of course. Thanks for having me.

SHANOOR SEERVAI: This episode of The Dose was produced by Jody Becker, Julia Melfi, Naomi Leibowitz, and Joshua Tallman. Special thanks to Barry Scholl for editing, Jen Wilson and Rose Wong for our art and design, and Paul Frame for web support. Our theme music is “Arizona Moon” by Blue Dot Sessions. Our website is thedose.show. There you’ll find show notes and other resources. That’s it for The Dose. I’m Shanoor Seervai. Thank you for listening.