ANALYSIS
robust evidence shows that disadvantaged groups gain the most health benefit from improved access to nature, 94 and trees and vegetation effectively reduce the urban heat island effect, which predominantly affects socioeconomically deprived communities with higher proportions of marginalised people. 95 More broadly, good access to nature for all in England would reduce NHS pressures equivalent to saving £2.1bn in health spending every year. 94 As one of the largest landowners in England, the NHS forms an anchor institution in communities across the country, through physical spaces for socialising, learning, recreation and exercise, and where people receive treatment for ill health. Interventions such as the NHS Forest Initiative — planting trees and meadows — offer several benefits to people and biodiversity, with one participant at Mount Vernon Cancer Centre stating, “ whenI felt like I was being poisoned on the inside with the chemotherapy drugs, it was very helpful to witness living things growing and carrying on in nature. It gave me hope. ” 83 To mitigate harm and maximise the health co-benefits of action, it is important that policies tackle climate change, biodiversity loss, and other environmental impacts together. Being in balance with the natural environment should be a priority; this means questioning the impact of our current health practices on planetary boundaries, 16 and doing what is required to restore the major earth systems to within their identified safe limits. Prioritised government investment and action towards improving access to nature in the most nature deprived communities, in line with the health co-benefits of environmental action, would deliver the most health benefits and cost savings. Achieving health co-benefits can be achieved by integrating health in all policies across all sectors, informed by the social and environmental determinants of health, as well as integrating social prescribing practices, such as green prescribing for mental health. 9096 Conclusions and recommendations The NHS cannot continue to operate effectively and maintain legitimacy without incorporating sustainability in the context of a climate and biodiversity crisis as a central consideration within every aspect of its functioning. Responsibilities and interventions are required to achieve this aim, delivered through purposeful and considered leadership, reinforced and supported by governance mechanisms, policies and standards, and proactive government investment. Staff should be empowered to engage with sustainability and net zero actions, encouraged to challenge and be proactive in suggesting service improvements, and supported to take wider climate action. 80 Opportunities should be given to patients and communities to actively shape and demand health promoting environments and services. We make the following recommendations to place sustainability at the centre of the NHS ’ s functioning. Develop and invest in data, metrics, and research that drive NHS sustainability and integrate climate risk — Essential national quality metrics should be developed for sustainability within the NHS, requiring all NHS trusts to collect and contribute to a centrally funded database for identifying improvements and guiding research. Sustainability metrics should be integrated into health information systems like the Greener NHS dashboard to standardise assessments of health risks and vulnerabilities owing to climate change. Commitment should be made to the necessary investment in information systems, research, and adaptation, and the establishment of strong partnerships with universities and local authorities to secure a sustainable NHS.
Much more needs to be done across the NHS and wider society to promote the benefits of eating more plant based foods. A public engagement campaign supported by the government with healthcare at the forefront to promote the health and environmental benefits of sustainable diets would help to drive the societal shifts required. Workforce The NHS workforce constitutes 1.3 million people, presenting an opportunity to upskill a large number in sustainable practice and climate preparedness. However, many healthcare workers experience barriers that limit their ability to act, including lack of education and training, policies and workplace guidance, and support from their peers. 74 Sustainability must be recognised as a core focus of practice that acknowledges the ethical and moral duty of doctors to play their part. Education for Sustainable Healthcare is a mandatory requirement of the medical regulator outcomes for graduates, 75 and the Health and Care Professions Council has produced guidance on education for sustainable healthcare for preregistration allied health professionals. 76 Medical schools, royal colleges, and other professional training organisations have started to integrate sustainability into their curriculums, 77 enabling students and trainees to influence and advocate for green issues within the teams they work in. The 2024 General Medical Council good medical practice guidelines reference the importance of sustainability. 78 However, more needs to be done; for example, training on sustainability within healthcare must be made mandatory across the UK, supported by investment and buy-in by national bodies and provider organisations. Action is required across the workforce. Executive and board level leadership teams could be supported by developing networks of learning and communities of practice that enable staff and wider stakeholders to learn from each other and provide opportunities to improve environmental sustainability and clinical care. 79 Healthcare workers, who are recognised to have a trusted voice and impactful messaging when talking about the climate crisis, are increasingly motivated to speak out as part of their professional responsibility to try and prevent a worsening of the climate crisis, and they should be supported in this. 748081 Rotational training — wasteful in terms of travel and resources, disruptive to trainees ’ lives and of arguable educational benefit — might be an area for reconsideration. 82 Nature and the environmental determinants of health A stable natural environment is critical for limiting the impacts of the climate crisis and achieving the UN ’ s sustainable development goals. Where the loss of biodiversity on land and water is a major threat to human, animal, and environmental health, repairing this loss is vital for health. A large and growing body of research has shown the positive impacts of more proximal green space for physical and mental health. 83 Access to green space results in substantial reductions in all cause mortality, 84 obesity, 85 cardiovascular disease, 86 type 2 diabetes, 87 improved pregnancy outcomes, 88 and improved immune system functioning. 89 In the NHS, nature based interventions have been recognised as valuable strategies for prevention of ill health, supporting patients recovering from illness, and promoting good health and wellbeing. 90 Participation in nature based activities is associated with a substantial positive effect on psychological, social, physical, and intellectual outcomes. 91 Recent analysis found that nature prescribing programmes could save the NHS £100m per 1.2 million people involved. 92 Additionally, access to green space is “ equigenic ” , meaning it is able to reduce health inequalities 93 ;
the bmj | BMJ 2024;385:e079259 | doi: 10.1136/bmj-2024-079259
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