The BMJ Commission on the Future of the NHS

ANALYSIS

Implement transparent, accountable national adaptation strategies — The government and NHS leadership should provide decisive and visionary leadership, governance, and investment to develop community led adaptation strategies, and develop a universal tracking system to monitor the health impacts of climate change. Government investment should target vulnerable communities and health facilities to empower local communities to mitigate and adapt to climate impacts. Implement sustainable interventions across infrastructure, technology, transport, food, and waste — Infrastructure, technology, food, and waste management should be transformed by adopting national sustainable procurement and prescribing practices and setting environmental standards for industry to decarbonise supply chains and clinical pathways, and reduce waste. Active travel should be prioritised in all NHS infrastructure planning, and catering in healthcare settings should shift towards locally sourced, seasonal, and primarily plant based menus to promote health and sustainability. Educate, embed, and build networks for sustainability through the NHS workforce — All levels of staff, including the executive and board members, should be equipped with the knowledge and skills for sustainable healthcare practices. National standards and a comprehensive plan should be developed in collaboration with key stakeholders, including government and NHS England, covering critical areas like food, workforce, and social prescribing. Promote nature and action on the environmental determinants of health — Government investment should be mobilised for infrastructure and nature. NHS boards and senior leadership should ensure and be supported in delivering facilities that are environmentally friendly, rich in biodiversity, and beneficial for both patients and staff, and promote accessibility for local communities. Ensure decisive and visionary NHS leadership, governance, and investment — Policies to achieve net zero emissions should be enforced, aligning with the Paris Agreement, including driving a ban on new oil and gas licensing in the UK. Health professionals should be recognised and supported in their influential role of addressing and communicating the climate and nature emergencies. Governance and leadership structures should demonstrate, through policies and systems, the value of investment in decarbonisation and climate adaptation in the NHS, in relation to achieving net zero targets and ensuring financial sustainability. Recommendations for a sustainable NHS • Develop and invest in data, metrics, and research that drive NHS sustainability and integrate climate risk • Implement transparent, accountable national adaptation strategies • Implement sustainable interventions across infrastructure, technology, transport, food, and waste • Educate, embed, and build networks for sustainability through the NHS workforce • Promote nature and action on the environmental determinants of health • Ensure decisive and visionary NHS leadership, governance, and investment Stewarding a sustainable NHS is a gift beyond carbon emissions, offering an opportunity for positive systems change across all aspects of society. Taking sustainability as a lens allows a holistic approach to health that reaches beyond the clinic walls and

prioritises health promotion and salutogenesis. Rather than being viewed as a daunting task or one at odds with the achievement of health, interventions that consider climate change, sustainability, and nature as integral to health system functioning offer opportunities to streamline and deliver better services, support healthier populations at source, deliver cost savings, and ensure a flourishing NHS for a further 75 years and beyond. AUTHOR AFFILIATIONS 1 School of Global Development, University of East Anglia, Norwich, UK 2 FXB Center for Health and Human Rights, T.H. Chan School of Public Health, Harvard University, Boston, MA, USA 3 Institute for Global Health, University College London, London, UK 4 Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA 5 Royal Sussex County Hospital, University Hospitals Sussex, Brighton, UK 6 Cardiff University, Cardiff, UK 7 University Hospital of Wales, Cardiff, UK 8 Curtin University, Perth, WA, Australia 9 The George Institute for Global Health at Imperial College London, London, UK 10 NHS Lothian, Scotland, UK 11 Imperial College Healthcare NHS Trust, London, UK 12 School of Public Health, Imperial College London, London, UK 13 UK Health Alliance on Climate Change, London, UK 14 Centre for Sustainable Healthcare, Oxford, UK Contributors and sources: RI is a GP, academic and advocate who has worked on the intersections of climate change and health for over a decade, including for the UN, humanitarian organisations and NGOs, and in and around the NHS. CF is an anaesthetics trainee and the current chief fellow at the Harvard Program in Global Surgery and Social Change, with a focus on sustainability of surgical systems. CB is an emergency medicine trainee with a special interest in sustainability. MM is a professor of intensive care medicine, intensive care specialist and BMJ columnist. KW is a psychiatry trainee and co-principal investigator of the MESSAGE project, focused on sex and gender equity in medical research. BK is a consultant paediatrician, professor of practice, and has integrated sustainable practice in his hospital trust. EM is the director of the UK Health Alliance on Climate Change. RS is the CEO and founder of the Centre for Sustainable Healthcare. RI guided the structure, organisation and writing of the piece, with the support of the whole authorship team. RI, EM, and RS wrote the introduction. RI led the section on why we need a sustainable NHS. CF wrote the sections on shocks and stressors, data, infrastructure and technology, along with MM, RS, EM, and RI. CB and KW wrote the sections on waste and food. RS, BK, and EM wrote the section on workforce and leadership. RS and EM wrote the section on nature; RI on the environmental determinants. All authors contributed to and reviewed all sections, and co-developed the recommendations. EM and RS are joint senior authors. RI, MM, KW, and BK are members of the BMJ Commission. RS is guarantor. Competing interests: We have read and understood BMJ policy on declaration of interests and declare: MM is an employee of TheBMJ and has acted in various advisory roles for the health service including for the Welsh Government. All other authors declare none.

Provenance and peer review: Commissioned; externally peer reviewed.

This article is part of The BMJ Commission on the Future of the NHS (https://www.bmj.com/nhs-com- mission). The purpose of the commission is to identify key areas for analysis, lay out a vision for a future NHS, and make recommendations as to how we get there. TheBMJ convened this commission, which was chaired independently by Victor Adebowale, Parveen Kumar, and Liam Smeeth. TheBMJ was responsible for the peer review, editing, and publication of the papers of the commission. The BMA, which owns TheBMJ , grants editorial freedom to the editor in chief of TheBMJ . Theviews expressed are those of the authors and may not necessarily comply with BMA policy.

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health emergency. Indian J Med Res 2023;158:-3. doi: 10.4103/0971-5916.388235. pmid: 37929357

the bmj | BMJ 2024;385:e079259 | doi: 10.1136/bmj-2024-079259