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A Moment of Risk for Sustainable Healthcare in England

The NHS has a lot to be proud of in relation to sustainability. In the last five years, the Greener NHS programme has put in place legally-binding carbon reduction targets, built a national infrastructure for reporting and monitoring progress, and seen tangible progress on national priority areas such as anaesthetic gases and inhalers.

But in 2026 we have reached a moment of significant risk. The merger of NHS England and the Department of Health and Social Care creates uncertainty regarding the future leadership arrangements for sustainable healthcare at national level. The legal carbon reduction duties that currently apply to NHS England will come to an end unless they are replaced with something new. At the same time, the loss of significant numbers of experienced sustainability leaders from integrated care boards, trusts and NHS regions means there is now less capacity in the system to drive this work forwards. And with intense pressure to improve performance on waiting times and other national targets, decarbonisation finds itself having to fight harder for airtime with NHS leaders.

There are two possibilities here. One is that we see sustainability sliding down the list of priorities, with emissions reductions slowing at the very point when we need to accelerate. This would be a tragedy for a health system often seen as being a world-leader on sustainability. The other is that policy makers use the current structural changes as an opportunity to embed sustainability across the system and to deliver benefits to patients, taxpayers and the planet by doing so.

To unlock faster progress, sustainability needs to become part of the routine oversight and performance management processes used by national bodies to hold NHS organisations to account. Getting these accountability arrangements right is the subject of a new research report published jointly by CSH and The King’s Fund, with support from the Health Foundation: ‘Environmental sustainability in the NHS. A new approach to national leadership and accountability’.

In our research, we examined how local NHS organisations in England (trusts and integrated care boards, ICBs) are held to account by national bodies, and how this could be strengthened in future. Sustainability leads in trusts and ICBs are already required to report annually to their own boards on the progress made in delivering the objectives set out in their green plans, creating a form of internal accountability within each organisation. However, our research highlighted that this internal accountability varies significantly in effectiveness, and we believe it cannot be relied on to deliver improvement at the speed needed. Instead, it needs to be accompanied by stronger external oversight and scrutiny.

Based on our analysis, we provide 10 recommendations for national policy-makers to drive action on sustainability at the scale and pace needed:

1. Build on and reinforce the work of the Greener NHS programme, including through a new statutory duty for the Secretary of State for Health and Social Care to report annually to parliament on carbon reduction in the NHS – replacing the legal duty that currently sits with NHS England.
2. Define clearer responsibilities for board-level leaders in trusts and integrated care boards in relation to environmental sustainability, including responsibility for ensuring that sustainability is embedded in core organisational processes.
3. Enhance the assurance role of Greener NHS regional leads by introducing annual review meetings at which each trust and ICB is required to give an account of their performance against local green plan goals and national expectations.
4. Make as much performance data as possible publicly available in a consistent and accessible format, to strengthen public accountability.
5. Identify a small set of high-impact priorities and use these to create energy and focus at the local level. This could involve a concerted national push on no more than three to four priority actions at a time, with the goal of creating a social movement in the NHS on each of these things.
6. Work towards having organisation-specific carbon reduction trajectories for each trust and ICB, giving local leaders a clearer picture of what their organisation’s contribution to the NHS’s overall carbon reduction goals needs to look like between now and 2040/45.
7. Embed sustainability in wider performance management processes at the regional level. Our research makes it clear that accountability for sustainability cannot be a ‘bolt-on’ process that is separate from wider accountability mechanisms. Instead, sustainability should be embedded in the performance management processes that trusts and ICBs are already subject to. This would need to involve national leaders directing senior staff at the regional level to incorporate sustainability within performance discussions.
8. Ensure national accountability mechanisms used for other priorities drive changes that are aligned with sustainability. As a first step, metrics on prevention, population health and reducing demand should be given greater emphasis in the NHS Oversight Framework.
9. Ensure the Care Quality Commission’s new assessment frameworks lead to greater prioritisation of sustainability in providers. Sustainability should be prominent enough in the assessment frameworks to ensure that organisational leaders understand that it is an important national requirement.
10. Make sustainability part of the national vision for a high-quality NHS by communicating the benefits for patients, staff and public finances. Sustainability is still seen as separate from quality and efficiency rather than essential to delivering them. Effective leadership and communication are needed to help make these links clearer.

The key limitation with the current approach to accountability is that the delivery of sustainability improvements tends to be assessed in isolation rather than embedding it in mainstream performance, financial or oversight frameworks. By implementing the recommendations of our report, policy makers can change this so that sustainability and resilience become part of the fabric of the NHS.

Doing so would allow the government to fulfil its mission of modernising the NHS and making it truly ‘fit for the future’.

Author: Chris Naylor, Policy Lead