Introduction

In 2020, the NHS became the world’s first health system to commit to reaching net zero emissions. The Delivering a Net Zero National Health Service report set out the scale of ambition. The Health and Care Act 2022 reinforced this commitment, placing new duties on integrated care boards (ICBs), NHS trusts and foundation trusts (referred to collectively in this guidance as trusts) to consider statutory emissions and environmental targets in their decisions.

Trusts and ICBs are expected to meet these duties through the delivery of board-approved green plans.

These plans now need to be refreshed in line with this statutory guidance by 31 July 2025.

Building on our progress

In 2021, NHS England guidance on how to produce a green plan asked systems and trusts to develop green plans spanning 3 years (2022/23 to 2024/25). Significant progress towards achieving net zero has been made over this period, including:

• over £1 billion in funding secured by NHS trusts through the Public Sector Decarbonisation Scheme (PSDS), which is expected to reduce NHS energy costs by over £260 million a year
• NHS-wide decommissioning of desflurane, an environmentally damaging anaesthetic gas with a higher global warming potential than its readily available alternatives
• ongoing reduction in waste from nitrous oxide, responsible for the largest overall volume of emissions from anaesthetic and medical gases, saving around £5 million annually
• progressing high-quality, lower-carbon respiratory care, supporting patients to improve their lung health while reducing inhaler emissions by around 300 kilotonnes of carbon (Kt/CO₂e) a year
• the introduction of requirements for NHS suppliers to disclose their emissions and publish a carbon reduction plan, in line with the NHS Net Zero Supplier Roadmap

This updated guidance supports systems and trusts to refresh their green plans for the next 3-year cycle with the aim of:

• prioritising interventions that support world-leading patient care and population health, and reduce inequalities, while tackling climate change and broader sustainability issues
• supporting NHS organisations to plan and make considered investments while increasing efficiencies and delivering value for taxpayers
• ensuring every NHS organisation supports the ambition to reach net zero carbon emissions, reflecting learning from delivery to date

Delivering a net zero NHS: better health and better care 

Climate change presents an immediate and growing threat to health. The UK is already experiencing more frequent and severe floods and heatwaves, as well as worsening air pollution. Up to 38,000 deaths a year are associated with air pollution alone, disproportionately affecting the most deprived and further exacerbating health inequalities.

The impact of climate change will also be expensive for society and the NHS, with the costs of heat-related mortalities from climate change estimated at £6.8 billion per year in the 2020s, rising to £14.7 billion per year in the 2050s.

Conversely, action to tackle climate change brings direct benefits for public health, health equity and taxpayers. Reducing the NHS’s environmental impact will help to build an NHS fit for the future that provides world-leading healthcare and supports the government’s mission to make Britain a clean energy superpower, including through:

• supporting high-quality, preventative and low-carbon care, in line with the NHS’s goal to boost out-of-hospital and digitally enabled care, improve prevention of ill health and reduce health inequalities
• reducing air pollution by decarbonising the NHS fleet, which is set to save the NHS over £59 million every year and deliver a range of health benefits valued at over £270 million.
• modernising and decarbonising the NHS estate, which is expected to reduce energy costs while creating a better environment for patient care
• minimising waste through circularity – where reusable, remanufactured or recycled solutions are used – which is often cost-saving and helps protect against external supply disruptions

Our range of case studies highlights the positive impact of adopting a net zero approach.

Refreshing your green plan

Action required of trusts and ICBs

Refreshed green plans should be approved by the organisation’s board or governing body, published in an accessible location on the organisation’s website and shared with NHS England by 31 July 2025.

We strongly recommend that ICBs work with their partner trusts throughout to support a coherent and co-ordinated approach. 

Organisations that have refreshed their green plan recently should ensure it is aligned with this guidance.

Approach

Green plans should set out the key actions each system and trust will take to deliver emissions reductions and support resilience to climate impacts over the next three years. This timeframe is considered a minimum and should allow green plans to strike an appropriate balance between immediate emissions reductions in some areas, alongside strategic development of capability in others.

Each organisation should:

• review progress to date and engage with key stakeholders about refreshing priorities, in particular clinical and staff groups who underpin green plan delivery
• take into account the national targets (and interim 80% emissions reduction goals) for the NHS carbon footprint and carbon footprint plus
• set out SMART (specific, measurable, achievable, relevant and time-bound) actions and associated key performance indicators (KPIs) for each area of focus
• ensure recommended governance arrangements and processes to measure and report on progress are in place
• comply with any applicable legal duties, including the duty to reduce inequalities, the Public Sector Equality Duty and the duty to have regard to all likely wider effect of decisions

System green plans

The ICB should lead on refreshing each system’s green plan.  

The system’s plan should not simply be an aggregation of partner trust green plans and should cover at minimum the ICB’s role in:

• providing system leadership on emissions reduction and engaging with wider system partners – for example, by working with local authorities on travel and transport initiatives
• supporting partner trusts to deliver their green plan objectives and overseeing progress, including through contract monitoring (NHS Standard Contract service conditions, section 18)
• supporting primary care providers to contribute to system-wide emissions reductions – for example, by working with and through overarching structures such as primary care networks and primary care committees
• sharing best practice across partner organisations, supporting collaboration and facilitating engagement with relevant research and innovation activities, such as through health innovation networks
• maximising opportunities to reduce emissions and improve population health when planning and commissioning NHS services
• ensuring that green plan priorities are aligned with and reflected in the ICB Joint forward plan, Integrated care system (ICS) infrastructure strategy and capital plans, and other relevant system-wide plans in line with the 4 core purposes of the ICS
• delivering a limited set of priority actions at system-level, as set out in areas of focus

Non-NHS organisations delivering health or social care do not need a green plan, although this guidance can be applied to those settings if useful.

Trust green plans

Trust green plans should consider:

• the role of the local system and provider collaboration in supporting delivery, such as through the spread and standardisation of best practice
• opportunities for collaboration with wider system partners to reduce emissions
• engagement with research and innovation activities to support the transition to a net zero NHS

Areas of focus

We recommend that all green plans continue to be structured in line with the chapter headings of Delivering a Net Zero National Health Service (2020), as outlined in How to produce a green plan.

Priority actions for each area of focus are outlined below. Some organisations may choose to add further sections to their plan based on their own sustainability priorities, such as linked actions to improve air quality and green space.

Organisations should not consider offsetting but instead should focus all efforts on reducing emissions.

Given the variation in context, including across community, mental health, ambulance and acute trusts, organisations should develop plans relevant to their setting. For example, some organisations do not use anaesthetic gases and would not include these in their plans.

SMART actions and associated KPIs should be set out for each focus area. Annex A: supporting metrics includes suggested metrics for progress tracking. Selected resources to support green plan development are set out in Annex B: selected resources.

Workforce and leadership

The transition to a net zero NHS will be driven by its people. There is already strong support for a greener future; 9 in 10 staff support the NHS net zero ambition, while 6 in 10 say they are more likely to stay in an organisation taking decisive climate action (YouGov, 2023).

Organisations should support their staff and leaders to learn, innovate and embed sustainability into everyday actions.

Key actions for systems and trusts:

• appoint a designated board-level net zero lead, generally an existing executive director, to oversee green plan delivery with clearly identified operational support
• assess workforce capacity and skill requirements for delivering the green plan, considering good practice examples such as hybrid roles, apprenticeships, fellowships and NHS estates sustainability career pathways
• promote, and consider setting uptake targets for, core training offers set out on the Greener NHS Training Hub
• promote specialist training for staff groups who underpin the delivery of green plans, such as board members, procurement, finance, estates and facilities staff and clinicians

Net zero clinical transformation

The NHS is committed to moving to out-of-hospital and digitally-enabled care where clinically appropriate, improving prevention of ill health and reducing health inequalities. These changes also underpin our commitment to net zero. Net zero clinical transformation should ensure high-quality, preventative, low-carbon care is provided to patients at every stage.    

Key actions for systems:

• support work to reduce emissions across patient pathways, spanning primary, secondary and community care and the third sector
• consider net zero principles in all service change, reconfiguration programmes and pathway redesign

Key actions for trusts:

• identify a clinical lead with oversight of net zero clinical transformation, with formal links into board-level leadership and governance
• focus on reducing emissions and improving quality of care for at least one clinical area (see suggested areas below), for example by:
  • establishing a clinical lead and multidisciplinary working group responsible for reducing emissions in the clinical area(s)
  • completing quality improvement project(s) in the clinical area(s) that focus on a measurable reduction in emissions, with co-benefits for outcomes and quality of care, efficiency and reducing healthcare inequalities (supported by resources in Annex B: selected resources)
  • Sharing learning and outcomes, for example, through clinical networks, the ICB and NHS England

Digital transformation

Strong digital foundations are essential for transforming care by improving access, quality, productivity and reducing emissions. However, digital services can also increase emissions. NHS England’s What good looks like framework encourages NHS organisations to prioritise sustainability in the procurement, design and management of digital services to meet the objectives of the Greening government: ICT and digital services strategy

Key actions for systems and trusts:

• maximise the benefits of digital transformation to reduce emissions and improve patient care, for example, by reducing the use of paper and providing virtual pathways where clinically appropriate (see also Net zero clinical transformation)
• supported by the Digital Maturity Assessment, consider opportunities to embed sustainability in digital services, such as by:
  • using circular and low-carbon approaches to IT hardware management, which may include longer device lifetimes, leasing models, buying refurbished or remanufactured equipment and PC power down configuration
  • considering low carbon hosting, promoting good data hygiene (such as, deduplication and archiving) and engaging digital suppliers (see also Supply chain and procurement)

Medicines

Medicines account for around 25% of NHS emissions. A few medicines account for a large portion of these emissions, for example, anaesthetic gases (2% of NHS emissions) and inhalers (3%). Organisations should build on progress in reducing these “point of use” emissions, while improving patient care and reducing waste. Actions to reduce emissions from the medicines supply chain are set out under Supply chain and procurement.

Key actions for systems:

• work with primary care to support high-quality, lower-carbon respiratory care in line with clinical guidelines for asthma and chronic obstructive pulmonary disease, including:
  • optimising inhaler choice (considering clinical appropriateness, the environmental impact of inhalers and patient preference)
  • improving inhaler use and adherence
  • encouraging patients to return their used or expired inhalers to community pharmacies for appropriate disposal
• in line with National medicines optimisation opportunities, address overprescribing and oversupply while supporting patients in greatest need, taking a shared decision-making approach and personalising care

Key actions for trusts:

• reduce nitrous oxide waste from medical gas pipeline systems (MGPS) by progressing the actions outlined in the updated nitrous oxide waste mitigation toolkit
• cease use of the volatile anaesthetic agent desflurane in line with national guidance, allowing exceptional use only as published by the Neuro Anaesthesia and Critical Care Society

In addition, trusts may wish to:

• support high-quality, lower-carbon respiratory care in secondary care, including supporting patients to choose the most appropriate inhaler(s) in alignment with clinical guidelines, performing inhaler technique checks with patients and promoting the appropriate disposal of inhalers

Travel and transport

The NHS fleet is the second largest in the country, consisting of over 20,000 vehicles. It directly contributes to harmful air pollution. The NHS Net zero travel and transport strategy outlines a roadmap to decarbonise NHS travel and transport, while also providing cost-saving and health benefits.

Key actions for systems and trusts (including ambulance trusts):

• develop a sustainable travel plan by December 2026, to be incorporated into the green plan (for example, as an annex), focusing on active travel, public transport and zero-emission vehicles, supported by a clear understanding of staff commuting (NHS England guidance will be available in 2025)
• offer only zero-emission vehicles through vehicle salary sacrifice schemes from December 2026 onwards (for new lease agreements)
• make arrangements to purchase, or enter into new lease arrangements for, zero-emission vehicles only from December 2027 onwards (excluding ambulances)

In addition, systems should:

• form partnerships with local authorities and local transport authorities to maximise funding and infrastructure opportunities on behalf of the ICS member organisations

In addition, ambulance trusts should:

• support zero-emission ambulance pilots, followed by evaluation and at-scale transformation in readiness for the procurement of zero-emission ambulances from 2030

Estates and facilities

There are significant opportunities across the NHS estate to reduce emissions and lower costs, while improving energy resilience and patient care.

Organisations should focus on:

• improving energy efficiency by installing measures such as LED lighting, insulation and double-glazed windows
• replacing fossil fuel heating systems with lower carbon alternatives, such as heat pumps or connecting to a heat network system
• increasing use of renewable energy by investing in on- or near-site renewable energy generation to meet NHS energy demand

As set out below (supporting resources), NHS England has been asked to develop a pipeline of revenue and carbon saving NHS projects for 2025/26 and beyond, with an initial expression of interest process (log in required) launched in December 2024. This will ensure that the NHS is optimally placed to secure any future funding made available across government.

Key actions for systems:

• work with local partners to ensure estate decarbonisation planning aligns with local priorities, infrastructure plans (for example, heat networks) and funding opportunities
• identify opportunities to support primary care estates decarbonisation, such as through the Boiler upgrade scheme
• support trusts that have not accessed PSDS funding previously to develop applications (this may include exploring joint bids between trusts or other partners)
• ensure the green plan aligns with the ICS 10-year infrastructure strategy

Key actions for trusts:

• develop a heat decarbonisation plan (HDP), which includes:
  • identifying and prioritising the phasing out of all existing fossil-fuel primary heating systems by 2032 and seeking to remove all oil primary heating systems by 2028
  • considering Local Area Energy Plans and opportunities from heat networks and other low-carbon solutions
  • identifying any installations in scope of the UK Emissions Trading Scheme and outline plans to reduce emissions in line with allocated targets
• develop business cases to deliver the measures outlined in the HDP, as well as accompanying energy efficiency and renewable energy interventions, with a view to submitting a funding application through the PSDS if projects cannot be financed through internal budgets
• ensure all applicable new building and major refurbishment projects are compliant with the NHS Net Zero Building Standard

Supply chain and procurement

The NHS net zero supplier roadmap outlines steps suppliers must follow to align with the NHS net zero ambition between now and 2030. Roadmap implementation is a shared responsibility across trusts, systems, regional procurement hubs and nationally. Organisations should also seek to embed circular solutions, such as using reusable, remanufactured or recycled solutions when clinically appropriate, which are often cost-saving.

Key actions for systems and trusts:

• embed NHS net zero supplier roadmap requirements into all relevant procurements and ensure they are monitored via KPIs
• encourage suppliers to go beyond minimum requirements and engage with the Evergreen Sustainable Supplier Assessment to support a single conversation between the NHS and its suppliers on sustainability priorities

In addition, trusts should:

• reduce reliance on single-use products, considering how to safely build this work into clinical improvement projects (see Net zero clinical transformation and Annex B: selected resources for additional support tools)

Food and nutrition

Organisations should continue implementing the National standards for healthcare food and drink, requiring NHS organisations to deliver high-quality, healthy and sustainable food and minimise waste.

Key action for trusts:

• measure food waste in line with the Estates Returns Information Collection (ERIC) and set reduction targets
• consider opportunities to make menus healthier and lower carbon by supporting the provision of seasonal menus high in fruits and vegetables and low in heavily processed foods

Adaptation

Climate change threatens the ability of the NHS to deliver its essential services in both the near and longer term. Resilience and adaptation should be built into business continuity and longer-term planning to avoid climate-related service disruptions. Partnership working between sustainability leads, public health, emergency response teams and estates leads at trust and system level is crucial.

Key actions for systems and trusts:

• all providers and commissioners of NHS-funded services must comply with the adaptation provisions within the NHS Core Standards for emergency preparedness, resilience and response (EPRR) and the NHS Standard Contract to support business continuity during adverse weather events
• set out actions to prepare for severe weather events and improve climate resilience of local sites and services, including digital services (see Annex B: selected resources for a supporting Climate Change Risk Assessment Tool)

In addition, systems should:

• in partnership with emergency response colleagues and others, identify interdependencies between services and the necessary mutual aid requirements to prevent service disruptions
• share findings with resilience partners (for example, local resilience forums and directors of public health) to ensure critical information is integrated into broader emergency planning and climate adaptation planning practices

In addition, trusts should:           

• factor in the effects of climate change when making infrastructure decisions and designing new facilities, including enhancements like improved green spaces, drainage systems and passive cooling solutions
• ensure adequate cascading of weather health alerts and relevant messaging across the organisation, in line with the government’s Adverse Weather and Health Plan

Green plan governance

Delivery of green plans should be overseen by a designated board-level net zero lead, generally an existing executive director, with clearly identified operational support.

The plan will also require senior leadership and oversight of delivery from a range of functions, which may include:

• chief medical, chief nursing, chief allied health professional officers and chief pharmacists
• directors of estates and facilities
• directors of procurement
• chief information officers
• directors of finance

When considering future resilience, requesting oversight from the accountable emergency officer may also be appropriate.

Organisations should put in place governance arrangements to co-ordinate delivery, such as a regular green plan delivery board chaired by the organisation’s board-level net zero lead and attended by relevant directors.

Each organisation should review and update its plans annually to consider progress made and any new priorities, guidance, technology and other enablers.

NHS England oversees NHS performance in England through its regional teams. We will work with ICBs and trusts to support delivery of green plans, reporting overall progress to government and Parliament. In addition, environmental sustainability – including leadership and delivery of green plans – is covered within the Care Quality Commission (CQC)’s Well-led framework and assessed as part of the CQC’s single assessment framework (see also supporting guidance for trusts).

Tracking and reporting progress

Reporting requirements

The Department of Health and Social Care (DHSC) group accounting manual, the Foundation trust annual reporting manual and the NHS Standard Contract set out sustainability reporting requirements for NHS organisations. NHS England will also consider progress on delivery of green plans as part of its annual assessment of ICB performance.

ICBs and trusts are required to report an annual summary of progress on delivery of green plans to their board and publish this in their annual report, including actions taken and planned, with quantitative progress data. 

Reporting on progress against green plans should include:

• narrative updates on progress to date and key achievements
• delivery of key milestones and risks to future delivery
• quantitative assessment of progress against defined targets (see Metrics to track progress)

There is no requirement for NHS organisations to calculate and report organisational carbon footprints.

Metrics to track progress

In the short term, it is difficult to use emissions alone as an indicator of progress towards the NHS’s long term net zero targets, due to lags in data availability, limitations of spend-based calculations and factors over which the NHS has no control, such as the rate of national electricity grid decarbonisation.

Annex A: supporting metrics includes a set of suggested emissions-based and non-emissions-based metrics to support organisations to track progress. Additional data and analytics tools are signposted in Annex B.

Supporting resources

Many of the interventions required to deliver a net zero NHS are ‘no-regrets’ actions, where benefits can be captured immediately with little requirement for financial investment, such as waste reduction, safe reuse of products or optimisation of medicines usage. 

Some initiatives do require initial capital investment but also offer substantial efficiency savings. Examples of this include LED lighting, systems to manage and reduce energy consumption, and the electrification of the NHS fleet in line with the Net Zero Travel and Transport Strategy. Organisations should consider how net zero principles can be routinely integrated into all business as-usual upgrades and backlog maintenance when developing their green plan.

The NHS also benefits from wider government funding to support the UK-wide transition to net zero.

• The NHS has already secured over £1 billion in investment to cut energy costs and reduce carbon emissions through the Public Sector Decarbonisation Scheme (PSDS)
• £40 million has been invested in LED lighting through the NHS Energy Efficiency Fund, with an additional £75 million available to support LED lighting and building management system projects in 2024/25
• Other schemes include the Public Sector Low Carbon Skills Fund, the Workplace Charging Scheme, and the Boiler Upgrade Scheme to support green heating installations in smaller properties such as primary care practices

In line with the Government’s clean energy and efficiency aims, NHS England has been asked to develop a pipeline of revenue and carbon saving NHS projects for 2025/26 and beyond, with an initial expression of interest process (log in required) launched in December 2024. This will ensure that the NHS is optimally placed to secure any funding made available across government, as well as to bid for any future capital funding where measures have positive returns on investment.

Organisations should consider what support might be required from existing funding schemes and ensure that they are ready to engage with any future funding opportunities, which will continue to be shared through the Greener NHS FutureNHS knowledge hub.

Annex A: supporting metrics

The table below sets out suggested metrics for tracking progress against green plan delivery. The list is not exhaustive and may be updated as new data streams become available.

Organisations may wish to consider other metrics to track progress locally against the actions outlined in areas of focus. For example, to assess the impact of low-carbon clinical improvement and digital transformation projects. Nationally available data sources are indicated. Where this data is significantly lagged, more recent local data should be used where available.

Annex B: selected resources

Supporting resources will continue to be updated on the Greener NHS FutureNHS knowledge hub.

Case studies

• Greener NHS system progress
• FutureNHS: Greener NHS case studies (login needed)

Data and analytics

• FutureNHS: Greener NHS Data and Analytics (login needed)
• Greener NHS Dashboard (login needed)
• FutureNHS: Green Plan Support Tool (login needed)

Workforce and leadership

• FutureNHS: Greener NHS training hub (login needed)
• Building a Net Zero NHS, an accessible introduction to climate change and healthcare
• Carbon Literacy for Healthcare eLearning Pathway, more advanced training to support staff drive positive net zero change
• Sustainability Leadership for Greener Health and Care, to support system leaders to deliver net zero.
• Centre for Sustainable Healthcare Networks
• FutureNHS: Nursing and Midwifery Sustainability Network (login needed)
• Estates and facilities workforce action plan and NHS estates recruitment and career pathways guidance

Net zero clinical transformation

• Critical and perioperative care – Green Theatre Checklist (Royal College of Surgeons of England, Royal College of Surgeons of Edinburgh, Royal College of Physicians and Surgeons of Glasgow) and Green Surgery report (UK Health Alliance on Climate Change, Brighton & Sussex Medical School, The Centre for Sustainable Healthcare)
• Mental health – Net Zero Mental Health Recommendations (Royal College of Psychiatrists)
• Urgent and emergency care – GreenED (Royal College of Emergency Medicine)
• Diagnostics – Green Endoscopy (British Society of Gastroenterology)
• Renal care – Sustainable Kidney Care Committee (UK Kidney Association)
• General practice – Net Zero Hub (Royal College of General Practitioners)
• Pharmacy – Royal Pharmaceutical Society Sustainability Policies
• Allied Health Professionals – Greener Allied Health Professional hub

Digital transformation

• FutureNHS: Digital Net Zero (login needed)
• What good looks like framework
• Greening government: ICT and digital services strategy 2020 – 2025
• Greenhouse Gas Protocol ICT Sector Guidance

Medicines

• Nitrous Oxide – Nitrous Oxide Waste Mitigation Toolkit and Health Technical Memorandum 02-01 – Medical gas pipeline systems
• Desflurane – Guidance: Desflurane decommissioning and clinical use
• High-quality, lower-carbon respiratory care:
• NICE NG245 Patient decision aid on asthma inhalers and climate change
• Asthma + Lung UK inhaler choices (for people living with a lung condition)
• Greener practice visual aid and asthma toolkit
• RightBreath – Information for clinicians on different inhalers
• Core20PLUS5 – an approach to reducing health inequalities
• Medicines optimisation – National Medicine Optimisation Opportunities and National Overprescribing Review (NOR)

Travel and transport

• FutureNHS: Net zero travel and transport (login needed)
• NHS Net Zero Travel and Transport Strategy

Estates and facilities

• FutureNHS: Estates Sustainability Hub (login needed)
• FutureNHS: Estates Net Zero Delivery Plan (login needed)
• NHS net zero building standard
• Green leases framework
• Greening the business case
• NHS clinical waste strategy and Health Technical Memorandum 07-01: Safe and sustainable management of healthcare waste

Supply chain and procurement

• FutureNHS: CCF sustainability hub (login needed)
• NHS Net Zero Supplier Roadmap
• Evergreen Sustainable Supplier Assessment
• NHS Net Zero Product Savings Calculator (login needed)
• DHSC Design for Life roadmap

Food and nutrition

• FutureNHS: Food and nutrition (login needed)

Adaptation

• NHS Climate Change Risk Assessment Tool (login needed)
• Third National Adaptation Programme (fourth report pending in 2024/25)
• Emergency preparedness resilience and response (EPRR) core standards
• UK Health Security Agency Adverse Weather and Health Plan

Publication reference: PRN01365