Next Article in Journal
Constructing Real-Time Meteorological Forecast Method of Short-Term Cyanobacteria Bloom Area Index Changes in the Lake Taihu
Previous Article in Journal
Evaluate and Analyze the Characteristics of Subway Transfer Station Facilities Based on Universal Design from the Cases of South Korea
 
 
Font Type:
Arial Georgia Verdana
Font Size:
Aa Aa Aa
Line Spacing:
Column Width:
Background:
Article

Decarbonizing the Healthcare Estate: Lessons Learned from NHS Trust Green Plans in England

1
Faculty of Science and Engineering, School of Engineering andthe Built Environment, Anglia Ruskin University, Bishop Hall Lane, Chelmsford CM1 1SQ, UK
2
Global Health and Infection Department, Brighton and Sussex Medical School, Medical School Teaching Building, Falmer BN1 9PX, UK
3
Department of ENT, Royal Sussex County Hospital, Eastern Road, Brighton BN2 5BE, UK
*
Author to whom correspondence should be addressed.
Sustainability 2025, 17(18), 8375; https://doi.org/10.3390/su17188375
Submission received: 25 July 2025 / Revised: 11 September 2025 / Accepted: 15 September 2025 / Published: 18 September 2025
(This article belongs to the Section Energy Sustainability)

Abstract

Climate change threatens human health and healthcare systems while also contributing to greenhouse gas emissions. NHS England has addressed this with the Health and Care Act 2022, which mandates NHS trusts to develop green plans for emission reduction from 2022 to 2025. This initiative presents an opportunity to assess national scale efforts to decarbonize the healthcare sector. The paper identifies the interventions NHS trusts are adopting to decarbonize their estates and meet national net-zero targets while also highlighting opportunities for further progress. A thematic content analysis was conducted on green plans developed by NHS trusts in England to outline their strategies to decarbonize the estate. The main elements the NHS trusts have considered in terms of reaching net zero through built asset management; implementing heat decarbonization; and switching to renewable and low-carbon sources of energy. The analysis has recognized a strategic shift towards decarbonizing the healthcare estate by prioritizing the maintenance, refurbishment, and repurposing of existing buildings over new construction, coupled with a heat decarbonization strategy focusing on the transition to low-carbon technologies. Most long-term decarbonization strategies, particularly for achieving net zero through built asset management, are still in the early stages. There is a lack of comparable KPIs for monitoring progress and insufficient information on essential passive strategies. NHS in England should adopt a more integrated approach to decarbonization including both active and passive interventions, improve the standardization of performance metrics, and establish SMART objectives and standardized KPIs to effectively monitor trusts’ progress towards net-zero emissions in future green plans.

1. Introduction

Climate change poses a significant global threat to human health and exerts immense pressure on healthcare systems [1]. These systems are on the frontline in addressing healthcare demands resulting from climate change [2,3]. However, they also contribute notably to CO2 emissions, accounting for 4.4% of the global total [4,5]. Healthcare systems must take practical steps to reduce greenhouse gas emissions to align with goals set at the United Nations Climate Change Conference (COP21) [6] and contribute to achieving SDGs related to climate change, sustainable consumption, water and sanitation, energy, employment, resilient infrastructure and health and well-being [7]. As part of the COP26 health programme, 80 countries pledged to develop climate-resilient and low-carbon health systems [8,9], with seven European countries—Belgium, Germany, Ireland, the Netherlands, Norway, Spain, and the UK—making formal commitments to decarbonize their healthcare systems [10]. In response to these challenges, many countries are implementing local audits, action plans, and interventions (e.g., in anesthesia, energy, transport, supply chains) [11]. Still, NHS England became the first health system to integrate net-zero principles into legislation with the Health and Care Act 2022 [12]. The Health and Care Act 2022 mandates NHS trusts to create green plans, outlining essential actions for reducing emissions and enhancing resilience to climate impacts, with the first iteration spanning from 2022/23 to 2024/25 [13].
With the report ‘Delivering a Net Zero National Health Service’ [14], the NHS outlines its carbon footprint, pathways to achieve net zero emissions, and necessary interventions. According to NHS England [14], hot water and space heating systems alone account for 80% of the NHS’s direct emissions. By March 2024, all NHS trusts were required to have a Heat Decarbonization Plan (HDP) in place. This strategic move is designed to shift from heating systems dependent on fossil fuels to those favoring low-carbon alternatives, significantly reducing the NHS’s carbon footprint. In 2022, NHS England also published the NHS Net Zero Building Standard [15], which provides a roadmap for reducing operational building energy demands, embodied carbon in construction and whole-life carbon of building elements used within them, with a focus mainly on new buildings [16]. However, NHS estates and facilities account for 15% of the overall carbon emissions profile [14], including more than 1200 hospitals and nearly 3000 additional treatment facilities, covering a total occupied area of approximately 24.3 million square meters [17]. Overall, 18% of the existing NHS trust estate predates the formation of the NHS and 43% is more than 30 years old [18], resulting in an estimated maintenance backlog of £10.2 billion as of 2022 [19].
Given these factors, achieving net-zero emissions and sustainability within the existing estate is a significant challenge. The current literature on decarbonizing healthcare estate mainly focuses on literature review [20,21,22] or individual case studies [23,24,25,26]. The green plans developed by NHS trusts in England provide a valuable opportunity to evaluate trends in decarbonizing the existing healthcare estate at a national scale, as this is recognized among the main nine areas of focus by NHS England [13]: workforce and leadership, net-zero clinical transformation, digital transformation, medicines, travel and transport, estates and facilities, supply chain and procurement, food and nutrition, and adaptation. Amamou et al. [16] examined the green plans to extract information on environmental scheme compliance, environmental management systems, progress measurement, estate Key Performance Indicators (KPIs), and references to adaptation strategies, while Tabakov and Bhutta [27] conducted a combination of qualitative and quantitative analyses to gather data on the proposed organizational structure for delivering the green plans, strategic commitments to sustainability, and the methods for measuring and reporting carbon and financial costs. This paper aims to contribute to the existing body of research on the green plans by identifying the direction of travel and preferred interventions that NHS trusts are implementing to decarbonize their estates to meet proposed net-zero targets at national scale while also highlighting opportunities for further progress.

2. Existing Strategies to Decarbonize Healthcare Estate

2.1. Reaching Net Zero Through Built Asset Management in Healthcare Estate

The current backlog of maintenance and the associated risks of the NHS healthcare estate present significant challenges for achieving climate-resilient and sustainable healthcare facilities [28]. Many healthcare facilities continue to rely on reactive maintenance, which can result in unexpected equipment downtime, increased costs, and potential risks to patient safety [29]. In contrast, adopting a preventive maintenance strategy is essential for identifying issues early, ensuring uninterrupted equipment operation, safeguarding the well-being of both patients and staff, and supporting an energy management program to lower energy consumption and improve resilience [29]. In addition, the transition to sustainable healthcare buildings also provides an opportunity to address the backlog maintenance [30].
To effectively implement mitigation strategies in the healthcare sector, it is essential to begin with energy audits. In their extensive literature review on health system capacity and preparedness for climate change, Braithwaite et al. [2] found that “the impetus to develop, use, and standardise tools for measuring and monitoring GHG emissions was a prominent theme (n = 70 publications)”. These audits help identify areas of energy waste and inefficiencies [20,31] and inform the implementation of targeted energy-saving measures [21,29]. García-Sanz-Calcedo et al. [32] emphasize the importance of maintenance audits to evaluate the effectiveness of current actions within hospital buildings and to predict future demand trends. Silvestro et al. [25] demonstrate that regular maintenance and close monitoring of energy consumption—along with the elimination of unnecessary energy use—resulted in an average annual reduction of approximately 20% in the need for corrective maintenance, leading to energy savings of 500 MWh per year. These initiatives aim to address several technical barriers to achieving energy efficiency in healthcare buildings, including inadequate information and knowledge, as well as a lack of professional staff and resources necessary for implementing and evaluating energy conservation measures [33].
In this context, Building Energy Management Systems (BEMSs) enable centralized control over healthcare building systems, real-time monitoring and control of energy consumption, allowing facility management professionals to identify inefficiencies and implement targeted energy-saving measures [29]. BEMSs in healthcare buildings can help achieve cost savings, enhance safety, facilitate quicker and easier communication between various subsystems, and increase management productivity [34]. BEMSs can be supported by sensors to measure the internal and external environment in a building and provide data for the system [24,35,36]. Additionally, it facilitates data collection, analysis, reporting, and progress tracking toward energy efficiency goals [37]. Adopting ISO 50001 standards can also aid in reducing energy usage and supporting green hospital initiatives by providing structured guidelines for setting and achieving energy management objectives [38]. The establishment of an energy manager is also crucial for efficient energy resource use [29,39]. Bevere and Faccilongo [29] emphasize the need for this role to be supported by hospital management and provided with dedicated financial resources. The ideal energy manager should be an internal member with a diverse skill set, including technical knowledge, IT expertise, and experience in data analysis, relying on monitoring data and energy performance indicators [39].
Energy performance in healthcare estate can also be improved by optimizing the design, retrofitting and maintenance of existing buildings while keeping energy efficiency in mind [20,40]. Some of the leading strategies proposed to optimize energy use of existing buildings are renovating building designs, optimizing lighting, upgrading equipment, implementing energy management systems, integrating renewable energy sources, providing staff training, enhancing Heating, Ventilation, and Air Conditioning (HVAC) efficiency, monitoring performance, use of alternative energy and water sources, use of a renewable energy source and fostering collaborations and partnerships [20,41,42,43].
Once these energy efficiency measures are implemented in existing healthcare buildings, it is essential to establish robust monitoring and measurement systems that track energy consumption, cost savings, and environmental impacts to evaluate their effectiveness to support the net-zero transition [20]. However, Tabakov and Bhutta [27] analyzed the green plans of NHS trusts in England to assess their governance structures for sustainability and evaluate commitments against the SMART (Specific, Measurable, Achievable, Realistic, Time-bound) framework. They found that only 14 of 190 plans met the SMART criteria across all four themes: Estates and Facilities, Travel and Transport, Supply Chain and Procurement, and On-Site Medicine Usage. In addition, from the analysis of the green plans carried out by Amamou et al. [16], it emerges that only 11% of trusts mentioned KPIs, and of these, only 15 trusts listed KPIs they were using to monitor the estate, and only five provided specific, measurable and time-bound KPIs values [16].

2.2. Implementing Heat Decarbonisation in Healthcare Estate

HVAC systems are a significant part of electrical energy consumption in hospitals [22] and can account for nearly half of their energy use [44]; therefore, improving their efficiency is a priority. These systems serve three main functions: heating, ventilation to renew and purify air, and cooling. The heating function is commonly used in cold climates, and the cooling function is commonly used in warm and hot climates. The central HVAC system consists of a heating unit, comprising a boiler, a ventilation unit comprising fans, and a cooling unit comprising a chiller. In HVAC systems, the heart of the cooling unit is the chiller, and the heart of the heating unit is the boiler [22]. The literature reports that affective strategies include replacing inefficient boilers or chillers and regular maintenance, as newer models consume less energy while providing the same or better performance and operational efficiency [45,46]. Chiller retrofit can reduce the energy consumption of the chiller plant by 30–50% compared to older systems [22,47]. A 2018 case study conducted by Pina et al. [48] at a Brazilian university hospital found that biomass was the most economically viable fuel for heat production, accounting for 87% of the total thermal energy generated. However, the same level of effectiveness was not achieved for cooling production, which relied entirely on electricity purchased from the grid. This suggests that electricity is more suitable for cooling production in electric chillers than for heat production in absorption chillers.
The use of low-carbon technologies, such as solar thermal energy, solid biomass, and ground-source heat pumps, for heat, cooling, and electricity generation is another option to reduce energy consumption [46]. The use of heat pumps can reduce energy consumption [24], increase energy efficiency in HVAC applications over time [22], and significantly reduce natural gas consumption for water heating and on-site greenhouse gas emissions [23]. Heat pumps also enhance energy efficiency compared to boilers, resulting in lower energy demand and improved local air quality due to reduced gas emissions [49]. In countries like the United Kingdom (UK), where the electricity grid becomes more decarbonized, a combustion-free strategy using heat pump technology can further reduce carbon emissions from burning [49].
Cogeneration, or Combined Heat and Power (CHP), is the simultaneous generation of electricity and heat from a single fuel type, such as natural gas, liquid natural gas, and biogas. Especially in buildings that use natural gas, cogeneration or trigeneration systems can be utilized to enhance energy efficiency [22]. CHP can achieve total efficiencies of 87% to 92%, compared to about 60% for traditional systems, while trigeneration plants can reach system efficiencies between 85% and 90% [22]. Daramola [50] states that CHP systems are viewed as a more effective and reliable source of power and heat in the UK’s healthcare sector.
The feasibility of supplying heat to a large hospital from a district heating network has also been analyzed, demonstrating both the technical and financial viability of the system, as well as a reduction in cumulative CO2 emissions [51]. However, providing hot water and steam at temperatures higher than those supplied by the district heating network presents a key challenge. To address this, an integrated solution that utilizes steam from an on-site medical waste incineration plant, along with waste heat recovery, heat storage, and a heat pump can be adopted [51].
Refurbishing the building envelope is always advantageous when considering energy savings, improved indoor microclimate, reduced polluting emissions, and technical and economic feasibility [26]. Passive interventions on the buildings, including the addition of thermal insulation of exposed external walls as well as replacing window framings and the use of blinds can improve temperature regulation of spaces, thereby reducing the need for additional measures such as air conditioning or heating, and in turn minimize energy losses [44,45,46]. Silva et al. [21] suggest that retrofitting existing healthcare buildings with passive strategies, such as improved insulation, upgraded windows, and green roofs, could lead to energy savings of up to 89%. Prada et al. [24] conclude that thermal rehabilitation of hospital envelopes reduces heat losses and improves interior comfort and energy efficiency, achieving a 71.82% to 78.39% reduction in annual primary energy consumption compared to initial levels.

2.3. Switching to Renewable and Low-Carbon Sources of Energy in Healthcare Estate

Supplement energy acquisition with on-site power generation in healthcare facilities has been suggested as a strategy to “[…] harmonises with the healthcare sector’s prohealth focus and raison d’être” [52], by reducing cost, GHG emissions [46,53] and reliance on the grid [20]. According to Filho et al. [54], healthcare facilities should transition to renewable energy sources, such as wind, solar, and geothermal energy, for both hospital heating and cooling requirements and to power medical equipment. Renewable energy sources can supply over 62.68% of heating and 75.51% of air conditioning needs, resulting in a 77% and 67% reduction in CO2 emissions, which positively impacts global warming and reduces pollution [24]. Therefore, it is recommended that hospital buildings be constructed using HVAC models with clear guidelines for utilizing solar energy to replace hydroelectric power and natural gas as primary energy sources [41].
According to Silva et al. [21], current research primarily focuses on photovoltaic (PV) panels to enhance power production and reduce grid reliance, while solar collectors are utilized for domestic hot water; however, challenges such as high upfront costs, limited space, and technical limitations persist. Several studies have concluded that PV systems offer excellent positive energy and economic performance compared to conventional energy systems and are competitive with the grid’s electricity costs [55,56,57]. However, there is a need to consider the favorable weather conditions of countries where these studies took place (Cyprus, Libya, and the Philippines) as the use of photovoltaic panels is weather and climate-dependent, requiring the use of hybrid systems [11]. They concluded that PV systems offer benefits such as reduced emissions, decreased fuel use, and annual savings, with a short payback period. Instead, WHO and PAHO [43] suggest installing a rooftop or ground-mounted PV system to offset as much electricity use as possible, and wind turbines in addition to or in conjunction with a PV system, if space, location, wind speed, prevailing wind direction, and building codes permit. Regarding the use of geothermal and residual waste, limited evidence of application is reported in the literature [21]. Hospitals can also explore opportunities for purchasing renewable energy from off-site sources through power purchase agreements or renewable energy certificates [20]). However, NHS trusts cannot enter into power purchase agreements or energy performance contracts due to the lease length involved and its impact on the available capital [30].

3. Materials and Methods

The paper presents the results of a thematic content analysis [58] on green plans developed by NHS trusts in England to outline their strategies to decarbonize the estate. The documents were collected between February and April 2024, and the analysis was carried out using NVivo (Lumivero, Denver) between April and November 2024. At the time of analysis, there were 211 NHS trusts registered with NHS England, all of which were expected to provide their bespoke decarbonization strategies for the period 2022–2025 in the form of a green plan [59]. The initial scoping process began with a broad internet search, followed by a focused search on the trust’s website. When this approach proved unproductive, a freedom of information request was submitted to a select few trusts. The final data sample consisted of one hundred seventy-five green plans. In 36 cases, it was not possible to acquire the green plans using any of the strategies mentioned earlier. However, for 15 of these trusts, the Sustainable Development Management Plans were obtained, which were included in the analysis due to their semantic and temporal similarities. In contrast, the remaining 21 trusts could not be included in the research.
Within the green plans, sentence strings were used as meaning units of analysis [60], focusing on sustainability commitments that were either already implemented or planned. A thematic content analysis of the documents was conducted by developing conceptual models based on codes and themes identified in these strings. In total, 16,123 units were identified that were divided into five broad decarbonization themes—Estates and Facilities, Travel and Transport, Supply Chain and Procurement, On-Site Medicine and Medical Gases Usage and Organizational Change. Four of these categories are in line with the areas of carbon emissions outlined in ‘Delivering a Net Zero National Service’ [14], whilst the category ‘Organizational Change’ was included to cover the organizational structures that trusts had developed to achieve implementation of the strategies. This paper focuses on the theme of Estates and Facilities and covers 4610 strings. The conceptual model for this paper is outlined in Figure 1.

4. Results

4.1. Reaching Net Zero Through Built Asset Management in the Green Plans

4.1.1. Planning

Objectives: The primary objective identified in the analysis is to develop Estate Decarbonization Strategies for energy and water reduction, and to enhance baseline efficiency across sites. These also included creating specific carbon reduction plans for buildings, implementing energy policies to promote sustainable energy use, and developing heat decarbonization plans to improve heating and hot water systems.
Assessing Energy Consumption and Footprint: To improve energy efficiency and reduce carbon emissions, NHS trusts have recognized the need for a detailed understanding of their estate’s energy consumption. This process involved evaluating both energy and water usage, reviewing the building stock, and developing a sustainable buildings action plan. According to the green plans, conducting thorough surveys, assessing air conditioning requirements and increasing metering can help identify opportunities for efficiency, whilst Building Information Modeling (BIM) can assist in measuring carbon emissions across assets to achieve net-zero emissions. NHS trusts are also committed to improving the use of existing facilities to maximize value and reduce their geographic footprint by conducting regular assessments of space utilization.
Funding: Investment strategies focused on upgrading site infrastructure to reduce energy demand, decrease carbon emissions, and, in some cases, build new units. This included allocating trusts’ capital budget for building infrastructure and fabric improvement projects, ensuring all construction and capital spend is net-zero carbon with a social value weighting, refreshing strategies to reflect net-zero commitments in capital tender specifications, developing capital investments with clear sustainability credentials, promoting sustainable construction methods and insulation standards. In addition, the green plans discussed investigating energy generation and saving schemes, focusing on minimizing energy demand through investments, utilize funding options outside capital for reducing energy and water usage, and energy performance contracts to ensure carbon targets are met. There was also significant emphasis on investments in technology to enhance the assessment and reporting of energy usage, as well as energy-saving measures to maximize the value of every kWh.
Net Zero Lead: The need to employ a Net Zero Lead was a recurring theme among the green plans. This figure was defined as a designated board-level executive, typically one of the existing directors, responsible for leading the development, resourcing, and delivery of green plans, and consistently reporting to the Coordinating Commissioner. Additionally, a Net Zero Lead was described as responsible for establishing net-zero networks that support and encourage all staff to innovate, initiate team projects, and contribute to the sustainability goals.

4.1.2. Built Asset Management Strategies

Maintenance: The green plans emphasized maintenance operations aimed at ensuring reliable functionality by addressing backlog maintenance. However, while backlog maintenance was described as a significant challenge and cost area, it was also seen as an opportunity to accelerate the decarbonization journey. To this end, it has been recognized that Planned Preventative Maintenance (PPM) needs to be improved to focus more on energy efficiency and to provide opportunities for identifying potential upgrades. These upgrades may include the implementation of technologies designed to reduce energy consumption, such as heat recovery systems, optimized lighting, and building management systems. Additionally, the need to develop management plans for gas and electricity supply, which should include scheduled reviews and maintenance, was also recognized.
Refurbishment: The green plans acknowledged the need to ensure that all new refurbishment projects included environmental impact assessments and carbon-saving measures. These projects should be carried out according to best practices, specify modern and efficient equipment, minimize carbon emissions, and enhance energy efficiency.
Improving lighting: One of the most reported strategies for achieving energy efficiency involved upgrading light fixtures throughout the estate to Light-Emitting Diode (LED) lighting. At the time of the analysis, 41% (78/190) of the trusts had already replaced their lighting with LEDs, 23% (43/190) had begun the replacement process but had not yet completed it, and 26% (49/190) planned to make the switch in the future.
Repurposing and Decommissioning Buildings: The green plans emphasized the importance of developing sustainable decision-making for capital projects, including repurposing and decommissioning. Key actions included conducting an initial survey and developing space management plans that prioritize the vacation and disposal of the oldest and least energy-efficient buildings, minimizing carbon emissions by decommissioning and demolishing the older sections of the current hospital, preparing for the future by exploring the potential to repurpose unused areas, such as roof spaces and walls, to enhance green spaces and create wildflower areas, and replacing maintenance vans with electric vehicles and utilizing electrically powered maintenance equipment.
New Design: Some NHS trusts acknowledged the need to invest in new, purpose-built units to replace aging buildings. They aim was to design new buildings without relying on fossil fuel heating systems wherever possible, prioritizing NHS Net Zero Building Standards and the NHS Net Zero Carbon Delivery Plan in their development projects. The design process should adopt a whole life costing approach to meet health and sustainability goals. Low-carbon buildings must be designed to exceed minimum energy efficiency standards, take climate predictions into account, enhance biodiversity and green spaces, and surpass expectations regarding insulation, energy efficiency, and material selections. New hospital buildings should utilize smart design and modern building methods. To support this transition, design briefs must request low-carbon and low-environmental-impact solutions from suppliers and partners.

4.1.3. Monitoring

Monitoring: The green plans emphasized the importance of monitoring the healthcare estate as a foundational step toward enhancing energy efficiency, reducing carbon emissions, and effective reporting. This approach included tracking essential emissions (such as energy, water, and waste), utilizing detailed data for utility consumption during refurbishments, and benchmarking electricity usage. Regular monitoring and optimization of energy use—such as implementing motion-controlled lighting and minimizing exterior lighting at night—were also critical components of this strategy.
KPIs: Most of the green plans did not report explicit KPIs. In some cases, only a general reduction in a specific indicator was presented. When KPIs were reported, they were presented in various formats, encompassing a broad range of areas, including electricity, gas, water, and overall utility consumption, as well as carbon emissions from buildings and infrastructure. Specifically, 4% (8/190) focused on achieving annual percentage reductions in energy consumption and carbon emissions (e.g., 5% or 6% year-over-year). In 14% (27/190) of the cases, KPIs set specific goals to be achieved by certain years (e.g., 2023, 2024, 2025). 5% (10/190) of the green pans used specific KPIs based on benchmarks and baselines (e.g., 2009 figures, 2018/19 level, 2013/14 base year) to measure progress.
Building Energy Management Systems (BEMS): BEMSs were presented as effective strategies for improving energy efficiency and reducing carbon emissions. However, only 4% of the green plans (7/190) reported having implemented a BEMS, while 3% (5/190) reported having implemented it but are still upgrading the system, and 7% (13/190) reported planning to install it in the future. Key initiatives included upgrading outdated systems, requiring BMESs installation in new properties, and providing consultations on best practices. BMESs can enhance stakeholder coordination and facilitate the integration of systems across buildings. They also optimize energy usage by incorporating technologies such as heat recovery and efficient lighting. Additionally, NHS trusts reported implementing the ISO 50001 Energy Management System to improve their energy management practices further.

4.2. Implementing Heat Decarbonisation in the Green Plans

4.2.1. Interventions on Existing Heating and Ventilation Systems

Heat Decarbonization Plans: The NHS trusts’ strategy for improving heating efficiency involved developing heat decarbonization plans, which included several key actions, such as upgrading HVAC, especially old gas boilers, to new energy-efficient models, and incorporating low-carbon alternatives like heat pumps to reduce carbon emissions and operational costs.
Upgrading HVAC: NHS trusts recognized the need to upgrade aged HVAC systems to achieve high standards of efficiency and control and ensure long-lasting improvements. These plans included incorporating HVAC system upgrades into the Energy and Engineering Strategy, reducing energy consumption through air conditioning unit upgrades, and prioritizing responses to issues such as overheating, competing infrastructure, and leaks. 9% of the green plans (18/190) reported plans to upgrade their HVAC systems, while 2% (4/190) had already completed an upgrade, and 1% (1/190) reported a partial upgrade with plans for future completion.
Upgrading Boilers: Replacing old boilers was considered essential by the NHS trusts to achieve their sustainability goals and reduce their carbon footprint. In fact, 26% of the green plans (49/190) reported that boilers would be replaced in the future, 6% (11/190) reported that boilers had already been replaced, while 2% (4/190) reported that trusts had already started the replacement program and would continue with the upgrade. This was justified in the documents, which explained that many existing boilers are inefficient, resulting in higher energy consumption and increased greenhouse gas emissions. By upgrading to energy-efficient models, such as dual-fuel boilers, gas condensing boilers, and heat pumps, NHS trusts aim to lower their carbon emissions and operational costs. Additionally, modern boilers offer better reliability and performance, reducing maintenance issues and ensuring a more resilient heating system.
De-steaming Heating System: A small number of trusts have reported plans to de-steam the heating system, with 2% of the green plans (3/190) indicating that they have already de-steamed the system and 4% (8/190) planning to do so. The focus is on replacing inefficient steam distribution systems with low-temperature hot water (LTHW) systems generated by low-carbon heating forms, such as heat pumps. In some cases, the plans also involve replacing plants with Combined Heat and Power (CHP) systems and more efficient boilers, reducing steam pressure, and investigating environmentally friendly ways to generate smaller steam loads where necessary. This includes installing electric autoclaves and new steam generators, as well as delivering capital projects to de-steam site heating infrastructure.
Upgrading Chiller Units: 4% of the documents (7/190) reported plans to upgrade chiller units, and 2% (3/190) reported having already completed the task. Strategies included replacing aged and defective chillers with new, efficient units, conducting thorough performance analysis, optimizing existing chillers to improve efficiency, and installing absorption chillers using CHPs.
Ventilation Systems: In terms of decarbonizing ventilation systems, whilst 3% (5/190) reported having already upgraded the ventilation system, 9% of the green plans (17/190) focus on exploring and implementing heat recovery and recirculating air filtration in buildings. They aimed to continuously improve and optimize heating and ventilation systems across the estate, reduce carbon emissions through natural ventilation, and invest in upgrading ventilation systems to incorporate low-carbon technologies.

4.2.2. Low-Carbon Heating Technologies

Heat Pumps: 6% of the green plans (12/190) reported having already implemented heat pumps, primarily focusing on air-source heat pumps (ASHPs) and, in some cases, ground-source heat pumps (GSHPs). 28% of the green plans (54/190) instead reported that heat pumps are part of new building projects and energy efficiency upgrades. According to the NHS trusts, the primary objectives of heat pumps implementations are to decarbonize the heating systems, enhance energy efficiency, and achieve high sustainability standards. However, to be able to invest in this technology, trusts recognized the need to conduct detailed energy surveys and secure significant grant funding.
CHP: 18% of the green plans (35/190) reported that NHS trusts have implemented several interventions to upgrade their Combined Heat and Power (CHP) systems, with an additional 5% (9/190) reported to plan to continue upgrading it in the future. Refurbishments and upgrades have been carried out on existing CHPs to enhance their performance and improve comfort levels within hospitals. These include adopting efficient heat-led gas-fired CHPs that are ready for future conversion to hydrogen, installing new CHP engines, and replacing older CHPs with heat pumps or similar technologies. Additionally, larger and more efficient CHP systems have been introduced to enhance fuel efficiency and increase electricity generation. Some trusts are focusing on transitioning from natural gas to zero-carbon fuels, such as hydrogen, biogas, and biomass solutions, in line with their carbon reduction targets. Some of the NHS trusts are also recognizing that “[…] with the emergence of novel technologies such as Air Source and Ground Source Heat Pumps (ASHPs or GSHPs), CHPs are now no longer considered the most sustainable option. Therefore, the Trust will no longer consider CHPs and will focus on more sustainable means of decarbonising our estate”. However, 11% of the green plans (21/190) reported the intentions of installing/upgrading CHP in the future.
District Heating: 11% of the green plans (21/190) reported that NHS Trusts are exploring the creation of District Heat Networks with neighboring partners and conducting feasibility studies to assess their potential, while only 1% (2/190) of the documents reported having already implemented district heating. They are collaborating with local councils, investigating connections to existing networks, and integrating district heating with renewable technologies, such as air-source heat pumps.
Biomass and Biofuel: The green plans reported that 2% of the NHS trusts (4/190) adopted biomass and biofuel for heating by transitioning from natural gas to bio-gas and biomass solutions for their CHP systems. They have installed biomass boilers using woodchip fuel, sought proposals for Biomass CHP systems, and prioritized decarbonizing heating systems. Instead, 3% (6/190) reported planning to implement this technology in the future. Plans include incorporating low-carbon CHP systems and continuing energy efficiency programs that utilize biomass boilers to enhance sustainability and reduce carbon emissions.
Solar Thermal: 4% of the green plans (8/190) reported that NHS trusts planning to adopt solar thermal systems for heating by integrating them with other renewable technologies, such as photovoltaic panels and heat pumps. They were conducting feasibility studies to assess the viability of solar thermal systems and reviewing potential investments to enhance sustainability. Solar thermal panels will be explicitly used for heating water, and new capital projects will include the installation of solar thermal arrays to increase renewable energy generation and reduce carbon emissions.

4.2.3. Heat Loss Reduction

Building Fabric Upgrade: NHS trusts recognized that there is a need to upgrade the building fabric to reduce heat loss and minimize the risk of overheating; however, the amount of reported details is limited. This is generally associated with a generic indication that the insulation needs improvement. In some cases, roof insulation was specifically mentioned, with two trusts specifying the thickness of the insulation and the change in U value.
Windows and Doors: NHS trusts reported that windows are a priority, especially for glazing upgrades. Glazing improvement is mainly associated with double glazing. One trust acknowledges that glazing improvements reduce heat loss, noise, and condensation, leading to health benefits, while others recognized that enhancing air tightness can further cut heat loss and improve comfort, but should be balanced with the risk of overheating and the need for adequate ventilation.

4.3. Switching to Renewable and Low-Carbon Sources of Energy in the Green Plans

4.3.1. No-Renewable Energy Sources Divestment

Fossil Fuel Divestment: NHS trusts aimed to reduce their dependence on fossil fuels across the estate by implementing a long-term strategy that focuses on transitioning away from natural gas and oil heating systems. Key objectives included creating wholly electric hospitals powered by renewable energy or sustainable suppliers, designing new builds that rely on no fossil fuels, and eliminating fossil fuel use in all buildings. The strategy emphasizes the adoption of low and zero-carbon energy sources and enhancing energy efficiency. Additional steps include reducing oil use annually, replacing oil heating with renewable alternatives, and converting oil points to gas outputs while capturing data on oil consumption to inform efforts aimed at reducing the carbon footprint. The long-term goal is to phase out the use of fossil fuels entirely by 2040.
Gas dDivestment: NHS trusts recognized the need to reduce carbon emissions from gas use, with the primary focus being the removal of natural-gas heating systems and gas-fired boilers.
Low and Zero-Carbon Energy Sources: NHS Trusts are implementing heating decarbonization roadmaps that include using hydrogen as an alternative heat source, phasing out gas boilers, and transitioning CHP plants to hydrogen. They are leveraging government support to facilitate this transition. Additionally, trusts are engaging in regional projects and participating in heating trials to convert the gas grid to hydrogen and achieve zero emissions.

4.3.2. Generating Renewable Energy On-Site

Generic Strategies: NHS trusts focused on increasing on-site renewable energy generation by identifying opportunities and enhancing capacity. This included generating renewable or ultra-low-carbon energy on-site, exploring possibilities across all sites, and maximizing the utilization of on-site renewables to minimize power import. The trusts’ aim was to support renewable energy and heat generation, coordinate efforts, and include renewable energy generation in all relevant projects. This collaborative approach can ensure efficient and effective implementation of renewable energy solutions. Long-term planning and routine improvements were also part of the strategy.
Solar Photovoltaic: 17% of the green plans (33/190) reported that NHS trusts have already significantly invested in PV to enhance energy efficiency and reduce carbon emissions. One trust reported that over 2500 solar panels had been installed across various sites, contributing to 8% of total electricity usage and significantly reducing reliance on grid electricity. In addition to large-scale projects, some trusts had also invested in several small-scale photovoltaic installations to supplement their energy needs. At the same time, 33% of the green plans (62/190) reported that trusts were planning to adopt PV systems by utilizing suitable roof spaces, installing PV panels during refurbishments, and integrating them with other renewable technologies. They aim to increase on-site energy generation and develop strategic plans for renewable energy. Regular monitoring and reporting of solar PV generation were also presented as key to their strategies for enhancing sustainability and reducing reliance on the electricity grid.
Wind turbine: Among the green plans mentioning wind turbines, only 1% (2/190) have already implemented them, while 8% (16/190) are still exploring ways to increase power availability at their owned buildings using renewable sources, such as wind, or commissioning surveys for feasibility studies. One trust reported that “Our hospital led the way in establishing self-generated renewable energy with the development of our wind turbine in 2016. This generates up to 11% of our energy usage and we are investigating further options to expand”.
Geothermal energy: 3% of the green plans (6/190) mentioned geothermal energy, with one trust reporting to have “incorporated a geothermal system from an adjacent reservoir. The geothermal system provides one-third of all the heating requirements, and 90% of the cooling requirements for the complex”, while the others reporting to still be in an explorative stage.
Solar farms: 2% of the green plans mentioned the solar farm as an opportunity, with one trust reporting that it has commissioned a feasibility study.

4.3.3. Purchasing Renewable Electricity

Targets: NHS trusts have set targets to switch to 100% renewable energy, with many aiming to achieve this by April 2021 or April 2022. They are purchasing renewable energy with REGO certification, specifying 100% renewable energy in new supplier agreements, and ensuring that all electricity consumed is from renewable sources.
Ongoing Achievements: According to the green plans, 34% of NHS trusts (64/190) had transitioned to 100% renewable electricity by sourcing energy exclusively from renewable sources and implementing measures such as Renewable Energy Guarantees of Origin (REGO) for certification. These trusts produced a significant portion of their electricity through green tariffs, with some achieving 100% procurement in recent years. They continue to purchase electricity from sustainable sources and recognize the importance of incorporating this in their energy procurement frameworks.
Future Strategies: 38% of NHS trusts (73/190) were still in an exploratory phase, investigating Power Purchasing Agreements (PPAs) for off-site renewables, possibly in collaboration with other NHS trusts or Integrated Care Boards (ICBs), to source electricity from suppliers with the cleanest and most sustainable fuel mix. They were also assessing the feasibility of procuring green energy and renewable gas while evaluating the carbon benefits of these options. Additionally, some of them were exploring the potential of green electricity providers that guarantee a percentage of their electricity comes from renewable sources. Additionally, PFI providers are also aligning with this goal.

5. Discussion

The NHS has integrated net-zero principles into legislation through the Health and Care Act 2022 [12]. NHS trusts are required by the Health and Care Act 2022 to develop green plans, outlining their strategies for reducing emissions and enhancing climate resilience over a three-year period. Green plans have provided an opportunity to evaluate large-scale interventions for decarbonizing healthcare infrastructure and to assess the strategies set for achieving net-zero targets [13]. From the conducted analysis of NHS trusts’ commitments to decarbonizing their estates and facilities, three main areas of priority have emerged: reaching net zero through built asset management, implementing heat decarbonization, and switching to renewable and low-carbon sources of energy.

5.1. Reaching Net Zero Through Built Asset Management

In this first iteration of the green plans, the NHS trusts appeared to still be in the planning stage. The primary aims included developing Estate Decarbonization Strategies focused on reducing energy and water consumption, improving baseline efficiency across sites, and formulating investment strategies to upgrade infrastructure. Key actions include allocating funds for net-zero projects, promoting sustainability, and investing in technology for better energy management. A limited number of trusts presented redevelopment projects based on new buildings not relying on fossil fuel heating systems, meeting the requirements of the NHS Net Zero Building Standards and the NHS Net Zero Carbon Delivery Plan. In most cases, emphasis was placed on the need to improve maintenance strategies, refurbishments, repurposing and decommissioning. The green plans acknowledged the need to ensure that all new refurbishment projects include environmental impact assessments and carbon-saving measures, in accordance with Tomanek [20] and Jain et al. [40]. However, while the trusts acknowledged that projects should be carried out according to best practices, specify modern and efficient equipment, minimize carbon emissions, and enhance energy efficiency, details on the specific interventions implemented are scarce and reported inconsistently, which makes extracting lessons difficult. In addition, the focus is mainly on strategies such as enhancing HVAC and optimizing lighting, which are recognized strategies to optimize energy efficiency [20,41,42,43]. In terms of maintenance, although backlog maintenance is a significant challenge for healthcare facilities [28], it was seen as an opportunity to accelerate the decarbonization journey, as identified by Pascale and Jones [30]. However, the trusts recognized that PPM needs to be improved to focus more on energy efficiency and to provide opportunities for identifying potential upgrades and to develop management plans for gas and electricity supply, which should include scheduled reviews and maintenance.
To improve energy efficiency and reduce carbon emissions, NHS trusts recognized the need for a detailed understanding and monitoring of their estate’s energy consumption, by evaluating both energy and water usage, reviewing the building stock, and developing a sustainable buildings action plan. This is in line with what was suggested by Tomanek [20]. 8% of NHS trusts mentioned BEMS in their green plans, while others were considering the implementation of an ISO 50001 Energy Management System to improve their energy management practices. This can reduce energy usage and support green hospital initiatives by offering guidelines for organizations to achieve their energy management goals [38]. BEMSs are recognized as an effective strategy for improving energy efficiency and reducing carbon emissions. BEMSs centralize energy data from various sources, enabling real-time monitoring and control of energy consumption. This allows facility managers to identify inefficiencies and implement energy-saving measures [29], which can lead to cost savings, enhanced safety, improved communication between subsystems, and increased management productivity [34]. Additionally, BEMSs support data collection and track progress [37]. In the green plans, the implementation of BEMSs was aligned with the need for Net Zero Leads, in line with current research [29,39].
Although the green plans clearly focus on monitoring the estate’s energy consumption, there is a noticeable absence of SMART targets and a lack of well-defined, consistent KPIs, as noted by Amamou et al. [16]. Some trusts focused on achieving annual percentage reductions in energy consumption and carbon emissions, which ensures continuous improvement and allows for regular monitoring and adjustments. Other KPIs utilized specific benchmarks and baselines to measure progress, providing a reference point for evaluating the effectiveness of reduction efforts. In other cases, KPIs were set to achieve specific short-term goals by a particular year, providing milestones that help maintain focus on immediate priorities. While different KPIs may have individual positive aspects, using KPIs with benchmarks and baselines allows for measuring progress rather than concentrating on overly broad short-term goals. Additionally, the lack of consistency across reporting on the decarbonization journey in the green plans will impede performance comparison and overall evaluation, as also concluded by Amamou et al. [16].

5.2. Implementing Heat Decarbonisation

The NHS trusts’ strategy for improving heating efficiency involves developing heat decarbonization plans, which involve several key actions: upgrading HVAC, replacing gas heating with renewable alternatives, developing long-term plans for low-carbon technologies, and commissioning new district heating networks as part of collaborative schemes to enhance energy efficiency and reduce carbon emissions. 30% of the green plans recognized the need to upgrade old gas boilers as crucial for meeting the trusts’ long-term objectives of decarbonizing heat and achieving net-zero carbon emissions, which is in line with recommendations reported in internation research [22,45,46]. Conversely, only 6% of the green plans reported upgrading the chiller units, which is in line with the current climate conditions in the UK [22]; however, it does not consider future climate changes. Strategies include replacing aged and defective chillers with new, efficient units, as also suggested by Gordo [45], which can reduce the energy consumption of the chiller plant by 30–50% compared to older systems [22,47].
The green plans demonstrated an interest in heat pumps across NHS trusts, with 6% reporting that they have already implemented them and 28% planning to do so, with marked preference towards ASHPs rather than GSHPs. In line with international literature, NHS trusts believe that the benefits of these implementations are substantial, including significant reductions in carbon emissions and energy consumption, as in the UK, the electricity grid is becoming more decarbonized [24,49]. With the emergence of novel technologies such as ASHPs or GSHPs, some NHS trusts recognized that CHPs are no longer considered the most sustainable option, in contrast with what reported by Daramola [50]. However, CHPs have already been implemented by 23% of the NHS trusts, while 11% of the green plans reported intentions to install CHPs in the future. In fact, CHP can achieve total efficiencies of 87% to 92% [22] and in 2020, they were still considered the more effective and reliable source of power and heat in the UK’s healthcare sector [50]. To address the issues related to the use of fossil fuels, refurbishments and upgrades have been carried out on existing CHPs, and some trusts are focusing on transitioning from natural gas to zero-carbon fuels, such as hydrogen, bio-gas, and biomass solutions. The green plans show that 2% of NHS trusts have switched from natural gas to biogas and biomass for their heating, installing biomass boilers that use woodchip fuel and prioritizing the decarbonization of their systems. Meanwhile, 3% plan to adopt this technology in the future. Upcoming efforts include implementing low-carbon CHP systems and continuing energy efficiency programs with biomass boilers to boost sustainability and reduce carbon emissions, which, in line with Pina et al. [48], is an economically viable fuel for heat production, which can account for 87% of the total thermal energy generated. 11% of the green plans reported that NHS trusts are exploring the creation of District Heat Networks with neighboring partners and conducting feasibility studies to assess their potential. According to Kalina and Pohl [51] supplying heat to a large hospital from a district heating network is technically and financially viable and can lead to reduction in cumulative CO2 emissions.
While the green plans provided detailed information on the active interventions implemented or planned for heat decarbonization, information on passive strategies has been less detailed. The green plans indicate upgrades to building fabric, windows, and doors aimed at reducing heat loss and minimizing the risk of overheating, but they often provide only general suggestions for improving insulation. Nonetheless, research highlights the significance of passive strategies. Retrofitting existing healthcare buildings with passive strategies—such as improved insulation, upgraded windows, and green roofs—could lead to energy savings of up to 89% [21,24]. This, in turn, reduces the need for additional measures, such as air conditioning or heating, and minimizes energy losses [26,44,45,46].

5.3. Switching to Renewable and Low-Carbon Sources of Energy

NHS Trusts are focused on reducing their dependence on fossil fuels and gas across their facilities by implementing a long-term strategy. This strategy emphasizes transitioning away from natural gas and oil heating systems. Key objectives include: (1) creating fully electric hospitals powered by renewable energy or sustainable suppliers; (2) designing new buildings that do not rely on fossil fuels; (3) eliminating fossil fuel use in all existing buildings; (4) remove natural gas heating systems and gas-fired boilers to achieve this goal.
In terms of generating renewable energy on-site, most trusts still report generic strategies, which could not be categorized in a specific code. However, there seems to be an emphasis on the importance of supporting renewable energy and heat generation through coordinated efforts, long-term planning and routine improvements. According to the literature, supplementing energy acquisition with on-site power generation in healthcare facilities aligns with the sector’s health focus by lowering costs and greenhouse gas (GHG) emissions while reducing grid reliance [20,46,52,53]. Renewable energy sources can fulfil over 62.68% of heating and 75.51% of air conditioning needs, cutting CO2 emissions by 77% and 67%, thus positively affecting global warming and reducing pollution [24].
While Filho et al. [54] recognize the merit of all the different energy sources, solar PV appears to be the preferred strategy among NHS trusts. According to the green plans, 17% of Trusts have already made significant investments in solar PV to enhance energy efficiency and reduce carbon emissions. Additionally, 33% of the green plans indicated that trusts were planning to adopt solar PV systems by utilizing appropriate roof spaces, installing PV panels during refurbishments, and integrating these systems with other renewable technologies. One trust reported installing over 2500 solar panels across various sites, which now account for 8% of their total electricity usage, significantly reducing their dependence on grid electricity. The focus on PV panels aligns with other experiences reported in the literature [21], as PV systems offer excellent positive energy and economic performance compared to conventional energy systems and are competitive with the grid’s electricity costs [55]. However, most of the existing evidence originates from countries with favorable weather, and, as the use of photovoltaic panels is weather and climate-dependent, they require the use of hybrid systems [11]. In contrast with PV, only 9% of the green plans mentioned wind turbines, 4% geothermal energy, and 3% solar farms as a renewable source of energy.
NHS Trusts have set targets to switch to 100% renewable energy, with 34% having already transitioned to 100% renewable electricity by sourcing energy from renewable sources and implementing measures such as REGO for certification and recognizing the importance of incorporating this in their energy procurement frameworks. However, 38% NHS Trusts are still in an exploratory phase. Trusts are also investigating PPAs for off-site renewable, possibly in collaboration with other NHS Trusts or ICBs, to source electricity from suppliers with the cleanest and most sustainable fuel mix. While this aligns with Tomanek’s suggestions [20], NHS trusts are limited by financial reasons as they cannot enter into power purchase agreements or energy performance contracts due to the lease length involved and its impact on available capital [30].

6. Conclusions

The evaluation of the green plans has provided a snapshot of the move of NHS England towards the decarbonization of the healthcare estate. Key findings reveal a commitment to reducing reliance on fossil fuels and transitioning towards low-carbon alternatives, and a clear focus on maintaining, refurbishing, and repurposing the existing estate rather than developing new buildings was identified. However, in almost all cases, the implementation of long-term decarbonization strategies, particularly in reaching net zero through built asset management, remains in the early stages of discussion. In addition, while avoiding the construction of new buildings can reduce the impact of the healthcare sector on the environment, guidelines focusing on the existing estate are necessary, and comparable KPIs are required to monitor progress.
Regarding heating efficiency, green plans demonstrate an emphasis on heat decarbonization plans, including the upgrade of dated HVAC systems. There is a clear focus on upgrading old gas boilers; however, in view of climate change, more attention should be paid to the upgrade of the chiller units. Trusts are also moving towards low-carbon technologies, with a preference for heat pumps over CHPS. However, there is a noticeable gap in information regarding passive strategies, which are essential for effective decarbonization. Consequently, a reassessment of England NHS priorities is needed to foster a more integrative approach toward decarbonization that encompasses both active and passive interventions.
In the current form of the green plans, while trusts recognized the necessity of eliminating oil and gas heating systems and implementing modernized approaches, the specifics of executed interventions remain inadequately documented and justified, leading to challenges in extracting meaningful lessons. The lack of standardized KPIs across trusts further complicates performance comparison and undermines comprehensive program evaluation. Overall, further efforts are required to enhance the standardization of performance metrics and reporting to effectively assess the trusts’ journey towards achieving net-zero emissions in the next iteration of the green plans, supported by setting SMART objectives and standardized KPIs. The low uptake and apparently haphazard approach to date also suggest a need for the government to provide more explicit guidance to trusts on priority areas of focus for decarbonization of the estate and for government investment to enable such change. Future work will assess the results of the next iteration of green plans, with the expectation of observing more meaningful and measurable progress.

Author Contributions

Conceptualization, methodology, and formal analysis, F.P. and P.T.; writing—original draft preparation, F.P.; writing—review and editing, F.P., P.T. and M.F.B.; visualization, P.T.; supervision, M.F.B.; funding acquisition, F.P. and M.F.B. All authors have read and agreed to the published version of the manuscript.

Funding

This work forms part of research fellowships to F.P. and M.F.B. funded by the Health Foundation’s grant to The Healthcare Improvement Studies Institute at the University of Cambridge.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Not applicable.

Conflicts of Interest

The authors declare no conflicts of interest.

Abbreviations

The following abbreviations are used in this manuscript:
BEMSsBuilding Energy Management Systems
HDP Heat Decarbonization Plan
HVACHeating, Ventilation, and Air Conditioning
ICBsIntegrated Care Boards
KPIKey Performance Indicators
PPAsPower Purchasing Agreements
REGORenewable Energy Guarantees of Origin
SMARTSpecific, Measurable, Achievable, Realistic, Time-bound

References

  1. Mosadeghrad, A.M.; Isfahani, P.; Eslambolchi, L.; Zahmatkesh, M.; Afshari, M. Strategies to Strengthen a Climate-Resilient Health System: A Scoping Review. Glob. Health 2023, 19, 62. [Google Scholar] [CrossRef]
  2. Braithwaite, J.; Smith, C.L.; Leask, E.; Wijekulasuriya, S.; Brooke-Cowden, K.; Fisher, G.; Patel, R.; Pagano, L.; Rahimi-Ardabili, H.; Spanos, S.; et al. Strategies and tactics to reduce the impact of healthcare on climate change: Systematic review. BMJ 2024, 387, e081284. [Google Scholar] [CrossRef]
  3. Salas, R.N.; Solomon, C.G. The Climate Crisis—Health and Care Delivery. N. Engl. J. Med. 2019, 381, e13. [Google Scholar] [CrossRef]
  4. Karliner, J.; Slotterback, S.; Boyd, R.; Ashby, B.; Steele, K.; Wang, J. Health Care’s Climate Footprint: The Health Sector Contribution and Opportunities for Action. Eur. J. Public Health 2020, 30. [Google Scholar] [CrossRef]
  5. Pichler, P.-P.; Jaccard, I.S.; Weisz, U.; Weisz, H. International Comparison of Health Care Carbon Footprints. Environ. Res. Lett. 2019, 14, 064004. [Google Scholar] [CrossRef]
  6. United Nations Framework Convention on Climate Change. Adoption of the Paris Agreement, Decision 1/CP.21; UNFCCC: Paris, France, 2015; Available online: https://unfccc.int/resource/docs/2015/cop21/eng/10a01.pdf (accessed on 30 April 2025).
  7. World Health Organization. WHO Guidance for Climate-Resilient and Environmentally Sustainable Health Care Facilities; WHO: Geneva, Switzerland, 2020; Available online: https://www.who.int/publications/i/item/9789240012226 (accessed on 30 April 2025).
  8. World Health Organization. Alliance for Transformative Action on Climate and Health (ATACH); WHO: Geneva, Switzerland, 2025; Available online: https://www.who.int/initiatives/alliance-for-transformative-action-on-climate-and-health (accessed on 30 April 2025).
  9. Wise, J. COP26: Fifty Countries Commit to Climate Resilient and Low Carbon Health Systems. BMJ 2021, 375, n2734. [Google Scholar] [CrossRef]
  10. Health Care Without Harm. Seven European Countries Commit to Developing Climate Resilient, Sustainable Low-Carbon Health Systems. 2022. Available online: https://europe.noharm.org/news/seven-european-countries-commit-developing-climate-resilient-sustainable-low-carbon-health (accessed on 30 April 2025).
  11. Mirow, J.; Venne, J.; Brand, A. Green Health: How to Decarbonise Global Healthcare Systems. Sustain. Earth Rev. 2024, 7, 28. [Google Scholar] [CrossRef]
  12. Department of Health and Social Care. Health and Care Act 2022; GOV.UK. 2022. Available online: https://www.gov.uk/government/collections/health-and-care-act-2022 (accessed on 30 April 2025).
  13. NHS England. Green Plan Guidance; NHS England: London, UK, 2025; Available online: https://www.england.nhs.uk/publication/green-plan-guidance (accessed on 30 April 2025).
  14. NHS England. Delivering a ‘Net Zero’ National Health Service; NHS England: London, UK, 2020; Available online: https://www.england.nhs.uk/greenernhs/wp-content/uploads/sites/51/2020/10/delivering-a-net-zero-national-health-service.pdf (accessed on 30 April 2025).
  15. NHS England. NHS Net Zero Building Standard; NHS England: London, UK, 2023; Available online: https://www.england.nhs.uk/publication/nhs-net-zero-building-standard/ (accessed on 30 April 2025).
  16. Amamou, A.; Blenkinsop, D.S.; Winter, D.C.; Heidrich, P.O. Net Zero in Healthcare Buildings: Lessons from Assessing the Strategies of 214 NHS Trusts in England. Build. Environ. 2025, 278, 112966. [Google Scholar] [CrossRef]
  17. NHS England. The NHS Premises Assurance Model (NHS PAM), Version 1.2; NHS England: London, UK, 2023; Available online: https://www.england.nhs.uk/wp-content/uploads/2023/05/Premises-Assurance-Model-NHS-PAM-2023.pdf (accessed on 30 April 2025).
  18. Department of Health and Social Care. NHS Property and Estates: Why the Estate Matters for Patients; HMSO: London, UK, 2017. Available online: https://www.gov.uk/government/publications/nhs-property-and-estates-naylor-review (accessed on 30 April 2025).
  19. NHS England. Estates Returns Information Collection (ERIC) 2021/22: Official Statistics; NHS England: London, UK, 2022; Last Updated 31 December 2024; Available online: https://digital.nhs.uk/data-and-information/publications/statistical/estates-returns-information-collection (accessed on 30 April 2025).
  20. Tomanek, M. Energy Efficiency in Hospitals—Towards Sustainable Healthcare. Builder 2024, 320, 38–41. [Google Scholar] [CrossRef]
  21. Silva, B.V.F.; Holm-Nielsen, J.B.; Sadrizadeh, S.; Teles, M.P.R.; Kiani-Moghaddam, M.; Arabkoohsar, A. Sustainable, Green, or Smart? Pathways for Energy-Efficient Healthcare Buildings. Sustain. Cities Soc. 2024, 100, 105013. [Google Scholar] [CrossRef]
  22. Teke, A.; Timur, O. Assessing the Energy Efficiency Improvement Potentials of HVAC Systems Considering Economic and Environmental Aspects at the Hospitals. Renew. Sustain. Energy Rev. 2014, 33, 224–235. [Google Scholar] [CrossRef]
  23. Atienza-Márquez, A.; Muñoz, F.D.; Hernández, F.F.; López, J.M.C. Domestic hot water production system in a hospital: Energy audit and evaluation of measuresto boost the solar contribution. Energy 2022, 261, 125275. [Google Scholar] [CrossRef]
  24. Prada, M.; Prada, I.F.; Cristea, M.; Popescu, D.E.; Bungău, C.; Aleya, L.; Bungău, C.C. New Solutions to Reduce Greenhouse Gas Emissions through Energy Efficiency of Buildings of Special Importance—Hospitals. Sci. Total. Environ. 2020, 718, 137446. [Google Scholar] [CrossRef] [PubMed]
  25. Silvestro, F.; Bagnasco, A.; Lanza, I.; Massucco, S.; Vinci, A. Energy Efficient Policy and Real Time Energy Monitoring in a Large Hospital Facility: A Case Study. Int. J. Heat Technol. 2017, 35, S221–S227. [Google Scholar] [CrossRef]
  26. Ascione, F.; Bianco, N.; De Masi, R.F.; Vanoli, G.P. Rehabilitation of the Building Envelope of Hospitals: Achievable Energy Savings and Microclimatic Control on Varying the HVAC Systems in Mediterranean Climates. Energy Build. 2013, 60, 125–138. [Google Scholar] [CrossRef]
  27. Tabakov, P.; Bhutta, M. Policy Brief: A Critical Evaluation of Green Plans to Support Decarbonisation of NHS Trusts in England. 2025. Available online: https://www.bsms.ac.uk/_pdf/about/nhs-decarbonisation-of-trusts-final.pdf (accessed on 1 September 2025).
  28. Pantzartzis, E.; Price, A.; Edum Fotwe, F. Roadmap Layers and Processes: Resilient and Sustainable Care Facilities. Eng. Constr. Arch. Manag. 2019, 26, 1986–2007. [Google Scholar] [CrossRef]
  29. Bevere, D.; Faccilongo, N. Shaping the Future of Healthcare: Integrating Ecology and Digital Innovation. Sustainability 2024, 16, 3835. [Google Scholar] [CrossRef]
  30. Pascale, F.; Jones, K. Existing Hospitals’ Journey into a Sustainable and Climate-Resilient Future: Barriers and Opportunities for Estates and Facilities Management. Facilities 2025. [Google Scholar] [CrossRef]
  31. Butler, K. How energy benchmarking in healthcare facilities supports greenhouse gas emission reduction. Healthc. Manag. Forum 2023, 36, 199–206. [Google Scholar] [CrossRef]
  32. García-Sanz-Calcedo, J.; Gómez-Chaparro, M.; Sanchez-Barroso, G. Electrical and Thermal Energy in Private Hospitals: Consumption Indicators Focused on Healthcare Activity. Sustain. Cities Soc. 2019, 47, 101482. [Google Scholar] [CrossRef]
  33. Wang, T.; Li, X.; Liao, P.-C.; Fang, D. Building Energy Efficiency for Public Hospitals and Healthcare Facilities in China: Barriers and Drivers. Energy 2016, 103, 588–597. [Google Scholar] [CrossRef]
  34. Yousefli, Z.; Nasiri, F.; Moselhi, O. Healthcare Facilities Maintenance Management: A Literature Review. J. Facil. Manag. 2017, 15, 352–375. [Google Scholar] [CrossRef]
  35. Pedersen, J.M.; Jebaei, F.; Jradi, M. Assessment of Building Automation and Control Systems in Danish Healthcare Facilities in the COVID-19 Era. Appl. Sci. 2022, 12, 427. [Google Scholar] [CrossRef]
  36. Peng, Y.; Zhang, M.; Yu, F.; Xu, J.; Gao, S. Digital Twin Hospital Buildings: An Exemplary Case Study through Continuous Lifecycle Integration. Adv. Civ. Eng. 2020, 2020, 8846667. [Google Scholar] [CrossRef]
  37. Alhurayess, S.; Darwish, M.K. Analysis of Energy Management in Hospitals. In Proceedings of the 2012 47th International Universities Power Engineering Conference (UPEC), Uxbridge, UK, 4–7 September 2012; pp. 1–4. [Google Scholar] [CrossRef]
  38. Dion, H.; Evans, M. Strategic Frameworks for Sustainability and Corporate Governance in Healthcare Facilities; Approaches to Energy-Efficient Hospital Management. Benchmarking Int. J. 2023, 31, 353–390. [Google Scholar] [CrossRef]
  39. Marino, A.; Pariso, P. Digital Innovation Government: Organizational and Energy Analysis in Italian Hospitals. Entrep. Sustain. Issues 2023, 10, 214–230. [Google Scholar] [CrossRef]
  40. Jain, N.; Burman, E.; Stamp, S.; Shrubsole, C.; Bunn, R.; Oberman, T.; Barrett, E.; Aletta, F.; Kang, J.; Raynham, P.; et al. Building Performance Evaluation of a New Hospital Building in the UK: Balancing Indoor Environmental Quality and Energy Performance. Atmosphere 2021, 12, 115. [Google Scholar] [CrossRef]
  41. Alotaiby, R.; Krenyácz, E. Energy Efficiency in Healthcare Institutions. Soc. Econ. 2023, 45, 494–511. [Google Scholar] [CrossRef]
  42. Gaspari, J.; Fabbri, K.; Gabrielli, L. Retrofitting Hospitals: A Parametric Design Approach to Optimize Energy Efficiency. IOP Conf. Ser. Earth Environ. Sci. 2019, 290, 012130. [Google Scholar] [CrossRef]
  43. World Health Organization; Pan American Health Organization. Smart Hospitals Toolkit: Technical Guidance; WHO/PAHO: Geneva, Switzerland, 2017; ISBN 978-92-75-11939-6. [Google Scholar]
  44. Čongradac, V.; Prebiračević, B.; Jorgovanović, N.; Stanišić, D. Assessing the Energy Consumption for Heating and Cooling in Hospitals. Energy Build. 2012, 48, 146–154. [Google Scholar] [CrossRef]
  45. Gordo, E.; Campos, A.; Coelho, D. Energy efficiency in a hospital building case study: Hospitais da Universidade de Coimbra. In Proceedings of the 2011 3rd International Youth Conference on Energetics (IYCE), Leiria, Portugal, 7–9 July 2011; pp. 1–6. [Google Scholar]
  46. Zaza, P.N.; Sepetis, A.; Bagos, P.G. Prediction and Optimization of the Cost of Energy Resources in Greek Public Hospitals. Energies 2022, 15, 381. [Google Scholar] [CrossRef]
  47. Abd Rahman, N.M.; Lim, C.H.; Fazlizan, A. Optimizing the Energy Saving Potential of Public Hospital through a Systematic Approach for Green Building Certification in Malaysia. J. Build. Eng. 2021, 43, 103088. [Google Scholar] [CrossRef]
  48. Pina, E.A.; Lozano, M.A.; Serra, L.M. Opportunities for the Integration of Solar Thermal Heat, Photovoltaics and Biomass in a Brazilian Hospital. In Proceedings of the EuroSun 2018—12th International Conference on Solar Energy for Buildings and Industry, Rapperswil, Switzerland, 10–13 September 2018. [Google Scholar] [CrossRef]
  49. European Bank, Supporting Guide. Energy and Resource Efficiency in Hospitals and Health Care Facilities. 2021. Available online: https://e5p.eu/public/upload/media/Healthcare.pdf (accessed on 30 April 2025).
  50. Daramola, O.O. A Review of Combined Heat and Power Systems for Hospitals Applications. Int. J. Sci. Eng. Res. 2020, 11, 312–319. [Google Scholar]
  51. Kalina, J.; Pohl, W. Integration of Hospital’s Thermal Loads with Municipal District Heating System. 2023. Available online: https://ssrn.com/abstract=4561774 (accessed on 30 April 2025).
  52. Burch, H.; Anstey, M.H.; McGain, F. Renewable Energy Use in Australian Public Hospitals. Med. J. Aust. 2021, 215, 160. [Google Scholar] [CrossRef]
  53. Duraivelu, R.; Elumalai, N. Performance evaluation of a decentralized rooftop solar photovoltaic system with a heat recovery cooling unit. Environ. Sci. Pollut. Res. 2021, 28, 19351–19366. [Google Scholar] [CrossRef] [PubMed]
  54. Filho, W.L.; Luetz, J.M.; Thanekar, U.D.; Alzira, M.; Forrester, M. Climate-Friendly Healthcare: Reducing the Impacts of the Healthcare Sector on the World’s Climate. Sustain. Sci. 2024, 19, 1103–1109. [Google Scholar] [CrossRef]
  55. Kassem, Y.; Gökçekuş, H.; Güvensoy, A. Techno-Economic Feasibility of Grid-Connected Solar PV System at near East University Hospital, Northern Cyprus. Energies 2021, 14, 7627. [Google Scholar] [CrossRef]
  56. Lemence, A.L.G.; Tamayao, M.M. Energy consumption profile estimation and benefits of hybrid solar energy system adoption for rural health units in the Philippines. Renew. Energy 2021, 178, 651–668. [Google Scholar] [CrossRef]
  57. Beitelmal, W.H.; Okonkwo, P.C.; Al Housni, F.; Grami, S.; Emori, W.; Uzoma, P.C.; Das, B.K. Renewable energy as a source of electricity for Murzuq health clinic during COVID-19. MRS Energy Sustain. 2022, 9, 79–93. [Google Scholar] [CrossRef]
  58. Kuckartz, U. Qualitative Text Analysis: A Systematic Approach. In Compendium for Early Career Researchers in Mathematics Education. ICME-13 Monographs; Kaiser, G., Presmeg, N., Eds.; Springer: Berlin/Heidelberg, Germany, 2019; pp. 181–197. [Google Scholar] [CrossRef]
  59. NHS England and NHS Improvement. How to Produce a Green Plan: A Three-Year Strategy for Carbon Reduction for Your NHS Organisation or System; NHS England: London, UK, 2021; Available online: https://www.england.nhs.uk/greenernhs (accessed on 30 April 2025).
  60. Erlingsson, C.; Brysiewicz, P. A Hands-on Guide to Doing Content Analysis. Afr. J. Emerg. Med. 2017, 7, 93–99. [Google Scholar] [CrossRef]
Figure 1. Conceptual Model for Thematic Analysis Used in this Study (authors own work).
Figure 1. Conceptual Model for Thematic Analysis Used in this Study (authors own work).
Sustainability 17 08375 g001
Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content.

Share and Cite

MDPI and ACS Style

Pascale, F.; Tabakov, P.; Bhutta, M.F. Decarbonizing the Healthcare Estate: Lessons Learned from NHS Trust Green Plans in England. Sustainability 2025, 17, 8375. https://doi.org/10.3390/su17188375

AMA Style

Pascale F, Tabakov P, Bhutta MF. Decarbonizing the Healthcare Estate: Lessons Learned from NHS Trust Green Plans in England. Sustainability. 2025; 17(18):8375. https://doi.org/10.3390/su17188375

Chicago/Turabian Style

Pascale, Federica, Petar Tabakov, and Mahmood F. Bhutta. 2025. "Decarbonizing the Healthcare Estate: Lessons Learned from NHS Trust Green Plans in England" Sustainability 17, no. 18: 8375. https://doi.org/10.3390/su17188375

APA Style

Pascale, F., Tabakov, P., & Bhutta, M. F. (2025). Decarbonizing the Healthcare Estate: Lessons Learned from NHS Trust Green Plans in England. Sustainability, 17(18), 8375. https://doi.org/10.3390/su17188375

Note that from the first issue of 2016, this journal uses article numbers instead of page numbers. See further details here.

Article Metrics

Back to TopTop