Climate change, on a global scale, is a bigger hazard than Aids, obesity or bird flu. Extremes of heat and cold, rising sea levels, droughts, floods, storms and food shortages - these are the likely effects. In turn, they threaten to lead to famine, drowning, destruction of human habitation, mass migration, the spread of deadly diseases and armed conflict as people fight over scare resources. One might expect the NHS to be on the case. It is, after all, the organisation most obviously committed to safeguarding the nation's health. But evidently, health professionals are better at tackling some risks than others.
The threat of bird flu is addressed with a 178-page pandemic influenza contingency plan. The Department of Health's website is bulging with initiatives on obesity. In the last five years, £41m has been ploughed into treatment centres for people with HIV and Aids. But there is nothing comparable addressing the problems of climate change.
Enormous power
In fact, the NHS has enormous power to do good, or harm, to human health and the natural environment, not just by providing health services, but also - and mainly - by deploying its vast corporate resources. It is the largest single organisation in the country. Its annual budget for England and Wales is more than £80bn, with £17bn spent on goods and services, and a workforce of more 1.3 million people - one of the largest in the world. It is planning to spend £11bn by 2010 on new hospital buildings.
At the last estimate, in 2001, it was found to have used over a million tonnes of fuel in a year, accounting for 1% of all energy consumed in the country. It produced 3.2m tonnes of emissions to the air - nearly all of it carbon dioxide. It was supplied with 49.8m litres of water, of which 14% was lost in leakage, and produced 400,000 tonnes of waste. For NHS-related purposes, staff, patients and visitors travelled almost 25bn km, 83% of that distance was by car or van.
This suggests the NHS could achieve a great deal by changing the rules that govern decisions about what it buys, what it builds and how it manages its affairs. It could also exert a powerful influence over individual patients, visitors and staff.
There are some encouraging signs that the NHS is beginning to acknowledge its responsibilities. In March this year, the Department of Health launched a web-based toolkit to promote "good corporate citizenship", aimed at helping NHS managers "embrace sustainable development and tackle health inequalities through their day-to-day activities". In six areas, including transport, building, procurement and management of energy, waste and water, it provides detailed guidance, a checklist to help managers judge their own performance, examples of good practice and supporting evidence.
The toolkit was developed by the UK Sustainable Development Commission, which has been building a library of case studies, showing what the NHS can do when it puts its best foot forward.
A primary care trust in Easington, County Durham, has introduced a "warmer homes on prescription scheme", which allows GPs to refer patients who are suffering from cold to have their homes insulated by the local council. It saves energy, cuts emissions and helps reduce the annual peaks of cold-related illness and death. Norfolk and Norwich university hospital trust has introduced a car sharing scheme to its new out-of-town site, aimed at reducing risks to health from air pollution and carbon emissions.
The in-house catering team at Bedford hospital, whose award-winning service feeds 1,500 patients daily, makes a point of using seasonal and locally sourced food wherever possible, dramatically reducing the number of polluting food miles required to bring in supplies. A midwife in the Isle of Man has persuaded the local hospital to switch to reusable nappies, reducing clinical waste by 83%.
Great Western hospital, a £100m new development outside Swindon, was built making maximum use of materials from renewable sources. A new 419-bed unit at Lewisham hospital, south London, is designed to use natural ventilation instead of air conditioning wherever possible.
These and other innovations are signs of passionate commitment harboured by individuals across the NHS. There is official support for them, up to a point. In addition to the corporate citizenship toolkit, there's a new Environmental Strategy for the National Health Service, published last July, which explains how the NHS can achieve cost savings and better quality services "by adopting a more sustainable, environmentally friendly approach". Similarly, the healthy urban development unit launched by Sue Atkinson, director of public health for London, aims to work with the capital's government and local councils to "create healthy, sustainable communities across the capital", where new health service buildings are influential in local regeneration.
But how many rows of seasonal, organic, locally sourced beans does this add up to? Anyone observing the NHS in the throes of its latest structural upheavals and budgetary crises would be hard pressed to recognise an organisation bent of saving the planet.
Most managers are rather understandably obsessed with their balance sheets. "Efficiency" still implies getting more things for less money, whatever the cost to the environment. Financial auditors and performance management systems still can't cope with the idea of long-term sustainability as a way of assessing value for money. Most clinicians, meanwhile, are focused on treating today's patients rather than avoiding tomorrow's ill health.
It remains too easy for NHS leaders to assume that responsibility for climate change belongs elsewhere in the public sector. No one gets fired for increasing carbon emissions, never mind failing to reduce them. Amid the guidance and policy documents, it is hard to find anything about tackling climate change that is compulsory, let alone a high priority.
Shift in opinion
A few green shoots, then, sprouting from rather unfavourable soil. But one can sense a shift in the weather of opinion that might help them to flourish.
The NHS Confederation, which represents health trusts and has its annual conference this week, has produced a statement on sustainable communities, urging the NHS to help make "safe, green, clean and healthy environments".
On Friday, the British Medical Journal will take up the issue of climate change, calling on health professionals to support a policy of "contraction and convergence", in which every individual has an annual carbon allowance, to be traded globally and reduced year on year. On Saturday, at a conference in London, the global health charity, Medact, which campaigns on international issues, will focus its efforts on climate change.
Most important, perhaps, is Monday's report from the government's taskforce on sustainable procurement, including the NHS, which sets out recommendations for all public bodies. It calls for clear policy leadership, emanating from the prime minister and reflected through the contracts of top civil servants and managers, and for performance to be audited for "long-term value for money and thus for sustainability".
If the government takes its own advice, there is a chance the NHS could reap a creditable harvest of green beans.
· Anna Coote, lead commissioner for health on the UK Sustainable Development Commission, will speak at a Medact conference, Global Inequality and Climate Change, in London on June 17. For more information call 020 7324 4739 or go to www.medact.org
