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Sustainable but Unequal: What NHS Net Zero Misses About Patient Access

May Thandar Min·Sep 30, 2026

In 2020, the NHS became the world's first health system to commit to reaching net zero carbon emissions, setting targets of 2040 for its directly controlled emissions and 2045 for its wider supply chain. It is an ambitious and necessary pledge: healthcare is both a victim of climate change and, through its own carbon footprint, a contributor to it. But as the strategy moves from policy paper to practice, a harder question is emerging: net zero for whom, and at what cost to whom?

The digital shortcut problem

A large share of the NHS's early carbon savings has come from a single lever: moving care online. Remote consultations, e-prescribing, and digital triage all cut the emissions associated with travel, printing, and physical estate. NHS England's own figures have cited hundreds of kilotonnes of carbon saved through the shift away from face-to-face appointments accelerated during the pandemic.

The trouble is that this is not a neutral efficiency gain. A systematised review published by the British Geriatrics Society found that while telehealth offers clear environmental benefits, it also creates real barriers for patients with low digital literacy, poor technology access, or complex health needs, groups that skew older, poorer, and more clinically vulnerable. Concerns have already been raised that the shift to phone and video appointments during the pandemic led to missed diagnoses among elderly patients without reliable access to technology. A carbon saving achieved by making care harder to reach for the patients who need it most is not sustainability. It is cost shifting, from the planet's ledger to the patient's.

When decarbonisation meets drug supply

The equity gap is not confined to digital access. Doctors' organisations have warned that new procurement rules aimed at greening the NHS supply chain risk squeezing already fragile markets for low margin but essential medicines, such as certain antibiotics and blood pressure treatments. The Department of Health has pushed back firmly, stating that patient care will always take precedence where supply is limited, and pointing to genuine wins, such as solar investment in Lincolnshire hospitals that has freed up money for frontline services. Both things can be true at once: net zero can generate real savings that benefit patients, while also introducing new fragilities into supply chains that already run close to the edge for the drugs poorer and more medically complex patients depend on most.

The upstream gap

Perhaps the more fundamental critique, raised by researchers at the Grantham Research Institute, is about what the NHS's net zero strategy leaves out rather than what it includes. The strategy focuses heavily on estates, transport, anaesthetic gases, and inhaler emissions, all worthwhile targets, but gives comparatively little attention to preventing the ill health that drives demand for carbon intensive treatment in the first place. Upstream prevention, tackling the social and environmental determinants that land disproportionately on low-income communities, is treated as a footnote rather than a pillar. Yet it is precisely this population level prevention work that would cut emissions and narrow health inequalities simultaneously, rather than trading one against the other.

Equity cannot be an afterthought

None of this is an argument against NHS net zero. The health sector cannot credibly ask patients to accept climate risk while doing nothing to reduce its own footprint, and some of the criticism has been met with legitimate, evidenced counterpoints from NHS leadership. But a decarbonisation strategy that is not explicitly designed around equity will, by default, reproduce existing inequalities under a green banner. Digital first care needs a funded, non-digital fallback that is treated as a standard, not an exception. Procurement reform needs supply chain resilience testing for essential, low margin medicines built in from the start, not bolted on after doctors raise alarms. And upstream prevention deserves the same strategic weight as boiler replacements and anaesthetic substitution, because it is where climate and health equity goals actually converge. Sustainability and access are not naturally opposed. But without a deliberate equity lens, a net zero NHS risks becoming a system that is greener on paper and less accessible in practice, and the patients least equipped to absorb that trade off will be the ones who pay for it.

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