Introduction The World Health Organisation (WHO) has declared that ‘climate change is the single biggest health threat facing humanity’. Paradoxically, healthcare organisations are significant contributors to this event. Whilst the NHS has committed to becoming the first healthcare service in the world to reach net-zero by 2040, it contributes to 4–5% of the UK’s total emissions (BMA, 2023). Of all NHS emissions, 15% can be attributed to its Estates & Facilities (E&F), only second to medicine.

However, this problem is largely underrepresented in the literature, particularly concerning the role of management in realising net zero. This oversight led us to our research, which aimed to identify the barriers and facilitators for management to achieve net zero in NHS Hospitals’ E&F. We would like to showcase the intricate challenges and opportunities we have found in the intersection of Healthcare Management and sustainability.

Aims and objectives of the research project or activity Our main aims and objectives were as follows:

Aim 1: To identify the barriers & facilitators for management to achieve net-zero in NHS E&F

Objective 1: Carry out a narrative literature review (NLR) to identify the general barriers & facilitators in both management and E&F to achieve net zero in NHS Hospitals’ E&F

Objective 2: Carry out semi-structured interviews (SSI) to identify the specific barriers & facilitators for Estates & Facilities Management (EFM), from the perspectives of sustainability leads, to achieve net zero in NHS Hospitals’ E&F

Aim 2: To help develop recommendations for management practice to achieve net zero in NHS Hospitals’ E&F

Objective 1: To synthesise results from the SSIs, to help develop recommendations for management practice from the perspectives of sustainability leads, to achieve net zero in NHS Hospitals’ E&F

Objective 2: Validate proposed recommendations, either by implementing a minimum viable product or engaging with relevant stakeholders to obtain their feedback.

Method or approach We conducted a narrative literature review to explore the considerations for management to achieve net-zero in NHS hospitals’ Estates and Facilities. Key gaps identified in the literature led to the following focused research question:

‘How Can Sustainability Leads Adapt Their Management Practices to Achieve Net-Zero in NHS Hospital’s Estates & Facilities?’

Specifically, we set out to identify the barriers and facilitators for sustainability leads to achieve net-zero and help us create management practices recommendations through semi-structured interviews. All participants held sustainability leadership positions in E&F either at the Trust, ICS or National level. 21 interviews were conducted, 8 of which were notable experts. Including Fiona Daly, National Deputy Director of Estates for NHS England. Six open-ended questions were discussed exploring management practices for NHS Hospital E&F net-zero goals. Thematic analysis of the transcripts was then carried out, following Braun and Clark’s six-step framework. Themes, meta-themes, and sub-themes were identified.

Findings Following our NLR and interviews, barriers included Engagement, Data, Estate Operations, Hierarchical Management and Funding. Funding was the most salient barrier we found. Some notable subthemes:

Return on investment: This may be exacerbated by competing priorities faced by the board and the perception that sustainability initiatives have a low Return on investment (ROI)

Inadequate Business Cases: Complicating things further, Interviewees highlighted that inadequate business plans produced by managers can cause the board to reject sustainability proposals.

Facilitators included Engagement, Hierarchical management, Estate Operations, Data, Policy, Training and Development. Some key themes:

Engagement needs to be addressed at both the board and staff level.

Value Proposition: To engage the board and get buy-in, the value proposition of a project needs to be aligned with stakeholder values

Working Groups: A shared collective goal, facilitated by working groups, can help to engage clinical personnel and align values.

Training and development

Mandatory training and development are necessary to bridge the knowledge gap in sustainability and drive awareness. This can be done by:

Up-skilling staff, including clinicians, to become greener champions

Data

There is a need to optimise the collection of high-quality data with integrated net-zero metrics. The analysis and handling of data should be done by competent personnel.

Key messages We created the Foundation Model of Estates and Facilities Management from these barriers and facilitators. Our novel model illustrates the seven key meta-themes identified in the discussion and their interactions downward and bottom-up. Ultimately, these findings fill a gap in the literature, highlighting the current barriers and facilitators experienced by Sustainability Leads in their efforts to decarbonise their Hospital E&F. Specifically, the lowermost ‘foundational’ themes, Engagement, T&D, and Data, are the most influential in driving decarbonisation efforts in Estate Operations.

These themes illustrate that the NHS needs a transformational change to decarbonise its hospital’s E&F. We propose a solution to one of the problems identified:

Problem 1: HCPs must be aware of sustainability projects within E&F.

Our solution: Using co-design and marketing principles, we developed an advert to raise staff awareness. Our advert strongly focuses on values, education, empowerment, and community creation. HCPs are educated on the need to reach net-zero and empowered by reinforcing the small actions they can do to help. Moreover, there is a strong emphasis on the community through ‘acting together’ for ‘our NHS’.