Unravelling the healthcare paradox: tensions in sustainable healthcare
Attending the CleanMed Europe 2025 conference in June, I came away uplifted by the urgency and seriousness with which the topic of sustainability in healthcare is being addressed by healthcare professionals and hospitals across Europe. In discussions about healthcare-derived air pollution, water pollution, PVC toxicity, heat stress, and anti-microbial resistance, there was widespread recognition that the contribution of healthcare to carbon emissions and climate change is significant and that the climate crisis is a health crisis - creating a ‘healthcare paradox’ in which it is impossible to ‘first, do no harm’. As many delegates and speakers noted, the effects of climate change are already being felt, increasing disparities and exposing the most vulnerable to greater risk. Inaction on healthcare’s contributions to these risks is not an option.
Stories of solutions and good practices abounded. Manufacturers are working to create low-carbon products and solutions, such as refillable anaesthetic gas cannisters provided as a service, the development of low-carbon inhalers, and the tailoring of instrument trays to specific users to reduce the number of items which are thrown away unused. Examples were given of hospitals examining their ecosystems, creating ‘forest hospitals’, filtering water polluted by prescribed medication, and switching from plastic baby bottles to glass to reduce infant exposure to microplastic contamination. Individual healthcare practitioners and teams described creating grassroots initiatives, switching from disposable to reusable PPE, piloting reusable drapes, gowns, and curtains, and creating green teams, green theatres, and green departments, all while sharing tools and experience for others to follow.
The event was attended by industry sponsors, NGOs, healthcare practitioners, procurement professionals, and academics. This resulted in multiple voices, multiple perspectives, and multiple priorities shared across the four days. Two key tensions arose amongst these conversations, lingering unaddressed – and possibly unnoticed – amid the busyness and urgency of effecting a transition.
How Cost–Care Trade-Offs Shape Sustainability Decisions
Regardless of role or background, speakers were united in their agreement that care is patient-centred and that sustainability initiatives should not and must not negatively impact patient care: “health outcomes always come first”. Sustainability initiatives were framed as bringing co-benefits to environment, patients, and budgets: “the first priority is still the patient, but good patient care can lead to economic and environmental improvements.”
On the surface this sentiment for care-focused wins for sustainability and economy sounds good. Unassailable even. Yet listening closely to the talks, a more complex picture appears.
One presentation reported the results from an ongoing pilot study of a new bandage in a UK hospital, finding that the bandage reduced the risk of post-surgical infection by 68%. The results were presented as showing the importance of a patient pathways approach to establish the cost and environmental savings resulting from the use of the new bandage. By including the cost and environmental impact of the entire patient pathway - including multiple return visits to address post-surgical infection - it became clear that the use of the new bandage could bring significant cost-savings to the trust and reduce carbon emissions. Further trials with the new bandage are ongoing.
So why is this important? Because if indeed “health outcomes always come first”, then the benefits of these bandages are already evident as they improve patient outcomes. But the cost per bandage is three times higher than traditional bandages, necessitating a business model approach to demonstrate why paying more at the outset saves costs in the long run. This should not and does not surprise us – cost-benefit analysis approaches to balancing patient outcomes and value-for-money are deeply embedded in the way healthcare is delivered and underpin the delivery of a quality service to all patients.
However, this cost-benefit approach does reveal that health outcomes do not always come first – health outcomes are reliant on the results of cost-benefit analyses. When the deciding factor is sustainability, there is no question of trade-offs which impact patient health outcomes – the prospect is unthinkable, despite the fact these trade-offs are made every day in relation to cost. My point is not that we should be putting sustainability above individual patient health outcomes, but that our unwillingness to do so – alongside our willingness to put cost above individual patient health outcomes - raises questions about what we value.
Budgets vs. Safety: Who Gets Prioritised in Sustainable Healthcare?
An example of an organisation challenging this value dynamic is provided by a hospital in Vienna, which replaced items made from PVC with more expensive alternatives in its neonatal intensive care unit (NICU), thanks to the support of a local government official who championed the change. Concerns have been raised for 30 years about the toxicity of PVC and its suitability for use in hospital equipment. Yet, PVC products often remain cheaper than less toxic alternatives and are widely used in hospital environments, including with the most vulnerable patients in NICUs. Spending more on safer products was only made possible in this case by the intervention and support of a key external player, who empowered the hospital to increase spending to safeguard vulnerable patients – putting health outcomes first, over and above cost implications.
Beyond Cost Savings: Aligning Values With Action
What I learned from the conference is that current sustainability initiatives in healthcare - in common with many other industries - are primarily cost-savings driven. Initiatives are justified via a business model approach to change in which patient care and environmental impact feature but are not the driving force for change. Trade-offs between quality care and cost are deeply embedded within existing decision-making, a model which is increasingly challenged by calls for better care of humans and the planet.
Furthermore, the emphasis on direct health outcomes for individual patients at the moment of care feeds the healthcare paradox – if resource-intensive healthcare is fuelling the manufacture of toxic products and human-induced climate change, then whose health outcomes do we prioritise? Which patient voices matter? And how can we protect the health of the unseen, the marginalised, the vulnerable, and those of future generations?
Recognising these trade-offs and being honest about how we value patient health outcomes and planetary health outcomes in relation to budgetary costs might be the first step towards a realistic conversation about what we value, enabling the conscious alignment of spoken values (human and environmental health) with physical and financial infrastructures which reflect these values. Thereby enabling health outcomes for people and planet to truly come first.
Why Change Is Being Pushed Downstream — And Why That Matters
Overall, the narrative of transition championed both top-down approaches to change – “real transformation is top-level transformation” – and bottom-up approaches – “clinicians are the key to change”. Both top-down and bottom-up approaches highlighted the importance of small steps which add up to significant impact, although at the top level this reliance stemmed from a perceived inability to make big changes: “we make small changes when big changes can’t be made.” Meanwhile, at grassroots level, small steps were prioritised because healthcare practitioners were poorly resourced, often running sustainability projects in their spare time.
The difficulties inherent in bringing about change outside the hospital and care settings was highlighted in several sessions – examples were given of an industry-led legal challenge that has been launched against forthcoming EU legislation designed to make polluters pay for enhanced water filter systems, and the continued subsidy of fossil fuels across the EU. Meanwhile, within hospital settings, everyday challenges include the difficulty of changing established laundry infrastructures, shortage of storage space, and practitioner resistance to change.
Doubtless, healthcare practitioners are on the front lines of increasing demand driven by climate change impacts (such as heat-related illness or rising cases of asthma linked to air pollution) this was likened to repeatedly treating the symptoms of a fish poisoned by the water in its tank without changing the water. Reducing demand for healthcare through ill health prevention was commonly cited as a means to reduce the environmental impact of healthcare and increase system resilience. Yet, ‘prevention’ meant different things to different stakeholders – representing vaccination programmes for industry, improved diet and lifestyle factors for practitioners, and tackling air and water pollution for NGOs.
Whilst conference speakers highlighted the importance of high-level influencers outside the local hospital, a far greater emphasis was placed on the role of clinicians in instigating change within their own departments. Clinicians are under increasing pressure to become knowledgeable about sustainability challenges, to embed sustainability within their practice, and to communicate the environmental impact of interventions with their patients. As a result, the burden for change is directed downstream towards an overworked and underfunded workforce rather than upstream towards the manufacturers, regulators and policy-makers who design waste into healthcare products. By focussing attention on the admirable activity of individual teams, departments, and hospitals we risk missing the wider systemic issues which have created such unsustainable systems in the first place.
Holding Trade-Offs in Tension: Imagining Alternative Futures
In this article I highlight two key tensions underlying efforts to address the unsustainability of healthcare in high-resource settings. The first relates to the trade-offs inherent in decision-making. Whilst cost-benefit analysis has long been used to inform decision-making in healthcare, its scope is narrow, based on outcomes for the individual patient, often at a single point in time. It overlooks the indirect harms to people and planet resulting from decisions – treating only the fish without addressing the poison. Its time for a much more nuanced approach to decision-making – one which is honest about the multiplicity and intractability of the complex trade-offs which impact health outcomes both directly and indirectly, now and in the future. Whilst daunting, Sarah Kaplan explains how complex trade-offs which cannot be resolved into win-win scenarios can be held in tension (Kaplan, 2020) creating a space where organisations thrive. Where win-wins are impossible, there is an opportunity for innovation, recognising the flaws in current practice and rethinking future scenarios in partnership with others facing similar challenges.
This brings me onto the second tension, in which I question whether responsibility for change is fairly distributed; it’s time for far more engagement from producers, manufacturers, regulators and policymakers in embracing the healthcare paradox and using it to envision and bring about alternative futures, like that shared in the ‘One Health’ documentary by hospital network Global Green and Healthy Hospitals, in which hospitals save rivers, protect the air and heal people.
