A lesson, not an exception. Governing for greener healthcare systems: Exploring climate action in the National Health Service in the UK.

BACKGROUND: Climate change poses significant risks to human health, at the same time healthcare systems are a large contributor to climate change. The NHS is regarded as a leader in the green health space, committing to achieving Net Zero by 2040, however little is known about how these policies are being implemented at the local level, or what governance approaches support effective climate action. OBJECTIVE: This study examined 1) current adaptation and mitigation actions within London NHS healthcare trusts; 2) barriers and enablers shaping these actions; and 3) governance characteristics that could be upscaled or adapted in other healthcare systems. METHODS: We conducted fourteen semi-structured interviews with Greener NHS staff, sustainability personnel and clinician leaders across London HCTs. We thematically analysed data to reveal barriers, enablers and governance features. RESULTS: At the time of data collection, mitigation was the primary focus, while adaptation received less attention. Key enabling factors included strong leadership, clear guidance from a central team, passionate advocates, robust data, and research, amongst others. Barriers included unclear prioritisation, complex funding processes, data gaps, resource constraints, ageing infrastructure, organisational apathy, and difficulties translating national examples to local level implementation. CONCLUSIONS: NHS's progress has been underpinned by strong governance, advocacy and pursing a results driven approach, and offers many lessons to other healthcare systems. We recommend that increasing sensitivity to trust-level contexts, and the support available to underperforming trusts could be beneficial. The NHS's achievements are noteworthy, they should not be seen as an exception, rather, they are a realistic model of what other high-income healthcare systems can achieve.