Getting to the root of the barriers to further improvement:
If we accept that in terms of improving energy performance across the NHS estate the low hanging fruit has largely been picked, where are future savings and efficiencies going to come from? HEFMA's energy roundtable, sponsored by Centrica Business Solutions, sought the answers to this dilemma and more.
From this intense, three-hour long debate, three key themes emerged – long-term strategy, the relationship with procurement and the need for education.
Each organisation needs to have a clear, long-term energy and carbon strategy, linked with other key strategies, such as the overall estates and the clinical strategies. However, in many cases this is lacking at the moment as Trusts favour short-term projects with a payback of less than five years. This is partly so they can see a quick benefit and partly because funding on advantageous terms is available for such schemes through Salix.
Taking such a short-term view does not allow the technologies available to be properly utilised and the NHS really needs to start looking further into the future.
There is clearly frustration with this lack of long-term planning. Luke Mitchell from Royal Devon and Exeter NHS Foundation Trust says: "If we know what we are doing for the next 15 years we can probably convince the finance people to make a decision on a longer payback. It's that sort of direction that needs to be in place."
Of even greater concern are the investment decisions that are made on an ad hoc and isolated basis without due consideration being given to the needs of the Trust in the long-term or whether the technology being procured will complement or work against existing systems in operation across the estate.
Cash v carbon
It is often said that initiatives to improve energy-efficiency by targeting a carbon reduction also have a positive financial impact in that using less energy reduces the overall energy bill, but it doesn't necessarily follow that carbon-saving and cost-saving are one and the same. The situation is more complex than that and at times carbon-saving and cost-saving initiatives can be in opposition to each other.
The government wants energy performance targets to be met but the NHS organisation needs to find ways of reducing expenditure and meeting both requirements can be a challenge, particularly when it comes to preparing a business case. Furthermore, this is a constantly moving picture as targets change, utility rates vary and demand for power is influenced by variables such as weather conditions or future trends that are difficult to predict, for instance, future charging requirements for electric vehicles.
This of course complicates the business case model even further, because it isn't always easy to predict key outcomes on investments, such as exactly how much a scheme will save. It is a situation that is made even more complex by the fact that the business case needs to be passed ultimately by decision-makers who are probably not estates or energy managers and want to be presented with simple facts. But there are no guarantees, only predictions, and changes that are not possible to predict can result in significant financial swings in the business case.
Driving change
Estates managers frequently find themselves having to ‘sell’ the concept of energy or sustainability projects to secure vital funding based on improvements to the patient environment or patient care rather than the nitty-gritty of the project itself. "It can be about talking the right language to colleagues,” says George Atkinson, Associate Director of Estates for Poole Hospital NHS Foundation Trust and Chair of the Energy Carbon Management Group for HEFMA South West Branch. “They might not want to hear about Salix and loans but they do want to hear about an improved patient environment. So that’s where you start.”
This is one way of looking at it, but it shouldn't be necessary to 'sell' the concept of sustainable projects – the NHS should be doing it anyway. The Sustainable Development Unit (SDU) recently published some statistics that 98% of NHS staff and 92% of the general public believe the NHS should work in a way that supports the environment, but the reality appears to be very different. Only 71% of NHS staff feel their employer allows them scope to support the environment at work, which means around one quarter of staff do not feel able to promote the sustainability agenda in the workplace. Furthermore, 43% believe they value the environment more than their employer does.
From the outset it is vital to get the right people onside with any energy project requiring significant investment. "There has to be an organisational commitment to energy improvement and sustainability," says HEFMA National Chair, Jonathan Stewart.
At North Devon NHS Trust, a significant EPC project with a new CHP, solar panels and biomass boilers is delivering big financial savings and means the Trust has also met its 2020 carbon target, but accessing the interest-free loan of £2.8 million from Salix was not straightforward because North Devon is not a Foundation Trust. Energy and Compliance Manager, Steve Gladwin, explains that it took the intervention of the Directors to stop the process going around in never-ending circles and for the loan to be approved. "I think it is really key to have the decision-makers on board - right from the top," he told the roundtable delegates.
Getting genuine commitment to Sustainable Development Management Plan (SDMP) projects can be tricky and comes back to the issue of lack of understanding from those who are not immersed in issues of energy and sustainability on a daily basis. This applies from the very top of the organisation down to every individual on the site because it should be recognised that sustainability is not just an estates function, it needs to be dealt with by everyone.
Royal Devon and Exeter has tackled this by commissioning the Centre for Sustainable Healthcare to run a green team competition throughout the Trust. This is an interesting initiative that has the potential to bring about real change in behaviour through ideas generated by the workforce.
The project began with a series of workshops that introduced the broader sustainability agenda and moved staff away from a fixation on recycling projects to an awareness that in terms of carbon, focusing efforts on procurement is the area that has the most potential to make a difference.
Luke is now evaluating the 40+ ideas generated by people within the Trust as a result of this initiative and quantifying the potential savings from just five ideas so far reveals they could be worth as much as £250,000 per year. "Just educating people about what sustainability is in a healthcare context has changed all their minds and transformed the thought process. It is now about empowering people in these departments to make these changes themselves."
The role of procurement
Eleni Pasdeki-Clewer, Technical Expert for Sustainable Procurement with the SDU, threw down a challenge to the energy and estates managers at the roundtable to get closer to their procurement colleagues. She describes the daily management of the NHS estate as a significant contributor to the carbon footprint, but even so it is "the tip of the iceberg." A far larger contributor is the carbon that is embedded in all of the goods and services that the NHS buys. This embedded carbon is far more difficult to influence because it involves complex supply chains and manufacturing processes that can only be tackled at the procurement stage by including energy-efficiency in energy-using devices as part of the specification.
"Sustainability managers talk about all the good things they can do, but leave everything else to procurement. I think the NHS needs to start building those bridges and start to establish better connections between those who use it and those who pay for it. Let's make everything a little bit more joined up."
The procurement model for the everyday, high volume, low value items used by the NHS is currently in the process of transferring from the old NHS Supply Chain function to a new model. The Department of Health and Social Care hopes the percentage of goods and services procured through this model will increase from the current level of around 40% to as much as 80% and Eleni believes this represents an opportunity to challenge the carbon embedded in procurement.
The SDU's new SDMP guidance document advises pragmatism, which Eleni believes is very important. "Try to pick areas you can really influence, not the mountains you can't shift," she advises. In other words, there is no point investing time and energy into an area that may be one of significant impact but over which you have no influence. It is far more sensible to choose an area where you can drive change, even if the impact on the sustainability agenda is not as great.
"This also encourages people to think beyond carbon," Eleni continues. "The NRF report touches on water, air quality impacts, transport and logistics. These are all areas we can quantify and qualify in connection with human health."
This approach can then strengthen the business case by connecting the actions decided on with the patient. Echoing George’s comment from earlier, she adds: "If you use the right language it resonates more with the decision-makers."
Taking Trusts to task
There are Trusts that have met their 2020 carbon targets, but it is believed that there are many more that are not on track to do so and even more that don't know what their energy expenditure is or understand why it is what it is. These are the Trusts that really need help. "The NHS has got to take itself to task. We can no longer have individual Trusts doing their own thing, leaving some Trusts to do nothing at all about energy management or to just dabble in it," says Jonathan Stewart.
"What process can we put in place to help Trusts to develop a proper strategy that's right for them, so they make the right investment decisions?"
The answer, believes Centrica Business Solutions’ Sales Director, Ian Hopkins, lies in education. Many Trusts do not have a dedicated energy manager and if the skill-set to tackle energy strategy is not there it is all too easy to do nothing. Invest in educating people so they do gain a level of understanding, share best practice and case studies among procurement, finance and estates functions, and talk to suppliers.
Measuring and monitoring
This is absolutely essential. "If you can't measure your energy use on a site you can't monitor it, and if you can't monitor it you can't look for any improvements," says Vasu Gadi, Distributed Energy Sales Manager for Centrica Business Solutions.
This is challenging for many hospital Trusts. With no clear metering - particularly sub-metering - the only information hospitals have is that provided on energy bills from their suppliers and that may not be backed by valid data. Vasu advises that without this data it is difficult to understand the demands of a site and provide solutions that will drive change for carbon and cost. "This is the biggest challenge I have seen - gathering the gas and heat data and how it's used across the site. There is a bill, but what is needed is a full understanding of exactly where the gas on a site is being used."
Taking this one step further, it isn't just having sub-metering but having the ability to act on the data provided by sub metering that is the issue. To do this, the data must be analysed, which requires resource.
But for many, the cost of installing sub-metering is a stumbling block that at the moment there is no clear way around.
Centrica has a clip-on solution for current measurement that is portable, quick and available at a completely different price point to the cost of installing a meter. It plugs into a power pack and provides an accurate proxy for kilowatt consumption. There is no need to switch anything off and the system will measure a floor or lighting circuit, a chiller or any given pump. It self-powers, connects to a bridge and transmits to the cloud. The consumption data is available quickly, but still needs acting on. This solution does not yet measure heat.
Technology & opportunity
Paradoxically, the journey to using more renewables is having some severe, unintended consequences with respect to gas. Centrica reports that the proliferation of wind and solar is leading to it selling more open-cycle gas generation than ever before. This is because people want a constant supply of power, which cannot be achieved by sole reliance on intermittent sources of generation, such as wind and solar, thus requiring the installation of a back-up source of generation.
"It is the mismatch between supply and demand that is causing us to install open-cycle gas generation that runs 500 hours a year in 20 megawatt chunks in sub stations all over the country. The direction of travel is definitely local grids with storage - both thermal and electrical. Value in intermittency and the ability to shift load is something that any consumer with a good solar connection should be exploring for revenue opportunity," says Ian Hopkins.
Delegates discussed several different technologies and it was clear that the market cannot expect a single new technology to emerge in the near future with the capability to transform energy-efficiency across the NHS estate in the short-term.
Solar technology and battery storage are both getting better. Recent changes in the regulations for imported Chinese solar panels has seen their price reduce so behind the meter solar became viable technology again without a feed-in tariff, but the efficiency of solar depends on many variables, including the availability of surface area.
New-build projects are an ideal opportunity to incorporate new technology. Tony Orton, Distributed Energy Sales Manager at Centrica Business Solutions, provides an example of a hospital embarking on a project to build a new multi-storey car park. It's an opportunity to incorporate solar panels and electric vehicle charging points, which brings the potential for future revenue generation by charging visitors and staff to plug in. Given the prediction that the grid will be under pressure from demand for electric vehicle charging, it may be necessary to incorporate batteries into any such projects, so battery technology in the future is going to be critical.
Absorption is sensible - that is, turning surplus heat into cooling, but it’s another example of a project that requires a long-term vision because of the length of the payback and all-too-often it is easier to install more efficient chillers.
A more integrated approach to generating energy from waste is another long-term consideration where some small-scale breakthroughs may be seen in the shorter turn.
A combination of measures is probably the best approach, starting with reducing and controlling demand through education and involving everyone on the site. Ian Hopkins also believes there is a definite trend pointing towards disaggregation of grid to local and NHS organisations are in a good position to participate with local, off-grid infrastructures.
"Exercising your assets and your connected capacity, which is sacrosanct in a way, is a good way of potentially making some money. But, you have got to be careful about what you do with that money - you have really got to invest that in the future," Ian concludes.
