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General Policy
Estates, Facilities and Capital Services
Estates Officer – Sustainability
Head of Sustainability
Director of Property & Asset Management
08 April 2024
08 April 2024
08 April 2025


NHS Fife acknowledges and agrees with the importance of regular and timely review of policy statements and aims to review policies within the timescales set out.  New policies will be subject to a review date of no more than 1 year from the date of first issue.

Reviewed policies will have a review date set that is relevant to the content (advised by the author) but will be no longer than 3 years.

If a policy is past its review date, then the content will remain extant until such time as the policy review is complete and the new version published, or if national policy or legislative changes are made.


1.1.    This policy recognises that the impact of NHS Fife Board’s activities on the wider environment locally, nationally, and globally is significant, therefore the Board has the responsibility to reduce its environmental footprint and protect the natural environment as much as possible.

1.2.    The Board has a duty to comply with all current environmental legislation and mandatory Scottish Government policies. The current primary legislation is the Environment Act (2021), and the current Scottish Government policy is the DL 38 (2021) – A policy for NHS Scotland on the Climate Emergency and Sustainable Development.

1.3.    To demonstrate our commitment, and to manage and measure the impact NHS Fife has upon the environment, an Environmental Management System (EMS) which meets the requirements of the ISO 14001:2015 Standard will be implemented across our estate and services. This international standard sets out the criteria for establishing an effective EMS.  

1.4.    This policy shall be maintained as documented information; be communicated within the organisation; and be available to interested parties.

1.5.    The EMS will be used as an essential tool for; identifying specific environmental impacts from the services we deliver; complying with relevant environmental legislation and regulations, and with other requirements to which the organisation subscribes; providing the framework for setting and reviewing environmental objectives and targets; ensuring all relevant information is documented, implemented, maintained, and communicated to all employees; and will be available to the public.  

1.5.1.    An EMS is similar to other management systems, such as those that manage quality or safety. It assesses an organisation’s strengths and weaknesses and helps to identify and manage environmental risks and opportunities. It requires the Board to comply with environmental legislation and provides a framework for continual improvement. 
1.6.    This Environmental Management Policy is intended to ensure that there is an efficient management structure in place to assess, manage, and monitor all environmental aspects and impacts in assets that it owns, occupies, or manages including third-party suppliers, contractors, and external partners. It outlines the guiding principles of the EMS that encompass all of the activities, products, and services undertaken by NHS Fife.  
1.7.    This Environmental Management policy and its associated procedures apply to all NHS Fife and Fife Health and Social Care Partnership premises; owned or occupied under lease, and, whether wholly operated under NHS Fife Management or under Service Level Agreements (SLAs) and Private Finance Initiatives (PFI’s). It also applies to any activities by NHS Fife or third parties that require the use of energy, water, and resources, and activities that produce waste. Where the operational management of buildings, areas occupied by NHS Fife, and/or patients is carried out by a third party, the requirements of this policy and procedures remain applicable. Implementation of site-specific risk and opportunity management requirements may also be managed by local policies (and those third-party organisations).

1.8.    It is the responsibility of the NHS Fife Senior Management to ensure that the requirements of this policy and procedure are notified to and complied with by all those carrying out work on NHS Fife’s behalf, throughout the organisation. All those carrying out work on NHS Fife’s behalf should be aware of their roles and responsibilities under this policy, and as such are required to undertake their activities in accordance with the Board's environmental compliance obligations as defined in the NHS Fife Environmental Legal Register. As required by the NHS Scotland Climate Emergency Strategy (Appendix 2): “Each Health Board will embed an EMS across the organisation and fully integrate environmental performance into all relevant governance and financial and non-financial reporting processes” (Page 30: Point 82).  This is also mentioned in the DL38 (Appendix 5).  

1.8.1.    The Strategy also states: “It is critical that environmental risk and compliance is managed at the highest level in the organisation, and that the necessary budgets and resources are assigned to environmental audits, repairs, and upgrades to ensure continual improvement... Adopting best practices as set out in the international standard on environmental management ISO 14001:2015 will reduce environmental risks” (Page 31: point 81). The Board will follow this guidance by using the EMS as a system to monitor progress.

1.9.    The Board is also mandated to “work towards the requirements of ISO 14090:2019 Adaptation to climate change” (Appendix 2: Page 29, point 77). NHS Fife is beginning to assess adaptation priorities across the Board and set goals based on these findings for climate change mitigation and adaptation.


2.1.    This policy applies to all existing and future NHS Fife premises, owned, or leased, where NHS staff are employed, or NHS patients receive any treatment or care. In the case of third parties such as suppliers, partners, and contractors, the Board has a responsibility to communicate its EMS policy to these suppliers in other locations and encourage the development of EMS and monitoring of associated emissions within those organisations.

2.2.    NHS Fife serves the county of Fife, which has a population of approximately 370,000 people, employs 9,800 employees directly, and owns/manages around 45 sites across the county.


3.1    Chief Executive

Following the approval of this policy, the Chief Executive Officer will direct the Board and raise awareness of the implementation of the EMS. The Chief Executive has overall accountability for ensuring that the organisational structure, arrangements, and resources are identified and made available to implement this policy, its objectives, and associated plans.

3.2    Directors/ Senior Management

The Director of Property and Asset Management also has the responsibility to oversee environmental compliance within NHS Fife and will report the overall progress of EMS implementation to the Chief Executive.

3.3    Heads of Service/ Department/ Service Managers/ General Managers (hereafter referred to as ‘Senior managers’)

Senior managers are responsible for implementing suitable and sufficient arrangements to ensure, so far as is reasonably practicable, the health, safety, and welfare of their staff, service users, and visitors.

The duties of line managers noted below also apply to senior managers.

3.4    Senior Charge Nurses/ Midwives, Heads of Department, Team Leaders, Supervisors, etc (hereafter referred to as ‘line managers’)

Line managers must, so far as is reasonably practicable:

•    Provide a safe working environment, and environmentally safe systems of work and support and implement policies and procedures which will underpin this policy.
•    Assess the environmental risks to employees and other persons within their area of responsibility, identify measures to reduce the level of risk, and introduce controls to ensure the risk is managed appropriately, in the same way as health and safety risks are managed.  
•    Have the authority to appoint risk assessors within their departments to undertake and record the risk assessment. However, implementing necessary actions to reduce risks and review of existing risks remains the responsibility of the manager.  
•    Are responsible for ensuring that employees receive information and instruction in safe working practices/safe systems of work (SSoW) on actual and potential risks and for identifying the appropriate level of environmental risk training required by their staff for reporting and responding to risks.
•    Are responsible for ensuring that all new employees are given work-based environmental training and instruction in relation to their role, and the details should be recorded.
•    Will ensure that relevant documents are introduced that address specific operational and organisational environmental risks within their area of responsibility.
•    Will monitor the implementation of local arrangements and implement place-based environmental action plans with support from the Sustainability team.

3.5     Employees

•    Take reasonable care to ensure the environmental safety of themselves and others who may be affected by their acts or omissions.
•    Co-operate with managers to ensure compliance with this policy, procedural and statutory requirements.
•    Ensure that items provided in the interests of environmental health and safety are not intentionally or recklessly interfered with.
•    Report any perceived danger of unsustainable or environmentally damaging working practices or conditions to their appropriate supervisor, manager, or staff side representative.
•    Be aware of emergency procedures.
•    Notify all environmental hazards, defects, accidents, and incidents, including near misses, to their line manager or supervisor and follow the organisation’s incident reporting procedures.
•    Undertake safety and risk management training where identified as a learning need or mandatory training requirement.

3.6    Contractors

Contractors carrying out work on NHS Fife premises are expected to comply with environmental legislation, this policy, and the NHS Fife Control of Contractors Policy Control of Contractors (Equipment & Building Maintenance) | NHS Fife and any relevant service or department procedures.

The person supervising the award of any contract must ensure that the contractors are aware of their environmental responsibilities and specify detailed health and safety, and environmental performance requirements in a written term of agreement.

3.7     The Sustainability Team

The NHS Fife Sustainability Team provides support for sustainability projects, compliance with environmental legislation, and other environmental matters. The Sustainability Team is responsible, through the Head of Sustainability for:

•    Delivering a suitable EMS for the Board including review and update of key EMS resources and procedures.
•    Providing necessary training, advice, and support to staff and managers.
•    Providing strategic direction and supporting the organisation in achieving environmental legislative compliance via an agreed environmental management plan (Appendix 6).
•    Supporting relevant Committees and groups.
•    Promoting a positive environmentally sustainable culture in the workplace.
•    Development and review of environmental related policies and procedures.
•    Any other relevant objectives as set by the Director of Property and Asset Management.

3.8    Further Responsibilities

Further responsibilities for environmental management across all directorates in NHS Fife will be outlined in the NHS Fife Environmental Management Procedures. Once the procedures are published, all sites are expected to become compliant with ISO14001:2015 requirements. In addition to the posts outlined above, the NHS Environmental Management Procedures will also describe in more detail the responsibilities, needs, and expectations of other key stakeholders, such as third-party contractors and suppliers, SEPA, Fife Council, Fife Health Charity, and any other organisations that contribute to the functioning of NHS Fife.  

While it is the responsibility of the Sustainability Team to create, manage, and coordinate the policies and procedures of the EMS, the compliance obligations and development of specific policies, procedures, forms, and templates on operational elements will sit with the various department heads that are responsible for the compliance with legislation for their respective sectors. 

3.9    The Resilience Team

The Resilience Team supports designated executives/managers & clinical leads with organisational emergency planning & operational business continuity planning (BCP) for civil contingencies preparedness.  BCP planning minimises the impacts from foreseen disruptive events in conjunction with the Sustainability Team who locally manage the effects of climate change & recovery/sustainability improvement within the delivery of services across NHS Fife Board.


NHS Fife delivers many services across a wide portfolio of settings that have an environmental impact; therefore, NHS Fife has a responsibility to effectively account for and manage these risks and impacts.

Consistent with a life cycle perspective, the Board shall:

•    Establish controls, as appropriate, to ensure that its environmental requirements are addressed in the design and development process for the services, considering each life cycle stage. 
•    Determine its environmental requirements for the procurement of products and services, as appropriate. 
•    Communicate relevant environmental requirements to external providers, including contractors.
•    Consider the need to provide information about potential significant environmental impacts associated with the transportation or delivery, use, end of life, treatment, and final disposal of its products and services. 

The components of the operational system are listed below and will be fully described in the Environmental Management Procedure. The EMS for NHS Fife will ensure that it has;

•    An up-to-date legal register.
•    The appropriate allocation of resources to allow the EMS to be set up and managed efficiently and effectively. 
•    An aspects and impacts register of its activities which identifies significant impacts on the environment.
•    Environmental management procedure documents, listing all the relevant information, operating criteria, and processes for the implementation and monitoring of the EMS. (Please note: Due to the extent of this management system and the organisational change required, it is expected that the procedures and required actions will be carried out in phases in the coming years)
•    Defined targets for emissions reductions, biodiversity contributions, sustainable procurement, and other necessary goals set within the scope of legislation. 
•    A regular environmental audit of relevant legislation once the EMS is fully implemented and holding the pertinent parties responsible for any issues pertaining to compliance with the standard.


5.1    The key risks involved with the implementation of this policy are: 

•    Lack of staff awareness of this policy, resulting in non-compliance. 
•    Lack of robust organisational arrangements around policy implementation. 
•    Failure to implement and maintain the required procedures associated with this policy. 
•    No access to up-to-date sources of information, advice, and guidance on EMS matters
•    The lack of dedicated expertise, time, and resources for the creation of the EMS could result in a significant delay in the implementation of an EMS, which is highly time-sensitive given the seriousness of the climate emergency. To deal with this issue, the legal review and procedures will address conformance and current gaps in resources and set timely aims to rectify this.  

5.2    High risks that either have substantial penalties or pose detrimental environmental harm will form part of the Corporate Risk Register and BAF (Board Assurance Framework) which will be monitored, maintained, and subject to quarterly review.   

5.3    The NHS Fife Internal Audit Department will periodically verify the system of internal controls and these findings will be presented via the Sustainability Team. Once the EMS is operational across the majority NHS Fife, the Board may decide to become certified in ISO14001, which requires an external audit. The process of dealing with non-conformities can be found in Appendix 6.


6.1    Appendix 1: For information on a more detailed definition of an EMS, see NetRegs Environmental guidance for your organisation in Northern Ireland & Scotland 
6.2    Appendix 2: NHS Scotland Climate Emergency Strategy
6.3    Appendix 3: NHS Fife and Fife Health and Social Care Partnership Environmental Governance Structure (TBD)
6.4    Appendix 4: ISO14001:2019
6.5    Appendix 5: DL38 
6.6    Appendix 6: Environmental Management Procedures (TBD)
6.7    Appendix 7: EMS Acronyms and Definitions