Achieving sustainable healthcare
We need people who care and have the courage to try
I was in our local corner shop today and saw the headline: “NHS heading for financial ruin!” When we first started talking about sustainable healthcare six years ago people thought that we were referring to financial sustainability—and of course that is one way that we measure the use of resources. But I like to say to people that money is not a real thing but rather something we use to measure value, and so we don’t have to worry about it as much as real resources like carbon or rare metals. That’s not to say that money is not a crucial measure of sustainability, as the potential for financial ruin is an indicator of unsustainable healthcare, but there are other important elements to consider, such as social and environmental sustainability.
Many people within the healthcare industry are currently focused on the environment because climate change is such an immediate and important threat, but of course social sustainability interacts with the other elements—there is no point in tackling climate change if we aren’t also looking at what kind of society we end up with and whether people want to live there. This is as much about the values we prioritise as it is about measuring and reducing our carbon footprint—partly because we will have to make some tough decisions fairly soon if we want to enjoy the type of healthcare we experience today for generations to come.
How environmentally sustainable we are needs to be tackled urgently—The BMJ and the Lancet have both campaigned about climate change, and top healthcare professionals have called it “the biggest health threat of the 21st century.” The NHS—the UK’s biggest employer and one with a “considerable carbon footprint”—is tasked with reducing carbon emissions by 80% by 2050; that is, in 35 years’ time—within our working lives. We are legally committed to this reduction as a country through the 2008 Climate Change Act, and it is necessary for all countries to adopt such seemingly massive changes if we are to have a chance of living healthy lives into the future.
But how are we going to do that? Many people assume that the biggest resource use in healthcare is the buildings and the direct energy use—the building, heating, and lighting of our large hospitals. This is why in many cases the responsibility for carbon reduction has been allied with energy efficiency and given to estates directors and energy managers within trusts. The TLC project at Barts Health NHS Trust is a great example because it shows direct benefits to patients as well as reduction of cost and carbon (box 1).
Box 1: Operation TLC
Barts and The London NHS Trust, the largest NHS trust, wanted to reduce its £13m (€16m, $22m) energy spend and make the trust more sustainable and so introduced a project called Operation TLC.
Operation TLC—three simple actions
- Turn off equipment when not in use, reducing excessive heat and noise
- Switch off lights to help promote sleep and reduce light pollution
- Close doors to improve patient safety and privacy and help regulate room temperatures
After four months, the trust saw improvements in energy use, including a 40% increase in lights out and 18% fewer open doors.
Patients in wards where the pilot took place also reported sleeping better, with a third fewer incidences of sleep disruption, and a quarter fewer privacy disruptions than in non-TLC wards.
The programme saved the trust £100 000, achieving payback within one year. 800 tonnes of carbon emissions were avoided through the programme, with 15 000 staff reached over a four month period.
But five years ago the NHS Sustainable Development Unit produced an analysis of the carbon footprint of the NHS in England, which showed, to everyone’s surprise, that all of their massive buildings and direct energy use amounted to only about 19% of the whole picture. Another 16% is attributable to transport, and most of all the carbon (65%) is from procurement—including drugs (20%) and medical devices and other things that the healthcare industry uses day to day (fig 1 1 ). In other words, even if we closed down all NHS buildings, we would have achieved only a quarter of the carbon reduction needed. We need to think of other ways to reduce resource use, and these must go to the heart of healthcare practice to transform systems and models of care.
This explains why, when I started the Centre for Sustainable Healthcare, an independent centre set up to help the NHS to reduce its carbon footprint, with Muir Gray in 2008, we concentrated on engaging healthcare professionals and their specialty networks. The specialties are the communities of practice within healthcare—the peer groups that work together, recognise one another nationally and internationally, and develop innovations in models of care.
Developing this idea, in 2010 Frances Mortimer, medical director of the Centre for Sustainable Healthcare, wrote an important article on how healthcare can reduce its footprint in which she set out the principles of sustainable healthcare (box 2).
Box 2: Principles of sustainable healthcare
- Disease prevention
- Patient education and empowerment
- Lean service delivery
- Low carbon treatments and technologies
We tried out our ideas in nephrology—working with the whole renal community, including patients, researchers, and industry as well as the national clinical director, consultants, nurses, and technicians. We seconded a registrar out of clinical practice for a year as a sustainability fellow to lead the work from a position of understanding real working conditions.
The green nephrology programme was a great success in terms of engaging people and achieving change; within a year we had a green representative in 85% of renal units and the fellow had published five papers and written up dozens of case studies showing innovations that could reduce cost and carbon. The Centre for Sustainable Healthcare calculated that the programme would also save 11 000 tonnes of greenhouse gases and 470 million litres of water if it was replicated across the UK. The programme wasn’t just good for the environment—it also makes financial sense. The programme was applauded in the Marmot Review, and if all of the changes were implemented across other renal units the estimated savings were £7m. Additionally, if similar projects were started in other specialties, the NHS would save £1bn a year. See the six minute film here: http://bit.ly/1mgfydx
The provision of high quality care to patients in the future depends absolutely on the transition to low carbon models of care. Achieving this goal will require innovation, leadership, and a systems approach—the green nephrology project provides a model for specialties to take a lead. We have since worked with respiratory medicine, occupational therapy, and mental health, and the plan is to engage all specialties as soon as possible.
Looking to the future
It is clear that doctors, nurses, and others who practise healthcare need to begin to understand the resources used to treat patients and to manage the use of these resources as part of their jobs. Patients too need to be involved in understanding the resources and be involved in these decisions about prioritising. We can no longer behave as if there are limitless resources when making decisions about treatment—either in terms of carbon or money; if we do, we will run out of options.
One thing we have observed while working on sustainability is that it seems to give permission for people to challenge the status quo and do things differently. This might be in practical ways such as suggesting telephone follow-ups instead of face to face, or giving patients a choice of sandwiches at lunch to avoid waste; or might be more qualitative, such as starting discussions on the importance of shared values at work. Healthcare practitioners are so busy in their daily work, but they do notice parts of systems that could be changed for the better, and it is sometimes the importance of sustainability that can empower them to take the lead.
We are heading for a resource cliff, but we still have time to find the path down in the next few years and even to enjoy the descent once we get our heads around it. There are ways to improve patient care, the financial outlook of the NHS, and the state of the environment simultaneously—it is not impossible, it just needs people who care about all of these things and are not afraid to try.
- The Centre for Sustainable Healthcare: www.sustainablehealthcare.org.uk
- The Climate and Health Council: www.climateandhealth.org
- Healthy Planet: www.healthyplanetuk.org
- The Sustainable Development Unit: www.sduhealth.org.uk
- Fair Medical Trade group at the BMA: www.bma.org.uk/fairmedtrade
- BMJ blogs: http://blogs.bmj.com/bmj/category/sustainable-healthcare/
Links to other BMJ/Student BMJ articles: climate change cluster
1Centre for Sustainable Healthcare, Oxford OX2 7JA, UK
Correspondence to: firstname.lastname@example.org
Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.
Provenance and peer review: Commissioned; not externally peer reviewed
- Managing the effects of climate change. Lancet 2014. www.thelancet.com/climate-change.
- Mayor S. NHS should bring in measures to reduce its carbon footprint, BMA says. BMJ 2008;336:740.2 www.bmj.com/content/336/7647/740.2?goto=reply.
- Reducing the UK’s greenhouse gas emissions by 80% by 2050. www.gov.uk/government/policies/reducing-the-uk-s-greenhouse-gas-emissions-by-80-by-2050.
- Global Action Plan. Operation TLC—nudging the NHS. http://globalactionplan.org.uk/node/1089.
- Mortimer F. The sustainable physician. Clin Med 2010;10:110-1.
- Limb M. NHS could save £1bn by adopting green strategies used in kidney units. BMJ 2013;346:f588.
- Green nephrology. Centre for Sustainable Healthcare, 2013. http://sustainablehealthcare.org.uk/green-nephrology/news/2013/02/bmj-nhs-could-save-%C2%A31bn-adopting-green-strategies-used-kidney-units.
Cite this as: Student BMJ 2014;22:g2900