First, do no harm

11th February 2013


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Becky Allen on how the NHS plans to cut its carbon footprint by 10% and place sustainable development at the heart of its operations

In 2010, the NHS in England emitted 20 million tonnes of CO2 equivalent (MtCO2eq), making it the largest public sector contributor to climate change in Europe. The NHS accounts for 25% of all public sector carbon emissions in England. Its annual carbon footprint is greater than that of many countries, such as the Dominican Republic, Estonia and Lithuania.

The numbers may be startling, but they are not surprising. The NHS has the largest property portfolio in Europe and employs more than 1.7 million people across the UK. According to health research charity the King’s Fund: “Spending on health and social care accounts for £1 in every £10 of the UK’s gross domestic product (GDP) – more than £150 billion a year. Any activity on this scale inevitably has consequences for the natural environment.”

Leading activity

In a bid to lessen its environmental impacts, the NHS has committed to reducing its carbon footprint by 10% by 2015. Leading its environmental efforts is Dr David Pencheon, director of the NHS sustainable development unit (SDU) who, despite the scale of challenge, seems surprisingly upbeat. In a recent blog on communicating sustainability for the British Medical Journal, Pencheon advised: “Be positive about the future. Martin Luther King did not say ‘I have a nightmare’.”

Pencheon joined the SDU when it was set up in 2008, after a career in public health. Over the past five years the unit, based in Cambridge with a handful of staff, has commissioned a raft of research on NHS carbon emissions. The first NHS carbon footprint, published in 2009, estimated emissions at 18 MtCO2eq. The third – and latest – published in 2012 put the figure at 20 MtCO2eq, a rise attributed to growth in the NHS and the fact it now measures all six greenhouse gases covered by the Kyoto protocol.

Recent evidence suggests the upward trend in emissions is starting to reverse, however. The research also reveals that, while energy use in its buildings accounts for 19% of emissions and travel 16%, some 11 MtCO2eq or 60% of emissions come from procurement.

“What we found interesting was that balance between procurement, energy and transport. It’s not that surprising, but lots of those we work with were struck by the procurement percentage,” Pencheon told the environmentalist.

“It’s an interesting issue for the NHS. You would think we’re a service rather than a product-based sector, but the size of the procurement footprint shows we buy a lot of stuff – from sheets and food to drugs.”

At 4.4 MtCO2eq, pharmaceuticals account for 22% of the NHS’s total carbon footprint (and 13% of its costs), with medical devices coming in at 1.6 MtCO2eq, figures that beg fundamental questions about the impact of healthcare on climate change and what a sustainable health service might look like.

Prevention better than cure

According to a report by the Health Protection Agency on the impact of climate change on health, more extreme weather events will put increasing strain on the NHS in the UK. Hospitals could see more admissions due to major emergencies, and there are likely to be more heat-related deaths, as well as more skin cancers, respiratory disorders, cataracts and cases of food poisoning.

But the flip side – the environmental impact of healthcare – is attracting most attention among researchers, revealing some fascinating links between health, sustainability and economics. It’s these synergies that underpin Pencheon’s optimism.

“When you think of a healthcare service – not a health service – it’s rescue and salvage. You pick up the end products of a disease process. It’s inevitable, and it happens globally, not just in the NHS,” he explains. “Take coronary heart disease, for example. Someone’s heart attack has its origins in their early years. If you focus further upstream you do patients and the public good by saving avoidable diseases and emissions.”

Prevention is key, according to Pencheon. “One big strategic principle is that if something is preventable, why is it not prevented? It’s a very important principle. For sustainable development you have to look at the whole system. For example, look at transport to hospital. We could deliver care closer to home, using better technology,” he says.

Some 5% of UK transport emissions come from healthcare-related journeys. But more car use not only means more pollution and more accidents, it also means more disease as people drive rather than walk or cycle. A report by the New Economics Foundation estimated that inactivity was costing the UK £8.3 billion annually, including £1.7 billion in direct healthcare costs to the NHS, and that a 10% increase in adult physical activity could save 6,000 lives and £500 million a year.

Evidence base

Now that it has the evidence, a key task for the SDU is convincing NHS staff and policymakers in the UK that mitigating climate change will save money and improve health.

“We spend £20 billion a year on goods and services. There’s a big carbon footprint and we could be a lot better on the triple bottom line – saving money, saving carbon and not at the expense of the service we offer,” says Pencheon. “Therein lies an important step in our journey; focusing not only on our efficiency but asking if can we do things differently, or do fewer things. It’s politically contentious.”

There are many ways the NHS can, and does, reduce its carbon footprint. Several hospitals are addressing energy issues (see panel, below), while others are looking at the environmental impacts of food (see below). But the scale of the challenge is such that improving operational efficiency is not enough: a transformation in service models is required.

“There are signs the health service takes the future seriously. There are good things, pockets of excellence, but we still don’t have a systematic approach,” acknowledges Pencheon. “We pay hospitals on activity, so there’s little incentive for change. If you incentivise hospitals in a different way you could keep patients out of hospital and deliver care closer to home.

“The current reorganisation of the health service may bring opportunities for hospitals and community services to work together – that would be a step change. The incentives would be aligned to save money, alongside improving health and sustainability.”

Getting the message out

For Pencheon, as for many sustainability professionals, communication is part of the challenge. A recent SDU survey of senior NHS leaders, found that 90% agree sustainability is important. And 60% believe it is essential to the running of their organisation, particularly during difficult times for the NHS, when sustainability offers an opportunity to engage staff as well as reinforce and clarify organisational values.

As elsewhere, cultural rather than practical issues are at play in the NHS, and that means several things for Pencheon: empowering and motivating staff, but also targeting the right messages at the right people.

“Sustainable development is a rather broad term, it means different things to different people, and it’s important to engage people in right way,” he says. “Some come at it from [the point of view of] money or compliance, while others from a reputation or organisational resilience perspective, and some because behaving unsustainably isn’t good for health, and health is our business.”

Given the trust the public places in health professionals, if the NHS gets sustainability right, the benefits could be even greater. Pencheon likens it to tobacco control. “One of the biggest changes in public behaviour came when doctors stopped smoking,” he says. “The one million contacts the NHS has with the public every 36 hours is a fantastic social force … The health service has to be future proofing and has to be seen to be doing it.”

It’s a leadership role that the World Health Organisation (WHO) believes health services globally should step up to. “Because its climate impact is so vast, the health sector can play a major role in mitigation efforts around the world,” the WHO says. “It is clear that the health sector can also play a leadership role … To honour its commitment to ‘first, do no harm’, the health sector has a responsibility to put its own house in order.”

Energy in Cambidge and Harlow

Direct energy use in buildings accounts for 19% of the total NHS carbon footprint and is the part of emissions output over which it has most control. Exploiting opportunities for natural heating, lighting and ventilation, and installing combined heating and power (CHP) systems are some of the ways the NHS can reduce energy use in buildings throughout its estate.

The roof of the Princess Alexandra Hospital in Harlow, Essex, for example, has one of the NHS’s largest arrays of solar panels (pictured above). In 2007, the hospital used a £400,000 grant from the health department’s energy fund to also install new boilers (pictured below), which are saving money as well as 16 tonnes of carbon a year.

At the end of 2012, work began on a new energy centre for Cambridge University Hospitals Trust (see an artist’s impression below). The existing CHP plant incinerates clinical waste to provide heat and hot water to both the main Addenbrooke’s hospital site and its maternity hospital, the Rosie. When it was installed 20 years ago, it was the first CHP plant in the NHS. The new incinerator and CHP system will be able to use sustainably-sourced woodchips as fuel alongside burning waste produced by the hospitals.

The new energy centre will come into operation in 2015, saving the trust almost 30,000 tonnes of CO2 a year, equivalent to a 47% cut in current carbon emissions. The combined heat and power unit will help Addenbrooke’s exceed its NHS sustainability target for carbon emissions by 27% and over 25 years should halve the hospital’s energy consumption. The trust is also upgrading the lighting systems throughout its hospitals.

Local food at Bristol NHS Trust

The food industry has a formidable carbon footprint so, given that the NHS in England spends £500 million on food and serves 300 million meals every year, there is enormous scope to source food more sustainably.

Following involvement with the Soil Association’s healthy food in hospitals initiative, North Bristol NHS Trust, which operates the Frenchay and Southmead hospitals, now buys more locally- and sustainably-produced food.

The trust’s catering team (pictured) works with existing suppliers to source food from within a 50-mile radius where possible. Milk is now sourced locally, and meat is supplied by a local butcher. Menus now also contain more seasonal foods.

Using local food for meals costs around £2 a day, within budget and well below the national average. And patient satisfaction with hospital food has increased.

“Patients now experience locally-sourced food, which is not only seasonal but is also very tasty and has all the best nutrients to get them on the road to recovery,” says Gary Wilkins, the trust’s catering manager. “It shows that it is possible to make significant changes to food by commitment, careful planning and a bit of enthusiasm.”

The trust’s chefs and children attending its nursery now grow organic food at an allotment on the grounds of the Frenchay hospital.


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