Clean bill of health

In order to create a more resilient, sustainable healthcare system, we need to look at what we truly value

by Rachel Stancliffe @SusHealthcare

The turning point in the response to Covid-19 in the UK was perhaps the stories from doctors on the frontline in Lombardy in northern Italy

who reported starkly that they were having to decide who to save. With limited resources, decisions about rationing healthcare always have to be made, but this truth is usually much more hidden from the public.

To this rationing of healthcare resources, the climate emergency has added the urgency of reducing carbon dioxide and other greenhouse gas emissions. If we are to reach net zero carbon emissions within 10 years (as the Intergovernmental Panel on Climate Change says we must if we are to mitigate the worst effects of climate change), we will have to, very quickly, make hard decisions about how we choose to use our resources. In the UK, for example, the NHS has a carbon footprint of about 20m tonnes of CO2 per year, the same as Bolivia. It is clear that this needs to be reduced.

What do we value?

In sustainable healthcare practices, we look at what we mean by resources and how we understand value. Value takes into account not only outputs — how many hip operations are carried out, for example — but also outcomes; such as how many patients have full mobility restored. It also looks beyond individuals to populations. Financial cost is extended to consider inputs including the use of environmental resources and social capital (the networks that people can draw upon within their family or wider community).

We need to initiate discussions about the outcomes we want as a society and how we collectively use our resources, so that we can decide how to allocate our remaining carbon budget over the next 10 years. The charity I founded, the Centre for Sustainable Healthcare (CSH), has pioneered the greening of healthcare for over a decade, working with healthcare professionals to understand what can change in the system to reduce environmental impact without negatively affecting patient outcomes.

A key challenge is the assumption that, just as organic vegetables cost more to the consumer (though less to the planet), sustainable healthcare practices will cost more. But we have shown that sustainable healthcare costs less than typical healthcare within a one-year timeframe. In 2014, independent economists analysed our work with the Academy of Medical Royal Colleges and estimated that £2bn could be saved by switching to proven sustainable measures.

Principles of sustainable healthcare

At CSH, we have set out four principles of sustainable healthcare; these are all relevant to the current pandemic. The first is prevention. Many of the diseases we spend most money on treating, such as diabetes and the complications that come with it, are largely preventable, as we understand the risk factors well. What is needed is work across sectors to prevent underlying risk factors (such as obesity), as well as a system change within healthcare to treat problems early once they start to show ill health effects.

Second, there is patient-centred care. This could involve patients with chronic conditions taking a more active role in their own disease management. Mutual peer networks and other online help could provide some of the support needed, and these produce less carbon and are often more convenient. During the Covid-19 crisis we are seeing healthcare move not only online, but into local communities, and this is unlikely to be fully reversed once things have returned to ‘normal’. GPs and pharmacists could, for example, be empowered and educated to give alternative options to drugs, such as physical exercise and lifestyle changes.

Third, we need to create ‘lean’ care pathways, by removing low-value activity. An example of this might be to de-prescribe some medicines. According to The BMJ, among others, over-treatment can cause significant harm to patients as well as waste resources.

The fourth principle is to focus on lower-carbon alternatives. In some ways, this is the most simple principle, as it means making changes that often do not directly affect patients’ care. One impactful change, for example, could be switching from MDI personal inhalers to dry powder alternatives (which do not require gas to propel the medicine into the lungs) that are just as clinically effective.

Developing resilient systems

The crisis provides many lessons in terms of resilience. A resilient supply chain might be one that is not dependent on just one supplier of any particular item. It might also mean spending more on better quality, longer-lasting items such as reusable, sterilisable gowns, masks and surgical instruments. These are not reliant on a supply chain in times of emergency, and are better for the environment. There is a perception that single-use instruments are always safer; in fact there have been studies showing that even single-use ‘sterile’ wrapped instruments are not fully clean.

Covid-19 has brought into sharp relief the value that we place on health and demonstrated that we can act decisively as a society when we see the need. Already our healthcare systems are changing to adopt practices that are more sustainable. And, of course, healthcare is just one example of broader lessons for public-sector services. We should use these changes as a jumping-off point to continue to transform healthcare so that it can have a sustainable future based on resilience, health equity and climate justice. In order to seize this opportunity, we must engage with the key question: what do we really value in our lives?

Rachel Stancliffe is the founder and Director of the Centre for Sustainable Healthcare