Can Healthcare Be Green?

Anna Sayburn

Disclosures

October 07, 2019

Climate change, pollution and extreme weather are potent causes of ill health and are likely to become more so in future, healthcare organisations from the World Health Organisation (WHO) to the newly-formed UK Health Alliance for Climate Change warn.

As the latter – an association of medical Royal Colleges, healthcare organisations and publications – warns on its website: 'Climate change undermines the foundations of health in the UK and worldwide – clean air, safe drinking water, sufficient food and secure shelter.'​

But what of the impact of healthcare on the environment? The NHS Sustainable Development Unit estimates that the health and social care sector accounts for around 6.3% of England's total carbon emissions. That's a significant amount. The government has set targets to reduce the NHS's carbon footprint by 80% by 2050.

Is the NHS on track to hit the target – and is it ambitious enough? Much focus has been on estates management, such as switching to lower-energy lightbulbs and sourcing renewable energy in hospitals. But clinical care itself is surprisingly carbon-intensive. We look at some of the hot spots, and some of the potential solutions.

National Targets

The 2008 Climate Change Act committed the government to ensure net UK carbon emissions were 80% below 1990 levels by 2050. In June 2019, this was raised to 100% - in effect to make the UK carbon neutral by 2050.

Immediate targets for the NHS are for a reduction of 34% of its carbon footprint by 2020 and 50% by 2025, with a long-term goal of 80% reduction by 2050. Progress is being monitored annually by the NHS Sustainable Development Unit.

The unit's 2018 report showed that only 39% of NHS providers reported they were "on track" to meet the 2020 target, a reduction of 2% on the previous year. The 2018 report on natural resource use in health and social care showed the total carbon footprint was down by 18.5% from a 2007 baseline. The report notes that the reduction in carbon use is against a backdrop of increased clinical demand and activity, but says "faster and more determined progress is required" to meet future targets.

Yet even though we seem to be some way off meeting current goals, some think the NHS needs to raise its sights further.

"It's not ambitious enough," says Rachel Stancliffe, director of the Centre for Sustainable Healthcare. "We have legislation for carbon zero by 2050 but most people think that is too late. Given that we [the UK] are well resourced and seen as a leader internationally, it's really important we say we have to do these things, and I would say by 2030."

She says the 2030 goal is "ambitious but doable if the resources are put in".

Thus far, says Ms Stancliffe, much of the drive towards sustainability has come from motivated individuals putting their own time and effort into initiatives, rather than work being properly funded. While that can make a difference on a local level, it's not enough for nationwide change and may explain why there is so much regional variation in achievement.

"What we have had is personal commitment and not really much structurally and from the centre. All those things have been personal commitment and sacrifice, people who have just done this outside their normal work times, pushed for things and done it alongside their normal jobs."

Where Are the Hotspots?

A breakdown of carbon costs shows that NHS carbon emissions come from three main sources:

  • Energy to power buildings

  • Transport of staff and patients

  • Procurement of goods and services

Perhaps surprisingly, procurement makes up by far the biggest piece of the cake, with an estimated 72% of carbon costs. Building costs account for approximately 15% and travel 13% of emissions.

So hospitals can move to renewable energy sources, encourage use of active and public transport, tackle waste and recycling – but unless they get to grips with procurement of everything from face masks and gloves to pharmaceuticals, it will be hard to meet targets. And the single biggest part of the procurement picture is pharmaceutical products, accounting for 16% of the entire health and social care carbon footprint.

Anaesthetic 'Greenhouse' Gases

Within hospitals, the operating theatre has one of the highest carbon footprints. The reason – perhaps unexpectedly – is not the single-use masks, instruments and drug packaging, or even the energy used, but the gases used to anaesthetise patients. Some of these have a greenhouse gas effect hundreds or thousands of times higher than CO2. These anaesthetic gases contribute the equivalent of around 5% of the carbon footprint of acute NHS Trusts. But things are changing.

Dr Cliff Shelton, an anaesthetist at Manchester University NHS Foundation Trust, explains: "There are at least three different vapours we can use to put people to sleep and keep them asleep and there is 20-fold difference in the global warming impact between the best of those and the worst of those."

Desflurane, a gas introduced in the 1990s, is the worst in greenhouse gas terms, with a global warming potential 2540 times that of an equal mass of CO2 (compared to 510 and 130 times for alternatives isoflurane and sevoflurane). The benefit of desflurane is that it is short-acting, meaning patients recover more quickly. However, says Dr Shelton, there are now alternatives such as intravenous anaesthesia and regional anaesthesia, as well as ways to monitor the depth of anaesthesia, which mean desflurane is less important.

"I think people got into the habit of using desflurane for sensible clinical reasons at a time, the early 1990s, when we were less interested in the climate change agenda, particularly relating to healthcare," he said. "But I think we've reached a place now where more and more people are abandoning desflurane for reasons associated with its environmental impact."

He said that the technique with the lowest global warming impact is total intravenous anaesthesia (TIVA), with anaesthetic administered through the veins. However, he says, some colleagues have doubted that because of the visible waste generated by TIVA.

"If I do a day's anaesthesia with TIVA I'll end up with a giant pile of discarded syringes and ampules that pass through my hands and a lot of colleagues will say 'don't we create a lot of waste doing that?' And quite frankly, yes we do. You can see how harmful TIVA is but we know the global warming potential of volatiles [gases] is several orders of magnitudes – 100 or 1000 times more than TIVA despite all the rubbish that we make."

He said that "at the moment"  most general anaesthetics are done using inhaled gases, but that "maybe in 10 years' time we should look to only a tiny minority being done that way and only when clinically indicated".

One of the people helping to make that switch is Dr Cathy Lawson, Association of Anaesthetists and Centre for Sustainable Healthcare Fellow in Environmentally Sustainable Anaesthesia at Newcastle upon Tyne Hospitals. Dr Lawson is working to develop reliable metrics for hospitals to record and publish their data on anaesthetic gas use. "So we will have an accurate picture of where we are in terms of how much gas is being used."

Energy Use and Waste in the Operating Theatre

She is also establishing a network of 'environmental champions', with the ambition to have at least one anaesthetist in each hospital across the UK to promote sustainability. She also plans for a case study library, so that people can record and publish their success stories, which can then be used by other hospitals wanting to make changes.

Beyond gases, she says, there are ways to reduce the 'resource intensive' nature of the operating theatre. "We do use a lot of energy; obviously we've got a lot of machinery that's using a lot of electricity." She explains that in some hospitals, air flow ventilation, gas scavenging and heating systems are centrally controlled so cannot be easily turned off by theatre staff. "You have to ring estates and they go up to the plant room and twiddle with things." The result is a lot of machinery running when it could be switched off when not in use.

In terms of physical waste, she says the key is to "try to reduce the amount of waste as high up the supply chain as we can," and points to an example where a trainee anaesthetist questioned the use of plastic hooks on face masks, which were intended to connect to a harness.

"We don't use that in the UK and haven't for ages... you open the packet and it [the plastic attachment] goes in the bin. It's only 2 grams of plastic but we use absolutely thousands on thousands of face masks."

Waste streaming is another initiative, although the legislation around clinical waste can make this complicated. Dr Lawson is working with specialists in waste management to outline a flowchart "with all the things we could potentially use for our waste and what kind of waste should go in each". She said this could become a guide for clinicians to use in hospitals to set up sustainable waste flows, which could lead to more work with specialist recycling agencies.

Waste makes up only a small proportion of the carbon footprint of the NHS, but still amounts to 224 megatonnes of waste by weight, of which 15% goes to landfill. However, a substantial proportion is incinerated as clinical waste, which is more carbon-intensive and expensive than landfill.

And not every area is up to speed on waste management. Professor Rashid Gatrad, a paediatric surgeon at Manor Hospital in Wallsall, set up Wallsall Against Single Use Plastic after becoming aware of the amount of plastic waste being generated.

"Two years ago, everything went into landfill," he said. "There was chaos about where to put rubbish. Now there are lots of different bins for recycling." He said he had worked with the chief executive and the recently-appointed sustainability and waste manager at the hospital: "There was no recycling but now we are working on that – our target is to put 10% of waste into recycling and decrease single use plastic by 10% in one year."

He highlighted a change to the big plastic bags once used by the hospital pharmacy to dispense medicines being taken home from hospital, but thinks hospitals could go further. "We could be promoting reusable nappies, glass syringes. There are a few simple steps. We used to do that [use metal and glass reusable instruments] before plastic came along."

Sustainable Dentistry

However, some researchers in the dental arena raise a note of caution about abandoning plastic and returning to reusable metal instruments.

Professor Nicolas Martin, consultant in restorative dentistry at Sheffield University, is researching single use plastics in healthcare, with a focus on items that are used a lot in dentistry, such as gloves, bibs and aspirators.

"The problem is nobody has really been looking at this," he said. "The drive for the past 10 years has been towards single use plastic in order to minimise [infection] risk. There's a lot of small things we could do but if we want to effect any sort of change it has to be on the back of some evidence of what we're producing, the impact of it, the cost of it and effectively the whole chain. Our research is trying to establish a baseline in terms of what is happening."

He said there is a "misconception" that the best way forward was always to move away from single use plastics. "For example, in our trust the sterilisation department is 20 miles away, so [if we used a reusable instrument] it has to be washed and go back and forth six times a day. So if you're thinking of the world, what is worst? It's a delicate balance we have to achieve."

His colleague, dentist Steven Mulligan, said there are some things that people can start to do, however. "Examples of things we would advise are making sure you are using digital radiography instead of film-based radiography because there's a lot less plastic waste with that. Also advertise to patients the concept of sustainability, recommend they bring in their waste plastic toothbrush tubes, toothbrushes for recycling."

Patient transport is a significant factor in carbon emissions for dentistry. "You can plan an appointment well in terms of patients [who] should travel as family to reduce [their] carbon footprint," he said.

He is investigating how the plastic in nitrile-based gloves can be reused in the construction industry, which would be possible if dental surgeries sorted waste into different bins at the point of use.

Dentistry too uses anaesthetic gases, usually nitrous oxide, for sedation. Prof Martin pointed out that 99% of anaesthesia in dentistry was done by local injections and that "dentistry is a very small user of these anaesthetic gases overall".

However, "nitrous oxide is quite a potent greenhouse gas," said Dr Mulligan . "Sedation services are being called upon to look at their use of that gas. When we use inhaled sedation in dentistry we don't really have an alternative, so it's about ensuring that it's kept to a minimum."

General Practice

Greenhouse gases are also an issue for general practice. More than 26 million metered dose inhalers for asthma are prescribed each year, propelled by hydrofluorocarbons (HFCs), potent greenhouse gases. According to the National Institute for Health and Care Excellence (NICE), metered dose inhalers have estimated carbon footprints of 500g CO2 equivalent per dose. This compares to 20g footprints for the alternative dry powder inhalers. Yet metered dose inhalers made up 70% of inhaler sales in the UK in 2011.

In April 2019 NICE published a patient decision aid in which the comparative carbon footprint of each inhaler was laid out side by side, in the hope that patients will ask for dry powder inhalers in preference to metered dose inhalers.

"There is work to be done on clinical education," said Rachel Stancliffe. "Most GPs will just hand out inhalers which are gas propelled because they think they work better, because they've been taught to use them – it's just a habit thing."

Reviewing prescriptions of metered dose inhalers is one of about 90 initiatives promoted in the Royal College of GP's Green Impact for Healthcare toolkit for practices.

The toolkit allows practices to move up an awards system from bronze to gold by adopting policies across a range of issues. Actions include:

  • Encouraging the use of social prescribing

  • Reviewing patients on 10 or more medicines

  • Reducing office waste, for example by double-sided printing

  • Encouraging staff and patients to cycle or walk rather than drive to appointments

Some 386 of the more than 7000 practices in England have registered to use the toolkit, according to Dr Terry Kemple, a Bristol GP (now retired) who developed the toolkit and is a former president of the RCGP.

He said that "the first thing" for general practice is "everybody having a sense of awareness that we all have to get involved in this" and "to be looking around at what we're doing".

He declined to give examples of the areas where practices should be prioritising their efforts in sustainability, however.

"You can't say you have to do this or that and that's a priority. We have to look at everything," he said.

"Certainly in the toolkit there are baby steps to take there but we need to look at bigger steps. Even if we implement everything in our toolkit we won't get to zero carbon. So we're going to have to go beyond that."

Pressed, he said that promoting active transport and addressing the "massive carbon footprint" of pharmaceuticals were likely to have "bigger effects". He made the point that "overdiagnosis and overtreatment" created a great deal of wasteful activity, from a carbon and financial perspective. He said the RCGP had a working group looking at these aspects of healthcare.

More broadly, he said, the healthcare system needs to prioritise disease prevention through helping to reduce pollution so people can breathe healthy air, encourage food policy towards healthy diets, and encourage people to get sufficient physical exercise to stay healthy. He pointed to the UK Health Alliance on Climate Change as an example of what could become a powerful lobbying voice with government.

Part of the difficulty with moving to prevention is that resources need to be refocused, said Ms Stancliffe. "If for example a GP had half an hour for each patient rather than 10 minutes they would be much more likely to listen to that patient, to give them support in other ways, to be able to suggest physical therapies which might be walking green routes rather than taking this drug," she said.

What Needs to Happen Next?

An important next step, says Ms Stancliffe, is proper international standards around carbon footprinting, so that people can make direct comparisons between different procedures. That would need to be accompanied by better accounting of all the costs – financial and carbon-related – incurred in each patient encounter. She said that NICE was interested in including carbon footprinting in its recommendations, alongside cost and clinical effectiveness, but would be unable to do so until a proper database of carbon accounting was in operation.

Addressing medicines waste through regular medication reviews, and better use of remote consultations by phone or video link, have big potential, she said, but current initiatives on digital consultation are "quite half-hearted".

Can the NHS afford to go green? Ms Stancliffe believes it can't afford not to.

"Basically the rule is, the more you spend, the more carbon you are emitting. Because unless you are spending money on physical therapies, you are buying something and that something will have a carbon footprint." She called for more money to be put into staff and time, and to be invested in public health and disease prevention, to cut costs further along the line.

Hope for the Future?

While some doctors addressing sustainability, such as Prof Gatrad and Dr Kemple, have worked in the NHS for their entire careers, it is notable that many of the most enthusiastic voices come from students, trainees and younger doctors.

Medical schools such as Keele, Brighton, and Southampton are including sustainable healthcare in the medical curriculum, while the GMC recently included 'principles of sustainable healthcare' in their document Outcomes for Graduates, which "sets out the knowledge, skills and behaviours that new UK medical graduates must be able to show".

"It really is being driven by the students and younger doctors," said Dr Lawson, while acknowledging "there are some very key players who have been talking about sustainability for a long time".

So can healthcare become truly sustainable?

Dr Shelton has the final say. "I think it's possible – in fact I think it's a must, a responsibility of ours to be as sustainable as we can. We need to think about not only serving the needs of the patients in front of us but their children and their children's children. It's incumbent that we practise in such a way that we're providing excellent care to this generation but we're able to continue to provide excellent care to future generations."

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