Net zero healthcare: a call for clinician action

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GREEN RECOVERY
Net zero healthcare: a call for clinician action
Health professionals are well positioned to eect change by reshaping individual practice,
influencing healthcare organisations, and setting clinical standards, argue Jodi Sherman and
colleagues
A
chieving net zero emissions
in healthcare will be possible
only with radical and immedi-
ate engagement of the clini-
cal community. The covid-19
pandemic has served as a wake-up call for
high income health systems that resources
are finite and globally interdependent,
vulnerable to massive surges in demands
and simultaneous infrastructure disrup-
tion, and that inequities in access to care
threaten health and wellbeing for everyone.
During the first months of the pandemic,
the medical community united at a
historic pace, rapidly sharing information,
redesigning models of care, conserving
and innovating resources, and moving
towards a circular economy. In comparison,
the task of transforming healthcare
culture and practice to halve healthcare
emissions by 2030 as recommended by
the Intergovernmental Panel on Climate
Change1 seems entirely feasible.
Planetary healthcare
Planetary healthcare requires embracing
an expanded notion of the principle “first
do no harm,” beyond care for individual
patients to a duty to protect the Earth’s
natural systems on which intergenerational
health and wellbeing depend.2 This plane-
tary health lens acknowledges crucial links
between ecological change, human health,
and our ability to thrive.2
Planetary accountability encompasses
actions taken by individual health
professionals within the clinical setting,
collective actions of clinicians in healthcare
organisations with the communities they
serve, and interactions of individuals and
collectives in professional societies with
regulatory and oversight bodies.
For clinicians, this means recognising
that healthcare consumes finite resources
and produces harmful pollution, accepting
that environmental stewardship is integral
to our fundamental duty of care, and that
we are quickly approaching a climate
tipping point.
Healthcare is one of the largest polluting
industries, responsible for nearly 5% of
total global greenhouse gases.3 Like all
industries, healthcare must rapidly and
substantially reduce its greenhouse gas
emissions to avoid the most catastrophic
outcomes to health and wellbeing from
climate change.
Achieving net zero emissions—that is,
reducing carbon output until it is in balance
with natural and engineered means of
absorption—necessitates optimising the
eciency and environmental performance
of healthcare delivery. However, these
alone are insucient. We must also work to
reduce the incidence and severity of disease
to decrease the amount and intensity
of care required. Furthermore, we must
match supply of health services to their
need, by ensuring appropriate care and
avoiding unnecessary investigations and
treatments. In this way, absolute emissions
can be reduced while expanding access to
healthcare and achieving co-benefits from
mitigating harm and costs from healthcare
pollution.
Health professionals are well positioned
agents of change at many levels, from
shaping individual clinical practices to
influencing healthcare organisations
and setting standards and policy. We
have previously published a planetary
healthcare framework setting out three
strands of action: reducing emissions
from healthcare services, matching supply
and demand, and reducing demand for
healthcare.4 Here we provide practical
suggestions to help clinicians enact that
framework (table 1).
Reducing emissions from supply of health
services
Reducing emissions from healthcare
services encompasses all activities that
consume materials and energy. Most
healthcare sustainability initiatives focus
on large scale facility operations, such as
improving hospital energy performance
and sourcing renewable electricity, which
typically are not under the control of cli-
nicians. However, clinicians influence
building use through decisions on care set-
tings—for example, whether to administer
monitoring or treatment in the home, clinic,
or hospital (which has the highest resource
and emissions intensity).
5
Virtual care for
patient-provider interactions that do not
require in-person examination reduces
travel and clinic emissions, obviating the
need for some clinical spaces, as seen in the
covid-19 pandemic.
Coordination between care
providers, such as through arranging
multidisciplinary consultations and
services on the same day, and proximal
diagnostic testing, can further minimise
emissions from patient travel. Such changes
often require reorganisation of processes
and commitment, which can be hindered
by lack of understanding of the need for
coordination.
The majority of health sector emissions
are embedded in the supply chain,
including pharmaceuticals and medical
devices.5 Embedded emissions are
dictated by materials and design, as well
as production and distribution practices.
Use of organisational purchasing power
and regulatory reform to influence
manufacturers to reduce product emissions
is critical but takes time. Clinicians have
an immediate role through preferential
use of lower emissions supplies (such
as choosing reusable rather than single
use medical devices,6 and dry powder
KEY RECOMMENDATIONS
•
Clinicians must work to reduce the
incidence and severity of disease to
decrease the amount and intensity of
care required
•
Use of resources must be optimised by
ensuring appropriate care and avoid-
ing unnecessary investigations and
treatments
•
Coordination of care between dier-
ent providers should be promoted
to avoid duplication of services and
reduce travel emissions and unneces-
sary building use
•
Health professionals shouldencourage
change through individual practice,
inuencing healthcare organisations,
and contributing to standards and
policy
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Intervention category Level of action
Individual practice Healthcare organisation Professional/regulatory/government
Reduce emissions from supply of health services
Green infrastructure
and operations
• Paperless operations
• Optimise environmental performance of oce/clinic space
(energy conservation, source renewable energy, safe chemicals
and cleaning supplies)
• Recycling
• Adhere to highest green building/retrotting standards (eg,
Leadership in Energy and Environmental Design)
• Green roofs and natural lighting
• Optimise eciency of clinical infrastructure (eg, reduce medical
imaging devices’ standby mode time)
• Food services: healthy diet options, reusable containers, waste
reduction strategies (eg, people to help feed patients, just-in-
time meal ordering) and waste management (biodigesters and
composting)
• Renewable energy sourcing
•Fossil fuel divestment
•Mandatory, standardised reporting of greenhouse gas and other
emissions by healthcare organisations, reductions targets and
timelines, public transparency
•Ambitious building construction and performance standards
•Solid waste reduction policies, zero waste targets
•Accelerated clean energy transition
Coordinated care
delivery, integrated
technology systems,
and virtual care
• Oer virtual communications; select appropriate/lowest tech
level
• Oer multidisciplinary consultations, coordinate care with other
providers to minimise patient travel
• Coordinate care delivery as close to home as possible
• Multidisciplinary clinics, co-locate providers and allied health/
support sta resource allocation
• Information technology infrastructure and support, including
integration with outside health systems to improve safety and
reduce waste
• Access to translation services
• Universal broadband
• Financial incentives for integration of electronic health records,
information sharing, and coordination
• Regulation of safe adoption and use of virtual care
Circular supply chains • Prescribe lowest carbon drug options
• Select reusable or environmentally preferable materials where
choices exist
• Avoid excess material consumption
• Adhere to evidence based infection control guidelines
• Innovate and redesign greener products
• Environmentally preferable procurement and contracting policies
• Maximise medical device reprocessing programmes
• Institute recycling programmes
• Evidence based infection prevention and control policies
• Policies for rational use of single use devices
• Professional guidance and facilitation to support low carbon
treatments
• Policies to support keeping materials in use at highest value
• Manufacturer demonstration of need for single use devices
• Producer responsibility for take- back programmes (eg,
packaging, electronics)
• Mandate manufacturing of appropriately sized drug vials and
comparably priced prelled syringes
• Revise infection control regulations and professional guidelines
to incorporate public health harms from healthcare pollution
• Accreditation policies that support environmental stewardship
Decarbonised transport • Select active or low carbon transport options, encourage patients
and sta to do likewise
• Provide commuter centres, carpool schemes, and subsidised
public transport
• Electrify vehicle fleet (owned and contracted) with renewable
sources
• Support structures for electric vehicles (eg, parking spaces with
free charging)
• Large scale renewable energy installations/low carbon grids
• Safe cycling and pedestrian infrastructure
• Green active transport corridors
• Bike share schemes
• Designated carpool parking
• Robust public transportation systems
Match supply of health services to demand
Appropriateness of
care and resource
stewardship
• Shared decision making and education (articulation of harms
and benets, distinguish appropriate care from rationing, beware
hidden curriculum/biases)
• Avoid indication/technology creep
• Avoid defensive medicine
• Bayesian decision making (potential benets should outweigh
potential harms; ensure test will change management)
• Maximise non-pharmacological and non-invasive treatment
options
• Care coordination to avoid duplication of tests and treatments
• Adherence to up-to-date evidence based guidelines
• Comprehensive, continuous resource conservation eorts
• End-of-life acceptance and palliative care optimisation
• Research and quality improvement project leadership around
resource conservation and emissions reductions
• Decision making aids and policies to support individual
providers, facilitate shared decision making
• Technology support for care coordination
• Limit conditions of use, such as through restricted ordering and
automatic stop orders
• Provider-level quality improvement feedback on resource use
(cost and emissions)
• Policies and institutional barriers to indication creep
• Protocols for de-adoption of low value care and health
technologies
• Support structures for multidisciplinary care
• Guidelines for shared decision making
• Professional guidelines that include resource stewardship and
prevention of healthcare pollution
• Policies to prevent indication creep
• Incentives to drive de-adoption of low value care and health
technologies
• QI requirements around resource stewardship and emissions
reductions for professional education and board recertication
• Regulatory requirements and oversight of emissions reporting
and reduction
• Payment models that discourage low value care and link
stewardship with accreditation
Table1 | Examples of how clinicians can act to achieve sustainable healthcare systems under a planetary health framework4
(Continued)
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inhalers over metered dose inhalers), and
especially through reducing unnecessary
consumption of supplies and treatments in
their clinical practice.
Matching supply to demand of health services
Inappropriate or low value care, in which
harms or costs outweigh benefits, is ubiq-
uitous in health systems in both high and
low income settings. It includes overuse
and underuse of healthcare services,
which often coexist in the same health
system (and even for the same patient).
Mismatches between supply and demand
of health services occur because of health
system structure and funding and behav-
iours of clinicians and patients that drive
misuse.
Underuse of necessary services leaves
patients vulnerable to avoidable disease.
Overuse results in harms to patients from
adverse events and exposures, financial
harms to health systems and possible
supply shortages, and population level
disease burden from pollution generated
by healthcare. Appropriate care optimises
health and wellbeing by delivery of what
is needed, wanted, clinically effective,
aordable, equitable, and responsible in
its use of resources.
7
High value care also
maximises environmental performance,
avoiding harm to public health.
A robust primary care system is
foundational to appropriate care and
provides a platform for overcoming barriers
to change.
8
In high income countries, lack
of access to, or inadequate primary and
preventive care services results in patients
interacting with more resource intensive
health services such as hospital based
treatment. For example, patients may
present with advanced disease that would
have been preventable or manageable if
detected earlier.
Clinicians can mitigate unnecessary use
of hospital services by facilitating access
to primary and community care services.
This includes identifying and targeting
underserved groups, moving beyond
treating the results of ethnic and economic
disparities and seeking to tackle the root
cause of inequities by building community
wealth (the “anchor mission”). Screening
patients for the social determinants of
health can identify those at risk and guide
health systems to influence community
investments. Clinicians can also engage in
innovative delivery models that allow care
historically oered in the acute setting to be
delivered in the community (for example,
using remote physiological monitoring and
mobile apps.)
Intervention category Level of action
Individual practice Healthcare organisation Professional/regulatory/government
Primary and community
care services
• Connect patients with primary and community care, ensuring
access for centralised, lifelong continuity
• Shi care to home services
• Expand home care services (remote monitoring, virtual care
when appropriate)
• Develop technology to facilitate communication between acute,
primary, and community services
•Improve remuneration for primary care providers and reduce
workforce shortages
• Universal healthcare
Reduce demand for health services
Social determinants of
health
• Support an anchor mission through connecting patients with
community and social services (eg, food banks, churches,
homeless shelters, home energy retrot schemes, income
assistance, and vocational training)
• Volunteer with free, aordable clinics
• Social and nature prescribing
•Adopt anchor mission mandate; establish community networks
and tools that support clinicians in connecting patients with them
• Provide food and transportation vouchers
• Develop free, aordable clinics for the uninsured and
underinsured
• Promote anchor mission model; work with local governments to
establish aordable housing and public transportation
• Address food deserts (eg, establish farmers’ markets and new
business incentives)
• Universal healthcare
• Climate change mitigation and resilience
Health promotion,
disease prevention,
and chronic disease
management
• Exemplify and promote clinician wellness (eg, healthy diet,
exercise, and stress reduction)
• Prescribe integrative therapies (eg, yoga, meditation,
chiropractic, and massage)
•Social and nature prescribing
•Violence screening
• Provide preventive services (smoking, alcohol, and illicit drug
screening, counselling and cessation aids; vaccination education
and provision; reproductive health)
•Person centred care, co-production/patient empowerment as
active partners in care
•Oer healthy diet options
• Allocate resources (funding, sta and space) for preventive
services (smoking, alcohol, and illicit drug cessation; vaccinations;
reproductive health)
• Identication and targeting of at risk groups for major diseases
• Early diagnosis and intervention in chronic/progressive disease
• Secondary and tertiary prevention (such as falls prevention
services)
• Promote sta health and wellbeing (eg, through mental health
awareness training, ethical employment practices, access to green
space, encouraging active travel and healthy diets)
• Fair compensation of health professionals for health promotion
and preventive services
• Urban infrastructure to promote health and wellbeing (pedestrian
and cycling lanes; green spaces)
• Taxation to discourage unhealthy behaviours
• Gun control policies
•Infectious disease/zoonosis prevention and control
•Clean air quality standards
• Heat and air quality index alerts
• Air conditioner vouchers
• Professional guidance and facilitation to support low carbon care
Table1 | Continued
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In light of the many harms resulting from
inappropriate delivery of health services,
clinical decision making should be viewed
through a stewardship lens—that is, the
careful and responsible management
of healthcare resources entrusted to
providers. Instead, evidence indicates
widespread overuse of resources such as
medical supplies, medications (beyond
opioids and antibiotics),9 and laboratory
and radiological investigations.10
Globally, a quarter of the total volume
of healthcare services is low value.7
Solutions include clinician education
and empowerment, development of and
adherence to evidence based standards
of care that incorporate environmental
harms, de-adoption11 of low value care,
shared decision making, care coordination,
and continuous quality improvement,
all grounded in a fundamental duty
of resource stewardship and care for
planetary health.
Evidence and education
Formal education should include training
in planetary health and stewardship princi-
ples.12 Continuing education is required to
remain up to date on best practices, as well
as indications for specific tests and inter-
ventions. The ability to critically appraise
evidence, extrapolate findings to appro-
priate patient populations, and identify
industry influence or conflicts of interest is
essential to providing high value care.
By keeping their knowledge thorough
and current, health professionals can
protect against “technology creep”—the
application of technologies or treatments
to expanded indications without
supporting evidence. New evidence or
alternative technologies can also result
in existing technologies or practices
becoming inappropriate or obsolete,
necessitating de-adoption strategies.11 A
core driver of resource misuse is ignorance
of the evidence and failure to change
practice.
13
This is compounded by ethical
failures around resource stewardship
and lack of appreciation of the rapid
rate of environmental degradation and
healthcare’s contribution to it.
It is also important to understand the
risks and benefits of different options,
including non-pharmacological and non-
invasive approaches. This knowledge
can help patients to have appropriate
expectations of what is knowable and
treatable. Rather than striving for “zero
harm,” which is unattainable and results
in unintended consequences, clinicians
should embrace risk reduction.14 A risk
reduction approach considers implications
for both the individual patient and society,
including from consumption of finite
resources and pollution generation.
Health professionals must apply
current evidence, critically evaluating the
likelihood that results of available tests
will inform management decisions or that
treatments will achieve desired outcomes.
If early detection has no benefit, patients
should be spared the inconvenience and
anxiety of close screening or surveillance
and the potential harm from treating false
positive findings. Eective communication
is essential to dispel mistaken notions that
resource stewardship is synonymous with
withholding care.
Shared decision making
Shared decision making involves clinicians
helping patients incorporate personal val-
ues and preferences into the weighing
of risks and benefits to arrive at tailored
solutions that best meet their needs. This
requires an appreciation of the harms
of overdiagnosis and overmedicalisa-
tion. Shared decision making embraces a
biopsychosocial approach to care and hon-
ours patient goals, tending to result in less
inappropriate disease focused treatment
(for example, chemotherapy at end of life,
and stenting in stable coronary artery dis-
ease).13 Studies of shared decision making
aids have shown that 20% of elective pro-
cedures would be unwanted if patients had
access to understandable, relevant clinical
information.13
Care coordination
Inadequate communication and coordi-
nation between providers lead to dupli-
cated and unnecessary services because of
incomplete information about a patient’s
history and current circumstances. Seam-
less and adequate communication between
primary care providers and specialists, and
between specialty services such as in multi-
disciplinary cancer teams, avoids unneces-
sary care, improves safety, and provides a
better patient experience. Barriers to this
coordination can be reduced by dedicated
sta and supporting technology such as
shared access to electronic health records
among dierent healthcare organisation
networks and non-aliated practices.
Institutional structures to drive high value
care
Clinicians can work with their healthcare
organisations to develop and implement
structures that promote adherence to evi-
dence based best practices and discourage
wasteful practices. Restrictions on antibi-
otic and opioid ordering,
15
automatic stop
dates on laboratory investigations, and
alerts for high fresh gas flow during anaes-
thesia embed stewardship into electronic
health records.
Institutional policies—for example,
those that recommend against routine
prophylaxis for stress ulcers (which data
show is harmful16) or restrict access to
desflurane (because of its disproportionate
climate impact17), hasten the uptake
of knowledge of harms and facilitate
de-adoption of low value care. Specialist
teams can standardise aspects of inpatient
care and ensure up-to-date best practice
through electronic decision support and
benchmarking tools.
Developing clinical practice guidelines
through professional societies lessens the
responsibility on individual clinicians and
confers a degree of medicolegal protection.
Similarly, hospital policies and procedures
can diuse decision making responsibility,
removing pressure that drives clinicians to
practise defensive medicine or relieving
ethical dilemmas around appropriate
allocation of limited resources and end-
of-life care, as happened in the covid-19
pandemic.18
Continuous quality improvement
Environmental performance should be
integrated into the core definition of quality
care, with best practices established for cli-
nicians and health systems and reinforced
through regulatory and oversight processes
that overcome obstacles to change. Inves-
tigations of appropriateness of care and
resource consumption lend themselves
to quality improvement initiatives, which
can be designed, initiated, and carried
out by individual clinicians within their
professional settings. Electronic health
records can provide feedback to clinicians
on resource use, costs, and emissions,
to gauge performance and drive quality
improvement.19
Reducing demand for health services
Reducing demand for health services
requires tackling drivers of poor health.
In the United States, over 50% of health-
care services are devoted to the 5% of the
population with advanced chronic dis-
ease.20 Most advanced disease develops
in people who had risk factors or early
stages of illness that were preventable or
reversible, often through behavioural and
lifestyle approaches alone.21 Furthermore,
healthcare services contribute to only 20%
of health and wellbeing, with the remain-
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der being the result of broader social, eco-
nomic, ecological, and political factors.
22
However, current healthcare strategies
routinely neglect social determinants of
health, missing opportunities to reduce
the burden, expense, and environmental
effect of chronic disease. An integrative
healthcare framework offers a potential
solution.23
Integrative healthcare is the delivery
of non-pharmacological and lifestyle
approaches to disease prevention
and treatment in coordination with
conventional treatments of chronic
disease.24 Smoking cessation, reducing
use of drugs (including alcohol), and
better dietary habits, activity levels, and
stress management can prevent or mitigate
many chronic diseases.7 Evidence based
approaches such as yoga, acupuncture,
massage, and mind-body practices are
particularly useful for pain reduction
and more appropriate than medications
(especially opioids) for chronic pain.
25
As
part of primary care, these approaches oer
opportunities to intervene upstream in
health promotion and disease prevention.
23
While these behavioural and social
determinants are not the sole responsibility
of healthcare services, helping patients
better engage and manage them could
go a long way towards reducing the need
for more expensive and environmentally
damaging interventions later.
Prescribing nature based interventions
and activities such as local walking
groups, community gardening, and
food growing projects can help meet
health needs. Benefits of green time are
most researched in mental health, with
protected areas worldwide estimated to
be worth the equivalent of $6tn (£4tn;
€5tn) annually in mental health services.
26
Recommending patients engage socially in
local community services can help tackle
some of the social determinants of health
such as food insecurity and social isolation.
Closing the information and practice gap
Environmental engineering tools and meth-
ods to quantify carbon and other environ-
mental emissions are well established, and
life cycle assessment is the gold standard
in healthcare sustainability research.27
Although the emissions and public health
damages from low value care are not yet
known, it stands to reason that reducing
unnecessary care would reduce emissions
and costs, provided that the emissions
intensity of required care is simultaneously
reduced.
The process of mobilising the clinical
community around planetary healthcare
requires a concomitant investment
in knowledge generation to identify
environmentally preferable practices,
establish evidence around high value
care, and guide public policy for optimal
population health. Clinicians should take
the lead in advancing this research agenda,
while healthcare institutions, universities,
and funding bodies must support the work
by prioritising planetary health mandates
and providing appropriate resources.
Competing interests: We have read and understood
BMJ policy on declaration of interests and have no
interests to declare.
Provenance and peer review: Commissioned;
externally peer reviewed.
This article is part of a series commissioned byThe
BMJfor the World Innovation Summit for Health
(WISH).The BMJpeer reviewed, edited, and made
the decisions to publish. The series, including open
access fees, is funded by WISH.
Jodi D Sherman, associate professor1
Forbes McGain, consultant2,3,4
Melissa Lem, clinical assistant professor5
Frances Mortimer, medical director6
Wayne B Jonas, clinical professor7,8,9
Andrea J MacNeill, clinical associate professor10
1Department of Anesthesiology, Yale School of Medicine,
Connecticut, USA
2Western Health, Footscray, Melbourne, Australia
3Department of Critical Care, University of Melbourne,
Melbourne, Australia
4School of Public Health, University of Sydney, Sydney,
Australia
5Department of Family Practice, University of British
Columbia, Vancouver, Canada
6Centre for Sustainable Healthcare, Oxford, England
7Samueli Integrative Health Programs, Corona Del Mar,
CA, USA
8Georgetown University School of Medicine, Washington,
DC, USA
9Uniformed Services University, Maryland, USA
10Department of Surgery, University of British Columbia,
Vancouver, Canada
Correspondence to: J D Sherman
jodi.sherman@yale.edu
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permits others to distribute, remix, adapt, build
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