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The sustainable physician

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The sustainable physician

110 © Royal College of Physicians, 2010. All rights reserved.
Clinical Medicine 2010, Vol 10, No 2: 110–11
EDITORIALS
A low-carbon health service will:
be better at preventing illness
give greater responsibility to patients in managing their
health
be leaner in service design and delivery
use the lowest carbon technologies.
The public funding of medical care inevitably diverts
resources from health-sustaining investment in education,
social welfare and housing. In return, health services are
asked to demonstrate a measure of cost effectiveness. The
provision of medical care, however, incurs not just financial
costs, but also significant environmental ones, in the form of
greenhouse gas emissions, pollution of air and water, changes
to land use, and so on. This could be viewed as spending eco-
logical capital, which is equally essential to population
health.
Just how important the environment is to health (or per-
haps how vulnerable it is to human-induced change) is only
lately being broadcast in the medical world. Climate change is
the clearest example. On World Health Day 2008, the director
general of the World Health Organization, Margaret Chan,
forecast an increase in deaths worldwide from malnutrition,
diarrhoea and infectious disease attributable to climate
change.1More recently, the UCL–Lancet Commission has
pointed to even greater probable impacts from population
displacement and armed conflict over productive land,
describing climate change as ‘the biggest threat to global
health in the 21st century’.2
The medical profession can therefore be seen as having a
particular responsibility to lead the fight against climate
change. Moreover, in the context of global agreements and
national legislation on carbon reduction, the health sector
will in any case be forced to reduce its emissions. In the UK,
from April 2010, NHS trusts will already be subject to the
government’s Carbon Reduction Commitment (CRC),
requiring them to pay up front for each year’s energy-
related carbon emissions.3The NHS’s own carbon reduc-
tion strategy, based on the national targets set by the
Climate Change Act 2008, commits the health service to
more than 80% reduction in emissions over the next three
decades.4
In the near future, environmental cost effectiveness will
become as important as financial cost effectiveness in medical
care.
What are the environmental costs of healthcare?
A study of the carbon emissions of NHS England found that,
in 2004, it was responsible for the emission of 18 million
tonnes of CO2– 3% of the UK total.5The greatest part of this
was not from heating and lighting, but from NHS purchasing
of goods and services, which use energy in their manufacture
and delivery. One of the most unexpected findings in the study
was the 4.06 million tonnes of CO2attributed to the procure-
ment of pharmaceuticals.
The implication is that sustainability is not just about effi-
ciency of NHS buildings: through use of equipment and con-
sumables, clinical care itself is responsible for the greatest envi-
ronmental impacts. Even the number of patient journeys and
the demand for building capacity are not immutable but are
the product of clinical decisions. If the NHS carbon reduction
targets are to be achieved, new low-carbon models of care are
needed.
How can clinical medicine respond?
Once the contribution of clinical activity to environmental
impact is recognised it becomes clear that wasted or low-value
activity is a double sin – triple, if you count the risks to patient
safety. Correspondingly, the use of‘lean principles’ to eliminate
duplications and poorly targeted investigations brings rewards
not just to finances, patient experience and safety, but also to
the environment. Provided, of course, that the savings are not
reinvested in carbon-intensive care.
Yet, the scale of transformation required demands that clin-
ical leaders think imaginatively and go beyond small efficiency
measures, to decouple patient outcome from resource use, and
create a service which is health promoting as well as skilled in
responding to immediate clinical need.
Four principles of sustainable clinical practice
The Campaign for Greener Healthcare has identified four prin-
ciples which underpin sustainable clinical practice. These are:
1Disease prevention and health promotion. All clinicians
should be involved in prevention. Through broader advo-
cacy and in individual patient care, specialties should aim
to tackle underlying causes of disease – the social,
economic and environmental determinants of health.
Where possible, interventions should capture environ-
mental co-benefits of healthy lifestyles, such as the
improvements in air quality and carbon emissions from a
shift to active travel.
Frances Mortimer, medical director, The Campaign for Greener
Health
The sustainable physician
Frances Mortimer
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The sustainable physician
© Royal College of Physicians, 2010. All rights reserved. 111
2Patient education and empowerment. To reduce disease pro-
gression and pre-empt complications, many patients could
be empowered to take on a greater role in the management
of their own health and healthcare. Informed patients are
also well placed to improve the coordination between clin-
ical teams and reduce misunderstandings or duplication.
3Lean service delivery. Improving clinical decision-making in
the selection and targeting of interventions will reduce
lower value activities and their associated environmental
impacts. Specialties can support this by describing the rele-
vant patient pathways and providing clear, evidence-based
guidance. Even where clinical input is of high value, a greater
use of online records, email and telephone can reduce travel
emissions by moving information in place of patients, staff
and laboratory samples. Further efficiencies can follow from
better integration of specialist services, such as diabetes,
cardiovascular and renal care, which have a common patient
base.
4Preferential use of treatment options and medical technologies
with lower environmental impact. Inclusion of sustainability
measures in the evaluation of medical technologies will
allow service planners, clinicians and patients to choose
clinically effective treatments with the best environmental
profile and will encourage their further development.
Sustainable specialties
In February 2009, senior clinicians and policy makers from
kidney care attended a green nephrology summit. A number of
existing initiatives were discussed, including dialysis water
recycling, heat exchangers, reduction of packaging and virtual
clinics, but it was clear that there was no shared learning or sys-
tematic approach to sustainability within the specialty. The
solution was a green nephrology fellowship, funded by NHS
Kidney Care and managed in partnership with the Renal
Association, the British Renal Society and the Campaign for
Greener Healthcare. Now in post, the green nephrology fellow
(a renal trainee) is tasked with exploring the environmental
impact of kidney care, building a network of green champions
and developing a toolkit for increasing the sustainability of
renal units.6Several other specialties are now preparing their
own Green Summits.
In a low-carbon future, the provision of high-quality care to
patients depends absolutely on the transition to low-carbon
models of care. Achieving this goal will require innovation,
leadership, and a systems approach – health services designed
around the needs not of institutions but of patient groups. The
green nephrology project provides a model for specialties to
take a lead.
References
1 Chan M. The impact of climate change on human health.Geneva:
WHO, 2008. www.who.int/mediacentre/news/statements/2008/
s05/en/index.html
2 UCL – Lancet Commission. Managing the health effects of climate
change. Lancet 2009;373:1693–733.
3 Department of Energy and Climate Change. Consultation on the
draft order to implement the Carbon Reduction Commitment.London:
DECC, 2009. www.decc.gov.uk/en/content/cms/consultations/crc/
crc.aspx
4 Sustainable Development Commission and Stockholm Environment
Institute. NHS England carbon emissions: carbon footprinting report.
2008. www.sd-commission.org.uk/publications/downloads/
NHS_Carbon_Emissions_modelling1.pdf
5 NHS Sustainable Development Unit. Saving carbon, improving
health: NHS carbon reduction strategy for England.London:
Sustainable Development Unit, 2009. www.sdu.nhs.uk/
page.php?page_id=94
6 Connor A, Tomson C, Mortimer F. Renal medicine can take the lead
in greener healthcare. Br J Ren Med 2009;14:19–22.
Address for correspondence: Dr F Mortimer,
The Campaign for Greener Healthcare,
Knowledge into Action, Summertown Pavilion,
Oxford OX2 7LG.
Email: frances.mortimer@kintoa.org
CMJ1002-Mortimer_ed.qxd 3/12/10 9:56 AM Page 111
... Four "principles of sustainable clinical practice" were identified by the Campaign for Greener Healthcare with the aim of decreasing the need for healthcare interventions and the ecological footprint of necessary activities, while maintaining high standards of care. 24 These four sustainable principles are : disease prevention and health promotion, patient education and empowerment, lean systems and pathways and preferential use of technologies and interventions with lower environmental impact. 22,24 To embed sustainable principles into every day clinical practice, gastroenterological scientific societies should also create quality certificates for the accreditation of endoscopy services that also provide a "green suite" certificate, indicating the protocols and sustainability standards adopted. ...
... 24 These four sustainable principles are : disease prevention and health promotion, patient education and empowerment, lean systems and pathways and preferential use of technologies and interventions with lower environmental impact. 22,24 To embed sustainable principles into every day clinical practice, gastroenterological scientific societies should also create quality certificates for the accreditation of endoscopy services that also provide a "green suite" certificate, indicating the protocols and sustainability standards adopted. The "green suite" certificate would be easy to institute, inexpensive and would promote lower production levels and higher recycling levels of waste. ...
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... This can be interpreted as a sign of low self-efficacy, suggesting that medical students have not yet fully realized the substantial amount of emissions they will be responsible for as a part of the healthcare sector, as well as their potential for decreasing these emissions. Examples of possible actions they can take in the future include counseling their patients on environmentally friendly behavior, promoting health, avoiding medical overuse, and giving preference to treatment options and medical technologies with a lower environmental impact [52]. As future medical professionals, the participants will hold a central role in decreasing healthcare's sizeable contribution to global greenhouse gas emissions, a need that urgently has to be addressed by all of the healthcare systems around the globe [53]. ...
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Renal medicine can take the lead in greener healthcare
  • A Connor
  • C Tomson
  • F Mortimer
Connor A, Tomson C, Mortimer F. Renal medicine can take the lead in greener healthcare. Br J Ren Med 2009;14:19-22.
UCL -Lancet Commission. Managing the health effects of climate change
UCL -Lancet Commission. Managing the health effects of climate change. Lancet 2009;373:1693-733.
Saving carbon, improving health: NHS carbon reduction strategy for England. London: Sustainable Development Unit
  • Nhs Sustainable Development
  • Unit
NHS Sustainable Development Unit. Saving carbon, improving health: NHS carbon reduction strategy for England. London: Sustainable Development Unit, 2009. www.sdu.nhs.uk/ page.php?page_id=94