Sustainability – what can we in health services do?
This appears to be a common question, perhaps indicating that the debate has moved on from questioning the scientific basis for both climate change and the data around environmental damage caused by human activities such as ocean acidification. These are of course global issues which can make one feel powerless. This need not be so.
In June 2015, The Lancet argued:
“tackling climate change could be the greatest health opportunity of the 21stcentury”
If this is so, then we could play an important role in both climate change and health.
This Lancet report followed on from Pope Francis’s encyclical
‘Laudato Si – care for our common home’.
The National Health Service Sustainable Development Unit(NHS SDU) welcomed the Lancet’s publication and argued that:
“The health sector can play a real role in making sure that its activities promote lower carbon and a more resilient infrastructure. This holds true in relation to every part of the sector including travel and transport systems, in relation to building infrastructure and through the procurement of products and services”.
This sets the context for us, but what can we actually do? First of all, we could consider those sectors of the health service in which that the SDU outline action can take place and ask what roles we can play, if at all in each.
A start would be to consider what level we can work at:
- On a personal level:
- Understand the facts: for example, learn what ‘carbon footprint’ means and what your personal footprint is. Access the resources published by The Lancet and the National Health Service Sustainable Development Unit. Access the literature on the subject. Understand the social-political and ecological determinants of health.
- Reflect on your values and assumptions about what the good life means on this planet. Consider the effects of consumerism, materialism and individualism on the quality of human relationships and our relationship to nature. Consider if modern culture is sustainable in its current form.
- Eat better: e.g. reduce your intake of red meats; perhaps try to cut out/down on processed/packaged foods; shop for locally and seasonally produced foods.
- Drink better: Consider your use of bottled water. See the ‘Story of Stuff’
- Move better: g. use public transport walk more, reduce your use of the car, buy a bicycle (called ‘active transport’).
- Communicate better: make full use of digital technologies.
- On an organisational level:
- Consider the core aspects of energy,travel,food, gases and drugs, waste, and medical devices.
- Energy: Between 2007/08 and 2013/14 the NHS carbon footprint in relation to building energy use dropped by 3.5% despite increases in activity of 13%. The decrease represents around £50m of energy costs for the NHS in England in 2013/14. Action: is there a plan for your clinical area to address energy consumption? Are you involved in innovations to reduce carbon emissions and increase renewables? Work with your organisation’s carbon reduction team (if it has one) or consider getting a carbon reduction team developed if it does not.
- NHS Derbyshire Community Health Services saved more than 3,000 hours of staff travel time, 20 tonnes of carbon, and over £100,000 by using teleconferencing services. Action: consider how patients and staff travel to and from services and whether it is always necessary.
- Nottingham University Hospitals NHS Trust shows how part of the health system can lead sustainable food systems. It serves fresh, healthy meals made with local, seasonal and organic ingredients. Action: find out where your food comes from and what it is? Discuss nutrition and food choices with your patients.
- Gases and medicines. The use of anaesthetic gases represents 5% of acute hospital CO2e emissions. These could be reduced with lower flow rates or substituted for instance moving away from nitrous oxide. Inhalers which represent 4.3% of the English health and care sector’s footprint could be replaced by a pulverised form as in Scandinavian countries. New meter dose inhalers without high environmental impact propellants could save nearly 7 million tCO2e over five years. Medicines are often a cornerstone of our health response be this through immunisations, diagnostics or therapeutic drugs. It is however sometimes more effective to prescribe physical activity, dietary changes or talking therapies. The pharmaceutical industry is similarly keen to help reduce environmental impacts involved in the production, use and disposal of medicines so are already important partners in this journey. Action: Find out about these practices if they apply to you, work with colleagues to address these issues.
- Contaminated waste. The health sector produces waste in vast quantities, some of which is contaminated and needs to be separated and disposed of effectively. We hold the key to doing this effectively and safely as well as reducing environmental impacts. Action:review waste management practices in your clinical area, search the literature for new approaches to waste. Find out what the waste processis and what it costs and how it is segregated.
- Medical devices. The use of multi-use or single-use items, balancing the ethical sourcing and material use with decontamination and/or recycling approaches needs to be fully understood and effectively implemented to minimise both visible and hidden costs and environmental impacts. Work with organisations such as the Infection Prevention Society on issues such as single use.
- The SDU argues “The very nature of our business which is now considered unsustainable economically, environmentally and socially means that we need to focus on improving health and reduce our reliance on acute settings. The NHS Five Year Forward View is addressing some of these through the development of Vanguard sites and it would be exemplary to be able to demonstrate the benefits in environmental and social terms too”.
- On a national/international level:
- Get involved with the help, support and action groups such as the Climate and Health Council and the National Health Service Sustainable Development Unit and the Centre for Sustainable Healthcare (UK)
- Network with Nurse action groups internationally such as the Alliance of Nurses for Healthy Environments (USA).
- Engage in civic and political action to understand and address the social, political and ecological determinants of health.
- Contact your local and national political representatives to let them now that climate change and health are priority issues
- Consider joining lobby groups such as 38 degrees
- Lobby for public transport, renewable energy sources, better cycling infrastructure.
We may wish to see this as a menu of choices for tackling climate and health, but remembering always climate change and carbon emissions are only one aspect of sustainable healthcare. We have to consider the economic, socialand other environmental aspects of sustainability as well. This is because social and political inequalities adversely affect the health of individuals, communities and populations.
We need to consider whether the global economic system is fair, just, equitable and is not a cause of environmental damage. There are concerns over social inequalities leading to health inequalities adversely affecting those lower down on the socio-economic scale. This takes us away from clinical considerations and into socio-political debates about how global governance affects human health and well-being. Another Lancet commission report questions whether the current system is fit for that purpose.
Selby’s 10 propositions.
David Selby, in 2007, produced 10 propositions for the education sector that might be useful as another framework for action in other areas:
- Confront denial(of climate change, health crises) by challenging our own base assumptions, knowledge and responses. We need to feel unease at the current situation. We should reflect on the potential for a very different world in which current cultural assumptions will not hold up to be true. For example, a belief in progress, and that our children will have a better standard of living, may not happen.
- Given the threat to human health, we need to address personal issues despairr, grief, loss. Once some of the facts are known, we may have to make a personal journey through challenging long-cherished worldviews, hopes and dreams. Our perspectives may have to shift to embrace wider loss and grief issues that flow from climate change.
- Shift to a holistic dynamic understanding of the relationship between humans and nature is an end in itself, not a means to an end. We may already have a holistic understanding of human health and approaches to care, but this goes beyond the individual to embrace the social and the natural. Health is too often reductive, i.e. it is reduced to body parts and systems existing as separate entities from other bodies and the physical environment. It is also thus individualistic, being located within a single individual’s body. Within this reductive individualised view of health people can still view themselves as healthy in a:
“disintegrating family, community or a destroyed or poisoned ecosystem”(Wendell Berry p89). A holistic dynamic view of health refutes this position.
- Cultivate a poetic understanding alongside a rational understanding – we need to develop awe, celebration, enchantment, reverence as well as classification, prediction, evaluation and exploitation of nature. This mirrors the ongoing debate within education concerning the art/science dichotomy and would provide another useful lens to address the need for scientific competence and artistic appreciation and application in praxis. There needs to be space to allow this and perhaps even academic credit?
- Marginalised ‘educations’ will be important, e.g. the field of non–violence. Rather more challenging for some fields of health care such as acute hospital care but may well be core to therapeutic approaches within mental health.
- Given the heating – sustainable and emergency education need to come together. Social dislocation, hunger, environmental disaster, tribalism necessitates nursing action that can respond, e.g. global citizenship, peace education, conflict resolution, anti-discriminatory education. Health care staff may well be key professionals in dealing with emergencies and disaster management and thus education and training that explicitly addresses these skills may well be valued and developed.
- Alternative ideas of what ‘the good life’means need exploring: Again this could be core to philosophy especially within the contexts of mental health and palliative care and living with long-term or life-limiting conditions.
- Rethinking notions of democracy, citizenship and sustainability could be part of the professional responsibilities of healthcare staff. ‘Global citizenship’ could be a core feature.
- Shift from atomistic/reductionist thinking to holistic ways of mediating reality. This means that we change our paradigms, our worldviews away from focusing on the individual as the core unit of being, to understanding that the individual cannot exist without community and nature. They are indivisible.
- Finally, Selby asks:
“Everyone has to understand and come to terms with the fact that we are threatening our own existence. To confront this requires a Copernican revolution in aims, structures, processes of education and perhaps in the loci of learning... as the heating happens, education and educational institutions ... will be deeply disrupted and if unresponsive to the need for transformation, will disintegrate as people find other more relevant loci for learning what they have to learn”.
Although this is written for education, in general, it is a challenge to all of us.
So what can we do?
Health care is an ethical practice and we are asked to address the health not just of individuals but of communities and populations. Health education, promotion and public health are core to much of healthcare practice. Healthcare organisations have accepted both environmental issues and climate change as a health threat. All health services need to save money and use resources better. Population health would improve through adopting low carbon lifestyles. Clinical leaders can assist in the transition from unsustainable health care delivery and lifestyles towards sustainable health care as they are on the ground and would be able to see where innovations and changes could be made.
The 6 Rs:
- Read – widely, inform yourself.
- Reflect – on your personal values, assumptions and beliefs.
- Revise – current ways of working.
- Renew – yourself, your workplace, your community.
- Reconnect – to your family, community, your social and political networks.
- Remember- this will not be easy.
Barna, S, Goodman, B. and Mortimer, F. (2012) The health effects of climate change; what does a nurse need to know? Nurse Education Today. 32(7) pp 765-71
Goodman, B. (2013) The Role of the nurse in addressing the health effects of climate change. Nursing Standard. 27 (35) pp 49-56
Griffiths, J. et al (2009) The Health Practitioner’s Guide to Climate Change. Earthscan. London.
Lang T and Rayner G (2012) Ecological public health: the 21stcentury’s big idea? British Medical Journal 345:e5466 doi 10.1136/bmj.e5466
Copyright © Benny Goodman 2018.
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Benny Goodman has asserted his right under the copyright, Designs and Patents Act 1988 to be identified as the author of this work.