Reducing the carbon footprint of hospital-based care
====================================================

* Charlie Tomson

## ABSTRACT

Climate change, driven by man-made greenhouse gas emissions, is a major threat to the health of this and future generations. Hospital-based healthcare generates large quantities of greenhouse gas emissions. Reducing the carbon footprint of healthcare requires direct action to reduce waste and energy use, but also requires radical reform of care pathways so that the only patients who come to or stay in hospital are people whose healthcare cannot safely be delivered closer to home. Achieving these reforms without major structural changes to the financial flows in the NHS will be extraordinarily difficult.

KEYWORDS 
*   Climate change
*   carbon footprint
*   care pathways
*   service redesign
*   waste
*   patient-centred care

## Introduction

There is now no reasonable doubt that anthropogenic climate change is happening1–3 and that it will have profound adverse consequences for human health worldwide – particularly in under-developed countries that have done least to contribute to greenhouse gas emissions.4–5 Healthcare professionals and planners have been slow to accept responsibility for taking action to mitigate climate change. Environmental sustainability should be included alongside safety, timeliness, effectiveness, efficiency, equity and patient-centredness as the seventh dimension of the quality of healthcare.6,7 The hospitals of the future have major opportunities to mitigate climate change – both directly, by reducing their own carbon footprint, and indirectly, by influencing others in the societies they serve to do so. Even if the required actions do nothing to influence the future climate, they will contribute significantly to the financial sustainability of the service.8

## Direct actions on greenhouse gas emissions

The healthcare industry itself is responsible, in England, for 18 million tonnes of CO2 emissions. This amounts to 30% of total public sector greenhouse gas emissions, and 3.2% of the total CO2 emissions of the country as a whole. Of these emissions, 22% come from building energy use, 18% from travel (of patients, visitors, and staff), and 59% from procurement9 (Fig 1). The acute sector contributes disproportionately to these emissions – for instance, acute Trusts are the source of 65% of total NHS CO2 emissions relating to building energy use. The CO2 emissions from the NHS in England are greater than the total emissions from all aircraft departing from Heathrow airport.8

![Fig 1.](http://www.rcpjournals.org/https://www.rcpjournals.org/content/futurehosp/2/1/57/F1.medium.gif)

[Fig 1.](http://www.rcpjournals.org/content/2/1/57/F1)

Fig 1. 
The carbon footprint of the NHS. Reproduced with permission from the NHS Sustainable Development Unit.9

### Direct energy use

The most obvious way in which hospitals can contribute to reduction in greenhouse gas emissions is to reduce energy use – for instance by taking actions on insulation, heating and lighting, by switching computers and monitors off when not in use, etc. Many estates departments have already achieved major financial savings, as well as carbon savings, in this way. Modern hospital architectural design can achieve major savings in this area, as discussed in greater detail in article by Sadler and Guenther in this issue.10 The NHS Sustainable Development Unit ([www.sduhealth.nhs.uk](http://www.sduhealth.nhs.uk)), Global Green and Healthy Hospitals ([www.gghhconnect.net](http://www.gghhconnect.net)) and the Campaign for Sustainable Healthcare ([www.sustainablehealthcare.org.uk](http://www.sustainablehealthcare.org.uk)) websites provide numerous resources and case examples. A recent report from the World Health Organization identified seven elements of a climate-friendly hospital (Box 1). #### Seven elements of a climate-friendly hospital.11

  
</br>![][1]</img>

Many of the changes required to reduce direct energy use will also save money.8 Money talks in the NHS: if individual directorates were provided with regular information on their energy expenditure (as they currently are with financial expenditure), and allowed to share in the some of the savings made, change would probably happen more rapidly.

Staff travel contributes significantly to the carbon footprint of healthcare. Hospitals should encourage active transport (walking or cycling) by collaborating with local authorities on suitable routes and by provision of secure cycle storage and shower/changing facilities; use of public transport (by collaboration with local providers); and car-sharing schemes. For those staff for whom car transport remains necessary, reimbursement and parking provision should incentivise use of low-carbon options such as electric or hybrid cars. Money talks: the practice of providing higher mileage reimbursement for users of cars with larger engine size should cease, or be reversed so that staff using low-carbon cars receive higher reimbursement per mile than those using ‘gas-guzzlers’. Free parking for low-carbon cars could provide an additional incentive.

Wherever possible, travel should be avoided, by better use of virtual meetings using teleconference, videoconference and web-enabled meeting facilities.12

Key actions from the NHS Sustainable Development Unit's report *Low carbon travel, transport, and access* are shown in Box 2.

#### Key actions from the NHS Sustainable Development Unit report *Low carbon travel, transport, and access*.12

  
</br>![][2]</img>

### Waste reduction

Hospital care produces large amounts of waste, with operating theatres contributing a large proportion.13–16 Disposal of ‘biohazard’ waste requires high-energy disposal processes, including incineration: putting potentially recyclable waste into a ‘biohazard’ container is therefore doubly wasteful. However, waste reduction is about much more than recycling. A recent comprehensive review from the Academy of Medical Royal Colleges provided seven recommendations and numerous case studies (Box 3). #### Recommendations made by the Academy of Medical Royal Colleges’ report on cutting waste in clinical care.17

  
</br>![][3]</img>

Each specialty has its own carbon footprint, and its own opportunities to save money and carbon. In nephrology, for instance, the carbon footprint of dialysis has been characterised fully.18,19 Examples of how money and carbon might be saved include the use of heat exchangers on dialysis machines, and the use of centralised dialysate supply or on-site preparation of dialysate (either of which avoids the use of large quantities of plastic containers to deliver dialysis concentrate to each machine). Re-using the reject water from reverse osmosis plants used to prepare ultra-pure water for haemodialysis can also save huge amounts of water.20 If all kidney units adopted all of the ‘sustainable’ practices collated in a recent survey using the green nephrology network, annual savings could amount to £7m, 11,000 tonnes of greenhouse gases (CO2 equivalent), and 470 million litres of water.21

### More efficient use of NHS buildings

According to a recent King's Fund report,22 the NHS occupies 28.4 million square metres, excluding primary care premises – more than 10 times the area of the City of London. Currently, models of care are designed around these buildings. Many of the older buildings are unfit for purpose; many of the newer ones have been built under Private Finance Initiative contracts that severely limit the flexibility with which the buildings can be used. New care pathways (discussed below) will require new buildings designed for flexible use. Achieving this will require a revolution in how the NHS manages its estates.

## Indirect actions to reduce greenhouse gas emissions

### Reduction in pharmaceutical use: ‘primum non nocere’

Procurement of pharmaceuticals contributes 22% of the entire carbon footprint of the NHS.9 Actions that could reduce the carbon and financial cost of pharmaceuticals include: 

*   reducing waste associated with medications that are sent to the ward but not used before their expiry date16

*   using the patient's own drugs during inpatient episodes16

*   shared decision-making: ensuring that patients share in the decision to take a particular treatment before prescribing and dispensing it – although the evidence that any intervention can improve adherence remains weak23

*   using ‘starter packs’ for new medication, so that only a short supply of treatment is wasted if the patient doesn't tolerate it

*   carrying out regular medication reviews: poly-pharmacy and inappropriate prescribing are common amongst the elderly.24–28 One study suggested that drug withdrawal (de-prescribing) in nursing home residents was associated with substantial reductions in 1-year mortality (21%, compared with 45% in a control group) and hospitalisation.24 A 2014 Cochrane review concluded that interventions to improve poly-pharmacy in older people reduced inappropriate prescribing, but with no convincing effect (in either direction) on mortality29 – evidence was of low quality, and further studies are needed.

### Sustainable procurement

The NHS has huge purchasing power: two-thirds of its carbon footprint is generated during the production of goods and services that it procures.30 NHS purchasers therefore have significant – but currently largely unused – power to influence their suppliers to ensure that these goods and services are produced in an environmentally sustainable way. Adopting a policy of purchasing food from local suppliers reduces the carbon footprint associated with transport of food, and supports the local economy. Similar advantages apply to the local purchase of many other consumables including office equipment. The NHS Supply Chain ([www.supplychain.nhs.uk](http://www.supplychain.nhs.uk)) provides a code of conduct that includes this statement: ‘We expect our suppliers to strive to support NHS Supply Chain's climate protection goals through the products and services they deliver (eg by providing relevant data on climate protection). In this regard, we also expect our suppliers to take climate protection appropriately into account in their own operations, for example by setting climate protection goals for themselves and achieving them.’31

### Influencing the local community

Hospitals have a major opportunity to influence public perception of the importance of environmental sustainability. Making a clear public commitment to environmental sustainability as a guiding principle in hospital design, purchasing policy, and in the design of care pathways sends a very clear message to employees, patients and visitors that the NHS considers climate change a real threat, and one that we can all do something about. Many hospitals now offer smoking cessation support to staff: the service is now being encouraged to take active steps to reduce obesity amongst its staff.32 Obesity itself carries a significant carbon footprint due to the higher food requirements of obese people and the increased fuel costs of transporting a heavier population.33 There are clear parallels here with how doctors’ changing attitudes to tobacco use eventually resulted in major reductions in smoking amongst the general public34 – with the difference that we cannot afford the 50-year delay between recognition of the problem and action to mitigate it.35

## Sustainable care pathways

Making future healthcare environmentally (and financially) sustainable is about very much more than switching off the lights and recycling: sustainability cannot be left with the Estates department. Reducing avoidable hospital admissions and reducing length of stay, for instance, will save both money and carbon. By some estimates, 60% of current hospital inpatients don't need to be in hospital.36

### Segregation of emergency and elective care

Current hospitals house three very different types of activity: outpatient consultations, emergency treatments, and elective surgery. There is no reason other than history and the convenience of some doctors that these three activities all need to happen in hospital. A strong case can be made for physical separation of elective surgery and emergency care, in separate buildings, so that maximum use can be made of operating facilities and beds; use of surgical beds (and the consequent cancellation of operating time) by emergency admissions causes waste of money and carbon.36 Although the Darzi ‘polyclinic’ idea was sold poorly,22 the basic concept remains sound: we would achieve better, cheaper, more environmentally sustainable healthcare if we created multi-purpose, flexible facilities for extended primary care teams, integrated community and social care staff, diagnostics, and specialist consultation.

### Telemedicine

Bringing people to hospital-based outpatient clinics for routine review can only be justified if the consultation provides sufficient added value.37 Every time a patient is seen in such a clinic, the clinician should ask themselves (and their patient) ‘what did we decide today that required a physical visit to the hospital?’ Diseases in which repeated physical examination by a specialist is required clearly require face-to-face consultations. Disorders in which management decisions are based on the history combined with laboratory or radiological investigation do not, on the face of it, require a face-to-face consultation – particularly if, as is commonly the case, the test or imaging results are not even available at the time of the visit. Bringing patients to clinic for ‘routine review’ so that the doctor can decide to order a test, followed by a review appointment in three months time so that the doctor is reminded to review the results of the test and make the next decision, sounds like a caricature – but is a frequent reality. This is not only poor care, but also shows institutional disrespect for patients and is wasteful of money and carbon.

There is no doubt that telemedicine could reduce the carbon footprint of healthcare.38 Particularly for patients with chronic disease who already know the doctor phoning them (for instance, kidney transplant recipients,39 the benefits far outweigh the risks. Whether telehealth generates *additional* benefits, for instance by increasing patient ‘empowerment’ or reducing readmission rate, remains less certain.40

### Improving the ‘empowerment’ of patients with chronic conditions

The majority of hospital inpatients are patients with multiple chronic conditions. There is high-quality evidence that patients who feel in control of their disease (empowered, or activated, patients) consume fewer healthcare resources, require fewer hospital admissions, and have better outcomes than those patients who remain passive recipients of healthcare.41–45 Association doesn't prove cause, however: higher activation scores are associated with higher educational attainment and socioeconomic status, which could be independently associated with different health behaviours. However, there is increasing evidence that low activation is a ‘treatable’ condition, and thus that interventions that improve patient's involvement and understanding of their own management can result in better outcomes – including lower utilization of hospital care46 and lower uptake of ‘preference-sensitive’ options.47 These findings put actions to improve patient engagement high on the agenda – both for the financial sustainability of the NHS32 and for its environmental sustainability. A series of systematic reviews summarise how to improve self-management,48 shared decision-making,49 patient experience,50 information and understanding,51 and promoting prevention.52

### Improving end of life care

Most people would prefer to die at home, yet many end up dying in hospital without a medical need to do so.53 The estimated cost for a day of community care at the end of life is £145, compared to £425 for a specialist palliative inpatient bed day in hospital.54 Improving end-of-life care by working more closely with hospices and social care agencies would therefore improve not only quality of death but also financial and environmental sustainability. Encouraging the use of advance directives by people with life-limiting chronic diseases could also help, yet the use of such directives remains the exception rather than the rule. How these options are presented can also influence whether people choose life-extending care over palliative care.55

### Reforming the payment system

Payment by Results has arguably improved some aspects of surgical provision, but now also provides a major financial incentive to increase hospital-based activity, regardless of results.8 Hospitals currently get paid if they see patients – and paid more if patients develop complications or require an intensive care unit (ITU) stay. Hospitals have little financial incentive to invest in upstream prevention of the need for hospital care. Negotiating payment for telephone or virtual clinics currently has to be done on an ad hoc basis, clinical commissioning group (CCG) by CCG. At the same time, GPs are paid by capitation and are being asked to take on ever-increasing responsibilities for chronic disease management without any additional funding. As Corrigan and Mitchell put it, ‘we have a funding mechanism that encourages the most expensive organisations to deal with more people without there being a similar encouragement for the less expensive parts of the NHS’.36 Similarly, the current creeping privatization of the NHS will inevitably provide further incentives to ‘do more work’, regardless of the value added: no provider with an obligation to return a profit for shareholders will have any interest in reducing its market share.

## Hypocrisy, tokenism, and shifting the curve

I have no direct conflicts of interest. I don't own a car, I cycle to work, and I grow my own vegetables. However, I have taken short-haul flights more often that I should, so I’m open to the charge of hypocrisy. Guilty as charged. But we only have a chance of improving the sustainability of the NHS if the great majority of people – we hypocrites included – take some steps to reduce their carbon footprint. If we allow the fact that we’re imperfect to provide an excuse for not taking action, and leave it to the perfect few (who never fly, drive, or turn the heating on) to change the world, we’ll never see change. Just as with blood pressure in the general population,56 shifting the entire population to consume slightly less carbon, and then even less, will generate far greater benefits than leaving the responsibility to those who are already nearly perfect.

## Declaration of Interest

*   © 2015 Royal College of Physicians

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