by Steve Gulati and Catherine Weir
The impact of Covid-19 on the UK National Health Service (NHS) was dramatic and instantaneous, and while some changes were immediate and obvious, others will arguably take months and years to become evident. One area where short term responses could have longer term implications is around the environmental impact, or sustainability, of healthcare delivery. This article will explore the role that healthcare can play in contributing to carbon reduction and how the sector can move towards improved sustainability. We will consider how the pandemic accelerated imperatives in health service delivery towards carbon reduction, wittingly or otherwise, including the use of innovations or initiatives that were previously available but sometimes under-utilised (telehealth, e-consultations, the greater use of patient self-monitoring for instance). These adaptations have long existed or been possible, but the ‘forced innovation’ and wider adoption provides a timely impetus towards sustainability, with benefits arguably also relating to improved patient care and experience.
Healthcare & Environmental Sustainability
The relationship between health, healthcare delivery and environmental impact is cyclical and symbiotic – ‘environment’, in its broadest sense, is a key determinant of health, and the resource-intensive delivery of healthcare in developed economies has a clear impact on the environment. To ensure a deeper understanding of how these factors interact, and how carbon reduction in healthcare is not only desirable but a plausible policy choice, it is worth exploring this relationship in more detail.
The links between climate change – the use of finite resources, the impact on the health of communities and populations, and the delivery of modern healthcare – has been the subject of study for many years. Even a brief review highlights some startling issues. As far back as 2011, carbon emissions from the healthcare sector in the United States accounted for 10% of total US emissions; in 2012, the King’s Fund pointed out that “carbon dioxide emissions attributable to the NHS in England alone are greater than the total emissions from all passenger aircraft departing from Heathrow Airport”; and more recently, a paper in the Lancet explored the tension that “health-care services are necessary for sustaining and improving human wellbeing, yet they have an environmental footprint that contributes to environment-related threats to human health”. The NHS made a bold commitment to ‘net zero’ in October 2020, acknowledging as it did so that “we therefore make no apologies for pushing for progress in this area while still continuing to confront coronavirus”. Meanwhile, for practitioners, the Centre for Sustainable Healthcare contains a myriad of material “…to engage healthcare professionals, patients and the wider community in understanding the connections between health and environment and reducing healthcare’s resource footprint”. This includes educational resources, analytical debate and practical toolkits. In some ways, therefore, the field around the environmental impact of healthcare commissioning and delivery, and thinking around sustainability, has never been richer, and the resources for policy-makers are wider than ever. The emergence of the coronavirus pandemic, however, pushed healthcare systems (such as the NHS) into a turbo-charged ‘adapt to survive’ crisis footing which, as we will turn to next, had significant implications for the use of scarce resources.
Covid-19 – the Impetus for Change
Much is written about how humankind will respond to climate change challenges, whether this will be through a carefully planned policy response with prospective adaptation, or reactive responses to various climate emergencies. Almost certainly, these two drivers will intertwine, each reinforcing the other in a feedback loop along with the occasional jolt from an external ‘shock’. The Covid-19 pandemic was just such an external shock, and it can be instructive to explore the response of health services through the lens of environmental impact – was this congruent with, or did it confound, the paradigm of the dual prospective and reactive response?
At an operational level, the impacts of the pandemic on health service delivery were immediate and obvious. Face to face consultations across all specialties were drastically reduced, and given that 90% of NHS interactions take place in primary care, this impact would have been highly noticeable to all users. What followed, not only in primary care but across all parts of the NHS, was remarkable.
Adaptation & Sustainability in Health
The NHS Long Term Plan, published in January 2019 signalled a move to ‘digital first’ primary care well before the advent of Covid-19. The importance of investing in digital technology has been signalled for many years (e.g. the Wanless Report and the Topol Review), although progress has been inconsistent. What happened, as a result of the pandemic, laid bare the drivers and determinants of health, with digital poverty and inequality as real as any of the more traditional drivers. It is indisputable that the pandemic has significantly accelerated digital health beyond all expectations with more than 99% of GP practices now activating remote platforms to provide some form of e- consultation, but this could just as easily reinforce other inequalities, such as digital poverty. Whilst the impact of remote GP consultations carbon reduction has not been quantified, it is intuitively indicated, most obviously via, for example, transportation emissions. However this needs to be considered (especially from a policy perspective) on a broader landscape of what is a ‘good life’ and a ‘good society’.
In addition to e-consultations there has been a massive roll out of remote self-monitoring for patients with pre-existing conditions and for those testing positive for Covid-19. Known as ‘digital health’ these innovations are set to have long-lasting implications for sustainability. For those with pre-existing conditions, the challenge has been how to replicate the support which multi-disciplinary acute and/ or community health teams were providing pre-pandemic. The development of virtual wards has been scaled up, enabling patients with long term conditions to be cared for at home and reducing the need for outpatient attendances and other follow up, with clear implications in reduced travel to clinical sites. In some cases, such as remote monitoring pilots, these changes have built on work already underway with the pandemic giving it extra impetus. For example, the Joined-up Care Approach across Yorkshire includes a project originally focussed on primary and secondary care extended to children and young people with life-limiting illness who are looked after by the paediatric palliative care team or those with a chronic condition like Cystic Fibrosis under the care of the paediatric respiratory team. The pandemic shifted the focus to enabling remote home monitoring of these children and young people to reduce their need to visit hospital. In another project (in the North East of England), a remote ECG pathway to support patients and staff during the pandemic met with overwhelmingly positive evaluation from patients and staff and offered clear benefits in reducing the need to travel to hospital. The NHS Trust involved has now taken the decision to use these permanently, procuring and distributing over 100 devices across 100 community teams.
Learning from and promoting best practice and rolling it out at scale has been a feature of the NHS response to the pandemic, with the provision of home monitoring of oxygen saturation levels being a good example (other responses can be seen here). Home oximetry (using small, cheap oximeter devices enabling self or carer monitoring) has been one digital enabler of the development and expansion of Covid Virtual wards. These were set up to enable hospital patients to be discharged home earlier with ongoing monitoring in place, with obvious benefits to patients and reduced resource consumption. The unprecedented national roll out of oximeters to assist those who test positive for Covid-19 and/or are otherwise at risk of silent hypoxia, helping them determine when to contact NHS111 or when to go to A&E, has seen 300,000 home oximeters supplied to patients across England by January 2021, and similar partnerships are springing up across the country and bringing undoubted patient benefit.
These examples illustrate how necessity can drive innovation, but that this can play into patient empowerment and carbon reduction simultaneously. The concept posited earlier in this piece, of the intertwining feedback loops around innovation and change, appears sound, with an interdependence evident. Many virtual wards have been built on the earlier principles of rapid response teams which already existed in many community trusts. The story of adaptation is not a foregone conclusion of positive outcomes, however. For instance, elsewhere digital pilots have been seen as less successful, such as the provision of iPads into care homes which have focussed on the provision of digital kit and neglected the equally important aspects of clarity of the pathway, especially escalation, and the enablement, education and support of other patients, carers and other parts in the care system. The use of technology for the sake of it can result in a cul-de-sac. The longer-term issue as we move into service resumption and recovery will be partly driven by ongoing financial viability in terms of the deployment and consumption of resources, and significantly driven by the ability to demonstrate transparent gains in terms of benefits to service users, their carers and families.
Any policy response to the environmental emergency facing the planet must be about leadership. A challenge for leaders is often framed as creating the conditions for change – articulating a vision, securing resources, understanding and nurturing motivation. At times such as these, in response to a massive external shock, that leadership challenge arguably morphs into riding the wave of change, securing the benefits and maintaining the impetus. Now, perhaps more than at any other time, the need for vision and the ability to develop strategic partnerships is more critical than ever. So, the role of the public sector leader also comes to the forefront; connecting and harnessing public good with real, operational change. Quite simply, healthcare consumes enormous amounts of resource, and so the potential impact of change is equally significant.
A policy response is as much a matter of an understanding – knowledge and attitude – as a set of ‘prescribed solutions’. Certainly, interested policy-makers can already access a range of resources that would surely find congruence in a range of contexts – in this area as much as any other, one size does not fit all, but that is not a reason for inaction. Sustainable healthcare is also a moral imperative, with clear congruence with other ethical dimensions of healthcare provision; ensuring that routes of access are as wide as possible, the efficient and equitable distribution and use of scare resources, patients and service users being completely clear about choices (and the limits of choice) and the implications of their choices. As trusted sources of health information, health workers can have a pivotal role in educating and informing colleagues and service users about the health effects of climate change and the need for an efficient use of resources from an environmental, not purely monetary, perspective.
So, viewed through the lens of sustainable healthcare, the response to the pandemic was a classic combination of a reactive response, but prompting long-needed innovation and change. Necessity forced innovation, but innovation creates momentum, which leaders can both consolidate to ‘bank the gain’ but also use a platform for sustained policy change. It is often the case in healthcare that the evidence base is constructed iteratively, and this can apply to wider carbon reduction and sustainability polices too. Healthcare adapted to survive the pandemic, and sustainable healthcare is arguably a more realistic and achievable policy choice as a result. In any event, this might be less a choice than a necessity in itself; in all likelihood, it will not be the last time that health emergency and climate emergency meet.