Environmentally sustainable health and social care: Scoping review and implications for the English NHS

Abstract

Objectives

To review the evidence on environmental sustainability in health and social care, describe what the implications of sustainability might be for service models and policy, and explore the connection between environmental and financial sustainability.

Methods

Literature review of 78 published articles and qualitative analysis of 28 semi-structured interviews.

Results

Provision of health and social care has a substantial impact on the environment, and opportunities exist at a number of levels to deliver services in a more sustainable way. While there is some scope to improve efficiency at the operational level, significant improvements in sustainability may require a more fundamental transformation in service models, for example, with a stronger emphasis on prevention. The current policy framework in England is perceived to create a number of barriers that discourage professionals from redesigning services in ways which could promote both environmental and financial sustainability.

Conclusions

Increasingly, health and social care will need to be delivered in ways that are not only financially sustainable, but environmentally sustainable too. Close conceptual connections exist with improving productivity – focusing on cost-effectiveness, value and prevention of avoidable activity could enhance sustainability from both an environmental and a financial perspective. Priorities for health care organisations could include prevention, exploring the opportunities presented by new technologies, and improving medicines management and prescribing practices. Policy-makers need to explore what changes are needed to create a more enabling environment, as well as how existing policies can be delivered in the most sustainable way.

Keywords

environmental impact of health services environmental sustainability of health services

Introduction

It is perhaps of little surprise that an industry consuming close to one pound in ten of national GDP, with the largest property portfolio in Europe and directly employing over 1.7 million people across the UK should also have a significant impact on the environment. The NHS alone accounts for 25% of all public sector carbon dioxide emissions in England, or around 4% of total emissions, with annual emissions exceeding those from all aircraft departing from Heathrow airport.¹

The term ‘sustainability’ can be used in a number of senses, including financial, environmental and social sustainability. In all three senses, the core principle is that of meeting existing needs without compromising the ability to meet future needs. This article focuses on environmental sustainability, which encapsulates the ideas of using natural resources in a sustainable way, and of improving resilience to anticipated changes to the natural environment.

The sustainable development agenda has attracted increasing attention in the health sector over the last decade, and much more is understood about the environmental impacts associated with delivering care than was known even five years ago. Studies commissioned by the NHS Sustainable Development Unit indicate that two thirds of NHS emissions in England are related to goods and services the NHS procures – notably pharmaceuticals and medical equipment – with the remainder attributable to direct energy use in NHS buildings (19%) and patient/staff travel (16%).²

Under the terms of the 2008 Climate Change Act, the UK as a whole is committed to reducing emissions by 34% by 2020, and by 80% by 2050. As a significant contributor to emissions, the health sector will be expected to play its part in meeting these targets, and a number of policy levers, such as the CRC Energy Efficiency Scheme (a mandatory emissions trading scheme), are creating financial incentives to do so.

In addition to reducing the impact of care on the environment (commonly referred to as ‘mitigation’), organisations will need to ensure they remain able to function in a changing natural environment (‘adaptation’). The environmental changes that can be anticipated over the coming decades include changes to the climate, but also increasing scarcity of natural resources including fossil fuels and water.³ These changes will have direct consequences for service provision, and are also predicted to have effects on the population's health needs.⁴

There are also more immediate incentives driving the health sector to engage with the issue of environmental sustainability. As described later in this article, there is an emerging literature on the potential synergies and co-benefits between the core objectives of healthcare and efforts to minimise environmental impacts, including opportunities to make financial savings and promote public health.

This article describes what opportunities exist to improve the environmental sustainability of health and social care, discusses the organisational behaviours that will be needed to implement these changes, identifies barriers at the system- and policy-level, and examines the potential connections between sustainability, productivity improvement and the concept of ‘value’ in healthcare.⁵ It is based on a scoping review commissioned by the Service Delivery and Organisation (SDO) programme of the National Institute for Health Research, and funded jointly with the Social Care Institute for Excellence through its Sustainable Social Care programme.

The article is focused in particular on implications for policy and practice in the NHS in England. However, environmental sustainability is an international challenge and many of the issues discussed here will be of relevance to health systems across the world.

Methods

The scoping review involved a review of published research and UK policy documents, semi-structured interviews with representatives of key stakeholder groups, and a structured web-based prioritisation exercise to identify research priorities. This article is based on the first two of these components.

Literature review

Research on environmental sustainability in health and social care was identified by searching bibliographic databases (PubMed, Emerald Insight, NHS Evidence, Social Care Online, Cochrane library, King's Fund library database, SHEBA database). Articles from the business and management literature exploring how other sectors are aligning sustainability and productivity/profitability were also included. Articles identified through database searching were supplemented with others identified through web searching and reference lists.

To be relevant for inclusion in the review, articles had to be based either on original empirical research or a substantial review of existing studies. Due to the exploratory nature of the study and the limited evidence-base on the subject area, we did not consider it appropriate to use a formal quality appraisal tool.

78 articles were reviewed in full and summarised using a standardised template, which recorded the scope and focus of each article plus a summary of the key messages of relevance. A meta-summary of these documents was then created, structured using an adapted version of a framework developed by the NHS Sustainable Development Unit.

Stakeholder interviews

Semi-structured interviews were conducted with 28 representatives of key stakeholder groups in the health and sustainability sectors in England. Table 1 provides a summary of the main groups from which interview participants were drawn (some participants are counted in more than one category).

Table 1.

Summary of expert interview participants.

Participant type	Number
NHS and local authority managers	4
Frontline care staff	3
Public health professionals	3
Sustainability consultants	2
Academics	5
Experts in care facilities	2
National representative and policy organisations	8
Private and voluntary sector care providers	3
Health service management consultants/independent experts	2

The interviews were analysed qualitatively using a thematic template. The points made under each thematic area were summarised in a separate document for each interview, with supporting evidence included in the form of direct quotations. These summaries were then compared and contrasted, and used to construct a meta-summary document which described the over-arching messages emerging. This analysis was structured using the same framework used in the analysis of the published literature.

Results

We describe the results of the literature review and qualitative interviews in an integrated fashion, under four thematic headings:

Linking sustainability and productivity improvement – findings regarding the potential connection between environmental sustainability and value for money;

Opportunities to improve the sustainability of health and social care – specific opportunities identified by our research;

Driving sustainability within organisations – evidence regarding how improvements can be promoted and implemented in practice;

Systemic and policy-level barriers that currently limit the adoption of sustainable approaches.

Linking sustainability and productivity improvement

A number of connections can be drawn between environmental sustainability and the drive to achieve better value for money in health and social care. Environmental impacts can be minimised by reducing avoidable or low-value activity and delivering efficient, effective care. This in turn implies a focus on evidence-based treatment and support, preventative and upstream approaches, and individualised care which generates maximum value for patients.

“Anything we can do to achieve the QIPP [productivity improvement] agenda, which is all about reducing waste and inefficiency, is likely to improve sustainability at the same time”

Consultant renal physician

“Whenever there is wasted expenditure, there is avoidable environmental damage as well”

Sustainability consultant

While the conceptual connection between sustainability and productivity is clear, the strength of the business case can be expected to vary in practice. The NHS Sustainable Development Unit has published a series of ‘Marginal Abatement Cost Curves’ which plot financial returns against carbon savings for a number of carbon reduction measures. If implemented across the NHS in England, the measures assessed could save an estimated £180 million and over 800,000 tonnes of CO₂ per year. Changes offering the greatest financial return on investment included reducing drug wastage, installing combined heat and power generators in acute trusts, and reducing business travel through teleconferencing.⁶

There are a number of case studies which indicate that some of these theoretical cost savings can be successfully achieved in practice. Changes implemented by organisations at the leading edge have delivered relatively quick financial returns. Indeed, several local authorities cite the need to make cost savings as a primary motivation driving the adoption of more sustainable approaches in social care.⁷

Outside of the health sector, a number of business leaders have argued that sustainable approaches can deliver financial returns, with some studies finding a correlation between measures of sustainability and profitability.⁸ It has been suggested that the critical link may be commercial sophistication and far-sighted management – which may be vital for both economic and environmental success.⁹ Others have argued that the challenge of improving environmental performance acts as a spur to promote creativity and innovation.¹⁰ Reputational benefits are also clearly important, and may become increasingly significant to health organisations in the UK as the extent of competition and choice in the sector increases.

Opportunities to improve the sustainability of health and social care

Opportunities at a number of levels were identified, including changes relating to where care is delivered, but also relating to more fundamental questions about what care is provided and how this is organised. As yet, detailed evidence on which care pathways have the greatest environmental impacts is only beginning to become available within a limited number of clinical areas, for example nephrology.¹¹ However, it is possible to outline in broad terms the kinds of approaches that may be needed. This section describes the main opportunities identified in the scoping review, and is structured using the distinction used above between where, what and how care is delivered (see Table 2).

Table 2.

Changing where, what and how care is delivered.

Where	What	How
• Making health and social care facilities more sustainable	• Giving increased emphasis to prevention and self-management	• Coordinating different elements of care
• Shifting locations of care and using technologies to minimise ‘care miles’	• Ensuring care is evidence-based	• Using pharmaceuticals & technologies more effectively
		• Building resilience to environmental change

Changing where care is delivered

Sustainable facilities

As reported above, direct energy use in hospitals and other buildings accounts for 19% of the NHS carbon footprint.² A number of innovations can help reduce these impacts, including exploiting opportunities for natural heating, lighting and ventilation, and installing combined heat and power systems. Some improvements could be made without significant upfront investment, for example by examining the feasibility of heating facilities to a lower temperature. There is also considerable scope to reduce environmental impacts associated with disposal of hospital waste materials, through more effective segregation of waste streams, and increased recycling and re-use where appropriate.¹² More fundamentally, there are opportunities to reduce reliance on buildings-based services over time, and where appropriate to shift care out of hospitals and other energy-intensive environments.

Minimising ‘care miles’

It may be possible to reduce travel-related carbon emissions by delivering care in different settings. For example, mobile breast screening in Norfolk reduced emissions by two thirds.¹³ However, impacts must be assessed in the round to ensure that reductions in patient travel are not outweighed by increases in staff travel or by other environmental impacts – for example, home-based kidney dialysis using currently available technology can have a larger carbon footprint (despite reductions in travel) when this means patients need to dialyse more frequently and for longer.¹¹

Telehealth and telecare interventions may also lead to emissions reductions.^14,15 For example, North Yorkshire county council is reported to have reduced emissions and saved around £1 million per year through using a telecare support package.⁷

Travel associated with home visits can be minimised through careful planning of rosters. Where travel is necessary, some services have explored lower impact options. For example, the ‘Go Low’ sustainable travel project in Bristol has reduced NHS business mileage claims and CO₂ emissions using car pools, smart cars and electric bikes.

Changing what care is delivered

Prevention & self-management

A strong message from our research was that prevention must be at the core of sustainable health and social care. Interviewees stressed that the most sustainable approach will be one which minimises care needs by preventing ill-health, encouraging health-promoting behaviours in the population, and supporting those who do develop health problems to manage their own condition as effectively as they can.

“The best thing that could be done for the environment, for quality of life and for the long-term viability of the NHS is to keep people healthy, stop people becoming patients in need of treatment. And you can do that in ways that are very environmentally-friendly, by encouraging healthier lifestyles”

Social policy expert and analyst

From a sustainability perspective, the objective here should be to identify interventions which prevent avoidable consumption of health care resources and reduce lifetime service use. Some public health measures could also have direct environmental benefits, for example promoting walking and cycling in place of motorised transport; reducing meat consumption; improving insulation in housing; and improving access to green spaces.¹⁶

Evidence-based care

An important component of environmentally sustainable healthcare will be continuing the drive for evidence-based care at all levels. Those forms of treatment or support which offer maximum value to service users for a given investment of resources (financial or natural) can be seen as being intrinsically more sustainable because they reduce wasteful use of these resources. For example, laparascopic interventions may be more sustainable than traditional surgical techniques precisely because they deliver improved outcomes and reduced risk for patients without significant additional consumption of natural resources.

“Evidence-based interventions by their nature should be greener – because they actually work”

Director of healthcare charity

Sustainability could be improved by implementing best-practice evidence more systematically, for example through identifying unwarranted variations in practice, reducing use of low-value interventions, and exploring the issue of supply-induced demand.

Changing how care is delivered

Well co-ordinated, integrated care

Just as the effectiveness and efficiency of individual interventions has an important bearing on the environmental impacts of care, so too does the efficiency of the overarching framework within which these interventions are delivered. Resources can be wasted through poor communication and information-sharing between organisations and different parts of the system. This could be improved through more shared or collaborative care arrangements, and better integration between health and social care. More integrated models providing better co-ordinated care could therefore be more sustainable in environmental as well as financial terms.

“A lot of the policy aspirations that we have about reducing duplication, joining up services, offering more integrated services, would also produce sustainability benefits”

Social care policy expert

“More integrated care is surely the holy grail of a sustainable healthcare system”

Sustainability adviser

Obtaining maximum value from pharmaceuticals & technologies

Pharmaceuticals account for around 22% of the overall NHS carbon footprint in England.² Addressing this will require reducing the large volumes of medicines wasted due to inadequate stock management or inappropriate prescribing, as well as the high proportion of drugs not taken as intended. Polypharmacy in older age and the large volumes of medications wasted as a result of inappropriate prescribing in care homes are areas where particular improvements could be made.

Innovations in medical equipment and care technologies could also have a significant impact, with new devices offering carbon and cost savings. A sustainable approach to healthcare would involve making the most of new technologies as they are developed, and rapidly diffusing innovation throughout the system.

Building resilience to environmental change

While climate change mitigation has received increasing attention within the health sector, limited attention has been given so far to the issue of adaptation and preparedness for environmental change – including both climate change and also the increased scarcity of natural resources such as fossil fuels and water. Organisations will need to take a number of steps, including identifying vulnerable groups in the local population, reviewing plans for responding to floods, heatwaves and other extreme weather events, and establishing contingency plans to deal with disruption to supplies of energy, food and water.¹⁷ There may be a role for social care and other professionals in building community resilience to the health effects of environmental change, and in ensuring that vulnerable groups are protected from the combined effects of climate change and rising prices for fuel, food and water.¹⁸

Driving sustainability within organisations

There is a significant evidence-base, albeit largely from outside the health sector, on how organisations can successfully adopt environmentally sustainable approaches. A consistent finding is that organisations must engage with their workforce to achieve improvements, as well as with customers. Given the complexity of the challenge, those organisations that are most successful at improving sustainability are likely to be those which permit experimentation and which are able to learn from success and failure alike. Finally, there is also considerable scope to use procurement processes to promote sustainability.

Engaging staff

One of the most consistent findings in the literature is that staff engagement at all levels is critical for success.^7,19,20 A number of barriers may deter health professionals from engaging with sustainability in the workplace, including a sense of not having sufficient power or the right knowledge or skills to be able to change existing practices; a lack of visibility of environmental costs attached to individual work practices; and diffusion of responsibility for resource use across organisations.²¹

Giving teams more detailed information on their use of resources could make responsibility for sustainability less diffuse. More disaggregated data collection processes (e.g. through electricity sub-metering) combined with changes to managerial practices (e.g. through service line management arrangements) may help to promote staff engagement by putting power and responsibility for sustainability in their hands.

Engaging patients and the public

Organisations will need to engage with patients and the public to build support for more sustainable approaches to care, particularly in the context of increased patient choice, the growth of any qualified provider markets and personalisation in social care.⁷

Public expectations can play a significant role in driving highly resource-intensive and potentially unsustainable practices. Attitudes towards end of life play an important part in this, given that the final months of life are typically when resources are used most intensively. As a society it may be necessary to examine these values if the aspiration for a sustainable healthcare system is to be met, in either the financial or environmental sense.

Developing a learning culture within organisations

Research examining organisational characteristics associated with adoption of sustainable approaches indicates that some of the most successful organisations are those which devolve responsibility for sustainability to individual employees and teams, allow improvisation and experimentation, and create conditions that foster learning in every-day practice, including opportunities for feedback and communication between staff in different parts of the organisation.^19,20 A consistent message from our expert interviews was that these enabling conditions are absent in many health and social care organisations.

Sustainable procurement

Procurement teams have some power to influence organisations in their supply chain to operate in an environmentally sustainable way, and some are already including environmental requirements in procurement processes. However, this sometimes appears to be a tokenistic exercise, with little active management of these requirements once the procurement is completed.²²

Sustainability consultants interviewed for our research suggested that suppliers to the health sector are often supportive, in principle, of developing more sustainable goods and services. However, progress can be held back because suppliers are not always clear what clients want in terms of sustainable products, or because health and social care organisations do not always have a sufficient understanding of what different suppliers can offer.

Systemic and policy barriers

A strong message from our expert interviews was that the existing financial reimbursement systems for healthcare providers often acts as a significant impediment in developing more environmentally sustainable approaches. There was widespread concern that the Payment by Results tariff system can create an incentive for increased activity and for (at times unnecessary) face-to-face contact, deterring providers from adopting innovative methods such as telephone-based consultation or preventative approaches.

Another consistent message was that certain characteristics of the healthcare system encourage a myopic focus and make it difficult for managers and other professionals to prioritise longer-term sustainability. Several factors may contribute to this short-termism, including the need to balance budgets on an annual basis, and the fact that organisations are not always permitted to hold onto budgetary surpluses for future investment. The highly politicised environment in which health and social care organisations operate may also encourage short-termism – as one of our interviewees described, this “is usually a recipe for dancing to a political tune rather than a sustainable agenda”.

“Some of our European counterparts set 15 to 20 year plans for population health which are not subject to change every 4 or 5 years depending on who thinks they're going to get the vote. And until we move to that sort of agenda we're going to still have problems with the sustainability of healthcare provision”

NHS Foundation Trust Medical Director

A lack of widely accepted metrics and methods for measuring environmental sustainability was seen as another key barrier. Without being able to readily quantify environmental impacts, it will not be possible to embed sustainability within routine management targets, objectives and indicators. There are currently a range of metrics available for environmental impact, but with significant discrepancies between different approaches. Tools developed in other sectors are available but these need adapting and refining so that they can be applied easily within health and social care without compromising on accuracy.

“We have to understand the metrics. Until we can measure these things it's just going to be hot air”

Oncologist

Discussion

Developing a more environmentally sustainable approach to health and social care will require substantial changes at a number of levels. While some progress can be made by improving efficiency and minimising unnecessary resource use at the day-to-day operational level, the scale of the environmental challenge means that a more fundamental transformation in service models may also be necessary.

The feasibility of bringing about such a transformation is enhanced by the fact that many of the service changes described in this article have already been called for on financial and quality grounds. For example, if services were provided in such a way that service users experience an efficient journey through the system, obtain maximum value from every contact with professionals, and receive well-coordinated support for their multiple needs, this should be more sustainable from both an environmental and financial perspective.

There are strong conceptual connections between sustainability, productivity and the concept of value as articulated by Porter and others.⁵ Ultimately, the most sustainable system will be one which minimises unnecessary or ineffective use of resources (financial or natural) and maximises patient outcomes for a given set of costs. Porter argues that the relevant set of costs to consider is not limited to the immediate costs of a service or intervention, but should include the total cost of all things that contributed to creating value for patients. From a sustainability perspective, these should include environmental costs.

Priorities for health and social care organisations

The importance of being a ‘good corporate citizen’ seems set to grow over time, particularly as market-based reforms in the health sector make organisational reputation an increasingly powerful determinant of financial success. While the majority of NHS organisations now have strategies on sustainability, progress at translating these strategic commitments into tangible action appears to be less consistent.^23,24 A common critique is that sustainability has not yet been ‘mainstreamed’ into standard business processes and is currently being driven by individual champions rather than a broad organisation-wide commitment.^7,25

The first priority for health and social care organisations should be to develop a more detailed local understanding of the problem – by measuring the impacts of the organisation's activities, and by assessing the risks to their operations posed by environmental change. Leaders will need to understand what the ‘quick wins’ are for their organisation, and what longer-term service changes will be needed to go beyond these initial steps.

Organisations should seek to exploit opportunities for service changes planned primarily for cost or quality reasons to also contribute towards improved environmental performance, thereby serving multiple objectives simultaneously. Priorities could include shifting to more preventative models of care, exploring the opportunities presented by new technologies, and improving medicines management and prescribing practices.

To reduce the significant embedded environmental costs of procured goods and services, organisations will need to engage with suppliers and use procurement and commissioning processes to drive sustainable practices in supply chains and service providers.

Implications for policy

The current policy framework in England creates a number of barriers which act to discourage organisations at the local level from developing more sustainable approaches. For example, payment systems need to be re-designed to reward providers for delivering lean, efficient care. To an extent this may be achieved through the efficiency factor in the payment by results tariff or through the move towards best practice tariffs. However, more sophisticated ways of paying for care may be needed in future, for example, based on payment for outcomes rather than activity, or through capitated budgets. Without this, there is the risk of the environmental benefits of efficiency improvements being undone by an expansion in activity levels.

Policy makers will need to consider how healthcare organisations can be held to account for their environmental sustainability as a part of routine system management processes. In England it will be important to identify levers for sustainability in the reformed system introduced by the 2012 Health and Social Care Act. For example, the new health and wellbeing boards could play a role by including a sustainability perspective within health and wellbeing strategies for local communities, as could local authorities more generally as they take on new responsibilities towards improving public health.

The claim that existing financial and political cycles tend to create a culture of short-termism that is antithetical to sustainability is highly pertinent in the context of the current reform agenda in England. The reforms have been framed as an attempt to loosen political control over the NHS and give more power over operational decision-making to local clinicians and managers. If the reforms fail to create an environment where organisations and professionals are able to take a longer-term view in planning service change, that will have been a significant missed opportunity.

Footnotes

Acknowledgements

We would like to thank the NIHR, SCIE, the NHS Sustainable Development Unit and Catherine Max for their ongoing support and expertise.

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