Abstract
Academic interest in strategies to reduce the impact of health services on climate change is quickening. Research has largely focused on local innovations with little consideration of the contextual and systemic elements that influence sustainable development across health systems. A realistic framework specifically to guide decision-making by health care providers is still needed. To address this deficit, the literature is explored in relation to health services and climate change mitigation strategies, and the contextual factors that influence efforts to mitigate climate effects in health service delivery environments are highlighted. A conceptual framework is proposed that offers a model for the pursuit of sustainable development practice in health services. A set of propositions is advanced to provide a systems approach to assist decision-making by decoding the challenges faced in implementing sustainable health services. This has important implications for health care providers, funders and legislators since the financial, policy and regulatory environment of health care, along with its leadership and models of care generally conflict with carbon literacy and climate change mitigation strategies.
Introduction
Health care delivery has a significant negative impact on the environment. It is resource-intensive and produces large amounts of waste via its continuous operation cycle.1–4 There is an imperative that health care providers adopt climate mitigation efforts that aim to reduce environmental impact in waste, energy and water usage, building design, procurement and travel.5,6 Research has focused on the successful mitigation efforts of organizations in high-income countries where strategies to reduce emissions have been framed in reference to environmental, financial and social ‘cobenefıts’.1,7,8 Sustainable development refers to the pattern of resource use that allows society to meet current needs, whilst preserving the environment in order that the needs of future generations might also be met.6,7,9
There has been less focus on the characteristics and context that act as facilitators to influence the uptake of sustainability efforts in, and across the health care sector. 5 My aim was to explore these and propose a realistic framework for sustainable development, applicable to both publicly and privately funded health service organizations. A set of propositions seeks to address the current gap by providing a systems approach to assist decision-making in favour of sustainable business and clinical practices in health care services. 5
Sustainable development in health care: theory, conceptions and existing research
Climate change has been posited as the biggest global health threat of the 21st century. 9 In the United States, the carbon footprint of the health care sector has been calculated at 7% of total carbon dioxide emissions.10,11 In the United Kingdom, the National Health Service is responsible for 4% of total emissions. 6 Although the carbon footprint of the Australian health care sector has not been calculated, one state found energy use to be commensurate with estimates from overseas.4,5
The academic literature provides examples of health service mitigation efforts in regard to sustainable development pursing local level innovations, including waste reduction, energy and water usage, building design, procurement and travel.1,5,10,12,13
A range of resources has been developed to assist health services in pursuing sustainable objectives. In the United States, the Healthier Hospitals Initiative is an online repository of tools to guide hospitals. 14 In the United Kingdom, the Sustainable Development Strategy offers a modularized format of eight ‘angles’ to help strengthen action within locally determined priorities. 15 Whilst these resources are of benefit, they do not seek to critically appraise two key dimensions of mitigation efforts: the characteristics of health care providers and the complex context within which providers operate.
Understanding climate change mitigation efforts: a conceptual model
The following section proposes a conceptual framework (Figure 1) that seeks to explain the factors that influence the challenges faced by health care providers in assuming climate mitigation responsibilities. It is necessary to consider both the characteristics and context of providers. A set of propositions is derived from the two sets of dimensions, which form the basis for understanding and addressing the pursuit of climate change mitigation efforts.
The conceptual framework guiding the article.
Characteristics and realities of health services
First, health services are inherently socially responsible. The underlying tenant of ‘Do no harm’ applies to all activities; yet the fact that hospitals generate vast quantities of waste materials places them in an unusual predicament. 16
The second feature is that health providers are responsible for delivering care that minimizes the impact of climate change.8,9 For the health sector, there is an imperative to adapt and mitigate, to ensure a health system that can be flexible, strategically allocated and robust into the future. 8
Third, interdisciplinary hierarchies and power differentials in health care services must be considered. Interprofessional rivalries serve to complicate the organizational landscape and can cause disparity between practice and professional and personal values.2,17–19 Researchers have found striking differences in the ways in which managers and clinicians perceive reform efforts in relation to financial restrictions, professional autonomy and work processes.18,19
It has been posited that health services are currently operating within a dominant paradigm of reactivity. ‘Zero sum competition’ serves to thwart innovation, and within the academic discourse there are calls for ‘disruptive innovation’ and a new paradigm of health care transformation to replace the existing business conceptualization of supply-driven value.20,21
Finally, as ‘late starters’ and ‘heavy producers’ of adverse environmental effects, providers have unrealized opportunities for assuming new roles and responsibilities. Health professionals could influence climate opinion within communities, via their contact with almost everyone in a local population. 12
Contextual determinants of sustainable development in health service organizations
To understand why health services have failed to grasp the opportunities available via the environmental agenda, the broader context within which they operate needs to be taken into account. ‘Systems thinking’ has been advocated as a suitable frame within which to view health services, for example, in examining how complex health service organizations are organized, governed and implement change over time. 22 ‘Systems thinking’ serves to highlight dynamic complexity and nonlinear interconnectedness, and is relevant for climate change efforts, wherein a lack of coordination and alignment between contextual determinants can hamper efforts to change policy and practice.
Key contextual factors that have a significant influence in health service organizations are discussed below; with each followed by a related proposition. The propositions assist in setting out a systems view of health service mitigation efforts; and provide practical signposts towards large-scale change in health systems.
Each of the posed contextual elements can act as a facilitator of, or barrier to, mitigation efforts. Indeed, key enablers have been noted previously by other health organization researchers, and include those that operate at the level of the individual (commitment), professional (competencies and transferability of skills), organization (senior management leadership), architecture (building design), community (partnerships), political (policy and regulation) and those which cut across the contextual elements proposed here.2,3,22,23
Policy, financial and regulatory environment
Health services operate in a controlled legislative and regulatory environment required for optimal clinical care delivery and outcomes. 17 Key elements of that environment can impede the application of climate mitigation efforts.
External policy environment
In an era of increasing access pressures and burgeoning care costs, policy makers may perceive climate change as posing little immediate risk. In addition, policy fragmentation and contradictions are often a serious problem across levels of government.8,9 The United Kingdom has made commendable efforts in regard to setting a target of an 80% reduction in carbon emissions on 1990 baseline levels by 2050, yet other wealthy nations, such as Australia remain bereft of climate political leadership, and are in the policy wilderness.6,12
Financial environment
Health service organizations typically operate within constrained resources and with a reactive mentality.2,3,17 Authors have lamented the challenges for sustainability, citing competition between providers, compliance requirements and outdated facilities as barriers to change. 23 The literature has noted that there can be perverse financial incentives, which deter health providers from adopting more sustainable approaches to care. Research in the NHS has found that the public health care system encourages short-termism, and makes it difficult for managers and other professionals to prioritize longer term sustainability. 6
Regulatory environment
The need to comply with regulatory requirements can impede health service organizations’ efforts to adopt sustainable practices. Clinical waste provides a case in point. Clinical waste disposal is regulated via a number of complex legislative and statutory measures. 13 Only a fraction of clinical waste needs to be treated as hazardous, yet the institutionalized conservatism of health care workers often prevents employees making sensible ethical judgements concerning environmental protection (e.g. relating to the re-use of equipment). Compliance measures can serve to allow a disassociation between the employee’s own ethical judgments and proactive environmental actions in the work context. 2
Conversely, other compliance levers can encourage environmental sustainability in health services. Health care quality and safety accreditation programs afford the opportunity to highlight governance functions associated with environmental stewardship. In Australia, the national hospital accreditation system recently introduced standards for waste and environmental management, with requirements for the management of waste, recycling, reducing and reusing processes and resource sustainability that are likely to be beneficial.
24
Aggregated performance reporting of health service organization participation in these standards is not yet available, however inclusion of sustainability measures is considered a progressive signpost. Proposition 1: Adjustments to the policy, financial and regulatory environments within which Health Service Organizations operate are required to support climate change mitigation efforts.
Leadership
Within health care settings, sustainable leadership requires stewardship of environmental and financial resources. However, the strategic imperatives and internal organizational structure of health service organizations can prevent concerted climate change efforts.10,16
Strategic profile
The UK NHS has grasped the strategic imperative for the health sector to lead by example in the sustainability arena, and, is committed to becoming the leading public sector organization on climate change. Yet, a critique from within the NHS is that sustainability is still not a normative business process, and is being driven by individual champions. 6
From the United States and Australia too, research has earmarked assimilation of sustainability measures into mainstream strategic planning processes as vital for progress. Routes via which this may be promoted include policy direction and innovation funding, and organizational mandates such as corporate plans, performance indicators, competencies and codes of conduct.16,17,25
From a corporate strategy planning perspective, the uptake of sustainability efforts is now recognized by many health services as a lever for enhanced competitive advantage. This is especially so in the United States, where hospital marketers highlight green credentials as a key competitive differentiator, with Leadership in Energy and Environmental Design (LEED) certification for hospital building construction considered desirable. 26 Market forces and the challenge posed via peer effects seem set to demand enhanced environmental citizenship credentials over time.23,25,26
Internal fragmentation
Internal fragmentation and siloed operations are typical of many health services, and can work against leaders’ overtures to promote mitigation efforts. Health professional lines of reporting in health service organizations are also notoriously complex, traversing a matrix of operational, disciplinary and clinical streams.18,19
Community leadership
Finally, as places that serve a vulnerable subset of the population, the current literature asserts that hospitals should be rigorous in implementing community-focused sustainable practices, environmental stewardship and community leadership in climate change.23,25 Proposition 2: Executive leadership must drive sustainability efforts in Health Service Organizations from a strategic imperative perspective, addressing the complications of internal fragmentation and grasping the opportunities presented for environmental leadership.
Models of care
The delivery of best practice care necessitates that care pathways are routinely examined to ensure congruence with available evidence. However, sustainability considerations are seldom considered in the development of clinical protocols. Providing improved management of chronic diseases, delivering care closer to home and use of technology are all themes associated with improved health care and saving resources. 12
What care is delivered?
Forms of clinical treatment that offer maximum efficiency and effectiveness are intrinsically more sustainable. For example, pharmaceuticals comprise around 22% of the carbon footprint of public health services, yet, large volumes of medicines are wasted due to inadequate stock management and/or inappropriate prescribing. 6
Where care is delivered?
‘Care miles’ accrued by workers and patients travelling to physical care locations contribute a large part of the health system’s ecological footprint. There has been some research to demonstrate that reductions in travel emissions can be achieved by bringing care closer to patients, or using e-based platforms. Oliveira et al.’s 2013 study found that teleconsultations led to a dramatic reduction in distances travelled and carbon emissions of 95%. 27 Bond et al. found that mobile breast screening reduced emissions by two-thirds. 28
How care is delivered?
Calls for more coordinated care are a core part of health reform efforts around the world, and are essential to the climate mitigation discourse. Indeed, the efficiency of the overarching framework within which care interventions are delivered is crucial.
6
Waste reductions as a consequence of more streamlined and seamless care is an area of opportunity. Proposition 3: Health service organizations must routinely examine models of care to ensure congruence with the sustainability agenda, including consideration of what, where and how care is delivered.
Carbon literacy and systems support
Outside of the health sector, a consistent finding in examination of successful business sustainability approaches is meaningful engagement with employees and customers. 29 Consultation with health workers has demonstrated their commitment to addressing climate change, and researchers have advocated including patients in the development of green initiatives.1,2,7
Carbon literacy and numeracy
The literature refers to the need to increase the carbon literacy and carbon numeracy of the health workforce.2,12 In Dunphy’s 2014 study of health professionals’ sustainability efforts, participants described lack of exposure to sustainability information in the workplace, and advised that professional development is required to allow clinicians to better support the environment in professional settings. 2 Topf 3 has argued that numerous psychological factors may contribute to ‘environmental numbness’ in hospitals. ‘Moral offset’ has also been noted as a contradictory, but not uncommon behaviour in regard to climate mitigation effort, where social responsibility in professional roles, can serve to provide a psychological discount regarding the responsibility felt to pursue proactive sustainability measures. 30
Another factor at play in the health sector is the lack of widely accepted metrics for measuring sustainability, which can manifest as a barrier to targeting and measuring mitigation efforts.2,6 The lack of indicators is keenly felt in the evidence-based health care field, which values that which it can measure. 2
Systems support
To promote sustainability measures in health services, appropriate systems must be available to staff to permit participation in mitigation measures. For example, waste containment and recycling systems must be designed to be fit-for-purpose, easy to use and practical.1,13 Departments and organizations that have had successes in implementing mitigation efforts have been found to be those which devolve responsibility for sustainability to individual employees and teams, allow improvization and experimentation, and create conditions that foster learning in every-day practice.
29
Proposition 4: Health Service Organizations must work to systematically improve the carbon literacy and numeracy of the workforce, and to ensure that appropriate systems support is available to staff to permit participation in mitigation measures.
Conclusion and future research
Health service organizations operate within a challenging and constrained context, which has served to hamper the widespread uptake of climate mitigation efforts. Nonetheless, this does not imply that all health service organizations have myopic leanings in relation to sustainability. On the contrary, there is evidence regarding the introduction of sustainable development efforts, and some health service organizations are managing to reap sustainability ‘cobenefits’, despite limiting realities.
On the other hand, there has been little system level consideration of the realities faced by health care providers in relation to climate mitigation. The framework developed in this essay offers useful insights into the characteristics and contextual factors that influence health service organizations’ efforts to implement climate change mitigation efforts. The policy, financial and regulatory environment, leadership, models of care, and carbon literacy and systems support are elements that traverse each health service and each health system. As such, the framework and propositions offered herein should be applicable to all hospitals and health services.
This article establishes a potential path forward for health professionals, health care administrators, policy makers, funders and researchers to address environmental concerns in health service organizations. There is a need empirically to test the framework and the propositions offered, so as to validate its components and their influence on sustainable development efforts.
Footnotes
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.