Sustainability means more than turning down the thermostat or installing bike racks. David Pencheon argues the NHS must change the way it delivers care if sustainability is to be a successful long term commitment.
Sustainability is becoming an increasingly popular word in the health service. It is being used by politicians, is being written in policy, and it is being used by managers and clinicians at a local level. But what does it actually mean and how do sustainable services benefit patients?
Sustainability means more that merely lasting or surviving: it means designing and delivering health care that use resources in ways that don’t prejudice future health and wellbeing. The NHS has much to gain by taking this issue seriously and much to lose by ignoring it.
Parts of the NHS like Nottingham, Bristol, Sheffield, Sandwell, University College London Hospitals, and many other places are already embedding the true meaning of sustainability into their core business.
The NHS in Nottingham and Cornwall have transformed the way they source and provide food for patients, UCLH, Bart’s and Guy’s and St Thomas’ have completely reassessed how they use all their resources to provide the best possible patient care, without doing unnecessary harm to the environment.
These trusts are paying forensic attention to how we source energy, food, drugs, and medical technology. This approach delivers the first benefit of sustainability: saving money. Other benefits soon follow: compliance with the law, enhancing reputation, improving the morale of the workforce, the care of patients and the health of the public.
But it is not just increased efficiency that delivers these benefits. We know that doing the same things more efficiently and in more environmentally sensitive ways will not deliver the long term changes we need. Even more benefit comes from redesigning newer models of care, based on patient preference, more informed and empowered primary care staff, medical technology, and more seamless systems of prevention and care based on a better understanding of population need and preference.
In fact, the most sustainable healthcare is when we have significantly reduced the need for care because of better prevention or early management. We need to deliver more health, not more medicine: and remember that very often, less is more.
Sustainability is an approach that focuses on genuinely long-term maintenance of wellbeing. Whether in business or in the public sector, the three broad dimensions are the same: economic, social and environmental. Importantly, its whole approach is highly aligned with that of the NHS: maintaining health and providing healthcare. Hence it can be found in the NHS Constitution.
The West London Cancer Network are doing just that. A group of hospitals using modern information technology are saving more than 15,500 hours of staff and consultants time by holding multi-disciplinary meetings in virtual space. It saves money, time, gives better health outcomes, and is better for patients. It is also good for the environment since staff do not have to waste their time, their safety, and NHS resources travelling between sites.
Although the West London Cancer Network has certainly benefitted from the true meaning of sustainability, many still consider sustainable services those that simply endure; even when we know that in a rapidly changing world, we often need services to be flexible and adapt to different circumstances. Sustainability means “doing no harm to the future” not merely “durable” or “lasting”.
We need to value future benefits and harms, not just those of today. Sadly, we rarely make strategic decisions in the health service based on these indirect costs: partly because it is difficult, partly because we are so focused on the needs of today, and partly because our accounting rules rarely recognise long term benefits – despite the fact that we know that investing in prevention, resilience and a future proof service offers huge savings and benefits for the NHS.
Do we really lack the foresight, imagination or resources to invest in the future, as well as the present? After all, if health is not a resource for future living, then what is it?
Organisations that survive and prosper in a rapidly changing world are those that take sustainability seriously in all three interconnected areas:
Without financial sustainability, all else is meaningless: assuming we consider financial sustainability over an appropriate time span. However, we are often burdened with accounting systems which value only the next year, or the next electoral cycle; not always helpful to make long term investments for long term benefit.
Our business plans and strategic intent would be more effective if they were to stretch to years and decades, not months and years. We have to question the effectiveness of an accounting system that fails to recognise a genuine investment in long term health just because it doesn’t deliver some process target within three years. Much of what the NHS invests in delivers benefits after many years, if not decades. We should measure and value this benefit properly, with appropriate measures of discounting.
Paradoxically, the private sector has been much quicker to recognise the value in embedding genuine sustainability. The sector has access to much more consistent and explicit accounting, reporting, and delivering on sustainability objectives where financial resilience is part of this triple bottom line.
Organisations that provide health care are learning from this lead, with many trusts - particularly foundation trusts - already adopting similar practices. Good governance of any organisation means acknowledging and integrating the multiple bottom lines.
Genuine sustainability can be defined as “development that meets the needs of the present without compromising the ability of future generations to meet their own needs”(1). Kenneth Boulding, John F Kennedy’s environmental advisor observed that “Anyone who believes in indefinite growth in anything physical, on a physically finite planet, is either mad or an economist.”
We clearly cannot live beyond our means. And we do not want to perpetuate those systems and models of care that are outdated, inconvenient, unaffordable, ineffective, and unsafe (not just those that do more harm than good now but also those that create more problems than benefit for in the future).
This is not simply about turning down the hospital thermostat or providing more cycle racks. This is about engaging professionals and the public in radically better ways of preventing and managing illness: using appropriate information technology and the best preventative, diagnostic, therapeutic care while harnessing the most valuable asset for the NHS: the public.
We know that most improvement comes, not just from recognising the benefits of new models of care, but also from stopping outdated and ineffective models of care.
If there is any sector that takes fairness seriously it is the NHS, especially by the public. Hence, there is a great opportunity for the NHS to maintain those values by managing resources fairly: between different groups of people now, and between generations, and to continue to set an example on an international stage. Although most of us are rightly focused on the day job, we do not want to, and should not want to do this at the expense of our ability to do it equally well tomorrow.
Incorporating financial, environmental and social considerations into the decision making process can reap significant and multiple benefits. The Gateway Surgical Centre at Newham University Hospital Trust in London uses the latest technology and streamlined pathways of care to improve the patient experience in the trust.
The community was consulted on the type of facility they wanted, resulting in a health village in Newham. Wireless technology supports the use of bedside electronic patient records and easier access to systems for patients and staff. Art, much of it from local schools, is used to guide users through the building. Natural light is maximised throughout the building with floor to ceiling windows. Rainwater is used to flush toilets and heat is recovered from the ventilation system. Forward thinking trusts, willing to put sustainability at the heart of their decision making process are an important part of creating a high quality service (2).
Nowhere do we need better measures of quality that in the health system - beyond just healthcare activity or even life expectancy. Genuine sustainability means measuring the contribution of the health sector to more relevant indicators of welfare such as social justice, mental health, and independence.
A high quality health system which is genuinely fit for the future addresses all three areas of sustainability: financial, environmental, and social. Just like the leading businesses in the top FTSE 100 where sustainability is much more commonly seen as a core dimension of quality, so we have NHS organisations that understand that these issues are mutually reinforcing, and who find themselves on an upward virtuous cycle of quality and reputation which is recognised by a correlation between clinical performance and sustainability performance (3).
In the USA, 87 per cent of Fortune 1000 CEOs believe that genuine sustainability is important for their organisation’s success (4). Health care organisations, be they providers or commissioners, ambulance trust or mental healthcare trust, have as much to gain, if not more.
Sustainability really means using resources appropriately and fairly in the interests of everyone, today and tomorrow. The first obligation of any health system and any health professional is to “do no harm”. Genuine sustainability is highly congruent with what the values of the NHS and what it has always being trying to achieve.
We have a duty of care to ensure the NHS can make these values real in everyday practice, from minimising waste, to designing better models of care. This will serve the NHS admirably both now and in the future.
As many people in the NHS are already demonstrating, these opportunities are happening on our watch. Whether we choose to grasp them as a system will be our legacy.
Find out more
- Our Common Future (The Brundtland Report): by the World Commission on Environment and Development. 1987.
- SHINE: Gateway Surgical Unit case study
- Leading the field: Foundation trusts and their approach to the sustainability agenda, NHS Confederation Network, 2009
- Sustainability and its Impact on the Corporate Agenda, Accenture, January 2009