Published: 01/07/2004, Volume II3, No. 5912 Page 30 31
Despite being one of the UK's largest organisations, the NHS does little to contribute to sustainable development. And as Jenny Griffiths explains, isolated pockets of enthusiasm are not enough
Sustainable development is the integration of social, economic and environmental factors and requires us to value nature and use natural resources prudently. The ecological systems that sustain life on earth are severely strained by excessive consumption and pollution of natural resources, resulting, for example, in global warming.
The NHS is one of the largest organisations in the UK and its facilities contribute to environmental damage.
Because health is influenced by environmental factors, sustainable development is also important in public health.Yet the NHS does remarkably little to help sustainable development.
The Department of Health, while supporting the government's strategy on sustainable development, has not issued explicit central guidance. Instead, requirements for trusts are specified through NHS Estates, the NHS Purchasing and Supply Agency, controls assurance standards and various public health policies.
NHS Estates has produced extensive guidance, especially Sustainable Development in the NHS, and the new environmental strategy for the NHS, with associated targets, tools and returns. It tells trusts to devise their own strategies to reduce pollution and the consumption of natural resources in energy, waste, water, transport and procurement. Other NHS Estates initiatives such as ProCure 21 and the better hospital food programme can also contribute.
Meanwhile, the Purchasing and Supply Agency provides guidance and support to the NHS on environmentally friendly procurement. Controls assurance requirements include standards on environmental management and waste management.
For public health, Tackling Health Inequalities: a programme for action mentions a few environmentrelated measures.
The main challenges to making sustainable development work are:
Few incentives Because sustainable development is a low priority, action on public health issues is becoming more important but is not usually linked to environmental improvement.Management capacity, particularly in primary care trusts, is limited.
Lack of corporate vision, policy and leadership from the centre Most chief executives and trust boards are unaware of the benefits of sustainable development and there are few champions at senior level. Trusts tend to displace responsibility for sustainable development, for example to local strategic partnerships led by local authorities.
Low awareness of NHS Estates strategies
This is with the exception of estates and facilities staff, who do not have a mandate to drive comprehensive implementation. Improving environmental performance is usually seen as a technical rather than a corporate issue.
Low profile of sustainable development in the public health community below regional level The lack of dialogue between the two key groups: public health staff and estates and facilities staff.
Little co-ordination of information and training Plus lack of training of many public health staff .
Nearly all trusts are doing something, somewhere, through the initiative of staff.However, the average national score for controls assurance standard on environmental management in 2002-03 was 39 per cent - higher in acute trusts and lower in PCTs.
The score for environmental management was by far the lowest of any of the 21 standards, which mostly averaged 60-80 per cent.My research suggests that about 20 per cent of trusts have implemented some environmental policies that have resulted in sustainable change - but that it is not usually comprehensive.
Just a few trusts have developed integrated sustainable development strategies, often during the redevelopment of their sites.
At Swindon and Marlborough trust, the Great Western Hospital opened in December 2002 in a new£100m building. Sustainable development was taken seriously throughout the private finance initiative and construction processes. So that the trust understood the long-term savings involved in using sustainable materials, environmental life cycle assessments were done on construction materials.
Transport impact was assessed for all major deliveries of material. A new bus stop for the site reduced traffic and emissions. Prefabricated components such as plasterboard walls reduced waste and delivery journeys (half of all UK waste is construction waste).
Biodiversity was protected. Trees from the original farm and new natural habitats for local wildlife were incorporated in the design.
The development also helped to boost the local economy and community. A jobcentre on the site promoted local employment.
The NHS food for Cornwall project involves five trusts in Cornwall which believe highquality food for patients, staff and visitors is crucial to healthcare provision.
Between them they spend about£1.2m a year on food. Keeping this cash in the South West would improve the wealth, and the social and physical health, of the local community. It would also reduce carbon dioxide emissions through minimising food transport.
Royal Cornwall Hospital trust has placed business with local suppliers. The trusts are now at the advanced planning stages of a central food production unit that will further increase the proportion of locally sourced food produce and goods.
Practical action for trusts Sustainable development can be undertaken in small, easy, enjoyable steps. Trusts should nurture networks of staff champions for energy saving, waste management, cycling and so on.
Incorporate nature into the healthcare environment
A green environment mediates stress, according to the Health Development Agency. Incorporating nature (views, gardens, daylight, plants, water, ponds) into the care environment helps patients physically and mentally with fewer analgesics, reduced length of stay, less patient violence, reduced errors and lower staff turnover.
Include environment in initiatives to tackle social and economic problems Improving air quality through less car use and greater energy efficiency improves health outcomes and reduces the impact of the NHS on global warming.
Procuring high-quality local food stimulates the local economy, reduces 'food miles' (lower carbon emissions) and improves nutrition.
Employing local people - for example, on NHS construction projects - with appropriate training, develops their skills, involves the community and reduces travel (lower carbon emissions).
Community conservation projects build social capital by improving mental health, encouraging physical activity and reducing social isolation.
The DoH could create an integrated policy framework to link sustainable development with clinical care and health improvement.
Ministers, the NHS chief executive and the chief medical officer could regularly state their support for environmental improvement.
Interest could be generated through a programme of awareness-raising for trust boards.
The work of public health, estates and facilities and purchasing staff could be brought together at all levels.
Joint learning opportunities could be provided.
Sustainable development, including environmental improvement, could be explicitly mentioned in the revised priorities and planning framework and in the Healthcare Commission's performance standards.
Simple guidance could be produced by the DoH on implementation of sustainable development, together with pump-priming funding.
National, regional and strategic health authority mechanisms could be developed to encourage and recognise best practice.
Trust boards could publicise their existing achievements through annual reports and by publishing environmental statements.
Trusts could nurture staff champions of sustainable development, including clinical business managers, and plan further action in the areas listed above. Non-executive champions could be nominated.
SHAs could integrate sustainable development and environmental improvement into their performancemanagement systems.
Sustainable NHS services: an NHS plan
1 Reduce energy consumption: obtain electricity from renewable sources.
2 Minimise waste: reduce product quantities, reuse, recycle, compost, recover energy.
3 Reduce water consumption: fit water-efficient taps, toilets and so on.
4 Procure environmentally sound products - locally, where possible.Use the NHS Purchasing and Supply Agency's guidance.
5 Minimise car use: develop transport and travel plans, recruit staff locally.
6 Increase biodiversity: more green space with mixed native planting on NHS land provides habitats for birds and insects and makes people feel better.
7 Incorporate environmental improvement into the design of new buildings and refurbishments.PFI and local improvement finance trusts provide opportunities for whole-life costing to balance higher initial capital outlay.
8 Undertake health and environmental impact assessments (or better still integrated appraisal) on all plans and developments.
9 Use an environmental management system, working towards the international standard ISO14001.
The NHS needs more incentives to take sustainable development to heart.
Achievements by trusts are largely due to personal commitment, and are not systematic.
A centrally backed programme of sustainable development could save money and would benefit staff, patients and visitors.
For further information
lNHS Estates www. nhsestates. gov. uk/sustainable_development/index. asp
Controls assurance standards: www. hcsu. org. uk/
Purchasing and Supply Agency www. pasa. nhs. uk/sustainabledevelopment/
Jenny Griffiths is an independent consultant.For a copy of her full research report on sustainable development in the NHS, e-mail GriffHobbs@aol. com