Published: 30/01/2003, Volume II3, No. 5840 Page 34 35
Though the NHS does have an environmental strategy, many trusts have neither the time nor the money to implement it. So what is being done in terms of sustainable development, asks Alison Moore
The NHS has rarely been a first-mover on the environmental front but it is now beginning to take its impact on the environment and society more seriously.
Earlier this year, NHS Estates drew up an environmental strategy which set targets for all trusts in key areas.
1There are three drivers for this new emphasis on the environment: saving money; EU directives that cover aspects such as landfill and climate change; and the general government commitment to sustainable development.
Sustainable development goes far beyond the traditional environmental considerations, such as waste disposal and recycling, to look at the overall impact of the NHS on the communities it serves. This can encompass the provision of jobs for local people, to offering opportunities for healthy living.
One of the first targets set by NHS Estates was that trusts should have a strategy covering energy, waste, water, transport and procurement.
Yet the indications are that compliance with this has been patchy, as the deadline was October 2002.
A spokesperson for NHS Estates says that the number of enquiries it had received suggested trusts were trying to meet the target. However, he acknowledged primary care trusts would take some time to get to grips with their newly acquired estates.
Dr Michael Dixon, chair of the NHS Alliance, agrees that few PCTs are likely to be producing environmental strategies yet. 'There are some things that have had to take priority and some things that go on the back burner, ' he says. PCTs' approaches to the environment are probably determined by the actions of their predecessor organisations, but the pace of change may have meant some things had been put on hold while more pressing priorities were dealt with.
Trevor Payne, head of facilities at Oxford Radcliffe Hospitals trust, admits its strategy is still being written.
'It is one of the things that has taken a back seat, ' he says.
'Colleagues I have spoken to have said they are in a similar position. They have priorities such as fire and privacy and dignity.'
These conflicting priorities are familiar to Mike Gallagher, facilities director at Blackpool, Fylde and Wyre Hospitals trust, who surveyed 161 trusts on their approach to the environment around 18 months ago as part of research for a PhD.
Then, lack of time, an absence of legal requirement and a lack of commitment from trusts were all seen as barriers to bringing in a strategy. Environmental management was seen as well down trusts' lists of priorities.
Has the NHS Estates strategy changed that? The managers who responded to Mr Gallagher's questionnaire said the drivers that would make trusts change are legislation, the controls assurance agenda and cost savings.
'The problem with the environment is that whatever people tell you, there is very little money in it, ' says Mr Gallagher.
Lack of time for estates managers and the pressure of other priorities may also inhibit change, he adds.
Peter Woolliscroft, vicechair of the Health Facilities Management Association, says the agenda facing his members is massive. 'At the trusts there is a must-must-do list, a must-do list and a when-you-get-round-to-it list. Sustainability is on the must-do list but not the mustmust-do list.
'It is a well thought out and much needed strategy but unless it comes with a slug of money to resource it, it has to sit in a list.'
The resources needed are not necessarily cash - though some changes will need it - but also manpower and skills to push the programme forward, he says.
But what of the targets themselves? (see box, below) 'They are demanding and quite expensive to meet.
There are concerns that we will have to invest in equipment to make savings, ' says Mr Payne.
Mr Gallagher suggests that the NHS actually does reasonably well on energy and waste management: the intractable problem may be transport - a 1,000-bed hospital can have as many as 20,000 vehicles a week coming on site. Smaller issues such as discharge to drains may also need to be addressed.
Mr Woolliscroft feels the strategy has been introduced too quickly and targets will be difficult to hit for older hospitals. One way of helping would be to allow trusts to borrow money for, for example, new energy-saving equipment and pay it back as the cost savings are made.
Private finance initiative projects may be able to address some of these issues:
backers will be able to take a long-term view of the 'payback' on energy-saving investment, for example.
But if trusts are slow to draw up a formal environmental strategy, that does not mean things are not happening.
Mr Payne points out sustainability is being addressed in his trust's PFI project to replace the old Radcliffe Infirmary in Oxford. 'It has started to creep into design as well now, rather than saying you should build something and then worry about its sustainability.'
Addressing sustainability right from the start has certainly been the approach at Swindon and Marlborough trust, where the new Great Western Hospital has been built under a PFI project (see page 31). Trust redevelopment project director Nigel Hodson describes it as 'a benchmark that other buildings will have to beat'.
Energy-saving initiatives include state-of-the-art roof insulation and double glazing throughout. Waste disposal has been minimised with the recycling of some excess materials such as wall linings, where off-cuts were returned to the manufacturer for re-use.
Much of this has been achieved at no extra cost, though making the new hospital easily accessible by public transport has been costly.
But should the NHS be thinking about sustainability in an even wider sense? Mr Gallagher points out the importance of where supplies are obtained and how they are produced, for example.
Though NHS Estates has mentioned it in its sustainable development booklet, there are no specific targets - and EU regulations could limit the emphasis that is put on it.
'Companies like Tesco are looking at their whole chain of supplies, ' he says.
'Procurement is one of the areas where we can make the greatest impact by simply asking our suppliers what they do about sustainability.'
Sustainable development: an assessment of the impact
A key part of sustainable development is assessing the impact of new buildings, changed policies and projects.
Appraisal tools and checklists exist for any number of elements of this - from the health impact of a new building to the environmental impact of changed transport policy. But the very number of these may deter their use.
However, a new scheme which has been developed in the North West will allow all these aspects to be looked at quickly - and allow more detailed examination of ones which are particularly important. It also encourages the benefits of government spending to be maximised, rather than the ill-effects minimised.
Potentially, the scheme has enormous impact on the NHS. It will encourage NHS investment to consider other elements of government policy; but it will also ensure that spending by other public sector organisations will take into account the impact on health.
Dominic Harrison, associate director of the Health Development Agency, says the integrated impact assessment tool, which the agency has developed with other public sector partners, is 'an enormous opportunity'.
'It has not been in the NHS's culture to look at things that are not directly to do with healthcare service delivery, ' he says. But many of the issues around sustainable development - from reducing pollution to encouraging local employment - are addressing determinants of ill health.
The NHS has not always looked at its own impact on many of these areas. 'The spending of the NHS may well be one of the most important levers we have, to improve the health of the population, ' says Mr Harrison.
The scheme, which is now in its final draft, was piloted on a planned£230m private finance initiative project at St Helens and Knowsley Hospitals trust. 'We have used it as a springboard, ' says Neil Grice, one of the managers of the project. 'It threw up some big issues for us around regeneration and workforce and so on.
'Some people were cynical - especially some of the very practical people - but a lot of it is very much common sense and good management practice. It is not out-of-this-world stuff.'
The trust then went on to do a specific health impact assessment.
Health impact is now a regular item on the project board.
The range of issues now being addressed is breathtaking - from childcare to rainwater collection, from cyclists' needs to disposal of hazardous materials. The range of potential partners that could contribute is immense.
One example, resulting from the integrated impact assessment, is the use of trees in the project. The Forestry Commission wants to increase the number of broadleaf trees in the region and has a budget to support planting.
Looking out at grass and trees - rather than concrete - has been shown to assist patients' recovery. Put the two together, and with money from the commission, more trees could be planted to the benefit of patients and staff.
'It is about doing things differently, not about costing more money, ' says Mr Harrison.
The assessment toolkit consists of a number of questions about the impact of projects, which have been drawn up in consultation with a wide range of public sector organisations in the area. It is not meant to be a 'tick box' activity, but rather to raise questions and encourage discussion, and has been kept deliberately short and easy to use.
It can be used to assess a scheme once it has been decided upon but Mr Harrison feels it is particularly useful at an earlier stage - to help plan and develop schemes so that from their instigation their impact is considered and the benefits they can bring maximised.
Target practice: reduced energy consumption There are few specific targets for trusts to meet in the NHS's new thrust towards sustainability - but those that exist are demanding. By 2010, the NHS should have reduced primary energy consumption by 15 per cent compared with 2000. New builds and refurbishments should meet a target of 35-55gj per 1,000m 3for energy efficiency performance; existing facilities should meet 55-65gj.
Suggested procedures for trusts and examples of good practice are outlined in NHS Estates documents.
1,2 There is also a CD-ROM toolkit available from NHS Estates.
1New environmental strategy for the NHS (under sustainable development).
www. nhsestates. gov. uk 2Sustainable development in the NHS. www. nhsestates. gov. uk