The way forward in carbon reduction is through creative commissioning for pathways of care. In the final part in our series on sustainability, Jennifer Taylor looks at how the new approach is gaining momentum
If the NHS is going to meet the government’s target of an 80 per cent reduction in carbon emissions by 2050, it needs to think strategically about how to deliver the fundamental objectives of the health service in quite different ways.
Salvaging the reject water from the dialysis unit for use in hospital toilets generated a 500 per cent return on investment over 10 years in Canterbury, and a 4,223 per cent return on investment over 10 years in Ashford, where the recycled water is used for laundry
That means thinking about pathways of care. The good news is that most revised pathways of care that meet the objectives of sustainability and carbon reduction are attractive for other reasons, including improved quality and reduced cost.
The document Fit for the Future, published by the NHS Sustainable Development Unit in September 2009, explores some of the ways a sustainable low carbon healthcare system might be achieved.
Sustainable Development Unit director David Pencheon recommends thinking in terms of how to deliver systems of care to people with particular conditions, rather than in terms of buildings.
“That’s really significant for a lot of people in the health service because you’re moving from a structure based system to a system based system,” he says.
Care delivery
Quite often commissioners do not think creatively about services because they only think about how to use the consultants and nurses who work in a particular building, instead of how those staff might be used elsewhere in the system.
The way forward is by commissioning pathways of care, rather than being locked into the present structures of buildings or personnel. That approach encourages providers to think more about how care is delivered.
If the commissioning criteria for people with diabetes are convenience for patients, value for money and high quality, providers who think innovatively are likely to decide that many of the services do not need to be in hospital because it is expensive to run and difficult to get to.
Instead they may decide to provide services closer to home, perhaps within GP premises. The result is a service that is more convenient for patients, empowers GPs and is more sustainable both environmentally and financially.
A disincentive to these new ways of thinking is that care is paid for on the basis of activity.
A contract could instead say that the provider will be paid not for the number of patients with diabetes treated but for the number of patients with diabetes who avoid hospital admission.
These new approaches to pathways of care are made easier by technology such as telephone surgeries and near patient testing.
The idea that sustainability should be embedded in commissioning decisions and designing services is just starting to take hold and the NHS has got some way to go, says NHS Confederation senior policy and research officer Stephan Groombridge.
He believes momentum will be created once some frontrunners are out there showing the rest how it can be done.
“There are a number of win-wins for the NHS - it ticks the efficiency box, the staff engagement box [and] the quality box. Once NHS leaders start to realise the opportunities which exist then we’ll see much more of it, he says.
Top tips
- Move towards commissioning pathways of care
- Avoid being restricted by structures of buildings and staff
- Reward providers for keeping patients out of hospital
- Exploit technologies such as telephone surgeries
Case study: NHS Kidney Care
The precise carbon footprint of kidney care is not yet known, but it is likely to have a bigger footprint than its proportionate NHS spend.
Most people on dialysis are on hospital based haemodialysis, which uses vast amounts of water and requires visiting the hospital three times a week. Home peritoneal dialysis requires less water but uses enormous amounts of plastic and packaging.
NHS Kidney Care is supporting a green nephrology fellow to calculate the carbon footprint of kidney services and create a methodology that can be used annually by local services to monitor their own carbon usage.
In the meantime efforts are being made to reduce the carbon footprint.
Coventry runs a transplant virtual follow-up clinic in which blood is taken locally and consultants hold telephone consultations. Patients like it because it saves them the hassle of travelling.
NHS Kidney Care would like to use the model elsewhere but the outpatient tariff is just £18 for a telephone consultation and £200-to £300 for a physical consultation, even though the two require a similar amount of work.
“We need to work with commissioning colleagues to reverse some of the perverse incentives for acute trusts to see people they could manage virtually,” says Donal O’Donoghue, national clinical director for kidney care at the Department of Health.
“I would recommend that we move towards commissioning pathways of care rather than episodes of care.
“Payment by outpatient visit isn’t set up to provide payment for quality.”
Another goal is to increase the number of people using home dialysis, which will save carbon by reducing travel, save costs and produce better clinical outcomes because of the ability to tailor the regime.
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