Steep carbon reduction targets for the NHS are being met with inconsistent and poorly informed practices among clinicians, despite them accounting for a large part of the health service’s carbon footprint
The targets of the Climate Change Act are very challenging for the NHS, which means fundamental transformation of clinical practices will be required to meet them.
‘Two of the three largest components of the carbon footprint for mental health are pharmaceuticals and medical equipment’
Sustainability in the NHS has mostly been concerned with reducing energy use and has been led by non-clinical departments such as corporate and estates.
But if the NHS is to meet the act’s target of an 80 per cent reduction in carbon emissions by 2050, then clinical practices will also have to be targeted as they make up most of the carbon footprint of the NHS (see table, below).
Two of the three largest components of the carbon footprint for mental health are pharmaceuticals and medical equipment.
In 2013, the Royal College of Psychiatrists, in collaboration with the Centre for Sustainable Healthcare, created a fellowship to explore the issue of sustainability within the provision of mental health services in the UK. In this role, fellows explore how mental healthcare delivery can change to become more sustainable.
The centre has developed principles of sustainability that, if widely adopted by clinicians, will lead to a reduced carbon burden. These are: prevention, patient empowerment, lean service design and use of low carbon technologies.
As part of the fellowship, the Psych SusNet network has begun to explore sustainability issues relating to the clinical aspects of mental health services, consisting of mental healthcare professionals interested in sustainability.
‘Clinicians generally say that they are poorly informed about sustainable practices within their trusts’
This year, two sustainability surveys have been undertaken. The first explored sustainable practices at a team level and was completed by clinicians, while the second was aimed at organisational level sustainable practices and was completed by trust sustainability leads.
Both surveys covered clinical and non-clinical aspects of mental healthcare delivery.
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The clinical survey had three sections covering travel, resource use and clinical care, while the corporate survey had seven sections: governance, procurement, resource and energy use, waste, estates and buildings, travel, and staff engagement and training.
It received 26 responses from 19 mental health trusts, with good representation from both rural and urban settings. Most clinicians were based in community settings (80 per cent) rather than inpatient settings (20 per cent).
The average sustainability score for teams was 4.7 out of 10, indicating variation of sustainable practices both between and within teams.
Lack of awareness
Clinicians generally said that they were poorly informed about sustainable practices within their trusts.
Regarding travel, when asked “does your trust reimburse for travel made by bicycle?” only 33 per cent answered “yes”; but when the same question was asked to sustainability leads, 56 per cent said that their trust did in fact reimburse for bicycle travel. This suggests many clinical staff are unaware of this option.
‘When asked about paper use, less than 10 per cent sent correspondence to GPs by email’
Some sustainable factors, however, are well understood. All respondents knew about the public transport links to the trust base and 63 per cent knew that their trust promoted the cycle to work scheme. Fifty per cent said walking and cycling were encouraged among patients, where appropriate.
When asked about resource use, 57 per cent of clinicians did not know whether low energy light bulbs were used or not; 19 per cent said motion sensor lighting was used and 62 per cent reported that lights were turned off when not required.
When asked about paper use, less than 10 per cent sent correspondence to GPs by email and only 24 per cent said that recycled paper was used for correspondence, although 52 per cent said that printers were set to print double-sided.
Regarding clinical transformation, clinicians indicated that environmental impact was the least important factor in making clinical decisions; less important than financial cost and management guidance. The most important factor was scientific evidence base.
Clinicians were asked if their team had developed any sustainable clinical practices according to the principles of sustainable healthcare. The table below shows the range of answers.
Sustainable models of care adopted by clinical teams
|Lean service design
|Use of technology
|Use of low carbon interventions
|Use of relapse prevention plans
|Created leaflets to empower patients to self-manage
|Improved referral systems
|Developed a user led phone and text support service
|Implemented therapeutic horticulture sessions
|Improved use of early intervention teams
|Shared ownership and creation of patient care plan
|Good links with third sector organisations
|Enabled patients to contribute to their own health record
|Improved exposure to nature
|Improved continuity of care
|Psychoeducation groups provided at day services
|Use of the My Shared Pathway programme to reduce length of stay
|Use of social media for patient support via clinic’s Facebook page
|Use of exercise referrals
|Use of wellness recovery action planning
|Encouraged self-referral to therapy groups
|Maximised prompts for appointments to reduce non-attendance rates
|Provided option of telehealth clinics
|Online CBT interventions available
|Started groups to resolve debt and develop coping strategies
|Use of child-appropriate therapy engagement programs
|Linked clinics to reduce patient attendances
|County-wide telephone triage service
|Use of crisis line service
Results for corporate survey
Ten responses were received for the corporate survey, each from different mental health trusts. Again, there was significant variation between trusts, with a mean sustainability score of 3.9 out of 10.
Regarding governance, 70 per cent of trusts had a sustainable development management plan and 40 per cent regularly included sustainability issues at board meetings.
‘Only 40 per cent of trusts included environmental issues in their staff induction programme’
Carbon reduction policies were implemented by 30 per cent of respondents and 10 per cent had an environmental management plan.
With regard to procurement, 10 per cent of trusts had a sustainable procurement policy and 30 per cent had a policy to procure food from local suppliers.
Resource and energy use varied between trusts. One trust used both solar panels and wind turbines, but 80 per cent did not use any form of renewable energy.
Regarding estates and buildings, in 20 per cent of trusts it was mandatory to have a Building Research Establishment Environmental Assessment Methodology “outstanding” rating. In 80 per cent of trusts, green spaces and views were provided for patients, whereas 60 per cent of trusts provided green spaces specifically for staff.
When it came to travel, 30 per cent of trusts used low emission vehicles but only 20 per cent had a flat rate per mile for staff travel expenses, which pays more for cars with larger engines; 30 per cent of trusts had an active travel plan, to encourage staff to use healthier methods of travel.
Case study: Athena Centre
The Athena Centre, a psychotherapy unit in Berkshire for people with personality disorder, has made several changes to reduce its environmental impact including energy efficient lighting (movement detection switches, and LED/CF lamps) and sealed unit windows to reduce heat loss.
Many patients walk to the unit and some staff and patients cycle. Tele and video conferencing are also frequently used.
The unit has created an environment centre where some of the therapy programme takes place. Activities include rural crafts groups that use natural or recycled materials such as willow sculptures, stone painting and making Christmas decorations.
An organic allotment provides a good amount of the food used by staff and patients, while leftovers are composted. Heating is provided by a log burning stove, which uses gathered waste wood.
When asked the question “how important is clinician engagement in promoting sustainability within the trust?” 80 per cent of sustainability leads answered “very” or “moderately important”. Despite this only 40 per cent of trusts included environmental issues in their staff induction programme and just 30 per cent provided training on environmental issues related to clinicians’ daily work.
Sustainability leads said the main barriers to clinicians’ engagement with sustainability included limited time, poor support from management, poor motivation, limited awareness and sustainability having a low priority for clinicians.
These surveys illustrate the differences in sustainable practices across mental health trusts in England. Their results suggest that trusts are inconsistent in both developing specific policies and informing staff about existing sustainable practices; this is despite a corporate desire to have clinicians more involved with sustainability issues.
They also suggest that sustainability is on the agenda for most trusts but that they lack the confidence and/or ambition to implement it.
‘Clinicians have a lot to learn from their facilities colleagues who have been responsible for reducing the carbon footprint of their organisations for many years’
More engagement from clinical staff on its own will not transform the NHS into a sustainable healthcare system, but it is a good starting position. The results suggest there is a lack of clinician awareness and engagement.
Clinicians need to be given more information about opportunities for sustainable development within their trust and more dialogue needs to occur between corporate and clinical structures.
These surveys indicate that staff training and induction programmes are not being best used to optimise sustainable development. They also indicate that many trusts and teams have easy wins available to them to reduce both costs and carbon footprint such as reviewing temperature regulation in their buildings, reviewing staff travel policies and improving use of email correspondence.
Clinicians have a lot to learn from their estates and those facilities colleagues who have been responsible for reducing the carbon footprint of their organisations for many years. This is a relatively new and important area in healthcare and greater collaboration is needed to improve carbon reductions and create more coordinated responses.
It is only with this high level of collaboration that the NHS will be able to meet the Climate Change Act targets and set the standard in the UK for environmental responsibility.
Daniel Maughan is Royal College of Psychiatrists sustainability fellow at the Centre for Sustainable Healthcare, Simon Wallace is medical student at Oxford University and Rob Lillywhite is a senior research fellow of the School of Life Sciences at Warwick University