The problem
- “The NHS and healthcare in general contribute roughly 4-5% of global CO2 emissions — that’s twice aviation and twice container shipping. 1
- NHS England carbon emissions constitute 4% of England’s total carbon footprint. 2
- Surgical procedures contribute 21-30 % of total NHS waste.
- Anaesthetic gases contribute an estimated 2% of the NHS’s total carbon emissions.
- Approximately 3.5% (9.5 billion miles) of all road travel in England relates to patients, visitors, staff and suppliers to the NHS; around 14% of the system’s total emissions.
Taking action
Sustainability will play a growing role in shaping the future of health services.
- Action to tackle climate change also reduces the burden of disease from air pollution, obesity and poor diet.
- Intervention has been shown to directly addresses health inequalities.
- Reaching the UK ambitions under the Paris Climate Change Agreement could see lives saved; around 100,000/year from healthier eating and 38,000/year from a more physically active population.
Recognise that climate change is a healthcare emergency
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Acknowledge the link between climate change and inequalities
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Create a more enabling environment
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Explore sustainability in pathways of care, travel and procurement
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Embed sustainability in governance, structures and culture.
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Assess risks and ensure services are resilient
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Publish a plan to get to net zero emissions
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Disinvest from fossil fuels
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‘Carbon Footprint’
The carbon footprint of the NHS is shaped as much by models of care and clinical behaviours as it is by the buildings and technologies used. For example, a typical NHS operation produces 150-170 kg CO2. This is equivalent to the CO2 produced driving from London to Edinburgh (450 miles) in a petrol fuelled car.3 Despite progress to date, a 26% reduction in emissions from 1990 levels, there is still a significant challenge ahead. To close the gap to net zero the NHS will need to remove 6.1 MtCO2 from the NHS Carbon Footprint and 24.9 MtCO2 from the NHS Carbon Footprint Plus, (see figure below).
1. Pichler PP, Jaccard IS, Weisz U, Weisz H. International comparison of health care carbon footprints. Environmental Research Letters. 2019;14(6):064004.
2. NHS Sustainable Development Unit (2012). Report. NHS England Carbon Footprint Update.
3. Rizan C, Steinbach I, Nicholson R, Lillywhite R, Reed M, Bhutta MF. The Carbon Footprint of Surgical Operations: A Systematic Review. Ann Surg. 2020;272(6):986-95.
The emissions we control directly - NHS Carbon Footprint
The emissions we can influence - NHS Carbon Footprint Plus
Targets
Each Trust and Integrated Care System (ICS) has been asked to produce a green plan, setting out its aims, objectives and delivery plans for carbon reduction reflecting national priorities:
In England 1
• For the NHS Carbon Footprint: Net zero by 2040, with 80% reduction by 2028 to 2032.
• For the NHS Carbon Footprint Plus: Net zero by 2045, with 80% reduction by 2036 to 2039.
UK health services make landmark pledge to achieve net zero. GOV.UK. 2021. https://www.gov.uk/government/news/uk-healthservices- make-landmark-pledge-to-achieve-net-zero (accessed 23 Feb 2022).
In Scotland 2
Brought forward its target date for achieving net zero emissions from 2045 to 2040.
NHS Scotland climate emergency and sustainability strategy 2022 to 2026 – draft: consultation. Scottish Government. 2021.https://www.gov.scot/publications/nhs-scotland-draft-climateemergency- sustainability-strategy/ (accessed 23 Feb 2022).
In Wales 3
The public sector is aiming for net zero carbon by 2030, with the NHS contributing a 34% reduction by the same deadline.
NHS Wales Decarbonisation Strategic Delivery Plan. Welsh Government. 2021.https://gov.wales/sites/default/files/publications/2021-03/nhswales- decarbonisation-strategic-delivery-plan.pdf (accessed 23 Feb 2022).
The public sector is aiming for net zero carbon by 2030, with the NHS contributing a 34% reduction by the same deadline.
Our response
The Vascular Society recognises that healthcare is a major contributor to the overall carbon footprint of a population.
Surgical specialities must respond to the health emergency associated with climate change.
- Storms, floods, heatwaves and the spread of infectious disease threaten to undermine recent health gains.
- We are already experiencing extreme weather events more frequently.
- For our speciality, unchecked climate change will contribute to the burden of cardiovascular disease and overwhelm vascular services.
The Society believes that we must take steps to both recognise where vascular surgery contributes to carbon production and take steps to reduce our environmental impact.
Our aim is for sustainability whilst maintaining excellent standards of patient care.
If carbon emissions are not reduced, we believe this will have a greater detrimental effect on global health than we cannot offset with the services that we deliver.
We therefore fully support the aim of delivering ‘net zero’ by 2045.What we can do
We can impact the carbon footprint of our care in multiple areas of the patient pathway.Examples include:
- telephone consultations to reduce travel emissions
- to conservative non interventional care for our patients with intermittent claudication.
- We can tackle waste segregation in our operating theatres as well as reducing the environmental impact of the medical supply chain. This also means working with our industry partners to reduce packaging, produce disposable equipment from compostable materials, and ensure other equipment can be repaired.
To achieve this ambition will require work across multiple fronts to reduce the carbon footprint of the care we deliver. Investment will in addition be needed in green energy, green travel, and carbon capture.
Sustainable Healthcare
Sustainable healthcare involves ensuring the ability to provide good quality care for future generations by balancing the economic, environmental, and social constraints and demands within health care settings. A sustainable healthcare system maintains population health, reduces disease burden, and minimises use of healthcare services.
Organisations must understand their broader impacts across economic, environmental and social domains. To improve sustainability, organisations must ensure that their use of resources does not exceed available supplies, and that their impacts do not negatively affect the wider community, the environment, or future generations.
Proposed solutions
To achieve such challenging targets requires action both in terms of both mitigation (carbon reduction) and adaptation to climate change. 'Net-zero’ models of care considered and implemented as part of the NHS Long Term Plan and how we deliver our services: Seven early steps to low-carbon vascular services
1. Models of care
1.1 Public and preventative health interventions
- Smoking cessation
- Exercise and fitness (i.e. supervised exercise for people with intermittent claudication)
- Diet -challenge packaging/ready meals/salt intake/fat intake/plant substitutes/high sugar
- Patient education to better manage their disease
- Patient empowerment
1.2. Digital care pathway redesign
- Electronic not postal communication with patients
- Opportunities for remote consultation
- Minimise the need for travel to a hospital for clinic appointment
- If patients do attend hospital, maximise the no. of specialties who see the patient to improve efficiency
- Time critical care to avoid deterioration requiring more complex intervention with greater healthcare resource cost
1.3. Conditions where surgery may not be indicated?
- Intermittent claudication
- Aortic aneurysm at low risk of rupture
- Asymptomatic carotid artery stenosis
1.4. Optimising the pre-op pathway
- Assessment at home or close to where people live
- ‘One stop’ clinics
- Virtual preassessment clinics for minor procedures
- Review current practice on ordering blood tests and G&S
1.5. Optimising vascular surgery and endovascular procedures
- Procedures under local or regional anaesthesia
- Low carbon – avoid waste and single use products
- Minimising blood loss
1.6. Optimising the post-op pathway
- Reduced length of hospital stay
- Reduced surgical site infections
- Reduced complications
- Virtual ward -with video conferences.
- Support post operative patients with remote monitoring (e,g, bp/pulse oximeters -remote access)
- Hospital at home models of care
- Reducing hospital readmissions
1.7. Reduce unnecessary waste of resources
- Overuse of gowns, gloves and aprons
- Too frequent dressing changes / Unnecessary dressings
- Scrubbing up each case (alcohol gel may be sufficient)
- Overuse of supplemental oxygen 1
- Unnecessary procedures (see below)
Procedures that may be unnecessary in vascular surgery
Antibiotic prescription (or too long a duration)
Too frequent dressing changes
Crossmatch of blood
Some blood tests.
Duplicated radiological examinations.
Urinary catheterisation
Non-evidence-based prescribing
General anaesthesia
Opportunities to avoid general anaesthesia
Regional (popliteal block) not general anaesthesia for angioplasty
Local anaesthesia for carotid endarterectomy
Regional anaesthesia for endovascular aortic aneurysm repair
Embed into each unit a regular meeting about sustainability, and discuss ‘how we can do better’
2. Medicines and supply chain
By working with our suppliers to ensure that all of them meet or exceed our commitment on net zero emissions before the end of the decade. Medicines account for 25% of the emissions within the NHS.
- Reducing unnecessary equipment / overage?
“Don’t open it unless you need it”
- Innovation: All business cases to have a sustainability question
- Procurement: Ask companies to support reusables, hybrid, or remanufactured equipment and refurbishment
- Procurement: Ask for use of recycled material (i.e. 100% recycled paper content)
- Checklist: Routine use of the sustainable surgery checklist
Single use items in vascular surgery
Make it a routine to review the waste generated by a single case -and consider how to reduce this?
- Unused single use items
- Items with a reusable alternative (i.e. sharps bins)
- Items with a low carbon alternative (i.e. skin suture not staple, prep in gallipot)
- Can items be recycled, refurbished or reused?
- Can items be repaired?
Recycling
Paper: Correspondence, documentation, patient information
Textiles: Drapes, gowns, masks, slide sheets, warming blankets and hats
Plastics: Gloves, aprons, suckers, light handles, IR covers, suction canisters, gallipots, kidney dishes, catheters, quivers, laryngoscopes.
Metal: Guidewires
Cardboard: Packaging,
Mixed: Wound dressings; Chlorhexidine ‘lollipops’; Diathermy, Batteries
Critical earth elements: Batteries, electronic equipment
1. L medical O2 equivalent to 0.7 kgCO2.
2. All volatile anaesthetic agents are potent Greenhouse Gases, with desflurane and nitrous oxide having the highest global warming potential. N2O contributes directly to the destruction of the ozone layer.
The Net Zero Supplier Roadmap has now been published as statutory guidance.
3. Transport and travel
A shift to zero-emission vehicles by 2032 for our workforce:
- Active travel (i.e. Cycle to work schemes, encourage staff not to drive to work ‘one-day-a-week campaign)
- Car sharing schemes
- Incentivise staff to use electric vehicles: Provision of charging points and Electric car leasing scheme
4. Innovation
By ensuring the digital transformation agenda aligns with our ambition to be a net zero health service and implementing a net zero horizon scanning function to identify future pipeline innovations.
- New low-carbon care pathways and treatments
- Mitigation (carbon reduction): Carbon capture technology and Nitrous oxide capture and reuse
- Products re-designed for reuse and/or low carbon footprint
Lower carbon alternatives
Bio-based polymers
Reusable PPE
Use of Total Intra-Venous Anaesthesia (TIVA) When Possible
5. Hospitals:
A new Net Zero Carbon Hospital Standard.
Energy efficiencies
LED Lighting
Window glazing
Energy-saving design features (i.e. encouraging use of the stairs)
Reduce water usage, especially from wastage
Turn power off when not needed
Renewable energy sources
Solar power
Wind power
Carbon offsetting
Re-wilding of hospital site
Meat free days
Local fruit and vegetables stalls on hospital sites
Reduced waste
Reduce food waste through better choices and greater flexibility
Reduce food miles of the food provided
Reduce waste from both clinical and non-clinical areas
Identify re-use opportunities in clinical and non-clinical areas
Increase recycling rates on all of our sites
Explore opportunities for food waste recycling segregation and collection across all sites
6. Adaptation efforts
By building resilience and adaptation into the heart of our net zero agenda, and vice versa, with the third Health and Social Care Sector Climate Change Adaptation Report in the coming months.
- Hotter, drier summers, with more heatwaves and droughts
- Modifying buildings to remain cool during summer
- Reducing water use to improve resilience to drought
- Wetter winters, with more flooding and severe storms 1
- Patient access to services
Risks of from climate change
Flooding 1
Disruption to supply chains
Morbidity associated with extremes of temperature
1 For example, 10% of London's hospitals are at risk of river flooding.
7. Values and our governance
By supporting an update to the VS MoA to include the response to climate change, launching a new national programme for greener vascular services, and appointment of a VS Council net zero lead, making it clear that this is a key responsibility for all our staff.
We plan to seek engagement with our industry partners to address areas around packaging and supply chain. At this year’s ASM in Brighton we will bring together a session to look at some of the solutions and our UK experience.
We plan to take this forward with the Journal of the Vascular Societies of Great Britain and Ireland (JVSGBI) to publish a tool kit to help our vascular units maximise their contribution to the control of climate change.
References
NHS Sustainable Development Unit (2012). Report. NHS England Carbon Footprint Update
Naylor C, Appleby J (2012). Report. Sustainable health and social care: Connecting environmental and financial performance
Achour N (2010). Journal article. 'Resilience strategies of healthcare facilities: present and future'. International Journal of Disaster Resilience in the Built Environment, vol 1, pt 3, pp 264–76.
London Climate Change Partnership (2011). Report. London's changing climate: In sickness and in health