How to save £20 000 and 780 staff hours a year on a single ward—by making one climate friendly change
BMJ 2023; 381 doi: https://doi.org/10.1136/bmj.p833 (Published 20 April 2023) Cite this as: BMJ 2023;381:p833
Gareth Murcutt, a renal technical manager at the Royal Free Hospital in London, remembers his “eureka moment.” After the pandemic his clinical director had asked him to look at sustainability—but at first it wasn’t his top priority, he told Medicine 2023, the Royal College of Physicians’ annual conference, held in March.
“We were struggling with all sorts of things,” he explains. “And not because I didn’t believe in the climate crisis, but I approached this from the idea that there is nothing we are going to do that is going to make the treatment worse for our patients, and thus I thought the gains would be fairly marginal.”
He then looked at how the renal team delivered acid concentrate to their dialysis machines: they loaded a new 5 L container of acid concentrate onto each machine for each patient. This was then lifted off each dialysis machine after each patient’s treatment session, several times a day. The team did an audit of how much was left in the can at the end of each treatment session.
“It’s fair to say the results shocked me immeasurably,” says Murcutt. “It turns out, on average, we’re throwing away around one third of every single can that we buy.” This was the light bulb pinging on: there had to be a better way.
And there is. He realised that switching the trust’s dialysis units (wards) to central delivery systems would immediately save a typical 30 bed dialysis unit £20 000 a year in acid concentrate. There were many other benefits, too. He calculated that staff in a typical dialysis unit were lifting a cumulative total of 1250 kg a day when they lifted the containers onto and off the machines, and getting rid of this task would give a unit at least 2.5 hours of staff time back each day. A single dialysis unit could save 6188 kg CO2 equivalent (CO2e) a year in concentrate and 22 299 kg CO2e from the difference in packaging. The switch will run as a trial on two units starting in summer 2023.
This inspired Murcutt to see what other changes he could make, such as asking manufacturers to put tubing sets in packs of two instead of one, or calculating the emission savings from using physiological fluid produced by the dialysis machines instead of pre-packaged saline bags—which are, as Murcutt says, “plastic wrapped in plastic.” This switch in saline saves each dialysis unit 4000 kg CO2e a year from the weight of the plastic alone.
Delivery by drone
Healthcare staff in Coventry have turned to the skies to save time and carbon. Sean James, operations lead at the Arden Tissue Bank based at University Hospital Coventry, worked with a local start-up to test whether it was feasible to use drones to transfer patient samples between Rugby and Coventry, two sites of the University Hospitals Coventry and Warwickshire NHS Trust.
Using a drone showed a more than 95% reduction in emissions when compared with road transport, and this remained more than 90% even when compared with an electric van, James told the conference. It also halves the journey time, which is crucial, for instance, if urgent blood or other equipment needs to be delivered between sites. James says that a drone was recently used to deliver a prosthesis from one site to the other, mid-operation. He explains, “If you have a patient in the theatre [in the Hospital of St Cross, Rugby], and the prosthetic is at Coventry, you can still get it done: it can fly you a prosthetic there, and it has happened—it happened two weeks ago.”
There are still some issues with this technology. One major factor for the UK is that the drones are not fond of rain, and the regulatory framework is still an area of active development. For James, however, the many potential benefits make this new technology difficult to ignore. He says, “The take home message is: massive reduction in carbon, drastic reduction in time taken, with caveats.”
Both James and Murcutt have delivered on the “triple bottom line,” an idea explained in the Centre for Sustainable Healthcare’s sustainable value equation.1 It encourages considerations about value in healthcare to help balance outcomes for patients and populations against the financial, social, and environmental costs—in contrast with the more traditional balancing of individual patient outcomes against monetary cost. This framework allows sustainability to be added to any quality improvement work already under way.
Their projects also demonstrate the impact of involving different professional groups in the endeavour towards sustainable healthcare. Nick Watts, NHS chief sustainability officer, told the conference that there was broad support from NHS staff for tackling climate change. “When you go out and you ask NHS staff what do you want to see the NHS do more of, the response is thunderous . . . 92% want to see the NHS tackle climate change directly,” he says.
This need to engage all staff is endorsed by the Royal College of Physicians’ position paper—launched at the conference—on healthcare sustainability and climate change.2 It calls on the government to update the NHS constitution with the NHS’s net zero targets and to “make it clear that this is a key responsibility for all staff.”
Several trusts in England have invested in onsite generation of renewable energy, demonstrating the money that can be saved, says Watts. “We have seen the savings roll in . . . hundreds and hundreds of thousands of pounds reinvested back into healthcare,” he says. “Every time we have tackled climate change, every single time, we have realised: number one, our patients love it; number two, our staff love it; and number three, it actually ends up saving money.”
Involving patients
James Connoley, who lives on the border of Victoria and New South Wales in Australia, told the conference about his experience with Crohn’s disease. In September 2022 his small town of 20 000 people was hit by a devastating flood, made all the more likely and more severe by climate change. For several months this cut off the town’s access to care in bigger cities and affected its pharmacy’s ability to supply medicines. Luckily, Connoley’s Crohn’s disease was stable at the time, but he says that “there were some cases where people had to be flown by the army . . . they would take people to Melbourne, big cities, to the hospitals, just because we couldn’t do anything.”
As well as increasingly bearing witness to the effects of climate change on health services, patients can be a part of the solution to more sustainable and resilient health systems. Kate Wylie, a GP in Australia and chair of Doctors for the Environment Australia, has already started to involve patients in her practice. “The first thing that we can all do in our work is talk about climate change,” she told the conference. Many may worry that this will feel uncomfortable, but Wylie says that, if we’re allowed to talk about sexual health and drug use, “we’re allowed to talk about the most pressing health problem of our time.”
This involves pointing out where she sees climate change affecting her patients, such as in patients with allergy, or screening for concerns about climate change in those with anxiety or depression. “I meet a lot of elderly women who are very worried about their grandchildren’s future,” she says.
Her advice for anyone who is unsure about discussing climate change in their consultations is, “Just start—just have a go. The first thing I did was to incorporate it into my care.” This includes looking at possible climate risks in patients’ care plans, such as ensuring that her patients with diabetes or cardiovascular disease know what to do in a heatwave.
She also talks to her patients about the health co-benefits of climate action, such as advising those with diabetes to “use your feet for transport, because that’s good for the planet and good for yourself.” She adds, “I’ve not had a patient be angry with me for bringing it up. Most people are very receptive to the message, and usually they’re quite relieved that someone is talking about it.”
Self-care as climate action
Frances Mortimer, medical director of the Centre for Sustainable Healthcare, says that patient self-care is one of five core ways of working towards a sustainable healthcare system (alongside prevention, lean service delivery, operational resource use, and low carbon alternatives).3 She explains, “Self-care is a shorthand, really: it’s about patient empowerment in decisions about their care so that what we are doing is high value for them. And also supporting people to be much more active in managing their care, leading to better outcomes and more appropriate use of the system.”
Mortimer told the conference about one example of this from an HIV service in Northamptonshire. The team realised that by adapting the care pathways for adherent and stable patients they could safely reduce their number of annual appointments. This meant switching from twice yearly face-to-face appointments and blood tests, to replacing one of these appointments with a phone call with a specialist nurse. For every patient there was a joint decision on whether to move to the stable pathway.
This reduced both the travel and equipment required for blood tests. It also freed up staff to spend more time with patients who had new diagnoses or needed more input. Over a year this saved the service £44 905 in costs and 25 958 kg CO2e—equivalent to driving 74 763 miles in a car.
Additionally, the team found that this change acted as an incentive for some patients to improve their adherence and move to the stable pathway. And for those on that pathway it not only saved them time in their visit but also around £9.20 in travelling costs each time, as well as any lost income from having to take time off work to come to the hospital.
William Stableforth, a consultant hepatologist in Cornwall, told the conference that not involving patients in discussions about individual changes “denies our patients potentially the benefits of sustainable healthcare.” Eddie Kinsella, chair of the Royal College of Physicians’ patient and carer network, added, “What strikes me in a very positive way are the examples where there’s shared decision making and patient engagement, and where sensible conclusions are arrived at that are both better for the patient and also better for the planet.”
What you can do to be more climate friendly in your work
Find out what’s already happening in your area. If you work in the NHS in England, every trust and integrated care system must have a “green plan.” If not, speak to your hospital board and management to find out what’s already happening.
Team up with others. Making change on your own can be hard and won’t be effective.
Start “greening your gaze”: where can you see changes that improve efficiency? The chances are there will be an opportunity to reduce the carbon footprint of healthcare.
Learn more. These organisations can help you see the biggest difference you can make:
Use the growing number of specialty specific resources, such as Greener Practice,9 GreenED,10 the Green Theatre Checklist,11 and Green Endoscopy.12
Incorporate sustainability measures in your next quality improvement project.
Consider talking to your patients about climate change where you see it affecting their health, or about the health co-benefits of climate action.
Footnotes
Competing interests: I have previously worked as a freelance external facilitator for the Centre for Sustainable Healthcare.
Provenance and peer review: Commissioned; not externally peer reviewed.