Climate Change and the NHS Why and how the NHS can and should be a leading sustainable and low carbon public sector organisation from now to Role of nurses, doctors and other clinical staff Dr Jammi Rao, FRCP FFPH Deputy Regional Director of Public Health, Department of Health, West Midlands, Government Office, Birmingham UHCW Grand Round, 22 Sept 2009

Background to sustainable development and climate change Why the NHS should be concerned The NHS Carbon Reduction Strategy What clinicians can and should do The role of clinical practice developments Outline of this brief seminar

What is Sustainable Development?

“Meeting our needs today… ….without compromising the ability to meet needs of others - today and tomorrow” Sustainable Development?

Principles of sustainable development Securing the Future – UK Government – 2005

Energy and carbon - the problem

Global addiction: very cheap, very useful and very dangerous 350 million years-worth of carbon locked away in fossil fuels suddenly released…. 150 years First Oil Well 100 years 4000 cars in USA NOW 600,000,000 cars 4,000,000,000 passenger flights 50 years First commercial jet ticket

Source: The Met Office’s Hadley Centre for Climate Protection and Research Observed and predicted global temperature change The 10 warmest years on record have occurred since 1990 Extreme weather events are also becoming more common

90% energy coming from fossil fuels is unsustainable for 3 reasons. Its running out. Some time soon we’ll have to get our energy elsewhere Climate change. (Some sceptics still deny this) Security of supply. Do we want to depend on unstable unpredictable regimes

The time is now At least 15,000 people died prematurely as a result of Europe’s heat wave in 2003 in France 1 1. Unprecedented heat-related deaths during the 2003 heat wave in Paris: consequences on emergency departments Jean-François Dhainaut, Yann - Erick Claessens, Christine Ginsburg, and Bruno Riou. Crit Care. 2004; 8(1): 1–2. Published online 2003 December 4. doi: /cc2404. and Bhattacharya, S. (October 2003), ‘European heat wave caused 35,000 deaths’, The New Scientist.

Although climate change can cause illness and death... - Heat-related deaths - Skin cancer and cataracts - Injuries and infectious diseases as a result of increased flooding - Respiratory disease - Insect-borne disease - Food poisoning

…there are even greater risks through civil unrest: Crop failure Water shortages Mass migration Resource wars Economic collapse Ecosystem collapse

UK CP09 Key points Winter Temp: +1.2 to 3.2 deg Celcius Summer Temp:+1.2 to 4.4 deg Overall precipitation: Little change Winter ppt:+13% Summer ppt:-16% Anticipiated problems: health, water shortages, flooding, environmental degradation

“Climate change is the biggest global health threat of the 21st century.”

Worth a read…

Why should the NHS act/lead? 1.The law: 80% reductions on 1990 baseline by Scientific evidence - IPCC 3.Opportunities for immediate health co-benefits for individuals, health care systems, and internationally. Physical activity and obesity / CHD / diabetes / Air pollution / Transport trauma / Mental health / fuel poverty / improving diet Self empowered chronic disease care closer to home with ICT 4.Potentially big savings (cost, tax, reputation…) and need for energy resilience and robustness flu, yes, but also floods, fuel, heatwaves 5.Willingness and commitment of NHS organisations 6.Special responsibility and opportunity to lead by visible example

Three levels of health co-benefits 1.Traditional person focussed benefit –Physical activity, mental health, trauma, air pollution, food and agriculture… 2.Benefits for health care system –Congruent with policy direction for many health care systems: care closer to home, empowered, self care, chronic disease management 3.Benefits for international (health) inequity –Cost effective leap frogging from pre-industrial, pre- carbon to post carbon, missing out high carbon step in the middle –Contraction and convergence –Concentrated solar power from warmer poorer countries

Saving Carbon, Improving Health: NHS Carbon Reduction Strategy Launched February CEO NHS - Permanent Secretary DH - RCP - Academy of Med RC - BMA - Carbon Trust - Environment Agency - FPH - HPA - Monitor - RCM - RCN - Sustainable Development Commission - UNISON

Carbon Footprint in NHS England c. 20 million tonnes carbon dioxide eq p.a. Travel: patients, staff, visitors = 18% Energy: heating, lighting, hot water, ventilation, cooling = 22% Procurement: supply chain activities of companies producing goods and services = 60%

National launch “…it’s a very important strategy for the NHS: it is really good for the environment, it's good for our society, it's good for our staff and for us most importantly it's good for our patients” David Nicholson, CEO NHS England 27th January 2009

“We need set structures and responsibilities and accountabilities in the system to make it a reality. Every Chief Executive in the system needs to have a responsibility to deliver a more sustainable service and reduce carbon. Individual boards need to take responsibility for this - to look at the totality of the services that they provide in the context of this strategy and the way they provide them.” DN Jan 2009

Reference: Carbon Reduction Strategy for England, NHS SDU, Jan

Shaping NHS policy and delivery 1.NHS Constitution 2.Performance management in national, regional, and local NHS frameworks 3.Part of the regulatory framework Vital signs, Care Quality Commission, Monitor, LSP, LAA, CAA… 4.World Class Commissioning Framework 5.Climate Change Act EU ETS >> Carbon Reduction Commitment

Special opportunities for Chairs and NEDs Good governance, clear accountability and responsiveness to those we serve Ask questions about understanding, measurement, management, and reduction of environmental impact of NHS Carbon and literacy, numeracy, and action at board level Objective setting with CEO and cascade

NHS Regional level reporting “Every SHA Board should receive at least annually a report about progress in meeting the requirements of this strategy in their region” (p.63). Building energy: collate the same nationally available trust level ERIC datasets and methodology as used for the national NHS Carbon Footprinting report Travel: assemble Trust level data where collated (patient transport services, fleet mileage and business mileage, travel surveys) Procurement: developing datasets from Regional Procurement Hubs

NHS WM Regional level actions Regional Steering Group set up – comprises Board level leads, chaired by Malcolm Stamp, CE of UHCW. Regional CRSD Network in operation for 2 years, brings together estates, energy managers –Building energy workstream: develop and encourage sound metrics Travel: SHA/PHO will develop methods to estimate health care related travel by patients and consequent CO2 emissions.

NHS – Role of Chairs / NEDs Awareness: NHS Carbon Reduction Strategy NHS Good Corporate Citizenship Toolkit Appointments processes – workforce development Objectives in senior posts Risk register Shadow carbon pricing for the NHS Resilience/Business Continuity Local economic investment “SHAs will have in place mechanisms to ensure that NHS Trusts have a Sustainable Development management plan ….” The Sustainable Board – development module Launch West Midlands: 30 th April 2009

15 GJ/100m 3 /year There was no cost premium for the sustainable design. Carbon dioxide emissions are only 31 tonnes/year, so climate change levy payments will be low Patient and staff experience highly favourable

NHS Good Corporate Citizenship Assessment Model

10 corporate actions now: 1.Chair: NHS Good Corporate Citizen sign up – CEO objective 2.CEOs: SD / CSR / Good corporate citizenship / carbon governance 3.All senior executives: sustainability objectives / reporting mechanisms 4.Corporate Climate change > a specific section on risk register 5.Finance: CRC, shadow carbon pricing, carbon standard, co- invest, clear risk management: e.g. single use vs. sterilise 6.Performance: CQC, Operating Framework, carbon governance 7.Estates/facilities: Energy measuring across all departments as possible: smart metering, access / travel planning – sustainable access, Liftshare, incentivising low carbon and active travel options 8.Commissioning and Procurement criteria and standards 9.Workforce. Board development > staff development / T&C 10.Comms: Staff and public buy-in, corporate objectives and image, website

10 things NHS Trusts should do: 1.Develop SD Management Plan 2.GCC guide and assessment – commission.gov.uk 3.Sustainable Transport and travel plan 4.Carbon Trust’s NHS carbon Management Programme 5.Consider Options for on site renewable energy 6.Energy Audit.. Incl DEC 7.Procurement Audit.. 8.Conduct a Waste Audit 9.Report to Board on CRC and its implications 10.Staff education and training programme

Quick examples and ideas Smart metering Travel and access policy Commissioning / procurement / contracts Energy efficiency of buildings Telephone follow up as substitutes for clinics Video and tele-conferencing –Does your next meeting have to be this carbon intensive? Cut down waste, procure less, save money

Measuring, monitoring, displaying

Better access, not more cars: - Car pooling - Lift sharing -Multi-occupancy vehicle parking e.g.

Commissioning / procuring: Example of statements “Criteria relating to sustainability and low carbon operations will increasingly be used in the commissioning of services and the procuring of goods” “Each year/cycle we will increase the weighting given to your qualitative and quantitative commitment to a sustainable and lower carbon health service”

Sustainable clinical practice? Think prevention Patient centred Develops lean pathways Considers carbon when choosing treatment

Health service changes Telephone follow up of patients instead of out-patient appointments Replace face to face committee meetings with conference calling Community staff to receive home visit itinerary and travel routes direct to their home so they don’t need to come in to a central base every day

Health Service Changes Tight monitoring of staff mileage claims Multi-skilling staff to avoid same patient being visited by different professionals within short space of time. Reduce waste of prescribed medications

Other action NHS Confederation Special Interest Group Metrics –The importance of establishing and validating measurement processes –Quality Observatories 1.3 million staff –Appointments Commission –Workforce development

Summary Multiple benefits for health service. –Law, science, money, health, economy, examples and future. Efficiency AND transformational change Needs to be part of core business / good governance throughout NHS organisations Leadership, staff empowerment, and middle management delivery: all essential The most serious and strategic health threat we face on our watch….