Green Nephrology Summit 2010

Birmingham Children's Hospital, 24 September 2010

Introduction

The Green Nephrology programme was founded in 2009 to improve the environmental sustainability of kidney care in the UK, harnessing the many benefits to patients, staff and the health service. The programme began with a small “Green Nephrology Summit” in February 2009, following which a project board was set up, including representation from the Renal Association, British Renal Society, Department of Health, NHS Kidney Care, National Kidney Federation, Association of Renal Industries, the Specialised Commissioning Forum and the NHS Sustainable Development Unit. With generous sponsorship from NHS Kidney Care, a new “Green Nephrology Fellowship” programme has been set up, hosted by the Campaign for Greener Healthcare. The first Fellow took up post in September 2009, working full time to explore the environmental impacts of the specialty and support local kidney services in taking action. One year later, 72 delegates from across the kidney community met in Birmingham at the Green Nephrology Summit 2010 – to celebrate the achievements of the programme so far, share experiences, and explore the way forward. This report provides a summary of the presentations and discussions which took place.

Summit Report

1. The seventh dimension of quality

Speaker: Dr Donal O’Donoghue, National Clinical Director for Kidney Care

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Summary: The concept of sustainability being part of the quality agenda, which first arose in discussion within the Green Nephrology group, is now starting to be mainstreamed. The NHS is in a time of change: the Government white paper "Equity & Excellence" puts quality at the heart of healthcare organisation, moving away from paying for activity to really trying to measure patient outcomes - be they years of life, or number of days off school. The challenge is to take the opportunities thrown up to reduce waste and increase value. We must be ambitious for better quality - and quality is sustainability: resources are limited.

Slides: 1_Donal ODonoghue Quality Sustainability 240910.pdf

Webinar recording: here

2. Context: sustainability in the NHS & beyond

Speaker: Dr David Pencheon, Director, NHS Sustainable Development Unit

Summary: Sustainable development means meeting our needs today without compromising the ability of others to meet their needs - today or tomorrow. Healthcare professionals are respected and influential members of society. Aside from the legal requirement to reduce carbon and the financial benefits of doing so, do healthcare professionals have an ethical duty of care to improve sustainability?

Emerging research questions for sustainable healthcare include: finding valid metrics and methods for assessing the quality of different models of care; quantifying and managing cost, risk and benefit (e.g. single use vs. decontamination of medical equipment); toxicity and safety issues; resilience of the health care system to major external disruptions; and, assessing economic co-benefits of taking action.

Slides: 2_David Pencheon Context 240910.pdf

Webinar recording: here

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Dr David Pencheon and Dr Donal O'Donoghue

3. Green Nephrology achievements of 2009-10

Speaker: Dr Andrew Connor, Green Nephrology Fellow 2009-10

Summary: The strength of the Green Nephrology programme has come from the collaboration from across the specialty, sharing learning between many committed individuals and teams. Achievements of the past year include: creation of a network of local representatives from over 80% of kidney units; a detailed survey of current sustainability practices; development of case studies and how-to guides. Carbon footprinting studies of a local renal service and of the haemodialysis care pathway have confirmed the importance of carbon “embedded” in pharmaceuticals and dialysis consumables, perhaps suggesting the priority areas for future work. The inclusion of the Green Nephrology programme as a case study in the Marmot Review of Health Inequalities is an example of the support it has received from beyond the specialty and the recognition of its benefits not only to sustainability but also to the wider determinants of health.

Slides: 3_Andy Connor Green Nephrology Progress 240910.pdf

Webinar recording: here

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Dr Andy Connor and Dr Tara Collidge, Green Nephrology Fellows 2009-10 and 2010-11

Morning workshops (“masterclasses):

4a. Carbon footprinting of a local renal service

Facilitator: Dr Andrew Connor, Green Nephrology Fellow 2009-10

Summary: Carbon footprinting is an assessment of the greenhouse gas emissions resulting from a product or process. When calculating a carbon footprint, it's important to be clear about the question you want to answer - this will affect what you include (e.g. supply chain emissions?) and the level of accuracy you need. Once you have collected your data on inputs to the product or process, these are multiplied by "emissions factors" and added together to give a figure - usually in kg of CO₂ equivalents. In healthcare, carbon footprinting can be difficult because of the lack of specific emissions factors (e.g. for medical equipment and drugs). However, if these can be overcome, carbon footprinting can be very useful to show where in healthcare the greatest impacts occur, and to compare different solutions.

Slides: 4a_Andy Connor Carbon Footprinting Workshop 240910.pdf

4b. Telephone clinics in renal transplant follow up

Facilitator: Dr Rob Higgins, Consultant Nephrologist, University Hospitals Coventry & Warwickshire

Summary: Why use telephone clinics? Convenience for patients (can fit around work), avoids spreading communicable diseases, can be cheaper and more efficient - and reduces mileage. Who? In Coventry, telephone follow up is offered to stable transplant patients > 1 year after transplant. About 1/2-2/3 take it up. How? Patients phone in at their appointment time; blood tests are done in advance at the GP surgery or at a local hospital; blood pressure is measured at home by the patients themselves. An important barrier can be funding arrangements, as Trusts may well not save money, and will need to negotiate a reasonable tariff with commissioners (guide tariff is too low).

Case study: here

4c. Waste water recovery

Facilitator: Steve Milne, Renal Technician, East Kent & Canterbury

Summary: Up to two-thirds of water entering haemodialysis units is discarded at the purification stage - despite being still drinkable (a very slightly raised sodium but no bacterial contamination). The total cost for waste and water is c £2.35 per cubic metre - dialysis units recovering the waste water for alternative uses can make an annual saving of c £10,000. At present, utility bills are not usually measured or paid for by units, which undermines incentives to change. However, the Kent & Canterbury have successfully implemented a water recovery scheme in partnership with their Estates department.

Slides: 4c_Steve Milne Water conservation 240910.pdf

Case study: here

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Delegates visiting the "Green Nephrology Knowledge Market" over lunch

5. Patient perspective

Speaker: Andy Williamson, Vice Chair, Guy’s and St Thomas Kidney Patients’ Association

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Summary: Andy Williamson spoke about his personal journey and the growing realisation of his dependence, as a kidney patient, on finite resources that are being used up with little thought. Meanwhile, a huge wasted resource is the patient. Although he now has a transplant, he is conscious that he may one day need to have dialysis again, and that his daughter may one day need kidney replacement therapy. Anything that we can do to reduce the destruction of the natural habitat we take for granted is very important – this is everyone’s responsibility.

Slides: 5_AndyWilliamson patient perspective 240910.pdf

Audio recording: here

Webinar recording: here (first half)

6. Commissioner perspective

Speaker: Nesta Hawker, Specialised Commissioning Manager, North West

Summary: Commissioners are responsible for planning services of the future, and ensuring the quality of services (no longer just counting numbers and activity). Sustainability is in the NHS White Paper, and the focus of the NHS on QIPP (quality, innovation, productivity & prevention) complements the four principles of Green Nephrology:

Disease Prevention – early identification, health promotion, looking at other care pathways and preventing acute kidney injury
Patient Empowerment – home therapy, transport, RenalPatientView, greater engagement with patients managing their own care
Lean – right patient right time, minimising low value activities including duplicated services
Low Carbon – reduce carbon footprint - making buildings and transport more efficient.

Commissioners have an opportunity to secure high quality, efficient, sustainable services throughout the patient pathway.

Slides: 6_Nesta Hawker Green Commissioning 240910.pdf

Webinar recording: here (second half)

Afternoon workshops (debate and planning):

7a. Developing the Green Nephrology Network, supporting local action

Facilitators: Dr Andrew Connor, Green Nephrology Fellow 2009-10, Dr Tara Collidge, Green Nephrology Fellow 2010-11

Summary: over 80% of kidney units in the UK now have staff green representatives. How can we support these champions in successfully engaging their colleagues and introducing local change?

Opportunities identified:

Join up local representatives – via web, email (link individuals who have succeeded in green projects to others working on similar projects). Make communication two-way.
Reduce exclusivity – more than one rep per unit
Smaller targets/actions – eg. 10:10 Checklist
More education / promotion

Actions:

Accessible slide sets for use by reps to communicate to their colleagues
Green reps directory, linked from website
Link up with RA / BRS – sub meeting
Launch of Green Stars initiative – up to four stars awarded to all UK kidney units for staff representative, patient representative, green action plan, case study contributions. (Look here to find out how many stars your unit has...)
Allow more reps per unit
Develop Green Nephrology working group on 2degrees web platform
Inform Trusts of work reps doing locally (Muir Gray & Charlie Tomson to write to Chairs of hospitals)

Webinar recording: see below – “The way forward: next steps”

7b. Sustainability and patient self-care

Facilitators: Andy Williamson, Vice Chair, Guy’s and St Thomas Kidney Patients’ Association, and Dr Steven Laitner, National Clinical Lead for Shared Decision Making, Department of Health

Summary: “The greatest untapped resource in healthcare is the patient” (Andy Williamson). Empowering patients in their own care can both improve health and reduce waste. "We need to get the doctors off their pedestals - but we also need to get the patients off their knees". Culture disruptors include personal care plans, RenalPatientView (giving patients access to their own results), decision aids (to help patients share in decision making about their care), patient leaders, and non-formal communication methods: “flattening the authority gradient provides a better experience and a safer one.” (Steven Laitner)

Opportunities identified:

Understand and better support a shift to supported self-management (forums, networking, peer support)
Local blood tests, RenalPatientView, remote consultations
Fully informed patients often choose less intervention – patient is the expert on what is valuable to them.
Telephone consults etc – disruptive! Because breaks out of doc-patient dynamic: human interaction

Actions:

Interacting as humans with a shared goal – improved decision making and risk assessment, avoid channelling patient into one direction
Decision aids for renal replacement therapy / conservative management – both planned and “crash-lander”
Where meeting obstruction, get an empowered patient from the service to go with clinicians to negotiate e.g. with IT dept.

Slides: 7b_AndyWilliamson patient self-care 240910.pdf
7b_Steven Laitner Shared Decisions 300910.pdf

Webinar recording: see below – “The way forward: next steps”

7c. Commissioning sustainable kidney care, Nesta Hawker

Facilitator: Nesta Hawker, Specialised Commissioning Manager, North West

Summary: attention to sustainability can enhance the quality and efficiency of care. Commissioning of renal services provides an opportunity to accelerate uptake of sustainable practices identified through Green Nephrology.

Opportunities identified:

Service specifications to include an aspect of sustainability measurement or plan (except acute kidney injury)
Specialised commissioning could take on commissioning the whole of the renal pathway at regional level (including outpatient care) to avoid split between GP- and specialised commissioning within renal pathway (creates inefficiencies/conflict of interest)
Green CQuINS (extra money for quality measures) – water recovery capital investment, home therapies, telephone clinics?

Actions:

Develop/share guidelines for telephone clinics
NHS Kidney Care Networks to work with GP commissioners to develop clear template for GPs to commission renal care

Webinar recording: see below – “The way forward: next steps”

7d. How can we procure sustainably in kidney care?

Facilitator: Dr Frances Mortimer, Medical Director, Campaign for Greener Healthcare

Summary: Procurement contributes 72% of the carbon footprint of kidney care, with the largest categories being pharmaceuticals, clinical supplies and waste disposal. Procurement processes provide an opportunity to influence the sustainability of products themselves, supplying organisations and their supply chains. Currently <10% of renal contracts have any reference to sustainability – due to competing pressures and lack of experience/practical guidance. The Green Nephrology programme has been developing draft sustainability clauses for inclusion in procurement contracts by renal services.

Opportunities identified:

Inclusion of sustainability criteria in new procurement contracts
Partnership working with existing suppliers
Centralised “sustainability rating” of suppliers / eco-label
Issue “innovation challenge” for new products/services

Actions:

Convene a multi-stakeholder group to define scope for project to pilot sustainable procurement of dialysis consumables (in 2-4 renal services).

Slides: 7d_Frances Mortimer sustainable procurement 230910.pdf

Webinar recording: see below – “The way forward: next steps”

8. The way forward: next steps

Facilitator: Sir Muir Gray, Director, NHS National Knowledge Service

Summary: it has been terrific working in kidney care - "the most sophisticated and best organised service in the NHS". The Campaign for Greener Healthcare is going to use the model developed with kidney care and apply to other clinical areas. The second opportunity for export is an international approach – would like to organise the first international conference on reducing carbon in healthcare (web-based). Within Green Nephrology there also many opportunities to build on work to date. Workshop groups presented the outputs from discussions in the afternoon workshops above (patient self-care, commissioning, procurement and supporting local action).

Webinar recording: here

9. Closing remarks

Speaker: Dr Charlie Tomson, President, Renal Association

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Summary: It is people who make change happen – and it is the people in this room have started to make that change: Muir, Donal, NHS Kidney care, the local reps, and others. Green Nephrology has real synergies with the financial crisis, and also with safe care and right care and productivity and patient centred care – all of which might save money but are just the right thing to do anyway. We have got also got a fantastic chance to re-engineer whole pathways, because we have to re-engineer whole pathways to save the NHS money.

Charlie Tomson presents the Green Nephrology Award 2010 to Andy Connor on behalf of the Project Board in recognition of his contribution in the last year.

Webinar recording: here (second half)

"The success of the Green Nephrology Programme stems from its collaborative approach - the Local Representatives, and the renal community in general, should feel very proud of the progress that is being made. I left the Summit full of optimism."

Andy Connor, Green Nephrology Fellow 2009-10

Green Nephrology Summit 2010