Counting the carbon cost of care
The NHS Carbon Reduction Strategy has set targets for the reduction of GHG emissions within the NHS. Taking 2007 levels as the baseline, the strategy requires an 80% reduction before 2050 and a 34% reduction as early as 2020. If we are to meet these challenging targets, our health economists will have to become as familiar with the rationing of healthcare of the basis of carbon as they presently are with financial resources. A scary thought? Well, no. This shouldn’t frighten clinicians at least - the sustainability, financial and clinical agendas can often be aligned. In fact, sustainability offers a further lever to achieve the financial and clinical targets required. Within nephrology for example, transplantation (surely the ultimate in recycling) will likely prove to have a lower environmental impact than dialysis, and pre-emptive living donor programmes will reduce emissions further.
But this is part of the (our) problem. We don’t know for sure if transplantation is greener than dialysis. In fact, we don’t know much about the carbon cost of the individual components of the healthcare we provide. So, effective carbon rationing within healthcare is going to require advances in our understanding of the carbon footprints of the different treatments and services provided. Renal medicine (and the Green Nephrology Programme) has been doing its bit to lead on this front, providing carbon footprints of treatments (HD) and services. We’ve done this by importing the carbon footprinting methodologies and standards accepted within other sectors (commerce, agriculture etc – everyone’s been doing it apart from us, it seems!) into the healthcare setting. But there remains a distinct need for further research to develop and refine the healthcare-specific emissions factors that are required to improve the accuracy and ease of use of these techniques.
Many of us would agree that it is regrettably difficult to envisage carbon rationing shaping the delivery of renal services in the immediate future. Instead, consideration must be given to other means of incentivising the delivery of sustainable healthcare and, until such measures are in place, those of us wishing to implement more sustainable models of care must remain vigilant for the sustainability opportunities that arise from the need for service reconfiguration driven by other influences (such as patient safety or cost-cuttting, for example). However, in order that such opportunities may be taken, tools must be developed to allow us to evaluate the environmental impacts of different treatments and pathways of care in a timely manner – from experience, the undertaking of detailed carbon footprinting studies in this setting is frankly not feasible. The development of a library of indicative carbon burdens covering standard episodes of patient care, such as those already determined for inpatient admissions and outpatient appointments, might allow approximate – but adequate – analyses to be built up in the double-quick time required to include them in business plans. With time, this library could be extended to include individual practical aspects of care such as catheterisation, endoscopy or renal biopsy. Some of the information is already out there: an Australian group have compared the life-cycles of disposable and re-usable central line insertion packs (McGain et al, 2012).
But who will do this research? The incorporation of sustainability into healthcare offers opportunities for the development of partnerships across the healthcare community that are mutually beneficial to healthcare providers, industry and the public. For example, although no such project exists at present, the development of an open-access database – to which companies might submit environmental data pertaining to their products (including, for example, the products’ carbon footprints or information about their recycling possibilities) – would be a valuable venture. Not only would this allow industry organisations to showcase good environmental practice, the information provided would be of benefit to a diverse group: commissioners seeking to implement sustainability criteria into procurement contracts; individual renal services wishing to improve local waste management strategies; and, healthcare providers hoping to compare the environmental impacts of different models of care (such a database would overlap usefully with the aforementioned library of indicative carbon burdens for healthcare episodes).
Enough parts of the delivery of healthcare have now been footprinted to ‘show that it can be done’. What we really need now is to join the dots. Collaboration between the pharmaceutical and medical equipment industries and those delivering the healthcare is required to make this effective. Why not start asking companies for the footprints of the items you’re purchasing…