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…
With our travel on holiday dialysis we have been to units in The Netherlands and Denmark. When we explained in the UK our "Health and Safety" and "Infection Control" police have prohibited reuse of acid they fell about laughing.
It was explained to us that a primary school child in science study is taught that bacteria does not grow in acid so is completely safe to reuse providing no external contaminents.
I have no idea if it is safe or not to reuse acid but it looks worthy of further study.
They perhaps wouldn't fall about laughing if their children were cross infected by a virus carried on the outside of the can from blood splatter during the previous treatment of an infected patient .
They perhaps also wouldn't find it amusing if an untrained worker poured the remainder of 1 formulation into another can of a different formulation and hence given the wrong mixed formulation resulting.
The law is exactly the same elsewhere in the EU in terms of the definition of Clinical Waste which is very specific and covers anything which may have been contaminated during use.
Hi Chris
You raise some good points but please help my understanding.
I have seen blood splatters and contamination on new unused cans. Sometimes a previous patient starts bleeding again and this splattered blood seems to go everywhere. Normal nursing procedeures must apply to both methods. I dont understand why you think unused cans are exempt from splatter. In a busy unit with pressure to not keep patients waiting unnecessairily long pack are often prepared in advance and in reach of blood splatter.
I have seen trained nurses making mistakes and using the wrong acid. I would have thought the same management controls and checking would apply. It would be nice to think that trained staff never made mistakes and all mistakes are generated from untrained staff and so avoidable.
If a law is wrong then it must be changed. In an ideal world with unlimited budgets perhaps it is safer not to reuse acid. Some of us would have seen that the law on not reusing nailclippers between patients because of a theriotical comptamination of Cjd is good but there have been more documented deaths because of using the lower quality of disposable clippers than reusable ones. Perhaps you need to declare that you supply medical consumables so may be biased.
Nothing in this world is ideal, we know that as patients and carers we have a high carbon footprint. We also know that by 2050 there will not be the resources to treat more than 1 in 5 patients. Calculated risks are necessairy. Sometimes the "cure" is worse than the problem.
Medical treatment is a serious metter but it is laughable to think that mistakes do not happen with whatever modality adopted and using only the most expensive option (as in disposable clippers) is always best. It may be best commercially for the suppliers but not necessairily for the patients.
Hi William,
I'm not sure that I did say unused cans were exempt from splatter?
Are you saying you set up the machine with a new can and other sterile disposables before the patient being taken off had gone and everything cleaned and disiinfected,surely not?
I have seen and heard of numerous issues with incorrect concentrates being used and also the wrong chemicals being put in the wrong cans and then connected up so my point was if it can happen it will whatever procedures are put in place accidents happen and we should all be taking steps to reduce this given the exponential rise in compensation payments being made by the NHS Litigation Authority.
Bit of a low blow to try and accuse me of being biased,not sure why that is called for,just putting over my personal opinion with 39 years of experience in Renal Care both NHS and commercial.
Unfortunately whether we agree with the current law or not unless it's changed we all have to comply and when we don't and patients are harmed as a result due to shortcuts being made thats why as above compensation payments are rocketing.
I really don't agree that suppliers such as myself are driving this it's EU law and all the private dialysis facilities are regularly checked with compliance which as far as I am aware isn't being done in the NHS units.
Bottom line on this to me is that anything which has been on the front of a machine during a treatment MAY be contaminated and therefore should be yellow bagged and incinerated.
If you do want to recycle the plastics such as the Bicart's and cans then they should be sterilised before exposing the refuse collectors and recyclers to prosecution and infection.