Healthcare is a leading contributor to global warming and environmental degeneration, (Medical Schools Council, 2022); if it were a country, healthcare would be the fifth biggest emitter of greenhouse gases globally. Health professionals have a duty of care to protect the public and, while healthcare is part of the global warming problem, clinical practitioners can be part of the solution.
In 2020, the NHS launched its For a Greener NHS campaign and became the world's first national health system to commit to meeting net zero. Two clear targets are outlined in the Delivering a ‘Net Zero’ National Health Service report (NHS England, 2022):
- For the NHS carbon footprint: for the emissions it controls directly to be net zero by 2040
- For the emissions the NHS can influence, eg those from the supply chain, to be net zero by 2045.
On 1 July 2022, the NHS embedded net zero into legislation through the Health and Care Act 2022; this places a duty on commissioners and providers of NHS services to address the net-zero emissions targets specifically. Trusts and integrated care systems meet this duty through the delivery of green plans, with a board-level lead to support them. The James Paget University Hospitals NHS Foundation Trust's green plan was launched in 2022. This plan states that research and innovation are key to delivering net-zero ambitions; however, sustainability is a broad and debated subject that can be difficult to apply to ‘real projects’ (Buffoli et al, 2013).
This article describes the development, delivery and outcomes of the EnSuRES (Exploring the Sustainable healthcare impacts of the James Paget University Hospitals Research, Evaluation and quality improvement Scholarship using the sustainable value framework) project; this was an evaluation designed to explore the sustainable healthcare impacts of this work, which is led by the Trust's Nursing Midwifery and Allied Health Professions Research and Evaluation Service team. This facilitation team, which was running the scholarship programme, undertook the EnSuRES project in parallel to it and used the delivery of the programme itself as the test measure.
The scholarship programme was piloted between May 2022 and February 2023 and aims to build the capacity, capability and confidence of staff in critical enquiry (Whitehouse et al, 2022). The EnSuRES project has now completed.
Language linked to sustainability can be difficult for health professionals unfamiliar with this issue, with the terms sustainable healthcare, green health and environmental sustainability often used interchangeably. In this article, the term sustainable healthcare is used for continuity.
Method
The quality improvement (SusQI) framework of sustainable value was used as the basis of our evaluation (Mortimer et al, 2018). This includes considerations of financial, environmental and social impacts:
Sustainable value = Outcome for patients and populations Environmental + social + financial impacts (Triple bottom line)
The measures listed were chosen based on the ease of linking them to the scholarship programme at this exploratory stage (Table 1). Monthly taught sessions were delivered face to face and used as the data collection points.
Table 1. Data collection approach used to reflect the triple bottom line components of sustainable value of face-to-face monthly modules
| Triple bottom line component | Measure applied | Method |
|---|---|---|
| Environmental | Calculation of carbon dioxide equivalent emissions using distance travelled to normal place of work versus that travelled to mandatory day venue | Adaptation of the Centre for Sustainable Healthcare (2022) carbon calculator for (avoided) patient travel |
| Financial | Cost of travel based upon mode of transport | Adaptation of the Centre for Sustainable Healthcare (2022) carbon calculator for (avoided) patient travel 2022 |
| Social | Social impact of integrated learning, materials provided and impact on scholar's projects | Field notes taken throughout the programme modules including anonymised quotes from scholars focused on sustainable healthcare learning and impact |
Data analysis was descriptive for quantitative data (financial and environmental components) and overarching themes using thematic analysis of quotes were used for the qualitative social component. Quantitative data was calculated using a spreadsheet provided by the Centre for Sustainable Healthcare (2022).
Outputs of scholars’ individual projects did not form part of this evaluation and will be presented in separate articles after they complete their work (anticipated mid-late 2024).
Mentors who were experts in measuring sustainable impacts of projects and data collection and analysis supported the robustness of data collection and sustainable considerations.
Results
Nine scholars completed the programme (100%) and five programme facilitators were involved in delivering the modules. The programme took place at three venues, with modules 3 and 4 hosted by partner organisations (Table 2 and Table 3). Data were collected throughout the 9-month programme and based solely on the face-to-face monthly modules.
Table 2. Carbon footprint based upon travel to and from mandatory days
| Module breakdown | Anticipated kgC02e | kgC02e reduction eg through car share, cycling or bus travel | Actual total kgC02e per module | Minus usual work travel amount of 56.97kgCO2e |
|---|---|---|---|---|
| Module 1 | 112.52 | 0 | 112.52 | 55.55 |
| Module 2 | 112.52 | 4.99 | 107.53 | 50.56 |
| Module 3 (partner site) | 141.79 | 39.77 | 102.02 | 45.05 |
| Module 4 (partner site) | 175.80 | 51.30 | 124.50 | 67.53 |
| Module 5 | 112.52 | 4.99 | 107.53 | 50.56 |
| Module 6 | 112.52 | 4.99 | 107.53 | 50.56 |
| Module 7 | 112.52 | 4.99 | 107.53 | 50.56 |
| Module 8 | 112.52 | 4.99 | 107.53 | 50.56 |
| Module 9 | 112.52 | 4.99 | 107.53 | 50.56 |
| Total | 1105.23 | 121.01 | 984.22 | 512.73* |
Table 3. Financial cost of the scholarship programme monthly face-to-face modules based on travel
| Module | Anticipated cost (£) | Cost avoidance (£) through use of car share, public transport, being on annual leave | Actual cos (£) |
|---|---|---|---|
| Module 1 | 190.50 | Nil | 190.50 |
| Module 2 | 190.50 | 55.49 | 135.01 |
| Module 3 | 272.40 | 4.50 | 267.90 |
| Module 4 | 381.84 | 93.69 | 288.15 |
| Module 5 | 190.50 | 4.50 | 186.00 |
| Module 6 | 190.50 | 4.50 | 186.00 |
| Module 7 | 190.50 | 4.50 | 186.00 |
| Module 8 | 190.50 | 4.50 | 186.00 |
| Module 9 | 190.50 | 4.50 | 186.00 |
| Total | 1987.74 | −£176.18 | 1811.56 |
Environmental impact
It was anticipated that the scholarship programme would generate 1105.23 kg carbon dioxide equivalent (CO2e) based on travel to the monthly module sessions. Table 2 shows the carbon footprint of scholars and programme facilitators, which totalled 512.73 kgCO2e.
After awareness of sustainable healthcare considerations was raised early in the programme, scholars had taken to using public transport and car-share opportunities by the time of module 2 (June 2022). Modules 3 and 4 were hosted by partner organisations and therefore involved increased travel for most scholars. This provided opportunities for car-sharing.
CO2e avoidance equated to 121 kgCO2e, resulting in a theoretical total programme environmental impact of 984kgCO2e. When considering carbon emissions from scholars’ and programme facilitators’ usual travel to work (which they would have been doing had they not been on the programme), the total worked out at 512.73kgCO2e – or half a ton of CO2e. This is equivalent to 10 million plastic straws, 220 fire extinguishers or six dairy cows’ CO2 emissions over 1 week. These figures were calculated with guidance, support and the calculator from the Centre for Sustainable Healthcare (2022) team.
The scholarship planning also included the planting of 25 NHS Forest trees – one per scholar, one per mentor and one per programme facilitator – as a symbolic gesture of growth and development. This also contributes to the environmental component of the triple bottom line through carbon offsetting. Four of the 25 trees planted would theoretically offset the carbon emissions generated by the scholarship programme.
Financial impact
A total cost of £1811.56 was attributed to the programme based upon fuel use for travel. This includes a cost saving of £176.18 created through car sharing, using public transport and virtual attendance. Car-share opportunities were taken up by scholars and programme facilitators 98% of the time; the remaining 2% was accounted for by individuals going elsewhere than home after the module sessions. Table 3 shows the cost of scholars and programme facilitators attending the face-to-face mandatory days for the whole programme based on travel costs.
Because COVID-19-related restrictions were in place at the time two modules were taking place, there were occasions where three scholars were unable to attend in person but felt able to attend online. Provisions were made for blended virtual/face-to-face learning using Microsoft Teams on these occasions. From an environmental impact measure, this reduced CO2e for those scholars by 7.33kgCO2e.
Social impact
Nine scholars (100%) provided qualitative data (they are numbered S1–S9 to protect anonymity). Five programme facilitators (PF1–PF5) provided reflections. Social impact was considered through lenses of relationships, learning and enhanced communication.
All scholars reported becoming more aware of sustainable healthcare and the link between their own practice and ways their work could impact planetary health.
Three programme facilitators had taken part in Centre for Sustainable Healthcare workshops (the SusQI course) in January 2022 before the scholarship programme started, which made them more aware of the issues:
‘I'd never connected the dots between planetary health and being a healthcare professional who has an element of influence by reducing illness.’
PF1
‘The carbon footprint of the healthcare system shocked me – I had no idea how much we contributed to climate change.’
PF4
Programme facilitators noted how much both they and the scholars had learned:
‘What became really clear was how scholars were talking about their workplace projects through a sustainable health lens … our shared learning was immense!’
PF5
‘Now I know, I can't not know.’
S3
Scholars reflected positively on the introductory session in module one:
‘It was like a seed had been planted which I couldn't shake off, now I can't let it go.’ [laughing]
S1
‘The interactivity helped me see practically how my project easily linked to planetary health.’
S4
The inclusion of sustainable healthcare as a key concept throughout the programme generated conversations:
‘You won't believe the conversations I've been having. All I can see are sushealth [sustainable healthcare] opportunities everywhere I look.’
S6
‘Some of my ward are really interested but couldn't understand how so I showed them the group work we did.’
S5
‘Since attending the SusQI course, I take every opportunity I can to incorporate sustainability into discussions.’
PF4
Scholars desired action:
‘I approached the programme team to change my project. I couldn't shake off the sushealth considerations and could see a really clear option to change our service and impact all aspects of the triple bottom line for our families.’
S1
‘We didn't really know about green plans but, since this work, I've been able to contribute and support the development of ours.’
S7
The impact of the training reached beyond the nine scholars:
‘Now I overhear other practitioners challenging “too many appointments” and “too many unnecessary journeys”. This is the incredibly important ripple effect that started from me having the understanding and confidence to share what I had learnt. Now in my workplace, many people have a sushealth awareness they didn't have before.’
S1
‘I've been asking why we don't have a sustainability committee linked to the development of our own green plan. I think it will happen now.’
S5
Some scholars and programme facilitators experienced the impact of virtual versus face-to-face sessions through COVID-19 isolation requirements:
‘I was so glad that you let me join online, and you all really made sure we were still included. I really felt I was missing out on the real buzz by not being there in person, though, because the group is so lovely.’
S7
‘It's not the same joining virtually as you don't get the “corridor” conversations and things in the breaks that you do when you're there in person. Often this is where you get the “ah-ha” moments.’
S3
Sustainable healthcare considerations became part of the scholars’ practice. This supported not only the environmental component of the triple bottom line but also the social aspect, bringing scholars closer together. This was particularly so in the case of the ‘fun bus’ for travel further afield, with 4-5 scholars in one car:
‘I loved the fun bus – it helped me get to know the other scholars and some of the programme team more personally.’
S5
‘Through car sharing, I was doing my little bit toward reducing my carbon footprint, but I realised I made friends as well as colleagues through doing this, and that means a lot.’
S6
The social value attributed to being face-to-face for some modules was strongly appreciated by the scholars:
‘We were effectively isolated for almost 2 years. Being back face to face reminded me just how important it is to be with people. Humans aren't meant to be isolated, are they? My mental health has improved so much because of this scholarship programme.’
S8
‘I'm so glad it was face to face from the start … With the face to face, it's the way you can build relationships, understand personalities and see personalities gradually coming out of their shell. It just wouldn't have happened like this online … this is the thing I've valued the most.’
S6
Discussion
Reaching zero emissions is a big challenge (Castello et al, 2009). Although there are opportunities to offset carbon emissions, there are questions over how equitable carbon offsetting is as an approach to sustainability. Wealthy companies may be able to continue working in traditional ways, without making changes, and pay to offset their carbon footprint. Those delivering projects within the health and care sector may not have the funds to do this, yet they retain responsibilities regarding climate change.
An offsetting mitigation hierarchy tool from the Australian Government (2022) seeks to limit the damage an action will have on the environment using three steps:
- Avoid
- Mitigate
- Offset.
It is accepted internationally that carbon offsetting should be applied only once impacts have been avoided and mitigated where possible (Zhang et al, 2018; Smith et al, 2020; Australian Government, 2022).
The authors recognise the value of collecting carbon footprint data but also acknowledge it is necessary to map out carbon emission avoidance and mitigation into projects and programmes at the planning phase. While the planting of 25 trees as part of our work symbolises new growth and enhances the picture of sustainable healthcare for the clinical organisations involved, an element of carbon offsetting can be recognised from this.
As well as carbon emissions and the cost of travel – the environmental and financial components of the triple bottom line – the social aspect of coming together required extensive thought by programme facilitators. The COVID-19 pandemic had significant psychological and social effects on the population: patients, the public and staff (Saladino et al, 2020). The most exposed groups, including health workers, were more likely to develop post-traumatic stress disorder, anxiety and other symptoms of distress. In pandemics and terrorism incidents, health workers see tragedy and are expected to continue on, and this has long-lasting mental health impacts (Medical Schools Council, 2022). Fear is an adaptive animal defence mechanism but, when it is chronic or disproportionate, it can become a component in the development of various psychological disorders (Tucci et al, 2017; Ornell et al, 2020).
Re-emergence from home working to being in public groups following almost 2 years of isolation can cause nervousness, social anxiety and fear (Dodds, 2021; Arad et al, 2022). In our scholar and facilitation cohort there was a mixture regarding where people worked, with 30% working from home, 50% on site and 20% working both from home and in the workplace.
The social aspect of the triple bottom line was of paramount importance in relation to re-emergence from the pandemic in this project. Support for scholars included the creation of a video by the facilitators which showed the route to the meeting point and this was shared ahead of the first module. It included descriptions of COVID-19 precautions such as the location of hand gel and masks at the venue entrance, as well as the venue's one-way system to support social distancing. This provided scholars with some reassurance and reduced social anxiety, and they valued the gradual return.
A global survey of 2817 medical schools across 112 countries suggested only 15% include climate change in their curricula (Arad et al, 2022). The General Medical Council (2018) and the Royal College of Nursing (2022) include sustainability in their curricula; however, the number of nursing and midwifery education providers that incorporate it within their teaching is unknown. Nonetheless, there is a rising trend of academic organisations educating and providing sustainable healthcare skills to students (Gupta et al, 2022). This is one step to growing capacity (support) and capability (training/ability) among students in understanding climate change and its impact on health (Tun, 2019) and it is acknowledged there is a growing demand from students to learn how to practise in a sustainable way (Gupta et al, 2022).
Although there are groups of health and care professionals championing green health, such as the Nursing Sustainability Network and Doctors for Greener Healthcare, there are also conflicting groups of the population who are not interested, resistant to change or simply unaware of the impacts of pollution and contributions to planetary health (Ho, 2022; Spooner et al, 2022). Where people are uneducated in the topic or simply unaware, this can be a barrier to both taking responsibility and creating changes underpinned by sustainable considerations (Nilsen et al, 2020). The question is: is the learning of those students who enter health and care arenas with sustainable healthcare knowledge being lost? If the answer to this is yes, health professionals within the health services are responsible for preserving and supporting this knowledge. This can be done through educational programmes such as the one described here, or through including sustainable healthcare at every discussion opportunity.
This narrative can be further challenged when training and education provided by academia is compared with the reality of healthcare delivery in health and care organisations. A lack of staff training and knowledge in clinical and healthcare organisations increases barriers to making sustainable changes in clinical practice (Carino et al, 2021). The resulting mismatch between those graduating from courses that include sustainable healthcare in the curriculum and those to whom planetary health remains somewhat of a mystery can exacerbate this stalemate. Equally, where a link between academic learning and clinical organisation understanding has been forged, the barriers can be overcome. In successful projects, there is evidence of increased awareness, interest and impact for staff and patients alike (Medical Schools Council, 2022). Health and care organisations have a responsibility to support and educate staff, allowing them space to innovate and develop ideas, pathways and working practices that positively impact planetary health (Walpole and Mortimer, 2017).
The phrase ‘you can't unsee what you've seen’ is relevant in the case of the scholarship programme for both the scholars and the programme team (Spooner et al, 2022). This project has identified the importance of proactive sustainable healthcare awareness-raising as well as creating formal educational opportunities for staff. The authors believe training to support sustainable healthcare is important for all health and care staff nationally. Implementation plans to support this with allocated resources provided nationally and supported by organisational leaders would help translate this learning into practice, providing health and care organisations with the blueprint for educating and supporting their workforce. Ultimately, this would reduce duplication of sustainable hotspots – areas of work that are at risk of being repeated, which would increase carbon dioxide emissions or environmental damage unnecessarily – in programme planning.
Limitations
The authors acknowledge their skills and knowledge of sustainable health were limited when they started this project. However, the premise was to explore what they had learnt as a facilitation team and to apply this collaborative learning in the real-world context. Mentorship from experts in the field supported the robustness of data collection and sustainable considerations throughout.
Conclusion
It is possible to explore the planetary healthcare impact of an educational programme centred in complex clinical practice environments using the triple bottom line conceptual framework.
Despite the difficulty in undertaking sustainable healthcare projects in the real world, it is important that they are carried out. There are challenges regarding staff training and education, with a mismatch between those entering clinical spaces following academic education and those already working in the NHS who may not have received sustainable healthcare training or education. The potential loss of knowledge because of this mismatch may contribute to difficulties in undertaking real-world projects.
Healthcare systems should encourage sustainable healthcare education, and national guidance and plans should be available to support the implementation of sustainable healthcare. Each component of SusQI should be considered of equal importance and value. This project has demonstrated the value and intertwined nature of these components.
KEY POINTS
- Healthcare is part of the global warming problem and health professionals can be part of the solution
- The sustainable quality improvement (SusQI) framework is a useful tool to understand the sustainable impacts of an educational programme
- Supporting health professionals to understand sustainable healthcare in the context of their clinical practice allows them to influence sustainability in patient care
- The social component SusQI framework is often viewed with less importance than the financial and environmental impacts of projects. However, it is highly valued by those involved
CPD reflective questions
- Why is it important to include sustainable healthcare in nursing and midwifery education?
- What impact does the practice of sustainable healthcare have on your patients?
- How might you include the sustainable value conceptual framework principles in a project you are delivering?