Human activity is changing the climate. This has consequences for health and healthcare. Heatwaves, flooding, changes in disease vectors and decreasing natural resources have adverse impacts on health. Older people, those living with frailty, people with disabilities and those with mental health problems are more vulnerable to the impacts. This document has been developed by the BGS Sustainability Group and is intended to provide both key messages regarding the relationship between climate change and older people’s healthcare, and some top tips on what individuals and systems can do to help.
1. Healthcare contributes significantly to global warming
Healthcare is associated with about 5% of global carbon emissions.1 The NHS in England accounts for around 40% of public sector emissions.2 The Health and Care Act 2022 legislated for the NHS in England to achieve net zero for the emissions it directly controls by 2040.2 The NHS in England has already cut emissions by 14% since 2019/20.2
2. Healthcare generates environmentally harmful waste
There are environmental impacts from healthcare waste and pharmaceutical residues. This can lead to the release of toxic pollutants into the environment if not disposed of properly, and contamination of drinking, surface and ground waters.3 The NHS in England has a waste reduction strategy which aims to reduce waste by approximately 30% and to save £11million per year.4
3. Sustainability should be embedded at all levels of healthcare
The Greener NHS initiative from NHS England outlines how changes across the health service can help to reduce carbon emissions. This includes different models of care, workforce initiatives, medicines, estates and facilities, travel and transport, supply chain, and food and nutrition.5
4. Delivering high-value care reduces both carbon emissions and patient harm
Care that is more efficient and more environmentally friendly often delivers better patient outcomes. This includes reducing unnecessary appointments and regularly reviewing medication to ensure that all medications are beneficial.
5. Prevention and supporting patient independence are central to sustainable healthcare
Prevention of ill health reduces demand on healthcare services and helps the health system to be more sustainable. Older people should be supported to remain healthy and independent for as long as possible.
What can I do in my clinical practice?
Individual practitioners and ward or departmental teams can make a difference to the delivery of sustainable healthcare. There is substantial alignment between the needs of the environment, the clinical needs of individuals for effective and appropriate healthcare, and efficiency within healthcare systems. The mantra ‘reduce, reuse, repair, repurpose, recycle’ holds as much in professional practice as it does at home.
1. Encourage lifestyle changes and implement healthcare interventions that prevent ill health and injury to reduce demand on health services.
All healthcare activity is carbon-intensive, so prevention of disease, injury and disability makes sense. Encouraging older people to make lifestyle changes to prevent ill health has benefits for the individual as well as reducing demand on health services. Positive lifestyle changes include a seasonally-adjusted, locally-produced, predominantly plant-based diet; active transport (prioritising walking and cycling); physical exercise; quitting smoking; undertaking purposeful activity; and maintaining supportive relationships.
2. Minimise hospital admissions and length of hospital stay
For older people who require hospital-level care, consider whether an alternative to hospital admission such as Hospital at Home is available and would be appropriate. For older people who are admitted to hospital, early discharge schemes should be employed where available and possible and people should be encouraged to mobilise as early as possible to prevent hospital-related deconditioning.
3. Ensure every test and appointment adds value and eliminate those that do not
The single most effective way to reduce carbon emission and improve patient experience is to eliminate unnecessary or low-value appointments, diagnostic tests and interventions. Only do tests where there is a clear clinical rationale and do not repeat tests where they have been done recently. Do not do monitoring tests beyond published minimum intervals, following guidelines from the Royal College of Pathologists.6 Diagnostic tests for academic, patient flow or defensive reasons should not be done. Use shared decision-making to ensure that patient outcomes are driving all decisions and that every intervention is warranted and wanted. If possible, use remote and digital consultations where in-person appointments are not needed.
4. Optimise use of medicines
Many older people are prescribed medications for multiple conditions and this can be associated with adverse effects and poor adherence. This also has a negative impact on the environment as carbon is used in the manufacture, distribution, dispensing and monitoring of drug prescriptions. Many older people struggle to adhere to complicated drug regimens, and it makes sense to minimise polypharmacy to achievable regimens. Those caring for older people should regularly review all drugs for effects, adverse effects and ongoing need. The BGS has produced a pragmatic prescribing guide which will help clinicians to make decisions about prescribing for older people.7
5. Choose lower-carbon drug alternatives where available and appropriate
Where appropriate, consider offering lower-carbon alternatives for older people when preferred by the individual and where outcomes are likely to be the same. These include dry powder over metered-dose aerosol inhalers, reusable cartridge insulin pens, oral over intravenous, tablets over liquids. Penicillin allergy labels should be checked and removed when found to be incorrect.
6. Assess for reversible causes of incontinence
Support older people and their carers to identify the causes of incontinence and, where possible, provide support to reverse incontinence. Where pads and devices are necessary, choose the most appropriate ones, and support older people and carers to use them optimally. Aim to reduce overuse and unnecessary changing of continence pads and devices.
7. Make the most of mobility and hearing aids.
Choose the most appropriate aids for the older person and ensure that the individual and carer are supported to use these devices properly. When no longer required, aids should be reused or recycled where possible. NHS England supports all trusts to run walking aid reuse schemes. If there is no recycling scheme in your area, then have a look at the NHS England guidance about setting one up.8
8. Reduce single-use medical devices where there are alternatives.
Do not use gloves or aprons in situations where they are not required. The UK government has committed to transitioning away from avoidable single-use medical care products. Segregate waste for more efficient processing and to maximise recycling.
9. Support older people to care for themselves during heatwaves.
Identify older people with heat-sensitive conditions and at dehydration risk and provide advice on omitting or modifying medications, such as diuretics, during periods of extreme heat. Both the BGS9 and the Society for Acute Medicine10 have published guidance on provision of healthcare during heatwaves.
10. Use low-temperature washing cycles for work clothes
Modern detergents work well at low temperatures, and high temperatures are not required for infection control.
What can systems do and how can individuals contribute?
Many interventions are required at a societal, system and organisational level including ensuring that buildings are well-insulated and adapted to minimise summer heating, producing or sourcing renewable energy, providing sustainable food choices, and ensuring optimal access to clinical information. Individuals work within organisational, governance and practical constraints. However, sustainable practice and carbon reduction are NHS priorities and there will be Trust, primary care and Integrated Care Board structures to support greener practice. Show leadership: engage with and support this work. Join a network, such as the Centre for Sustainable Healthcare,11 Greener Practice12 or RealZero.13
1. Estates, energy, procurement
Sustainability should be embedded in planning for new and ungraded estates. This could include improving energy efficiency with measures such as installing LED lighting, insulation and double-glazed windows; replacing fossil fuel systems with lower carbon alternatives such as heat pumps; and increasing use of renewable energy where possible. This will both reduce emissions and lower costs.14
2. Service design
When designing services, sustainability should be a key consideration. Services that are more efficient are better for the environment, better for patients and are a more efficient use of resources.
3. Embedding sustainability in Quality Improvement
All quality improvement initiatives should have sustainability embedded within them to ensure that changes are beneficial for patients, systems and the environment. When policies and procedures are reviewed, carbon cost should be considered alongside financial cost.
4. Influencing policy, committees, networks
The Royal College of Physicians,15 the UK Health Alliance on Climate Change16 and various specialist societies have published advice on reducing impact and mitigating the effects of climate change. Systems should support these initiatives and take opportunities to influence local and national policies as and when these arise.
Sharing good practice in sustainable healthcareThe BGS Sustainability Subgroup is keen to hear from you if you would like to share examples of good practice in your own Trust or GP Practice. Such exemplars can then be added to the shared content on the Sustainability page of our website here: https://www.bgs.org.uk/bgs-environmental-policy |
