HEALTH SERVICES RESEARCH CSIRO PUBLISHING
Australian Health Review, 2015, 39, 417–424 http://dx.doi.org/10.1071/AH14086
Becoming environmentally sustainable in healthcare: an overview Maggie Jamieson1,3 BA, MPH, PhD, Associate Professor Public Health Alison Wicks1 MHSC(OT), BAppSc(OT), PhD, Associate Professor Occupational Therapy Tara Boulding2 BSc(Hons), PhD candidate 1
Faculty of Health, University of Canberra, Locked Bag 1, Canberra, ACT 2601, Australia. Email: [email protected] 2 Faculty of Education, Science, Technology & Mathematics, University of Canberra, Locked Bag 1, Canberra, ACT 2601, Australia. Email: [email protected] 3 Corresponding author. Email: [email protected]
Abstract. This paper provides an overview of environmental sustainability in healthcare and highlights the need for a policy framework for action. Examples from overseas demonstrate what has effectively enabled mitigation of and adaptation to the threat of climate change. The need to overcome perceived limits and barriers to health professionals’ engagement in sustainable practice is noted. The scientific evidence recommends immediate action. What is known about the topic? Climate change has negative impacts on human health. There are co-benefits in mitigating and adapting to climate change that will benefit both humans and health systems, increasing wellbeing, financial and health system efficiency. There is a need for health professionals to engage with sustainability. Australia’s health policy makers could learn useful lessons about how to be sustainable from the significant policy and legislation work occurring elsewhere. What does this paper add? This paper reports on the context of and need for becoming sustainable in healthcare. It provides brief examples of what has occurred in other countries and advocates for a policy framework to support further action in Australia. What are the implications for practitioners? The significance of this paper is that it notes the need for a consistent, wholeof-country approach to carbon reduction in many aspects of the healthcare system. From an increased preventative focus on population health, coupled with actions in patient care, and developing a whole-of-healthcare-system approach, benefits will be realised that serve to reduce carbon emission, thereby tackling the longer-term effects of climate change. This view is supported by the noted success of increasing sustainable health system actions in the United Kingdom National Health Service and elsewhere. Additional keywords: sustainability, healthcare. Received 2 June 2014, accepted 4 February 2015, published online 20 April 2015
Introduction Since the industrial revolution (around 1750) there has been exploitation of fossil fuels for energy production. This use of fossil fuels has resulted in a substantial increase in the concentration of the atmospheric greenhouse gas carbon dioxide.1 After much dispute, there is now an almost unanimous consensus within the scientific community that the rising concentration of atmospheric greenhouse gasses is catalysing climate change, through disruption of the natural carbon cycle, which is causing global warming.2 The adverse effects of severe weather events due to climate change will undoubtedly have an impact on human health, particularly on the health of vulnerable people in society: the very young, the poor and the elderly.3–5 Health effects of climate change The recent 2014 International Panel on Climate Change synthesis report notes that since 1950 there have been a rise in sea levels, Journal compilation Ó AHHA 2015
increased warm temperatures and increasing extreme rainfall in some areas, with human influence being a likely factor.6 As a consequence of changes to fundamental physical systems, there are several adverse effects on human health.4 First, an increase in frequency and severity of extreme weather events leads to an increase in mortality and illness from thermal stress, and from increasing occurrence of natural disasters, such as fire storms, drought, prolonged dryness and floods, all affecting the physical and mental health of communities.7 Second, changes to ecosystems lead to increased microbial proliferation and changes in vector–pathogen–host relations, resulting in a loss of crops, livestock and decreased fishery yields, affecting livelihoods and leading to impaired nutrition through decreased food security. In combination and alone, these factors affect physical and mental health.4 Additionally, the adverse effects of continued reliance on fossil fuels contributes to decreased air quality. These factors as solo entities and in combination result in climate change being www.publish.csiro.au/journals/ahr
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one of the greatest problems facing the human species, with an increasing burden of disease, injury and poverty for the already vulnerable and disenfranchised members of our populations.8–13 Australian climate change policy In Australia, a country already subjected to extremes of climate, there are geographical areas where ecosystems have been identified as under threat, for example, the Great Barrier Reef, Alpine regions and the Murray–Darling river system.14 Australia’s vast, arid landscape means populations are at risk as a result of climate change. For example, small scattered inland communities have been experiencing prolonged drought, and conversely, large populations in coastal regions are being overwhelmed by flooding.15 Internationally, in recognition of the urgent need to tackle climate change, an international treaty, the Kyoto Protocol, was developed in 1997 under the United Nations Framework Convention on Climate Change. The Kyoto Protocol commits industrialised countries to reducing their greenhouse gas emissions by 5% from 1990 levels. On the 3 December 2007, Australia signed the Kyoto Protocol, thereby pledging to reduce Australia’s greenhouse gas emissions by 5% by 2012.16 However, the first commitment period of the Kyoto Protocol has ended and as yet, the Australian Government has not signed up for the second commitment period. Nationally, the Carbon Tax policy was abolished on 17 July 2014, leaving Australia with a less visible suite of policies relating to climate change and carbon reduction.17 However, the current Abbott government has released a Green Paper for a ‘Direct Action Plan’ which would retain the commitment for a 5% emissions reduction as well as a 20% increase in renewable energy by 2020.18 One of the main components of this policy is the ‘Emissions Reduction Fund’. The fund details were released in a White Paper on 24 April 2014, (http://www.environment. gov.au/resources/emissions-reduction-fund-white-paper, cited October 2014). In essence, people will no longer pay a carbon tax on emissions related to goods and services. Instead monies from taxation sources will provide grants and reward businesses for projects that will either lower their emissions or completely offset them.19 It has been argued that in Australia and elsewhere current policy approaches to tackling climate change are reductionist, targeting it in isolation, and giving the impression that governments can solve these problems without undue changes.20 Climate change and its effect on human and planetary health are not abstract matters to be put off for the future, but rather they require immediate attention. Having a national policy on carbon reduction gives a clear, imperative message to tackle climate change through carbon reduction. An example of an overarching policy process which Australia could use as a model is the UK government’s 2005 sustainable development strategy, ‘Securing the Future’, comprising five key areas: living within environmental limits; ensuring a strong healthy and just society; achieving a sustainable economy; promoting good governance; and using sound science responsibly.21 This strategic framework was enacted in the UK National Health Service (NHS) through the establishment of the NHS Sustainable Development Unit (SDU) in 2008. Led by a core expert team, with an initial focus on tackling carbon reduction in the NHS, the work
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of this unit demonstrates that there is scope for the healthcare sector to take the lead in essential social change by: (1) Communicating the health risks of climate change. (2) Tackling issues to improve population health that also reduce environmental impact. (3) Engaging in and educating about sustainable practice to mitigate the impact of health service delivery. The Australian healthcare sector Climate change impacts on health and concurrently healthcare systems impact on climate change. In Australia the healthcare sector is responsible for 7% of the total emissions from buildings, with further emissions from procurement and clinical practice.22 Additionally, healthcare services consume large amounts of money, food and other resources, creating a large amount of waste, much of which can be avoided.23 Consequently, there is significant scope for the sector to mitigate its carbon footprint by implementing energy efficiency measures and changing practice.20,24,25 It is worth acknowledging that across Australia there are actions underway, predominately focusing on energy efficiency and waste reduction. How can we tackle climate change in healthcare? As climate change has become a certainty, so too has the need for the health sector and health professionals to anticipate, manage and ameliorate the burdens climate change will impose,26 and acknowledge that the health of populations depends on a successful transition to sustainability.27,28 But what is sustainability? Simply put, sustainability is a measure of long-term viability of an entity or process or both,29 requiring a refocus on prevention. In the context of climate change, primary prevention refers to mitigation of climate change itself, whereas secondary and tertiary prevention refer to adaptation to the effects of climate change.1 Mitigation strategies include direct actions, such as use of renewable energy sources and energy efficiency, but also include work, such as forest preservation and replanting.3 Adaptive strategies include protective technologies, public health education, government legislation and administration. For obvious reasons, mitigation is the preferred action, however, adaptive modes are easier to implement, both practically and politically.30 Mitigating and adapting to climate change are complex matters requiring multilevel innovative approaches and solutions across all sections of our society. From an individual perspective, there is a need to continue to advance population health through health promotion, for example by encouraging active travel or reducing food miles, both of these activities reduce reliance on fossil fuels, improve health, and are, as a co-benefit, less harmful to the environment. At the system level of healthcare delivery there needs to be fundamental changes to models of clinical practice, system governance, the way practitioners work, consumer expectations of health services and the business model of healthcare delivery.31 The transition to sustainability needs to be embedded in the normal business of healthcare, through leadership, innovation and collaboration on many levels. As Schroeder et al. noted in their book, Sustainable Healthcare, for clinicians, it may mean that a value-based model would
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(re)engage them in the delivery of sustainable patient care, particularly within evidence-based practice models. This means examining current and future models of clinical care, including models that aim to transform how people become involved in their own care, by engaging individuals in co-production of care, enabling a greater patient voice, and reviewing the professional role to a partnership approach.29 There are many challenges that health professionals face when advocating action against climate change. Indeed, the challenge perhaps is too great and intangible to comprehend; after all, the effects are not immediate, so it seems essential to frame the challenge as how best to improve population health. First, they need to be able to present the evidence in a coherent and nonthreatening way to make other health professionals and the public aware of the enormity of the problem. Second, health professionals need to persuade others that change can be made to mitigate the problem.32 Framing health improvement coupled with quality service provision as core to sustainability is a way forward, as is promoting the understanding that sustainable healthcare is high quality care: lean, responsive and compassionate.24 The discussion of co-benefits is beyond the scope of this paper, yet worth mentioning given their importance to sustainability. Co-benefits enable engagement and action. They are best illustrated by the following example: by changing policy to advocate for a change to travel for staff, patients and visitors to hospitals, from cars to active travel (including public transport), physical activity is increased, helping to reduce obesity and improve cardiovascular health, while also diminishing carbon emissions and improving air quality. Overall there is a win–win situation with increased health, reduced environmental impact and money saved for health services by reducing admissions. This ‘virtuous cycle’ results in improved health benefits for people and planet.29 Enabling the virtuous cycle, is underpinned by organisational activity, including, but not limited to, the development of local policy using evidence-based information, enacting working groups with change champions, monitoring activity including costs, and giving incentives to staff to enable behavioural change.23,24 All these activities serve to progress change that continues to improve health. Health system delivery needs at its core leaders who are resilient, committed and supported at multiple levels within the organisation so that the virtuous cycle of change is invested in at all organisational levels. Structurally, in the corporate and infrastructure services, enabling sustainability supports the simultaneous achievement of the three interlinked goals of economic prosperity, environmental protection and social equity. These goals are sometimes referred to as the ‘triple bottom line’.33 To adapt to and improve population health and diminish the carbon impact of heath delivery, there is a need to seek solutions that will maximise the benefits of a transition to sustainability in healthcare and to grasp opportunities for health improvement.20 At a minimum there is a need to start a debate within the health sector about the implications for health services if a ‘businessas-usual approach’ is maintained in what we know to be an unsustainable system. In the context of health services, becoming sustainable recognises that multiple systems are interlinked and, in some cases, dependant on one another. The challenge of moving to sustainability in health services should not be viewed as a simple task; rather it will require a system-level approach.31
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However, the focus of this paper is on the possible actions of the healthcare sector to become environmentally sustainable, in order to improve the health of populations and diminish the impact of health service delivery. What is sustainable healthcare? The ideals of the NHS SDU are encapsulated in the concept that being sustainable is ‘the balance required between financial, social and environmental factors in order that future generations do not suffer because of the way we live today’.34 According to the NHS SDU, a sustainable healthcare system ‘is achieved by delivering high quality care and improved public health without exhausting natural resources or causing severe ecological damage’.35 As others have noted, sustainability will require change at multiple system and individual levels, supported by research, evidence, alliances, cultural change, policy and legislation.23,24 There are multiple benefits to the healthcare sector to take the lead on sustainability, including environmental, health, financial and reputational benefits.25 Some authors have even proposed that the healthcare sector and healthcare workers have a professional responsibility to promote and protect health by assisting in climate change adaptation and mitigation and policy advocacy.20,24,36 Previously, several different strategies that the healthcare sector could implement in order to adapt to climate change have been suggested. These strategies include development of early alert systems and enhanced vaccination programs, plus improved surveillance for disease indicators and health outcomes.3,26 Some people have also proposed the introduction of climate change education into the curriculum of medical students, postgraduate general practitioners and nurses.25,37 Practical actions include measuring and reducing the carbon footprint of energy use for heating, cooling, hot water and ventilation.24,38 Additionally, the use of high-quality insulation, combined heat and power units, and motion sensitive lighting as well as local generation of electricity in both new and existing facilities are recommended. Finally, reducing patient, staff and visitor travel and travel related to the procurement of drugs, equipment, food and other services are other tried and tested strategies for reducing carbon footprint.24 Sustainable health care is not solely about energy, waste, design and travel. It should include sustainable clinical practice; that is practice that is evidence-based and further develops the discussion about the effective use of pharmaceuticals, medical devices10 and diagnostic testing.39 Engaging with sustainability: lessons from elsewhere On the world stage 2014 saw two major international events where health and climate change have been major themes. The World Health Organization conference in August 2014 called for a systematic approach to increase health resilience to the risks that climate change pose, with particular reference to mitigation to prevent deaths from air pollution through reduction in carbon emissions.40 The second congress, The United Nations Climate Summit, a precursor to the meeting in Paris 2015, placed health at the centre of climate change discussion, with an emphasis on the opportunities to
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improve health by sustainable action in transport, power generation, food production and food security.41 These two events help to reinforce the need to have health as integral to policy initiatives tackling climate change, such as implementing policy on pricing carbon, tackling air pollution through legislation and divesting from fossil fuel production.41 These two recent international meetings serve to emphasise, through existing evidence (e.g. the International Monetary fund report on carbon pricing),42 that health and climate change policy can come together in ways that will promote local action in many countries that will see health resilience, health benefits and climate protection through reduction in fossil fuel emissions. However, country-by-country agreements are still to be realised and acceptance may be varied, but these meetings have served to further link health and climate change and to enable positive discussion and influence policy directions.40,41 In the UK To date, the most well-known example of a health and social care sector working towards sustainable practice is that of the UK’s NHS. The NHS SDU is becoming a leader in low-carbon, sustainable practice. The approach in the NHS is unique internationally in terms of its scope. Many countries have tackled issues such as power and waste, but few have a comprehensive organisational strategy, that includes organisational development. The NHS has a carbon footprint of 21 million tonnes of CO2 equivalent each year from heating, cooling, lighting, equipment, procurement and waste, patient, staff and visitor transport.43–45 The NHS’s goal is to reduce its carbon footprint from 1990 levels by 10% by 2015 and by 80% by 2050.46 To assist healthcare services in meeting the NHS carbonreduction goals, a Carbon Reduction Strategy was published in 2009.44 It specified a range of ways to reduce the carbon footprint and contribute towards healthcare sustainability.44,47 The key areas of the strategy are: (1) Every organisation should: review the need for staff, patients and visitors to travel; provide incentives for low carbon travel; and promote home working opportunities. (2) Every organisation should ensure efficiencies by monitoring water and heating usage. (3) Every organisation should monitor domestic and clinical waste and, where possible, review its approach to single-use items versus decontamination options. (4) Every organisation should become carbon literate and numerate to ensure that appropriate investments can be made to meet carbon targets and to prepare for future carbon policies.44 As well as having a clear strategic framework to legitimise carbon reduction activity, an education intervention was also developed to educate healthcare professionals on climate change, sustainability and health, to encourage them to become advocates for sustainable practice.43 This intervention was replicated in Australia in 2011.48 The carbon foot print of the NHS has grown over the past 10plus years, as a result of increased activity and workload45 but the carbon intensity of healthcare (that is, emissions per unit of expenditure) has fallen and evidence from the NHS SDU suggests
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that this upward trend is starting to reverse, linked perhaps to a combination of strategy, policy, technology and education, there was a 5.5% reduction in NHS carbon emissions between 2007 and 2012.46 In their 2012 report Naylor and Appleby,45 noted that goods and services procurement accounted for the greatest amount (60%) of emissions, especially pharmaceuticals and medical equipment, while patient and staff travel and direct energy use made up the rest. While the SDU strongly advocates for sustainability, responsibility and action sits with individual trusts and practices. Examples include hospitals, such as in North Bristol, working with suppliers to source all produce from within a 50-mile radius, ensuring fresh produce for patients and a food supply with a small carbon footprint.49 In Cambridge, Addenbrooke’s Hospital adopted a ‘green travel plan’ encouraging staff and patients to walk, cycle or use public transport by providing several incentives, such as interest-free loans to buy bicycles and subsidised weekly bus tickets.50 In Manchester, the Central Manchester Trust implemented a program of staff-engagement using the Green Impact Model, to change daily behaviours around energy use, resulting in cost efficiencies and energy savings.51 In London, Barts Health NHS Trust’s sustainability program has, to date, saved £2mil by simple measures such as turning off lights and unused equipment.52 The Green Nephrology network, founded in 2009 to improve the sustainability of renal care in the UK,53 crosses over institutional boundaries and is an example of sustainable healthcare driven by clinicians. A single haemodialysis treatment produces 2.5 kg of clinical waste, which is around 390 kg per patient per year.53 To aid individual renal units in reducing their carbon footprint, the Centre for Sustainable Healthcare created a ‘10 : 10 Renal Checklist’, specifying 10 ways units can reduce their CO2 emissions.54 Many facilities have benefited, one exemplar being the Renal Unit at the Cornwall Hospital. After 2 years, its CO2 emissions were reduced by 52.3 tonnes per year, with savings of approximately £57 500 per year. All of these examples have co-benefits that are social, economic, improve care quality, and have become part the norm for these organisations, albeit to differing levels of success. The approach in the NHS is unique internationally in terms of its scope. Many countries have tackled issues such as power and waste, but few have a comprehensive strategy that includes organisational development. NHS Trusts and social care institutions are increasingly aware of the need to be sustainable, but that does not mean there is consistency of approach nor progress in translating strategy into policy.45 In the United States While it is obvious that the NHS has progressed sustainable healthcare, it is not alone. In USA, the Healthier Hospitals Initiative, (part of the Healthcare without Harm and Global Green Hospital initiatives), is a non-government organisation assisting hospitals in achieving sustainable practice.55 The initiative is unique in that individual hospitals sign up and pledge to move towards achieving several sustainability-related goals, which include leaner energy, less waste, smarter purchasing, engaged leadership, healthier foods and safer chemicals. While the initiative is relatively new (formed in 2012), more than 1000 hospitals
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have signed on, indicating the potential to greatly impact the sustainability of the USA healthcare system. Policy guidance, such as the Center for Disease Control and Prevention’s policy on Climate Change and Public Health56 in USA has served to create a framework for national public health action, especially in response to disaster preparedness, following Hurricane Katrina. Much of this work is being supported by the American Public Health Association underpinned by legislation and policy enabling direct action by federal and other agencies,57 and researchers such as Frumkin and colleagues, translating the scientific literature into public policy as part of a focus on adapting to climate change.26 In Asia In some parts of Asia there is a move to sustainable healthcare practice. For example, National Cheng Kung University Hospital in Taiwan implemented a sensor-controlled lighting system and upgraded heating and cooling systems to more energy-efficient models.58 It is estimated that these changes saved the hospital US $700 000 and cut carbon emissions by 5 000 tonnes per year. In South Korea, The Yonsei University Hospital, in addition to improving thermo-regulation and energy efficiency, also established a small task force to develop sustainable green hospital management.59 It is estimated that these changes have saved the hospital approximately US$2mil and reduced carbon emissions by 5 300 tonnes per year. Healthcare sustainability in Australia Currently in Australia, the Climate and Health Alliance, formed in 2010, includes organisations and health professionals working to develop and implement cost-effective environmental initiatives in the healthcare sector.60 The Alliance advocates for effective public policy and engages and informs health professionals, policy makers and the community about the effects of climate change and the benefits of sustainable practice.61 Additionally, the group, Doctors for the Environment (http://dea.org. au) is gaining momentum in its advocacy for change, following an established path of health professionals leading and advocating for change.20 Thus far, the response in Australia and elsewhere of health professionals to the challenge of sustainability has been reductionist and piecemeal.3,4 It is interesting that this is the case given the clear benefits of improved care and the meeting of triple bottom-line targets by improving efficiency and engaging in sustainable healthcare practice seen in the UK and elsewhere.23,46,52,62 In Australia, the lack of an explicit strategic framework to drive expectations of sustainability and reduce carbon across all aspects of healthcare practice may hamper an overt approach. Four main reasons have been given as to why health professionals do not engage in sustainable practice.43 First, they are overly sceptical of new health threats as they naturally apply a critical and balanced approach to all new evidence. Second, they are very busy delivering and reacting to immediate care needs and hence have less time for long-term issues such as climate change and sustainability. Third, they are focussed on reacting to current issues and not on being proactive in preparation or preventative measures. Last, they feel they are already making a worthy
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contribution to society by working in healthcare.43 It has also been suggested that for some organisations efficiency is the most important issue and reaching economic targets is valued higher than reaching energy or carbon targets on a day-to-day basis.32 Chivian notes that in the past, the medical community was successful in translating the impact of nuclear war to the public, perhaps helped by the tangible results of Hiroshima and Nagasaki.42 In contrast, climate change is much less tangible, occurring slowly but with devastating effect. There is an imperative for clinicians to give concrete, clear-language examples of the impact of climate change on people’s health, including the impact of continued carbon dioxide release. Clinicians are implored to practice advocacy and action using the traditional medical model that supports risk taking even when there is limited knowledge, while making best use of existing knowledge and evidence. For the current and future impact of climate change, there is not the luxury of waiting for absolute proof of impact on our physical systems and population health. The risk of doing nothing is too grave. Finally, and importantly, Chivian cautions against underestimating the power of public disinformation and the powerful lobby groups who have much to lose if there is continued disinvestment in fossil fuels, highlighting that taking action is not just a matter of making simple changes.42 What can be done? There are many challenges that health professionals face when advocating action in the light of the impact of climate change on health, not least making other health professionals and the general public aware of the enormity of the problem; and persuading them that changes can be made to mitigate the problem. There have been numerous suggestions on how to educate, persuade and engage health professionals in the issues of climate change and sustainability. McCoy et al. advocate that there are three areas in which health professionals can (and need to) take a lead on in tackling climate change.63 Specifically, health professionals need to: *
*
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Support divestment from fossil fuels by health services and government agencies and advocate for reinvestment in renewable energy sources; Change the minds and behaviours of others, especially people of influence; Build alliances between medical and other health professionals to speak clearly to the public, the media, governments, and intergovernmental bodies to provide a strong and unified message – that climate change is real, is already having an effect and is the result of human activity, but there are already practical actions that can be taken.63
In Australia, groups such as Climate and Health Alliance and Doctors for the Environment have and continue to lobby for engagement across politics and the health system. The literature is clear on the processes and actions that serve to raise awareness and enable action. First, the basics of climate change and its impact on human health must be clearly explained and common terms used in the sustainability discourse must be carefully described.43,48 Second, the message needs to be tailored to the audience (e.g. most clinicians and general practitioners will respond best to the health co-benefits argument, whereas finance directors and chief
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executives will be more interested in the financial and reputational benefits).43 Third, there should be a focus on realistic, practical achievements and methods for incorporating sustainability in the work place, for example, including sustainability as one of the indicators of care quality.64 Also, framing the issue as ‘sustainability to improve health and system efficiency’, rather than ‘mitigation of climate change’ is critical.23,43 The NHS SDU advocates for the health system to become sustainable through transforming care. In so doing, it advocates for an improved quality of life,34 recognising that such systemic change is not without challenges. Transformation will require leadership and engagement not just in health care, but across industry, government and society, requiring a collaborative and integrative approach across society. Only then will triple-bottomline sustainability be achieved within health and other sectors. In healthcare the key tenants of transformation include: *
*
*
*
*
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Leadership and engagement across traditional bureaucratic boundaries; Engagement and enablement of clinicians to be leaders in transforming care; Focus on and investment in prevention, health improvement, wellness and independence; Co-designed, integrated health services that include users and clinicians; Focus on living well to minimise acute and specialist intervention; Dying well by beginning the discussion.29
Conclusion There are clear environmental, health, financial and reputation benefits from engaging in sustainable practice.24,31 The healthcare sector is in a unique position, in that health professionals have an extensive history of both contributing to and leading social change.20 Without action, climate change will have an unprecedented effect on human health as well as economic and social structures. To avoid this, there needs to be unparalleled global change in the emission of greenhouse gases and the attitude towards acting in mitigation. However, such change will require societal, systemic and individual transformational change. This will require leadership across multiple levels of organisations, but importantly there needs to be a coherent and consistent all-ofgovernment policy framework that supports and legitimises action. Learning from elsewhere, there is no doubt that having a specialist, expert focus and leadership, through a mechanism such as the NHS SDU, may well be a way forward. However, such a development in Australia would require political, policy and financial support at federal and state levels. While there is already adaptive action in underway in many places, there is likely to be significant variation across the system. A cohesive, united policy approach is required to enable practice and process change, yet perhaps this is difficult in the light of the current government stance on climate change. Yet in many ways, in Australia, the time is ripe for investment in actions to improve population health and in-system delivery. The impact is already apparent in our arid climate, with increasingly hot summers, prolonged drought and dryness in rural areas and increasing hospital admissions, so why, given evidence from elsewhere, is there no systemic action? In the words of Naylor and Appleby,
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‘The most sustainable system is one that minimises unnecessary or ineffective use of resources (financial or natural) by delivering the right care, in the right place, at the right time, and by preventing care needs from arising at all, where possible’45(p.3) These simple words exemplify the current desires for an effective health system, hardly radical, but sustainability is yet to be core to our systems here in Australia due to a lack of cohesive and coordinated action. This needs to change, and while the discussion of such change is beyond the scope of this paper, the message from the literature is clear: the time to act is now.65 Competing interests None declared. Acknowledgements This project was supported by an internal University of Canberra Faculty of Health grant. The paper was part of a larger project that had ethics approval from the University of Canberra Human Research Ethics Committee (Approval No: 13–174).
References 1
Grambsch A, Menne B. Adaptation and adaptive capacity in the public health context. In: McMichael AJ, Campbell-Lendrum DH, Corvalan CF, Ebi KL, Githeko A, Scheraga JD, et al, editors. Climate Change and Health: Risks and Responses. Geneva: World Health Organization; 2003: 220–36. 2 International Panel on Climate Change. Climate Change 2007: the physical science basis. Cambridge: Cambridge University Press; 2007. 3 Haines A, Kovats RS, Campbell-Lendrum D, Corvalan C. Climate change and human health: impacts, vulnerability and public health. Public Health 2006; 120: 585–96. doi:10.1016/j.puhe.2006.01.002 4 McMichael AJ, Woodruff RE, Hales S. Climate change and human health: present and future risks. Lancet 2006; 367: 859–69. doi:10.1016/ S0140-6736(06)68079-3 5 McMichael A, Kovats S. Climate change and climate variability: adaptations to reduce adverse health impacts. Environ Monit Assess 2000; 61: 49–64. doi:10.1023/A:1006357800521 6 International Panel on Climate Change. Climate change 2014: Synthesis Report. Geneva. Available at: http://www.ipcc.ch/pdf/assessment-report/ar5/syr/SYR_AR5_LONGERREPORT_Corr2.pdf www.ipcc.ch/ report/ar5/syn [verified 10 December 2014]. 7 OBrien LV, Berry HL, Coleman C, Hanigan IC. Drought as a mental health exposure. Environ Res 2014; 131: 181–7. doi:10.1016/j.envres. 2014.03.014 8 The Lancet. Climate change and health – action please, not words. Lancet 2014; 384: 1017. 9 Costello A, Abbas M, Allen A, Ball S, Bell S, Bellamy R, Friel S, Groce N, Johnson A, Kett M, Lee M, Levy C, Maslin M, McCoy D, McGuire B, Montgomery H, Napier D, Pagel C, Patel J, de Oliveira JA, Redclift N, Rees H, Rogger D, Scott J, Stephenson J, Twigg J, Wolff J, Patterson C. Managing the health effects of climate change: Lancet and University College London Institute for Global Health Commission. Lancet 2009; 373: 1693–733. 10 McGain F, Naylor C. Environmental sustainability in hospitals: a systematic review and research agenda. J Health Services Res Policy 2014; 19: 245–52. 11 Friel S, Marmot M, McMichael AJ. Global health equity and climate stabilisation: a common agenda. Lancet 2008; 372: 1677–83. doi:10.1016/S0140-6736(08)61692-X
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12 McMichael A, Montgomery H, Costello A. Health risks, present and future, from global climate change. BMJ 2012; 344: e1359. doi:10.1136/ bmj.e1359 13 McMichael A. Globalization, climate change and human health. N Engl J Med 2013; 368: 1335–43. doi:10.1056/NEJMra1109341 14 Hughes L. Climate change and Australia: trends, projections and impacts. Austral Ecol 2003; 28: 423–43. doi:10.1046/j.1442-9993.2003.01300.x 15 Blashki G, McMichael T, Karoly DJ. Climate change and primary health care. Aust Fam Physician 2007; 36: 986–9. 16 Department of Environment. Kyoto Protocol 2013. Available at: http:// www.climatechange.gov.au/international/negotiations/history-negotiations/kyoto-protocol [verified 17 January 2014]. 17 Department of Environment. Repealing the carbon tax. Canberra: Department of the Environment; 2013. Available at: http://www.environment.gov.au/topics/cleaner-environment/clean-air/repealing-carbontax [verified 17 January 2014]. 18 Department of Environment. The Government’s Direct Action Plan: Parliament of Australia; Canberra. 2013. Available at: http://www.aph. gov.au/Parliamentary_Business/Committees/Senate/Environment_and_ Communications/Direct_Action_Plan [verified 17 January 2014]. 19 McMichael A. Climate change: health risks mount while Nero fiddles. Med J Aust 2014; 200: 507–8. doi:10.5694/mja14.00307 20 McCartney G, Hanlon P. What can health professionals contribute to the challenge of sustainability? Public Health 2009; 123: 761–4. doi:10.1016/j.puhe.2009.09.008 21 UK Department of Environment. Securing the future – delivering a sustainable development strategy. London: Her Majesty’s Stationary Office (HMSO); 2005. 22 Low Carbon Australia 2014. Final Annual Report of Low Carbon Australia 2013–14. Brisbane. Available at: http://www.cleanenergyfinancecorp.com.au/media/106763/lowcarbon-annual-report-2013-14_lr. pdf [verified February 2015]. 23 Charlesworth KE, Madden DL, Capon AG. Environmentally sustainable health care: using an educational intervention to engage the public health medical workforce in Australia. NSW Public Health Bull 2013; 24: 76–80. doi:10.1071/NB12097 24 Pencheon D. Health services and climate change: what can be done? J Health Serv Res Policy 2009; 14: 2–4. doi:10.1258/jhsrp.2008.008147 25 Green EI, Blashki G, Berry HL, Harley D, Horton G, Hall G. Preparing Australian medical students for climate change. Aust Fam Physician 2009; 38: 726–9. 26 Frumkin H, Hess J, Luber G, Malilay J, McGeehin M. Climate change: the public health response. Am J Public Health 2008; 98: 435–45. doi:10.2105/AJPH.2007.119362 27 Diamond J. Collapse: how societies choose to fail or survive. London: Penguin; 2006. 28 McKee M, McMichael A. The Health of nations. BMJ 2008; 337: a2811. doi:10.1136/bmj.a2811 29 Schroeder K, Thompson T, Frith K, Pencheon D. Sustainable healthcare. London: John Wiley and Sons; 2013. 30 Kovats RS, Menne B, McMichael AJ, Corvalan C, Bertollini R. Climate change and human health: impact and adaptation. Geneva: World Health Organization; 2000. 31 Pencheon D. Developing a sustainable health and care system: lessons for research and policy. J Health Serv Res Policy 2013; 8: 93–4. 32 Coote A. What health services could do about climate change. BMJ 2006; 332: 1343–4. doi:10.1136/bmj.332.7554.1343 33 Savitz A. The triple bottom line. San Francisco: Jossey-Bass; 2006. 34 National Health Service Sustainable Development Unit (NHS SDU). Route map for sustainable health. Fulbourn: NHS SDU: 2011. 35 National Health Service Sustainable Development Unit (NHS SDU). What is sustainable health? NHS SDU; 2014. Available at: http://www. sduhealth.org.uk/sustainable-health/what-is-sustainable-health.aspx [verified 15 January 2014].
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36 Bell E, Horton G, Blashki G, Seidel BM. Climate change: could it help develop ‘adaptive expertise’? Adv Health Sci Educ Theory Pract 2012; 17: 211–24. doi:10.1007/s10459-010-9245-4 37 Goodman B. The need for a ‘sustainability curriculum’ in nurse education. Nurse Educ Today 2011; 31: 733–7. doi:10.1016/j.nedt.2010. 12.010 38 Griffiths J, Rao M, Adshead F, Thorpe E. The health practitioner’s guide to climate change: diagnosis and cure. Abingdon: Routledge; 2009. 39 Glasziou P, Moynihan R, Richards T, Godlee F. . Too much medicine: too little care. BMJ 2013; 347: f4247. 40 World Health Organization (WHO). WHO conference on Health and Climate; 27–29 August 2014; Geneva, Switzerland. 41 United Nations 2014 Climate Change Summit Summary, Chair’s Summary. Available at: http://www.un.org/climatechange/summit/2014/09/ 2014-climate-change-summary-chairs-summary/ [verified 2 March 2015]. 42 Parry IW, Veung C, Heine D. How much carbon pricing is in countries own interest? The critical role of co-benefits. Washington, DC: International Monetary Fund; 2014. http://www.imf.org/external/pubs/ft/wp/ 2014/wp14174.pdf [verified 18 December 2014]. 43 Charlesworth KE, Ray S, Head F, Pencheon D. Developing an environmentally sustainable NHS: outcomes of implementing an educational intervention on sustainable health care with UK public health registrars. NSW Public Health Bull 2012; 23: 27–30. doi:10.1071/NB11018 44 Abbott A, Arnold M, Best J, Brockway P, Cosford DP, Coulson K, Edwards D, Francis S, Freathy S, French R, Garratt E, Goldsack D, Gregson C, Hall C, Holme L, Insall P, Kirkup B, Lockwood L, MacGregor R, Martin g, Mckay N, Reynolds J, Scally G, Service T, Taylor R, Wathey D, Whitehead L, Pencheon D, Cointet S, Brown J, Howley J, Tennison I, Greensmith H, Wright, S. Saving Carbon, Improving Health National Health Service, Carbon Reduction Strategy for England. Cambridge: National Health Service Sustainable Development Unit; 2009. 45 Naylor CJ, Appleby J. Sustainable health and social care. London: Kings Fund; 2012. 46 National Health Service Sustainable Development Unit (NHS SDU). Carbon Footprint update for NHS England 2012. Cambridge: NHS SDU; 2012. 47 Climate Change Act 2008 (c.27), House of Lords Hansard Vol.705 Col.1477, House of Commons Hansard Vol.485 Col.855. London: Her Majesty’s Stationary Office (HMSO); 26 November 2008. 48 Charlesworth KE, Madden DL, Capon AG, Engelhard S. Climate change, sustainability and health workshops for medical professionals evaluation report. Sydney: AFPHM; 2011, Australasian Faculty of Public Health Medicine. Available at: http://www.racp.edu.au/page/racp-faculties/australasian-faculty-of-public-health-medicine/news-and-events/reports/ [verified June 2014]. 49 National Health Service Sustainable Development Unit. Case study: North Bristol NHS Trust. 2013 Available at: http://www.sdu.nhs.uk/ publications-resources/case-studies.aspx [verified 20 January 2014]. 50 National Health Service Sustainable Development Unit. Access to Addenbrooke’s – a travel plan. Cambridge University Hospitals NHS Trust; 2012. Available at: http://www.sdu.nhs.uk/publicationsresources/case-studies.aspx [verified 17 January 2014]. 51 National Health Service (NHS) Sustainable Development Unit. Case study: Central Manchester NHS Trust. 2013. Available at: http://www. sdu.nhs.uk/publications-resources/case-studies.aspx [verified 30 May 2014]. 52 National Health Service Sustainable Development Unit. Sustainability: Barts Health. 2013. Available at: http://www.bartshealth.nhs.uk/aboutus/sustainability/ [verified 21 January 2014]. 53 Centre for Sustainable Healthcare. Green nephrology: reduce, re-use, recycle in the dialysis unit. Oxford: Green Nephrology; 2010. Available at: http://sustainablehealthcare.org.uk/sites/default/files/case_study_reduce_reuse_recycle_in_the_dialysis_unit_v1.0.pdf [verified 20 January 2014].
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54 Centre for Sustainable Healthcare. 10 : 10 renal checklist. Oxford: Centre for Sustainable Healthcare; 2010. Available at: http://sustainablehealthcare.org.uk/1010-renal-checklist [verified 12 January 2014]. 55 Healthier Hospitals Initiative. 2013 Milestone Report; 2013. Available at: http://healthierhospitals.org/sites/default/files/IMCE/msr_final_draft_ post.pdf [verified 17 January 2014]. 56 Center for Disease Control and Prevention. Climate change and public health. Atlanta: Center for Disease Control; 2009. 57 Hess JJ, Schramm PJ, Luber G. Public health and climate change adaptation at the federal level: one agency’s response to executive order 13514. Am J Public Health 2014; 104: e22–30. doi:10.2105/AJPH.2013. 301796 58 Green G, Hospitals H. Energy saving and carbon reduction policies at the Taiwan National Cheng Kung University Hospital. 2013 Available at: http://greenhospitals.net/wp-content/uploads/2013/06/National-ChengKung-University-Hospital-Taiwan-Energy.pdf [verified 17 January 2014]. 59 Green G, Hospitals H. Greenhouse gas emissions reduction and availability for energy-saving practices in the special context of a hospital environment. 2013 Available at: http://greenhospitals.net/wp-content/ uploads/2013/06/Yonsei-University-Health-System-Korea-Energy.pdf [verified 17 January 2014].
60 Hanna L, Armstrong F. Annual report 2012–13. Climate and health alliance; 2013. Available at: http://caha.org.au/wp-content/uploads/ 2012/12/CAHA-Annual-Report-2012-2013-compressed.pdf [verified March 2015]. 61 Climate and Health Alliance. Climate and Health Alliance Declaration. Melbourne: Climate and Health Alliance; 2010. Available at: http://caha. org.au/wp-content/uploads/2010/11/Declaration_010111.pdf [verified 7 February 2014]. 62 Centre for Sustainable Healthcare. Renal Unit, Royal Cornwall Hospital. Oxford: Centre for Sustainable Healthcare; 2011. Available at: http://sap. sustainablehealthcare.org.uk/royal-cornwall-hospital-renal-unit [verified 23 January 2014]. 63 McCoy D, Montgomery H, Sabaratnam A, Godlee F. Climate change and human survival. BMJ 2014; 348: g2351. doi:10.1136/bmj.g2351 64 Atkinson S, Ingham J, Cheshire M, Went S. Defining quality and quality improvement. Clin Med 2010; 10: 537–9. doi:10.7861/clinmedicine.106-537 65 The Lancet. Climate change: how soon is now? Lancet 2014; 383: 1693. doi:10.1016/S0140-6736(14)60813-8
www.publish.csiro.au/journals/ahr
Australian Health Review, 2015, 39, 417–424 http://dx.doi.org/10.1071/AH14086
Becoming environmentally sustainable in healthcare: an overview Maggie Jamieson1,3 BA, MPH, PhD, Associate Professor Public Health Alison Wicks1 MHSC(OT), BAppSc(OT), PhD, Associate Professor Occupational Therapy Tara Boulding2 BSc(Hons), PhD candidate 1
Faculty of Health, University of Canberra, Locked Bag 1, Canberra, ACT 2601, Australia. Email: [email protected] 2 Faculty of Education, Science, Technology & Mathematics, University of Canberra, Locked Bag 1, Canberra, ACT 2601, Australia. Email: [email protected] 3 Corresponding author. Email: [email protected]
Abstract. This paper provides an overview of environmental sustainability in healthcare and highlights the need for a policy framework for action. Examples from overseas demonstrate what has effectively enabled mitigation of and adaptation to the threat of climate change. The need to overcome perceived limits and barriers to health professionals’ engagement in sustainable practice is noted. The scientific evidence recommends immediate action. What is known about the topic? Climate change has negative impacts on human health. There are co-benefits in mitigating and adapting to climate change that will benefit both humans and health systems, increasing wellbeing, financial and health system efficiency. There is a need for health professionals to engage with sustainability. Australia’s health policy makers could learn useful lessons about how to be sustainable from the significant policy and legislation work occurring elsewhere. What does this paper add? This paper reports on the context of and need for becoming sustainable in healthcare. It provides brief examples of what has occurred in other countries and advocates for a policy framework to support further action in Australia. What are the implications for practitioners? The significance of this paper is that it notes the need for a consistent, wholeof-country approach to carbon reduction in many aspects of the healthcare system. From an increased preventative focus on population health, coupled with actions in patient care, and developing a whole-of-healthcare-system approach, benefits will be realised that serve to reduce carbon emission, thereby tackling the longer-term effects of climate change. This view is supported by the noted success of increasing sustainable health system actions in the United Kingdom National Health Service and elsewhere. Additional keywords: sustainability, healthcare. Received 2 June 2014, accepted 4 February 2015, published online 20 April 2015
Introduction Since the industrial revolution (around 1750) there has been exploitation of fossil fuels for energy production. This use of fossil fuels has resulted in a substantial increase in the concentration of the atmospheric greenhouse gas carbon dioxide.1 After much dispute, there is now an almost unanimous consensus within the scientific community that the rising concentration of atmospheric greenhouse gasses is catalysing climate change, through disruption of the natural carbon cycle, which is causing global warming.2 The adverse effects of severe weather events due to climate change will undoubtedly have an impact on human health, particularly on the health of vulnerable people in society: the very young, the poor and the elderly.3–5 Health effects of climate change The recent 2014 International Panel on Climate Change synthesis report notes that since 1950 there have been a rise in sea levels, Journal compilation Ó AHHA 2015
increased warm temperatures and increasing extreme rainfall in some areas, with human influence being a likely factor.6 As a consequence of changes to fundamental physical systems, there are several adverse effects on human health.4 First, an increase in frequency and severity of extreme weather events leads to an increase in mortality and illness from thermal stress, and from increasing occurrence of natural disasters, such as fire storms, drought, prolonged dryness and floods, all affecting the physical and mental health of communities.7 Second, changes to ecosystems lead to increased microbial proliferation and changes in vector–pathogen–host relations, resulting in a loss of crops, livestock and decreased fishery yields, affecting livelihoods and leading to impaired nutrition through decreased food security. In combination and alone, these factors affect physical and mental health.4 Additionally, the adverse effects of continued reliance on fossil fuels contributes to decreased air quality. These factors as solo entities and in combination result in climate change being www.publish.csiro.au/journals/ahr
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one of the greatest problems facing the human species, with an increasing burden of disease, injury and poverty for the already vulnerable and disenfranchised members of our populations.8–13 Australian climate change policy In Australia, a country already subjected to extremes of climate, there are geographical areas where ecosystems have been identified as under threat, for example, the Great Barrier Reef, Alpine regions and the Murray–Darling river system.14 Australia’s vast, arid landscape means populations are at risk as a result of climate change. For example, small scattered inland communities have been experiencing prolonged drought, and conversely, large populations in coastal regions are being overwhelmed by flooding.15 Internationally, in recognition of the urgent need to tackle climate change, an international treaty, the Kyoto Protocol, was developed in 1997 under the United Nations Framework Convention on Climate Change. The Kyoto Protocol commits industrialised countries to reducing their greenhouse gas emissions by 5% from 1990 levels. On the 3 December 2007, Australia signed the Kyoto Protocol, thereby pledging to reduce Australia’s greenhouse gas emissions by 5% by 2012.16 However, the first commitment period of the Kyoto Protocol has ended and as yet, the Australian Government has not signed up for the second commitment period. Nationally, the Carbon Tax policy was abolished on 17 July 2014, leaving Australia with a less visible suite of policies relating to climate change and carbon reduction.17 However, the current Abbott government has released a Green Paper for a ‘Direct Action Plan’ which would retain the commitment for a 5% emissions reduction as well as a 20% increase in renewable energy by 2020.18 One of the main components of this policy is the ‘Emissions Reduction Fund’. The fund details were released in a White Paper on 24 April 2014, (http://www.environment. gov.au/resources/emissions-reduction-fund-white-paper, cited October 2014). In essence, people will no longer pay a carbon tax on emissions related to goods and services. Instead monies from taxation sources will provide grants and reward businesses for projects that will either lower their emissions or completely offset them.19 It has been argued that in Australia and elsewhere current policy approaches to tackling climate change are reductionist, targeting it in isolation, and giving the impression that governments can solve these problems without undue changes.20 Climate change and its effect on human and planetary health are not abstract matters to be put off for the future, but rather they require immediate attention. Having a national policy on carbon reduction gives a clear, imperative message to tackle climate change through carbon reduction. An example of an overarching policy process which Australia could use as a model is the UK government’s 2005 sustainable development strategy, ‘Securing the Future’, comprising five key areas: living within environmental limits; ensuring a strong healthy and just society; achieving a sustainable economy; promoting good governance; and using sound science responsibly.21 This strategic framework was enacted in the UK National Health Service (NHS) through the establishment of the NHS Sustainable Development Unit (SDU) in 2008. Led by a core expert team, with an initial focus on tackling carbon reduction in the NHS, the work
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of this unit demonstrates that there is scope for the healthcare sector to take the lead in essential social change by: (1) Communicating the health risks of climate change. (2) Tackling issues to improve population health that also reduce environmental impact. (3) Engaging in and educating about sustainable practice to mitigate the impact of health service delivery. The Australian healthcare sector Climate change impacts on health and concurrently healthcare systems impact on climate change. In Australia the healthcare sector is responsible for 7% of the total emissions from buildings, with further emissions from procurement and clinical practice.22 Additionally, healthcare services consume large amounts of money, food and other resources, creating a large amount of waste, much of which can be avoided.23 Consequently, there is significant scope for the sector to mitigate its carbon footprint by implementing energy efficiency measures and changing practice.20,24,25 It is worth acknowledging that across Australia there are actions underway, predominately focusing on energy efficiency and waste reduction. How can we tackle climate change in healthcare? As climate change has become a certainty, so too has the need for the health sector and health professionals to anticipate, manage and ameliorate the burdens climate change will impose,26 and acknowledge that the health of populations depends on a successful transition to sustainability.27,28 But what is sustainability? Simply put, sustainability is a measure of long-term viability of an entity or process or both,29 requiring a refocus on prevention. In the context of climate change, primary prevention refers to mitigation of climate change itself, whereas secondary and tertiary prevention refer to adaptation to the effects of climate change.1 Mitigation strategies include direct actions, such as use of renewable energy sources and energy efficiency, but also include work, such as forest preservation and replanting.3 Adaptive strategies include protective technologies, public health education, government legislation and administration. For obvious reasons, mitigation is the preferred action, however, adaptive modes are easier to implement, both practically and politically.30 Mitigating and adapting to climate change are complex matters requiring multilevel innovative approaches and solutions across all sections of our society. From an individual perspective, there is a need to continue to advance population health through health promotion, for example by encouraging active travel or reducing food miles, both of these activities reduce reliance on fossil fuels, improve health, and are, as a co-benefit, less harmful to the environment. At the system level of healthcare delivery there needs to be fundamental changes to models of clinical practice, system governance, the way practitioners work, consumer expectations of health services and the business model of healthcare delivery.31 The transition to sustainability needs to be embedded in the normal business of healthcare, through leadership, innovation and collaboration on many levels. As Schroeder et al. noted in their book, Sustainable Healthcare, for clinicians, it may mean that a value-based model would
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(re)engage them in the delivery of sustainable patient care, particularly within evidence-based practice models. This means examining current and future models of clinical care, including models that aim to transform how people become involved in their own care, by engaging individuals in co-production of care, enabling a greater patient voice, and reviewing the professional role to a partnership approach.29 There are many challenges that health professionals face when advocating action against climate change. Indeed, the challenge perhaps is too great and intangible to comprehend; after all, the effects are not immediate, so it seems essential to frame the challenge as how best to improve population health. First, they need to be able to present the evidence in a coherent and nonthreatening way to make other health professionals and the public aware of the enormity of the problem. Second, health professionals need to persuade others that change can be made to mitigate the problem.32 Framing health improvement coupled with quality service provision as core to sustainability is a way forward, as is promoting the understanding that sustainable healthcare is high quality care: lean, responsive and compassionate.24 The discussion of co-benefits is beyond the scope of this paper, yet worth mentioning given their importance to sustainability. Co-benefits enable engagement and action. They are best illustrated by the following example: by changing policy to advocate for a change to travel for staff, patients and visitors to hospitals, from cars to active travel (including public transport), physical activity is increased, helping to reduce obesity and improve cardiovascular health, while also diminishing carbon emissions and improving air quality. Overall there is a win–win situation with increased health, reduced environmental impact and money saved for health services by reducing admissions. This ‘virtuous cycle’ results in improved health benefits for people and planet.29 Enabling the virtuous cycle, is underpinned by organisational activity, including, but not limited to, the development of local policy using evidence-based information, enacting working groups with change champions, monitoring activity including costs, and giving incentives to staff to enable behavioural change.23,24 All these activities serve to progress change that continues to improve health. Health system delivery needs at its core leaders who are resilient, committed and supported at multiple levels within the organisation so that the virtuous cycle of change is invested in at all organisational levels. Structurally, in the corporate and infrastructure services, enabling sustainability supports the simultaneous achievement of the three interlinked goals of economic prosperity, environmental protection and social equity. These goals are sometimes referred to as the ‘triple bottom line’.33 To adapt to and improve population health and diminish the carbon impact of heath delivery, there is a need to seek solutions that will maximise the benefits of a transition to sustainability in healthcare and to grasp opportunities for health improvement.20 At a minimum there is a need to start a debate within the health sector about the implications for health services if a ‘businessas-usual approach’ is maintained in what we know to be an unsustainable system. In the context of health services, becoming sustainable recognises that multiple systems are interlinked and, in some cases, dependant on one another. The challenge of moving to sustainability in health services should not be viewed as a simple task; rather it will require a system-level approach.31
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However, the focus of this paper is on the possible actions of the healthcare sector to become environmentally sustainable, in order to improve the health of populations and diminish the impact of health service delivery. What is sustainable healthcare? The ideals of the NHS SDU are encapsulated in the concept that being sustainable is ‘the balance required between financial, social and environmental factors in order that future generations do not suffer because of the way we live today’.34 According to the NHS SDU, a sustainable healthcare system ‘is achieved by delivering high quality care and improved public health without exhausting natural resources or causing severe ecological damage’.35 As others have noted, sustainability will require change at multiple system and individual levels, supported by research, evidence, alliances, cultural change, policy and legislation.23,24 There are multiple benefits to the healthcare sector to take the lead on sustainability, including environmental, health, financial and reputational benefits.25 Some authors have even proposed that the healthcare sector and healthcare workers have a professional responsibility to promote and protect health by assisting in climate change adaptation and mitigation and policy advocacy.20,24,36 Previously, several different strategies that the healthcare sector could implement in order to adapt to climate change have been suggested. These strategies include development of early alert systems and enhanced vaccination programs, plus improved surveillance for disease indicators and health outcomes.3,26 Some people have also proposed the introduction of climate change education into the curriculum of medical students, postgraduate general practitioners and nurses.25,37 Practical actions include measuring and reducing the carbon footprint of energy use for heating, cooling, hot water and ventilation.24,38 Additionally, the use of high-quality insulation, combined heat and power units, and motion sensitive lighting as well as local generation of electricity in both new and existing facilities are recommended. Finally, reducing patient, staff and visitor travel and travel related to the procurement of drugs, equipment, food and other services are other tried and tested strategies for reducing carbon footprint.24 Sustainable health care is not solely about energy, waste, design and travel. It should include sustainable clinical practice; that is practice that is evidence-based and further develops the discussion about the effective use of pharmaceuticals, medical devices10 and diagnostic testing.39 Engaging with sustainability: lessons from elsewhere On the world stage 2014 saw two major international events where health and climate change have been major themes. The World Health Organization conference in August 2014 called for a systematic approach to increase health resilience to the risks that climate change pose, with particular reference to mitigation to prevent deaths from air pollution through reduction in carbon emissions.40 The second congress, The United Nations Climate Summit, a precursor to the meeting in Paris 2015, placed health at the centre of climate change discussion, with an emphasis on the opportunities to
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improve health by sustainable action in transport, power generation, food production and food security.41 These two events help to reinforce the need to have health as integral to policy initiatives tackling climate change, such as implementing policy on pricing carbon, tackling air pollution through legislation and divesting from fossil fuel production.41 These two recent international meetings serve to emphasise, through existing evidence (e.g. the International Monetary fund report on carbon pricing),42 that health and climate change policy can come together in ways that will promote local action in many countries that will see health resilience, health benefits and climate protection through reduction in fossil fuel emissions. However, country-by-country agreements are still to be realised and acceptance may be varied, but these meetings have served to further link health and climate change and to enable positive discussion and influence policy directions.40,41 In the UK To date, the most well-known example of a health and social care sector working towards sustainable practice is that of the UK’s NHS. The NHS SDU is becoming a leader in low-carbon, sustainable practice. The approach in the NHS is unique internationally in terms of its scope. Many countries have tackled issues such as power and waste, but few have a comprehensive organisational strategy, that includes organisational development. The NHS has a carbon footprint of 21 million tonnes of CO2 equivalent each year from heating, cooling, lighting, equipment, procurement and waste, patient, staff and visitor transport.43–45 The NHS’s goal is to reduce its carbon footprint from 1990 levels by 10% by 2015 and by 80% by 2050.46 To assist healthcare services in meeting the NHS carbonreduction goals, a Carbon Reduction Strategy was published in 2009.44 It specified a range of ways to reduce the carbon footprint and contribute towards healthcare sustainability.44,47 The key areas of the strategy are: (1) Every organisation should: review the need for staff, patients and visitors to travel; provide incentives for low carbon travel; and promote home working opportunities. (2) Every organisation should ensure efficiencies by monitoring water and heating usage. (3) Every organisation should monitor domestic and clinical waste and, where possible, review its approach to single-use items versus decontamination options. (4) Every organisation should become carbon literate and numerate to ensure that appropriate investments can be made to meet carbon targets and to prepare for future carbon policies.44 As well as having a clear strategic framework to legitimise carbon reduction activity, an education intervention was also developed to educate healthcare professionals on climate change, sustainability and health, to encourage them to become advocates for sustainable practice.43 This intervention was replicated in Australia in 2011.48 The carbon foot print of the NHS has grown over the past 10plus years, as a result of increased activity and workload45 but the carbon intensity of healthcare (that is, emissions per unit of expenditure) has fallen and evidence from the NHS SDU suggests
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that this upward trend is starting to reverse, linked perhaps to a combination of strategy, policy, technology and education, there was a 5.5% reduction in NHS carbon emissions between 2007 and 2012.46 In their 2012 report Naylor and Appleby,45 noted that goods and services procurement accounted for the greatest amount (60%) of emissions, especially pharmaceuticals and medical equipment, while patient and staff travel and direct energy use made up the rest. While the SDU strongly advocates for sustainability, responsibility and action sits with individual trusts and practices. Examples include hospitals, such as in North Bristol, working with suppliers to source all produce from within a 50-mile radius, ensuring fresh produce for patients and a food supply with a small carbon footprint.49 In Cambridge, Addenbrooke’s Hospital adopted a ‘green travel plan’ encouraging staff and patients to walk, cycle or use public transport by providing several incentives, such as interest-free loans to buy bicycles and subsidised weekly bus tickets.50 In Manchester, the Central Manchester Trust implemented a program of staff-engagement using the Green Impact Model, to change daily behaviours around energy use, resulting in cost efficiencies and energy savings.51 In London, Barts Health NHS Trust’s sustainability program has, to date, saved £2mil by simple measures such as turning off lights and unused equipment.52 The Green Nephrology network, founded in 2009 to improve the sustainability of renal care in the UK,53 crosses over institutional boundaries and is an example of sustainable healthcare driven by clinicians. A single haemodialysis treatment produces 2.5 kg of clinical waste, which is around 390 kg per patient per year.53 To aid individual renal units in reducing their carbon footprint, the Centre for Sustainable Healthcare created a ‘10 : 10 Renal Checklist’, specifying 10 ways units can reduce their CO2 emissions.54 Many facilities have benefited, one exemplar being the Renal Unit at the Cornwall Hospital. After 2 years, its CO2 emissions were reduced by 52.3 tonnes per year, with savings of approximately £57 500 per year. All of these examples have co-benefits that are social, economic, improve care quality, and have become part the norm for these organisations, albeit to differing levels of success. The approach in the NHS is unique internationally in terms of its scope. Many countries have tackled issues such as power and waste, but few have a comprehensive strategy that includes organisational development. NHS Trusts and social care institutions are increasingly aware of the need to be sustainable, but that does not mean there is consistency of approach nor progress in translating strategy into policy.45 In the United States While it is obvious that the NHS has progressed sustainable healthcare, it is not alone. In USA, the Healthier Hospitals Initiative, (part of the Healthcare without Harm and Global Green Hospital initiatives), is a non-government organisation assisting hospitals in achieving sustainable practice.55 The initiative is unique in that individual hospitals sign up and pledge to move towards achieving several sustainability-related goals, which include leaner energy, less waste, smarter purchasing, engaged leadership, healthier foods and safer chemicals. While the initiative is relatively new (formed in 2012), more than 1000 hospitals
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have signed on, indicating the potential to greatly impact the sustainability of the USA healthcare system. Policy guidance, such as the Center for Disease Control and Prevention’s policy on Climate Change and Public Health56 in USA has served to create a framework for national public health action, especially in response to disaster preparedness, following Hurricane Katrina. Much of this work is being supported by the American Public Health Association underpinned by legislation and policy enabling direct action by federal and other agencies,57 and researchers such as Frumkin and colleagues, translating the scientific literature into public policy as part of a focus on adapting to climate change.26 In Asia In some parts of Asia there is a move to sustainable healthcare practice. For example, National Cheng Kung University Hospital in Taiwan implemented a sensor-controlled lighting system and upgraded heating and cooling systems to more energy-efficient models.58 It is estimated that these changes saved the hospital US $700 000 and cut carbon emissions by 5 000 tonnes per year. In South Korea, The Yonsei University Hospital, in addition to improving thermo-regulation and energy efficiency, also established a small task force to develop sustainable green hospital management.59 It is estimated that these changes have saved the hospital approximately US$2mil and reduced carbon emissions by 5 300 tonnes per year. Healthcare sustainability in Australia Currently in Australia, the Climate and Health Alliance, formed in 2010, includes organisations and health professionals working to develop and implement cost-effective environmental initiatives in the healthcare sector.60 The Alliance advocates for effective public policy and engages and informs health professionals, policy makers and the community about the effects of climate change and the benefits of sustainable practice.61 Additionally, the group, Doctors for the Environment (http://dea.org. au) is gaining momentum in its advocacy for change, following an established path of health professionals leading and advocating for change.20 Thus far, the response in Australia and elsewhere of health professionals to the challenge of sustainability has been reductionist and piecemeal.3,4 It is interesting that this is the case given the clear benefits of improved care and the meeting of triple bottom-line targets by improving efficiency and engaging in sustainable healthcare practice seen in the UK and elsewhere.23,46,52,62 In Australia, the lack of an explicit strategic framework to drive expectations of sustainability and reduce carbon across all aspects of healthcare practice may hamper an overt approach. Four main reasons have been given as to why health professionals do not engage in sustainable practice.43 First, they are overly sceptical of new health threats as they naturally apply a critical and balanced approach to all new evidence. Second, they are very busy delivering and reacting to immediate care needs and hence have less time for long-term issues such as climate change and sustainability. Third, they are focussed on reacting to current issues and not on being proactive in preparation or preventative measures. Last, they feel they are already making a worthy
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contribution to society by working in healthcare.43 It has also been suggested that for some organisations efficiency is the most important issue and reaching economic targets is valued higher than reaching energy or carbon targets on a day-to-day basis.32 Chivian notes that in the past, the medical community was successful in translating the impact of nuclear war to the public, perhaps helped by the tangible results of Hiroshima and Nagasaki.42 In contrast, climate change is much less tangible, occurring slowly but with devastating effect. There is an imperative for clinicians to give concrete, clear-language examples of the impact of climate change on people’s health, including the impact of continued carbon dioxide release. Clinicians are implored to practice advocacy and action using the traditional medical model that supports risk taking even when there is limited knowledge, while making best use of existing knowledge and evidence. For the current and future impact of climate change, there is not the luxury of waiting for absolute proof of impact on our physical systems and population health. The risk of doing nothing is too grave. Finally, and importantly, Chivian cautions against underestimating the power of public disinformation and the powerful lobby groups who have much to lose if there is continued disinvestment in fossil fuels, highlighting that taking action is not just a matter of making simple changes.42 What can be done? There are many challenges that health professionals face when advocating action in the light of the impact of climate change on health, not least making other health professionals and the general public aware of the enormity of the problem; and persuading them that changes can be made to mitigate the problem. There have been numerous suggestions on how to educate, persuade and engage health professionals in the issues of climate change and sustainability. McCoy et al. advocate that there are three areas in which health professionals can (and need to) take a lead on in tackling climate change.63 Specifically, health professionals need to: *
*
*
Support divestment from fossil fuels by health services and government agencies and advocate for reinvestment in renewable energy sources; Change the minds and behaviours of others, especially people of influence; Build alliances between medical and other health professionals to speak clearly to the public, the media, governments, and intergovernmental bodies to provide a strong and unified message – that climate change is real, is already having an effect and is the result of human activity, but there are already practical actions that can be taken.63
In Australia, groups such as Climate and Health Alliance and Doctors for the Environment have and continue to lobby for engagement across politics and the health system. The literature is clear on the processes and actions that serve to raise awareness and enable action. First, the basics of climate change and its impact on human health must be clearly explained and common terms used in the sustainability discourse must be carefully described.43,48 Second, the message needs to be tailored to the audience (e.g. most clinicians and general practitioners will respond best to the health co-benefits argument, whereas finance directors and chief
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executives will be more interested in the financial and reputational benefits).43 Third, there should be a focus on realistic, practical achievements and methods for incorporating sustainability in the work place, for example, including sustainability as one of the indicators of care quality.64 Also, framing the issue as ‘sustainability to improve health and system efficiency’, rather than ‘mitigation of climate change’ is critical.23,43 The NHS SDU advocates for the health system to become sustainable through transforming care. In so doing, it advocates for an improved quality of life,34 recognising that such systemic change is not without challenges. Transformation will require leadership and engagement not just in health care, but across industry, government and society, requiring a collaborative and integrative approach across society. Only then will triple-bottomline sustainability be achieved within health and other sectors. In healthcare the key tenants of transformation include: *
*
*
*
*
*
Leadership and engagement across traditional bureaucratic boundaries; Engagement and enablement of clinicians to be leaders in transforming care; Focus on and investment in prevention, health improvement, wellness and independence; Co-designed, integrated health services that include users and clinicians; Focus on living well to minimise acute and specialist intervention; Dying well by beginning the discussion.29
Conclusion There are clear environmental, health, financial and reputation benefits from engaging in sustainable practice.24,31 The healthcare sector is in a unique position, in that health professionals have an extensive history of both contributing to and leading social change.20 Without action, climate change will have an unprecedented effect on human health as well as economic and social structures. To avoid this, there needs to be unparalleled global change in the emission of greenhouse gases and the attitude towards acting in mitigation. However, such change will require societal, systemic and individual transformational change. This will require leadership across multiple levels of organisations, but importantly there needs to be a coherent and consistent all-ofgovernment policy framework that supports and legitimises action. Learning from elsewhere, there is no doubt that having a specialist, expert focus and leadership, through a mechanism such as the NHS SDU, may well be a way forward. However, such a development in Australia would require political, policy and financial support at federal and state levels. While there is already adaptive action in underway in many places, there is likely to be significant variation across the system. A cohesive, united policy approach is required to enable practice and process change, yet perhaps this is difficult in the light of the current government stance on climate change. Yet in many ways, in Australia, the time is ripe for investment in actions to improve population health and in-system delivery. The impact is already apparent in our arid climate, with increasingly hot summers, prolonged drought and dryness in rural areas and increasing hospital admissions, so why, given evidence from elsewhere, is there no systemic action? In the words of Naylor and Appleby,
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‘The most sustainable system is one that minimises unnecessary or ineffective use of resources (financial or natural) by delivering the right care, in the right place, at the right time, and by preventing care needs from arising at all, where possible’45(p.3) These simple words exemplify the current desires for an effective health system, hardly radical, but sustainability is yet to be core to our systems here in Australia due to a lack of cohesive and coordinated action. This needs to change, and while the discussion of such change is beyond the scope of this paper, the message from the literature is clear: the time to act is now.65 Competing interests None declared. Acknowledgements This project was supported by an internal University of Canberra Faculty of Health grant. The paper was part of a larger project that had ethics approval from the University of Canberra Human Research Ethics Committee (Approval No: 13–174).
References 1
Grambsch A, Menne B. Adaptation and adaptive capacity in the public health context. In: McMichael AJ, Campbell-Lendrum DH, Corvalan CF, Ebi KL, Githeko A, Scheraga JD, et al, editors. Climate Change and Health: Risks and Responses. Geneva: World Health Organization; 2003: 220–36. 2 International Panel on Climate Change. Climate Change 2007: the physical science basis. Cambridge: Cambridge University Press; 2007. 3 Haines A, Kovats RS, Campbell-Lendrum D, Corvalan C. Climate change and human health: impacts, vulnerability and public health. Public Health 2006; 120: 585–96. doi:10.1016/j.puhe.2006.01.002 4 McMichael AJ, Woodruff RE, Hales S. Climate change and human health: present and future risks. Lancet 2006; 367: 859–69. doi:10.1016/ S0140-6736(06)68079-3 5 McMichael A, Kovats S. Climate change and climate variability: adaptations to reduce adverse health impacts. Environ Monit Assess 2000; 61: 49–64. doi:10.1023/A:1006357800521 6 International Panel on Climate Change. Climate change 2014: Synthesis Report. Geneva. Available at: http://www.ipcc.ch/pdf/assessment-report/ar5/syr/SYR_AR5_LONGERREPORT_Corr2.pdf www.ipcc.ch/ report/ar5/syn [verified 10 December 2014]. 7 OBrien LV, Berry HL, Coleman C, Hanigan IC. Drought as a mental health exposure. Environ Res 2014; 131: 181–7. doi:10.1016/j.envres. 2014.03.014 8 The Lancet. Climate change and health – action please, not words. Lancet 2014; 384: 1017. 9 Costello A, Abbas M, Allen A, Ball S, Bell S, Bellamy R, Friel S, Groce N, Johnson A, Kett M, Lee M, Levy C, Maslin M, McCoy D, McGuire B, Montgomery H, Napier D, Pagel C, Patel J, de Oliveira JA, Redclift N, Rees H, Rogger D, Scott J, Stephenson J, Twigg J, Wolff J, Patterson C. Managing the health effects of climate change: Lancet and University College London Institute for Global Health Commission. Lancet 2009; 373: 1693–733. 10 McGain F, Naylor C. Environmental sustainability in hospitals: a systematic review and research agenda. J Health Services Res Policy 2014; 19: 245–52. 11 Friel S, Marmot M, McMichael AJ. Global health equity and climate stabilisation: a common agenda. Lancet 2008; 372: 1677–83. doi:10.1016/S0140-6736(08)61692-X
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12 McMichael A, Montgomery H, Costello A. Health risks, present and future, from global climate change. BMJ 2012; 344: e1359. doi:10.1136/ bmj.e1359 13 McMichael A. Globalization, climate change and human health. N Engl J Med 2013; 368: 1335–43. doi:10.1056/NEJMra1109341 14 Hughes L. Climate change and Australia: trends, projections and impacts. Austral Ecol 2003; 28: 423–43. doi:10.1046/j.1442-9993.2003.01300.x 15 Blashki G, McMichael T, Karoly DJ. Climate change and primary health care. Aust Fam Physician 2007; 36: 986–9. 16 Department of Environment. Kyoto Protocol 2013. Available at: http:// www.climatechange.gov.au/international/negotiations/history-negotiations/kyoto-protocol [verified 17 January 2014]. 17 Department of Environment. Repealing the carbon tax. Canberra: Department of the Environment; 2013. Available at: http://www.environment.gov.au/topics/cleaner-environment/clean-air/repealing-carbontax [verified 17 January 2014]. 18 Department of Environment. The Government’s Direct Action Plan: Parliament of Australia; Canberra. 2013. Available at: http://www.aph. gov.au/Parliamentary_Business/Committees/Senate/Environment_and_ Communications/Direct_Action_Plan [verified 17 January 2014]. 19 McMichael A. Climate change: health risks mount while Nero fiddles. Med J Aust 2014; 200: 507–8. doi:10.5694/mja14.00307 20 McCartney G, Hanlon P. What can health professionals contribute to the challenge of sustainability? Public Health 2009; 123: 761–4. doi:10.1016/j.puhe.2009.09.008 21 UK Department of Environment. Securing the future – delivering a sustainable development strategy. London: Her Majesty’s Stationary Office (HMSO); 2005. 22 Low Carbon Australia 2014. Final Annual Report of Low Carbon Australia 2013–14. Brisbane. Available at: http://www.cleanenergyfinancecorp.com.au/media/106763/lowcarbon-annual-report-2013-14_lr. pdf [verified February 2015]. 23 Charlesworth KE, Madden DL, Capon AG. Environmentally sustainable health care: using an educational intervention to engage the public health medical workforce in Australia. NSW Public Health Bull 2013; 24: 76–80. doi:10.1071/NB12097 24 Pencheon D. Health services and climate change: what can be done? J Health Serv Res Policy 2009; 14: 2–4. doi:10.1258/jhsrp.2008.008147 25 Green EI, Blashki G, Berry HL, Harley D, Horton G, Hall G. Preparing Australian medical students for climate change. Aust Fam Physician 2009; 38: 726–9. 26 Frumkin H, Hess J, Luber G, Malilay J, McGeehin M. Climate change: the public health response. Am J Public Health 2008; 98: 435–45. doi:10.2105/AJPH.2007.119362 27 Diamond J. Collapse: how societies choose to fail or survive. London: Penguin; 2006. 28 McKee M, McMichael A. The Health of nations. BMJ 2008; 337: a2811. doi:10.1136/bmj.a2811 29 Schroeder K, Thompson T, Frith K, Pencheon D. Sustainable healthcare. London: John Wiley and Sons; 2013. 30 Kovats RS, Menne B, McMichael AJ, Corvalan C, Bertollini R. Climate change and human health: impact and adaptation. Geneva: World Health Organization; 2000. 31 Pencheon D. Developing a sustainable health and care system: lessons for research and policy. J Health Serv Res Policy 2013; 8: 93–4. 32 Coote A. What health services could do about climate change. BMJ 2006; 332: 1343–4. doi:10.1136/bmj.332.7554.1343 33 Savitz A. The triple bottom line. San Francisco: Jossey-Bass; 2006. 34 National Health Service Sustainable Development Unit (NHS SDU). Route map for sustainable health. Fulbourn: NHS SDU: 2011. 35 National Health Service Sustainable Development Unit (NHS SDU). What is sustainable health? NHS SDU; 2014. Available at: http://www. sduhealth.org.uk/sustainable-health/what-is-sustainable-health.aspx [verified 15 January 2014].
Australian Health Review
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36 Bell E, Horton G, Blashki G, Seidel BM. Climate change: could it help develop ‘adaptive expertise’? Adv Health Sci Educ Theory Pract 2012; 17: 211–24. doi:10.1007/s10459-010-9245-4 37 Goodman B. The need for a ‘sustainability curriculum’ in nurse education. Nurse Educ Today 2011; 31: 733–7. doi:10.1016/j.nedt.2010. 12.010 38 Griffiths J, Rao M, Adshead F, Thorpe E. The health practitioner’s guide to climate change: diagnosis and cure. Abingdon: Routledge; 2009. 39 Glasziou P, Moynihan R, Richards T, Godlee F. . Too much medicine: too little care. BMJ 2013; 347: f4247. 40 World Health Organization (WHO). WHO conference on Health and Climate; 27–29 August 2014; Geneva, Switzerland. 41 United Nations 2014 Climate Change Summit Summary, Chair’s Summary. Available at: http://www.un.org/climatechange/summit/2014/09/ 2014-climate-change-summary-chairs-summary/ [verified 2 March 2015]. 42 Parry IW, Veung C, Heine D. How much carbon pricing is in countries own interest? The critical role of co-benefits. Washington, DC: International Monetary Fund; 2014. http://www.imf.org/external/pubs/ft/wp/ 2014/wp14174.pdf [verified 18 December 2014]. 43 Charlesworth KE, Ray S, Head F, Pencheon D. Developing an environmentally sustainable NHS: outcomes of implementing an educational intervention on sustainable health care with UK public health registrars. NSW Public Health Bull 2012; 23: 27–30. doi:10.1071/NB11018 44 Abbott A, Arnold M, Best J, Brockway P, Cosford DP, Coulson K, Edwards D, Francis S, Freathy S, French R, Garratt E, Goldsack D, Gregson C, Hall C, Holme L, Insall P, Kirkup B, Lockwood L, MacGregor R, Martin g, Mckay N, Reynolds J, Scally G, Service T, Taylor R, Wathey D, Whitehead L, Pencheon D, Cointet S, Brown J, Howley J, Tennison I, Greensmith H, Wright, S. Saving Carbon, Improving Health National Health Service, Carbon Reduction Strategy for England. Cambridge: National Health Service Sustainable Development Unit; 2009. 45 Naylor CJ, Appleby J. Sustainable health and social care. London: Kings Fund; 2012. 46 National Health Service Sustainable Development Unit (NHS SDU). Carbon Footprint update for NHS England 2012. Cambridge: NHS SDU; 2012. 47 Climate Change Act 2008 (c.27), House of Lords Hansard Vol.705 Col.1477, House of Commons Hansard Vol.485 Col.855. London: Her Majesty’s Stationary Office (HMSO); 26 November 2008. 48 Charlesworth KE, Madden DL, Capon AG, Engelhard S. Climate change, sustainability and health workshops for medical professionals evaluation report. Sydney: AFPHM; 2011, Australasian Faculty of Public Health Medicine. Available at: http://www.racp.edu.au/page/racp-faculties/australasian-faculty-of-public-health-medicine/news-and-events/reports/ [verified June 2014]. 49 National Health Service Sustainable Development Unit. Case study: North Bristol NHS Trust. 2013 Available at: http://www.sdu.nhs.uk/ publications-resources/case-studies.aspx [verified 20 January 2014]. 50 National Health Service Sustainable Development Unit. Access to Addenbrooke’s – a travel plan. Cambridge University Hospitals NHS Trust; 2012. Available at: http://www.sdu.nhs.uk/publicationsresources/case-studies.aspx [verified 17 January 2014]. 51 National Health Service (NHS) Sustainable Development Unit. Case study: Central Manchester NHS Trust. 2013. Available at: http://www. sdu.nhs.uk/publications-resources/case-studies.aspx [verified 30 May 2014]. 52 National Health Service Sustainable Development Unit. Sustainability: Barts Health. 2013. Available at: http://www.bartshealth.nhs.uk/aboutus/sustainability/ [verified 21 January 2014]. 53 Centre for Sustainable Healthcare. Green nephrology: reduce, re-use, recycle in the dialysis unit. Oxford: Green Nephrology; 2010. Available at: http://sustainablehealthcare.org.uk/sites/default/files/case_study_reduce_reuse_recycle_in_the_dialysis_unit_v1.0.pdf [verified 20 January 2014].
424
Australian Health Review
M. Jamieson et al.
54 Centre for Sustainable Healthcare. 10 : 10 renal checklist. Oxford: Centre for Sustainable Healthcare; 2010. Available at: http://sustainablehealthcare.org.uk/1010-renal-checklist [verified 12 January 2014]. 55 Healthier Hospitals Initiative. 2013 Milestone Report; 2013. Available at: http://healthierhospitals.org/sites/default/files/IMCE/msr_final_draft_ post.pdf [verified 17 January 2014]. 56 Center for Disease Control and Prevention. Climate change and public health. Atlanta: Center for Disease Control; 2009. 57 Hess JJ, Schramm PJ, Luber G. Public health and climate change adaptation at the federal level: one agency’s response to executive order 13514. Am J Public Health 2014; 104: e22–30. doi:10.2105/AJPH.2013. 301796 58 Green G, Hospitals H. Energy saving and carbon reduction policies at the Taiwan National Cheng Kung University Hospital. 2013 Available at: http://greenhospitals.net/wp-content/uploads/2013/06/National-ChengKung-University-Hospital-Taiwan-Energy.pdf [verified 17 January 2014]. 59 Green G, Hospitals H. Greenhouse gas emissions reduction and availability for energy-saving practices in the special context of a hospital environment. 2013 Available at: http://greenhospitals.net/wp-content/ uploads/2013/06/Yonsei-University-Health-System-Korea-Energy.pdf [verified 17 January 2014].
60 Hanna L, Armstrong F. Annual report 2012–13. Climate and health alliance; 2013. Available at: http://caha.org.au/wp-content/uploads/ 2012/12/CAHA-Annual-Report-2012-2013-compressed.pdf [verified March 2015]. 61 Climate and Health Alliance. Climate and Health Alliance Declaration. Melbourne: Climate and Health Alliance; 2010. Available at: http://caha. org.au/wp-content/uploads/2010/11/Declaration_010111.pdf [verified 7 February 2014]. 62 Centre for Sustainable Healthcare. Renal Unit, Royal Cornwall Hospital. Oxford: Centre for Sustainable Healthcare; 2011. Available at: http://sap. sustainablehealthcare.org.uk/royal-cornwall-hospital-renal-unit [verified 23 January 2014]. 63 McCoy D, Montgomery H, Sabaratnam A, Godlee F. Climate change and human survival. BMJ 2014; 348: g2351. doi:10.1136/bmj.g2351 64 Atkinson S, Ingham J, Cheshire M, Went S. Defining quality and quality improvement. Clin Med 2010; 10: 537–9. doi:10.7861/clinmedicine.106-537 65 The Lancet. Climate change: how soon is now? Lancet 2014; 383: 1693. doi:10.1016/S0140-6736(14)60813-8
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