ANALYSIS
notable decrease in transport related emissions. 55 Because almost every person will visit healthcare facilities at some point, the NHS must be an advocate for the wider infrastructure changes and government investment needed to facilitate active travel, as a health co-benefit. Technology Reducing supply chain emissions for medical equipment and drugs has the potential to deliver substantial gains in NHS emission reductions. Within the healthcare sector, scope 3 emissions comprise the greatest proportion of emissions; 62% of all emissions in the NHS are attributable to the supply chain. 24 The NHS can use its influence as one of the biggest single investors in healthcare goods and services globally to drive the prioritisation of reduced carbon emissions, along with financial cost and quality-safety profile factors, in procurement decisions; Greener NHS has made progress on this by setting targets for suppliers. 56 Such an approach could help to bring about a broader health sector wide move towards improved sustainability and reduced carbon emissions. To do this effectively, the NHS should strive for a more cohesive national procurement approach — one means of achieving this would be through setting and enforcing environmental standards for national healthcare procurement. There is also a role for reduced national procurement of the most environmentally harmful drugs and preparations, and their eventual removal from national formularies. This change would require legislation and input from government, NHS leaders, senior clinicians, pharmacists, and organisations parallel to the NHS, such as NICE (National Institute for Health and Care Excellence), MHRA (Medicines and Healthcare products Regulatory Agency), and others. Anaesthetic gases, including nitrous oxide often used for labour analgesia (as Entonox), and metered dose inhalers are particularly polluting — volatile gases constitute 5% of all emissions from acute NHS hospitals 34 — and contribute directly to global warming. 3031 The NHS has recently decommissioned the use of desflurane from 2023-24 because of sizeable emissions where reasonable, less polluting alternatives exist. 35 Digital technology is being increasingly used in healthcare delivery to ensure personalisation of care. A move towards a patient centred approach to care can support better patient experiences by giving increased autonomy to patients, along with benefits in terms of sustainability. Tools such as eHealth or mHealth apps have the potential to reduce inappropriate or unnecessary investigations and treatments, reduce the impact of patient transport or travel to the clinic setting, improve health (particularly in patients with complex chronic disease), and decentralise care out of hospitals and into communities and homes. 37 Importantly, patient care should not be compromised. Waste Waste in the NHS includes “ wasteful practices ”— the unnecessary use of services and products — and excessive or inappropriate material waste generation. Wasteful practices, which are often overlooked, account for a substantial proportion of inefficiency and waste of resources, personnel, and capacity in the health system. The best way to reduce waste is to minimise unnecessary use, first and foremost by maintaining a healthy population, proactive primary and secondary prevention, accuracy in diagnostics and treatment, and choosing products wisely. An estimated 10% of items dispensed in primary care are overprescribed and 15% of people take five or more drugs a day. 57 Around one in five hospital admissions in people aged 65 and older is caused by the adverse
effects of drugs. Up to half of all drugs are wasted, costing the NHS up to £300m a year. 1858 The NHS produces substantial quantities of material waste. The 156 000 tonnes of waste that are collected as “ clinical waste ” eachyear are incinerated at high temperatures — an expensive operation — and disposed of by landfill or an alternative method. Drug waste contributes to landfill, greenhouse gas emissions, and environmental harm as a result of wasted pharmaceuticals entering waterways. 1858 A whole system approach is needed, with investment in research to measure the ecological footprint of drugs that enables prescribers and patients to make environmentally informed choices. 59 All NHS organisations should have a testing regime in place for surveillance and addressing these issues as a responsibility of the Health and Safety Executive. Single use plastics and equipment in operating theatres and clinical areas still outnumber use of sterilisable tools and reusable surgical kits. The NHS often does not have accessible recycling bins in office, catering, and ward spaces. Reasons cited for the use of single use surgical gowns and drapes include convenience and misconceptions about clinical safety and infection control. However, reusable gowns have been shown to provide greater protection and durability, a 60 – 95% reduction in energy use and cost savings, and there is no evidence that reusable personal protective equipment results in higher healthcare associated infection rates. 6061 Cradle-to-grave life cycle assessments of products or components of care are increasingly common 62 -64 and must factor in the entire lifetime impact of the product or care assessed. For example, while minimally invasive surgeries produce greater emissions compared with open surgical techniques, 65 the often associated shorter length of stay and fewer postoperative complications might balance towards a net environmental benefit. 65 Key principles of the circular economy can be applied to keep healthcare products in circulation as long as possible: refusing to use an item, reducing the frequency of use, reusing items when possible (with sterilisation or washing), renewing (through repair or remanufacture), and recycling. 19 Food The food and agriculture sector is responsible for 30% of the world ’ s greenhouse gas emissions, and the main cause of terrestrial biodiversity loss. 66 Five standards have been set by the Department for Health and Social Care for hospital food, one of which is sustainability. 67 -69 A sustainable approach to food and nutrition in the NHS requires thorough consideration of the processes around food provision for inpatients and staff in NHS facilities. Currently one in six meals are left uneaten, 70 and nutritional education and advice for the public is needed to drive behaviour change. 71 At trust level, simple approaches that benefit both health and environment include NHS sourcing of local, sustainably grown, plant based options; minimising food packaging; and reducing food waste. Hospital trusts that bring catering in-house are more likely to find food of better quality, produced locally, offering better value formoney. 72 Outsourcing of catering in the NHS, while often chosen as a cost saving tactic, has been linked to poorer health outcomes. 72 Health benefits accompany a more sustainable approach to food. Engaging local staff to highlight specific areas of their practice where improvements could be made would enhance impact and buy-in. 73 Successful actions taken by hospitals have included “ meatless Mondays ” , on-site vegetable and herb gardens, sharing unserved food with community kitchens, and sending food waste to local farms and on-site anaerobic digestion units.
the bmj | BMJ 2024;385:e079259 | doi: 10.1136/bmj-2024-079259
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