Sustainable healthcare: Difference between revisions
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| ⚫ | [[File:Visualization of pillars of sustainability.webp|thumb|upright=1.6|Commonly used schematics of the tripartite description of sustainability: Left, typical representation of sustainability as three intersecting circles. Right, alternative depictions: literal 'pillars' and a nested circles approach.<ref name="Purvis">{{Cite journal|last1=Purvis|first1=Ben|last2=Mao|first2=Yong|last3=Robinson|first3=Darren|date=2019|title=Three pillars of sustainability: in search of conceptual origins|journal=Sustainability Science|language=en|volume=14|issue=3|pages=681–695|doi=10.1007/s11625-018-0627-5|issn=1862-4065|doi-access=free}} [[File:CC-BY icon.svg|50px]] Text was copied from this source, which is available under a [https://creativecommons.org/licenses/by/4.0/ Creative Commons Attribution 4.0 International License]</ref>]] |
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The [[World Health |
The [[World Health Organization]] (WHO) defines an environmentally sustainable health care system as ‘as a health system that improves, maintains or restores health, while minimizing negative impacts on the environment and leveraging opportunities to restore and improve it, to the benefit of the health and well-being of current and future generations’....<ref name="auto2">Environmentally sustainable health systems: a strategic document (who.int). WHO Regional Office for Europe (2017) Retrieved 17 August 2022</ref> |
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It aims to reframe medical practice and the health sector to address human health in the context of [[Planetary health]]<ref>MacNeill AJ, McGain F, Sherman JD (2021) Planetary health care: a framework for sustainable health systems. The Lancet Planetary Health. 5: e66 – e68 https://doi.org/10.1016/S2542-5196(21)00005-X</ref> |
It aims to reframe medical practice and the health sector to address human health in the context of [[Planetary health]],<ref>MacNeill AJ, McGain F, Sherman JD (2021) Planetary health care: a framework for sustainable health systems. The Lancet Planetary Health. 5: e66 – e68 https://doi.org/10.1016/S2542-5196(21)00005-X</ref> where earth systems and humans are reciprocal. |
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Sustainable healthcare acknowledges all these dimensions of sustainability (environmental, economic and social, also called the 3 pillars of sustainability), delivering healthcare that does not damage the environment (either now or in the future), is economical and has a positive social impact |
Sustainable healthcare acknowledges all these dimensions of sustainability (environmental, economic and social, also called the 3 pillars of sustainability), delivering healthcare that does not damage the environment (either now or in the future), is economical and has a positive social impact.<ref>"Introduction to Sustainable Healthcare" https://sustainablehealthcare.org.uk/courses/introduction-sustainable-healthcare. Retrieved 1 August 2022</ref> |
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{{Main article|Effects of climate change on human health}} |
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[[File:Overview on effect of climate change.jpg|thumb|Overview on effect of climate change]] |
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==Background== |
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| ⚫ | The [[World Health Organization]] (WHO) has described climate change as the biggest health threat facing humanity,<ref name="auto4">Climate change and health (who.int) https://www.who.int/news-room/fact-sheets/detail/climate-change-and-health (accessed 08/05/2022)</ref> highlighting that those in low-income and disadvantaged communities, who historically contributed least to the causes of climate change, are being affected first and hit the hardest.<ref name="auto4"/> These concerns are also seen in ‘The Lancet Countdown’, an annual report published in The Lancet medical journal by a group of international experts; it makes an assessment of how climate change is impacting human health. In 2016 the report described the effects of climate change on human health as ‘potentially catastrophic’.<ref>Watts N, Adger WN, Ayeb-Karlsson S et al. (2016) The Lancet Countdown: tracking progress on health and climate change. Lancet 389: 1151-1164</ref> |
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Until relatively recently the way healthcare is delivered has been largely left out of the debate of how sustainable development is achieved<ref name="auto7">Hoop, E.d.; Loeber, A.; Essink, D. (2022) Exploring, Diversifying and Debating Sustainable Health (Care) Approaches. Sustainability, 14, 1698. https://doi.org/ 10.3390/su14031698</ref>. However this is changing, with a significant growth of published studies considering ‘sustainability’ and ‘healthcare’ over the last 20 years<ref name="auto6">Borgonovi, E.; Adinolfi, P.; Palumbo, R.; Piscopo, G. (2018) Framing the Shades of Sustainability in Health Care: Pitfalls and Perspectives from Western EU Countries. Sustainability, 10, 4439.</ref>. |
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| ⚫ | Threats to human health vary from direct injury following extreme weather events, exacerbation of respiratory disease due to air pollution, change in the distribution of vector borne disease, increase likelihood of zoonotic diseases, malnutrition following crop failures, negative impact on mental health, heat related illness and many more.<ref name="auto4"/> |
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== The impact of healthcare on climate change == |
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Historically there has been some variability of its use in the scientific literature<ref name="auto6"/>, <ref name="auto7"/>, this reflects the varied way ‘[[sustainability]]’ can be defined and interpreted, depending on the context of its use. For example, the interpretation of ‘sustainable healthcare’ in a socio-economic sense could mean how financially viable a healthcare system is<ref name="auto7"/>, whereas in a technological sense it could mean sustaining newly implemented innovations<ref name="auto7"/>. However, these interpretations fail to recognise other important aspects of [[sustainability]]; such as social value and environmental responsibility. |
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| ⚫ | Healthcare is a significant contributor to climate change and environmental degradation. According to estimates, healthcare is responsible for approximately 4.4% of global net emissions,<ref name="auto3">Karliner J, Slotterback S, Boyd R, Ashby B, Steele K. Health Care’s Climate Footprint. Health Care without Harm and Arup, 2019. Available at Health care climate footprint report | Health Care Without Harm (noharm-uscanada.org)</ref> this means if the worlds healthcare systems were one country, it would be the fifth-largest emitter on the planet.<ref name="auto3"/> |
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In 1987 the UN produced a report ‘[[Our Common Future]]’ (also known as the [[Brundtland Report]]) within which the modern concept of sustainable development was defined<ref name="auto5">United Nations General Assembly (1987) Report of the World Commission on Environment and Development: Our Common Future. Transmitted to the General Assembly as an Annex to document A/42/427 – Development and International Co-operation: Environment.</ref>. It is also one of the first times that the way healthcare is delivered was recognised to be important in sustainable development<ref name="auto5"/>, <ref name="auto7"/>. More recently, the [[United Nations General Assembly]] (UN-GA) published the seventeen ‘[[Sustainable Development Goals]]’ (SDG), intended as a "blueprint to achieve a better and more sustainable future for all"<ref>United Nations (2017) Resolution adopted by the General Assembly on 6 July 2017, Work of the Statistical Commission pertaining to the 2030 Agenda for Sustainable Development (A/RES/71/313 Archived 28 November 2020 at the Wayback Machine)</ref>. [[Sustainable Development Goal 3]] considers ‘good health and wellbeing’, however the way in which health care is delivered is not specifically covered in the SDGs. |
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| ⚫ | In addition to greenhouse gas emissions, healthcare also contributes to local [[air pollution]]. For example, in England it is estimated that 3.5% of all road travel in the country is related to the [[National Health Service]] (NHS);<ref>Greener NHS, 2020 Delivering a ‘Net Zero’ National Health Service report. Retrieved 17 August 2022</ref> due to a combination of patient, visitor and staff travel and delivery of supplies. |
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The evolution of these concepts is comparable. The concept of [[sustainable development]] was born out of environmental concerns and over time the definition evolved, today it incorporates [[economic development]], social development and [[environmental protection]]. In a similar way, the current concept of ‘sustainable healthcare’ has also grown out of increasing awareness of the relationship between human health and the natural environment. [[Planetary health]] refers to "the health of human civilization and the state of the natural systems on which it depends"<ref>Whitmee, Sarah (2015-11-14). "Safeguarding human health in the Anthropocene epoch: report of The Rockefeller Foundation–Lancet Commission on planetary health". The Lancet. 386 (10007): 1973–2028 doi:10.1016/S0140-6736(15)60901-1 Retrieved 25th August 2022</ref>, acknowledging that the health of humans is directly linked to the health of the natural environment, and the first cannot exist without the later. Today sustainable healthcare is rooted in this understanding, whilst also recognising that social and economic value are needed in conjunction with environmental protection. |
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| ⚫ | The waste generated by healthcare, such as pharmaceuticals and [[plastic pollution]], also has a negative impact on [[planetary health]]. In the United States, it is estimated that pollution caused by healthcare results in a loss of 388,000 disability-adjusted life years (DALYs) annually.<ref>MJ Eckelman, K Huang, R Lagasse, E Senay, R Dubrow, JD Sherman. Health care pollution and public health damage in the United States: an update. Health Aff (Millwood)2020; 39:2071-2079</ref> |
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Reducing the environmental impact of healthcare has a positive impact on both climate change and human health. |
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==Environmental issues in sustainable healthcare== |
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| ⚫ | In 2017 the [[World Health Organization]] (WHO) published a strategic document outlining 10 actions points to improve environmental sustainability in healthcare systems.<ref name="auto2"/> This included points such as sustainable procurement, reducing air pollution and greenhouse gas emissions from healthcare, prioritising public health measures to prevent disease and improving efficiency of resource use. |
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| ⚫ | In 2021, prior to the 26th UN Climate Change [[Conference of Parties]] (COP) in Glasgow, a joint editorial published simultaneously in 233 medical journals around the world highlighted the health consequences of climate change and the need for immediate political action.<ref name="auto1">Atwoli, L.; Baqui, A.H.; Benfield, T et al. (2021) Call for Emergency Action to Limit Global Temperature Increases, Restore Biodiversity, and Protect Health. BMJ, 374, n1734.</ref> It also called on healthcare professionals to ‘join in the work of achieve environmentally sustainable health systems before 2030’.<ref name="auto1"/> Emphasizing that this will inevitably mean a change in clinical practice. |
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===Greener NHS=== |
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The [[World Health Organisation]] (WHO) has describes climate change as the biggest health threat facing humanity<ref name="auto4">Climate change and health (who.int) https://www.who.int/news-room/fact-sheets/detail/climate-change-and-health (accessed 08/05/2022)</ref>, highlighting that those in low-income and disadvantaged communities, who did the least to cause climate change, are being affected first and hit the hardest<ref name="auto4"/>. |
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| ⚫ | Threats to human health vary from direct injury following extreme weather events, exacerbation of respiratory disease due to air pollution, change in the distribution of vector borne disease, increase likelihood of zoonotic diseases, malnutrition following crop failures, negative impact on mental health, heat related illness and many more<ref name="auto4"/> |
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| ⚫ | One example of a healthcare system making changes towards sustainability is the UK’s [[National Health Service]] (NHS). In 2020 it became the first healthcare service in the world to commit to a target of net zero.<ref>Greener NHS » Delivering a net zero NHS (england.nhs.uk) https://www.england.nhs.uk/greenernhs/a-net-zero-nhs/. Retrieved 1 August 2022</ref> To achieve this target the ‘Greener NHS programme’ was created. In 2020 Greener NHS published a report ‘Delivering a Net Zero National Health Service’,<ref>Greener NHS, 2020 Delivering a ‘Net Zero’ National Health Service report. https://www.england.nhs.uk/greenernhs/publication/delivering-a-net-zero-national-health-service/ Retrieved 17 August</ref> which outlines how the NHS can achieve net zero. In this report the sources of carbon emissions across the NHS are summarised, this highlights various ‘hotspots’ where a high proportion of emissions can be targeted. Estates and facilities (including building energy) is highlighted as one hotspot, but there are also opportunities for change in supply chain, pharmaceuticals, medical devices and travel;<ref>Greener NHS, 2020 Delivering a ‘Net Zero’ National Health Service report. https://www.england.nhs.uk/greenernhs/publication/delivering-a-net-zero-national-health-service/. Retrieved 17 August</ref> all of which are directly influenced by the choices of clinicians, recognising that a change in clinical practice will be required. |
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===Healthcare without Harm=== |
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Healthcare without Harm is a [[nongovernmental organization]] (NGO) that aims to reduce the environmental impact of healthcare around the world.<ref name="noharm-global.org">About: Healthcare Without Harm https://noharm-global.org/content/global/about (accessed 22/02/2023)</ref> It was established in the United States of America (USA) in 1996 after a team of health care professionals realised the bi-products of the medical waste incinerators were having a direct negative impact on the health of the local population.<ref name="noharm-global.org"/> The organisation now works internationally to assist health care organisations in delivering healthcare, without negatively impacting human health or causing environmental damage. |
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===The |
===The Global Climate and Health Alliance=== |
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The [[Global Climate and Health Alliance]] (GCHA) is an international organisation of health care and development groups.<ref name="climateandhealthalliance.org">About: The Global Climate Health Alliance https://climateandhealthalliance.org/about/our-history/ (accessed 28/02/23)</ref> The aim of the organisation is centred around minimising the health impacts of climate change and encouraging the health co-benefits achieved by tackling climate change.<ref name="climateandhealthalliance.org"/> |
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| ⚫ | The ‘Five Principles of Sustainable Healthcare’ have been proposed as a model to facilitate sustainable decision making at all levels of the healthcare system and clinical practice. The order of the principles was specifically designed to reflect their power (and therefore importance) to achieve sustainable change<ref name="Mortimer F 2010">Mortimer F (2010) The sustainable physician. Clin Med 10:110–11.</ref> |
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If the environmental impact of healthcare is reduced, this in turn would reduce the negative effects of climate change and in theory reduce the human health consequences, therefore reducing demand on healthcare systems. |
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In order they are ‘Prevention’<ref name="Mortimer F 2010"/> (preventing disease and encouraging healthier populations), ‘patient self-care’<ref name="Mortimer F 2010"/> (equipping patients to manage own health), ‘lean service delivery’<ref name="Mortimer F 2010"/> (improving efficiency), ‘low carbon alternatives’<ref name="Mortimer F 2010"/> (of treatments or interventions where available) and ‘facilities’ (minimising environmental impact of infrastructure). |
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| ⚫ | The quality of care delivered in a health care system often depends on a complex network of processes and pathways.<ref>Quality improvement made simple. The Health Foundation; 2021 (www.health.org.uk/publications/quality-improvement-made-simple) Retrieved 9 May 2022</ref> Quality Improvement in healthcare is when health care professionals familiar with these processes and pathways use a systematic approach to address specific problems in their field, thereby improving the process or pathway with a measurable effect. Traditionally this measurable effect may be improved clinical outcomes, time saved or money saved. |
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| ⚫ | Sustainable quality improvement looks to take a broader view of the measurable effect, considering social and environmental outcomes alongside financial ones. This is also known as the [[Triple Bottom Line]]. This principle was applied to the sustainable value of healthcare<ref name="auto">Mortimer, F.; Isherwood, J.; Vaux, E. (2018) Sustainability in Quality Improvement: Redefining Value. Future Healthc. J. 5: 88–93.</ref> by including sustainability as a domain of quality in healthcare.<ref name="auto"/> Rather than just assessing a treatment or interventions value against its clinical outcome and financial cost, social and environmental cost are also considered. |
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| ⚫ | In 2017 the [[World Health |
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| ⚫ | In 2021, prior to the 26th UN Climate Change [[Conference of Parties]] (COP) in Glasgow, a joint editorial published simultaneously in 233 medical journals around the world highlighted the health consequences of climate change and the need for immediate political action<ref name="auto1">Atwoli, L.; Baqui, A.H.; Benfield, T et al. (2021) Call for Emergency Action to Limit Global Temperature Increases, Restore Biodiversity, and Protect Health. BMJ, 374, n1734.</ref> |
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| ⚫ | One example of a healthcare system making changes towards sustainability is the UK’s [[National Health Service]] (NHS). In 2020 it became the first healthcare service in the world to commit to a target of net zero<ref>Greener NHS » Delivering a net zero NHS (england.nhs.uk) https://www.england.nhs.uk/greenernhs/a-net-zero-nhs/. Retrieved |
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[[Category:Health care reform]] |
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There are several models available to clinicians and health care providers wanting to improve the sustainability of the healthcare they provide. Some of the more recent and commonly used approaches are summarise below. |
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[[Category:Publicly funded health care]] |
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For clinicians who want to focus on what they can do in their practice the ‘Four Principles of Sustainable Healthcare’ have been proposed as a model to facilitate sustainable decision making at all levels of the healthcare system and clinical practice. |
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1. ''First Principle:'' 'Prevention'<ref>Mortimer F (2010) The sustainable physician. Clin Med 10:110–11.</ref>. The most effective way to reduce the environmental impact of healthcare activity is to reduce the amount of healthcare activity needed by preventing disease and encouraging healthier populations. |
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2. ''Second Principle:'' 'Patient self-care'<ref>Mortimer F (2010) The sustainable physician. Clin Med 10:110–11.</ref>. Equipping patients with the knowledge and skills needed to take a more active role in managing their health. |
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3. ''Third Principle:'' 'Lean service delivery'<ref>Mortimer F (2010) The sustainable physician. Clin Med 10:110–11.</ref>. Improving the efficiency of health care activity that is necessary, streamlining processes and minimising waste. |
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4. ''Forth Principle:'' 'Low carbon alternatives'<ref>Mortimer F (2010) The sustainable physician. Clin Med 10:110–11.</ref>. Where options are available (that do not compromise the clinical care that is needed) treatments or interventions with the lowest carbon footprint should be selected. |
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| ⚫ | The quality of care delivered in a health care system often depends on a complex network of processes and pathways<ref>Quality improvement made simple. The Health Foundation; 2021 (www.health.org.uk/publications/quality-improvement-made-simple) Retrieved |
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| ⚫ | Sustainable quality improvement looks to take a broader view of the measurable effect, considering social and environmental outcomes alongside financial ones. This is also known as the [[Triple Bottom Line]]. This principle was applied to the sustainable value of healthcare<ref name="auto">Mortimer, F.; Isherwood, J.; Vaux, E. (2018) Sustainability in Quality Improvement: Redefining Value. Future Healthc. J. 5: 88–93.</ref> by including sustainability as a domain of quality in healthcare<ref name="auto"/> |
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Latest revision as of 11:36, 16 December 2024
Sustainable healthcare is organised medical care that ensures the health needs of the current population are met, without compromising environmental, economic or social resources for future generations.
The World Health Organization (WHO) defines an environmentally sustainable health care system as ‘as a health system that improves, maintains or restores health, while minimizing negative impacts on the environment and leveraging opportunities to restore and improve it, to the benefit of the health and well-being of current and future generations’....[2] It aims to reframe medical practice and the health sector to address human health in the context of Planetary health,[3] where earth systems and humans are reciprocal.
Sustainable healthcare acknowledges all these dimensions of sustainability (environmental, economic and social, also called the 3 pillars of sustainability), delivering healthcare that does not damage the environment (either now or in the future), is economical and has a positive social impact.[4]
The effects of climate change on human health
[edit]
The World Health Organization (WHO) has described climate change as the biggest health threat facing humanity,[5] highlighting that those in low-income and disadvantaged communities, who historically contributed least to the causes of climate change, are being affected first and hit the hardest.[5] These concerns are also seen in ‘The Lancet Countdown’, an annual report published in The Lancet medical journal by a group of international experts; it makes an assessment of how climate change is impacting human health. In 2016 the report described the effects of climate change on human health as ‘potentially catastrophic’.[6]
Threats to human health vary from direct injury following extreme weather events, exacerbation of respiratory disease due to air pollution, change in the distribution of vector borne disease, increase likelihood of zoonotic diseases, malnutrition following crop failures, negative impact on mental health, heat related illness and many more.[5]
The impact of healthcare on climate change
[edit]Healthcare is a significant contributor to climate change and environmental degradation. According to estimates, healthcare is responsible for approximately 4.4% of global net emissions,[7] this means if the worlds healthcare systems were one country, it would be the fifth-largest emitter on the planet.[7]
In addition to greenhouse gas emissions, healthcare also contributes to local air pollution. For example, in England it is estimated that 3.5% of all road travel in the country is related to the National Health Service (NHS);[8] due to a combination of patient, visitor and staff travel and delivery of supplies. The waste generated by healthcare, such as pharmaceuticals and plastic pollution, also has a negative impact on planetary health. In the United States, it is estimated that pollution caused by healthcare results in a loss of 388,000 disability-adjusted life years (DALYs) annually.[9]
Reducing the environmental impact of healthcare has a positive impact on both climate change and human health.
Approaches to Sustainable Healthcare
[edit]In 2017 the World Health Organization (WHO) published a strategic document outlining 10 actions points to improve environmental sustainability in healthcare systems.[2] This included points such as sustainable procurement, reducing air pollution and greenhouse gas emissions from healthcare, prioritising public health measures to prevent disease and improving efficiency of resource use.
In 2021, prior to the 26th UN Climate Change Conference of Parties (COP) in Glasgow, a joint editorial published simultaneously in 233 medical journals around the world highlighted the health consequences of climate change and the need for immediate political action.[10] It also called on healthcare professionals to ‘join in the work of achieve environmentally sustainable health systems before 2030’.[10] Emphasizing that this will inevitably mean a change in clinical practice.
Greener NHS
[edit]One example of a healthcare system making changes towards sustainability is the UK’s National Health Service (NHS). In 2020 it became the first healthcare service in the world to commit to a target of net zero.[11] To achieve this target the ‘Greener NHS programme’ was created. In 2020 Greener NHS published a report ‘Delivering a Net Zero National Health Service’,[12] which outlines how the NHS can achieve net zero. In this report the sources of carbon emissions across the NHS are summarised, this highlights various ‘hotspots’ where a high proportion of emissions can be targeted. Estates and facilities (including building energy) is highlighted as one hotspot, but there are also opportunities for change in supply chain, pharmaceuticals, medical devices and travel;[13] all of which are directly influenced by the choices of clinicians, recognising that a change in clinical practice will be required.
Healthcare without Harm
[edit]Healthcare without Harm is a nongovernmental organization (NGO) that aims to reduce the environmental impact of healthcare around the world.[14] It was established in the United States of America (USA) in 1996 after a team of health care professionals realised the bi-products of the medical waste incinerators were having a direct negative impact on the health of the local population.[14] The organisation now works internationally to assist health care organisations in delivering healthcare, without negatively impacting human health or causing environmental damage.
The Global Climate and Health Alliance
[edit]The Global Climate and Health Alliance (GCHA) is an international organisation of health care and development groups.[15] The aim of the organisation is centred around minimising the health impacts of climate change and encouraging the health co-benefits achieved by tackling climate change.[15]
Five Principles of Sustainable Healthcare
[edit]The ‘Five Principles of Sustainable Healthcare’ have been proposed as a model to facilitate sustainable decision making at all levels of the healthcare system and clinical practice. The order of the principles was specifically designed to reflect their power (and therefore importance) to achieve sustainable change[16]
In order they are ‘Prevention’[16] (preventing disease and encouraging healthier populations), ‘patient self-care’[16] (equipping patients to manage own health), ‘lean service delivery’[16] (improving efficiency), ‘low carbon alternatives’[16] (of treatments or interventions where available) and ‘facilities’ (minimising environmental impact of infrastructure).
Sustainability in Quality Improvement
[edit]The quality of care delivered in a health care system often depends on a complex network of processes and pathways.[17] Quality Improvement in healthcare is when health care professionals familiar with these processes and pathways use a systematic approach to address specific problems in their field, thereby improving the process or pathway with a measurable effect. Traditionally this measurable effect may be improved clinical outcomes, time saved or money saved.
Sustainable quality improvement looks to take a broader view of the measurable effect, considering social and environmental outcomes alongside financial ones. This is also known as the Triple Bottom Line. This principle was applied to the sustainable value of healthcare[18] by including sustainability as a domain of quality in healthcare.[18] Rather than just assessing a treatment or interventions value against its clinical outcome and financial cost, social and environmental cost are also considered.
References
[edit]- ^ Purvis, Ben; Mao, Yong; Robinson, Darren (2019). "Three pillars of sustainability: in search of conceptual origins". Sustainability Science. 14 (3): 681–695. doi:10.1007/s11625-018-0627-5. ISSN 1862-4065.
Text was copied from this source, which is available under a Creative Commons Attribution 4.0 International License
- ^ a b Environmentally sustainable health systems: a strategic document (who.int). WHO Regional Office for Europe (2017) Retrieved 17 August 2022
- ^ MacNeill AJ, McGain F, Sherman JD (2021) Planetary health care: a framework for sustainable health systems. The Lancet Planetary Health. 5: e66 – e68 https://doi.org/10.1016/S2542-5196(21)00005-X
- ^ "Introduction to Sustainable Healthcare" https://sustainablehealthcare.org.uk/courses/introduction-sustainable-healthcare. Retrieved 1 August 2022
- ^ a b c Climate change and health (who.int) https://www.who.int/news-room/fact-sheets/detail/climate-change-and-health (accessed 08/05/2022)
- ^ Watts N, Adger WN, Ayeb-Karlsson S et al. (2016) The Lancet Countdown: tracking progress on health and climate change. Lancet 389: 1151-1164
- ^ a b Karliner J, Slotterback S, Boyd R, Ashby B, Steele K. Health Care’s Climate Footprint. Health Care without Harm and Arup, 2019. Available at Health care climate footprint report | Health Care Without Harm (noharm-uscanada.org)
- ^ Greener NHS, 2020 Delivering a ‘Net Zero’ National Health Service report. Retrieved 17 August 2022
- ^ MJ Eckelman, K Huang, R Lagasse, E Senay, R Dubrow, JD Sherman. Health care pollution and public health damage in the United States: an update. Health Aff (Millwood)2020; 39:2071-2079
- ^ a b Atwoli, L.; Baqui, A.H.; Benfield, T et al. (2021) Call for Emergency Action to Limit Global Temperature Increases, Restore Biodiversity, and Protect Health. BMJ, 374, n1734.
- ^ Greener NHS » Delivering a net zero NHS (england.nhs.uk) https://www.england.nhs.uk/greenernhs/a-net-zero-nhs/. Retrieved 1 August 2022
- ^ Greener NHS, 2020 Delivering a ‘Net Zero’ National Health Service report. https://www.england.nhs.uk/greenernhs/publication/delivering-a-net-zero-national-health-service/ Retrieved 17 August
- ^ Greener NHS, 2020 Delivering a ‘Net Zero’ National Health Service report. https://www.england.nhs.uk/greenernhs/publication/delivering-a-net-zero-national-health-service/. Retrieved 17 August
- ^ a b About: Healthcare Without Harm https://noharm-global.org/content/global/about (accessed 22/02/2023)
- ^ a b About: The Global Climate Health Alliance https://climateandhealthalliance.org/about/our-history/ (accessed 28/02/23)
- ^ a b c d e Mortimer F (2010) The sustainable physician. Clin Med 10:110–11.
- ^ Quality improvement made simple. The Health Foundation; 2021 (www.health.org.uk/publications/quality-improvement-made-simple) Retrieved 9 May 2022
- ^ a b Mortimer, F.; Isherwood, J.; Vaux, E. (2018) Sustainability in Quality Improvement: Redefining Value. Future Healthc. J. 5: 88–93.
