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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 Organisation (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’[1]. It aims to reframe medical practice and the health sector to address human health in the context of Planetary health[2], 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 [3].

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.[4]

Background

Until relatively recently the way healthcare is delivered has been largely left out of the debate of how sustainable development is achieved[5]. However this is changing, with a significant growth of published studies considering ‘sustainability’ and ‘healthcare’ over the last 20 years[6].


Historically there has been some variability of its use in the scientific literature[6], [5], 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[5], whereas in a technological sense it could mean sustaining newly implemented innovations[5]. However, these interpretations fail to recognise other important aspects of sustainability; such as social value and environmental responsibility.

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[7]. It is also one of the first times that the way healthcare is delivered was recognised to be important in sustainable development[7], [5]. 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"[8]. 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.

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"[9], 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.

Environmental issues in sustainable healthcare

The consequences of climate change on human health

The World Health Organisation (WHO) has describes climate change as the biggest health threat facing humanity[10], 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[10]. 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[10].

The ‘Lancet Countdown’ is 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’[11].


The consequences of healthcare on climate change

Modern day healthcare is contributing to climate change, estimates suggest healthcare generates around 4.4% of global net emissions [12]. Put another way; If the worlds healthcare systems were one country, they would be the fifth-largest emitter on the planet [12].

As well as greenhouse gas emission healthcare also contributes to local air pollution. For example, in England it has been estimated that 3.5% of all road travel in the country is related to the National Health Service (NHS)[13]; due to a combination of patient, visitor and staff travel and delivery of supplies. Waste from healthcare, namely plastic and pharmaceuticals, also impacts negatively on planetary health. In the United States of America (USA) it has been estimated that the pollution caused by healthcare results in a loss of 388,000 disability-adjusted life years (DALYs) every year[14].

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.


Making changes towards Sustainable Healthcare

In 2017 the World Health Organisation (WHO) published a strategic document outlining 10 actions points to improve environmental sustainability in healthcare systems[1]. 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[15]. It also called on healthcare professionals to ‘join in the work to achieve environmentally sustainable health systems before 2040’[15]. Emphasizing that this will inevitably mean a change in clinical practice.

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[16]. To achieve this target the ‘Greener NHS programme’ was created. In 2020 Greener NHS published a report ‘Delivering a Net Zero National Health Service’[17], 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[18];all of which are directly influenced by the choices of clinicians, recognising that that a change in clinical practice will be required.

Approaches to Sustainable Healthcare in clinical practice

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.

The Principles of Sustainable Healthcare

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.

The order of the four principles was specifically designed to reflect their power (and therefore importance) to achieve sustainable change. They are being used widely as a framework for improving sustainability in healthcare[19].

1. First Principle: 'Prevention'[20]. 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.

2. Second Principle: 'Patient self-care'[21]. Equipping patients with the knowledge and skills needed to take a more active role in managing their health.

3. Third Principle: 'Lean service delivery'[22]. Improving the efficiency of health care activity that is necessary, streamlining processes and minimising waste.

4. Forth Principle: 'Low carbon alternatives'[23]. 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.

Sustainability in Quality Improvement

The quality of care delivered in a health care system often depends on a complex network of processes and pathways[24]. 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[25] by including sustainability as a domain of quality in healthcare[25]. Rather than just assessing a treatment or interventions value against its clinical outcome and financial cost, social and environmental cost are also considered.

References

  1. ^ a b Environmentally sustainable health systems: a strategic document (who.int). WHO Regional Office for Europe (2017) Retrieved 17th August 2022
  2. ^ 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
  3. ^ “Introduction to Sustainable Healthcare” https://sustainablehealthcare.org.uk/courses/introduction-sustainable-healthcare. Retrieved 1st August 2022
  4. ^ 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
  5. ^ a b c d e 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
  6. ^ a b 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.
  7. ^ a b 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.
  8. ^ 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)
  9. ^ 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
  10. ^ 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)
  11. ^ Watts N, Adger WN, Ayeb-Karlsson S et al. (2016) The Lancet Countdown: tracking progress on health and climate change. Lancet 389: 1151-1164
  12. ^ 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)
  13. ^ Greener NHS, 2020 Delivering a ‘Net Zero’ National Health Service report. Retrieved 17th August 2022
  14. ^ 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
  15. ^ 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.
  16. ^ Greener NHS » Delivering a net zero NHS (england.nhs.uk) https://www.england.nhs.uk/greenernhs/a-net-zero-nhs/. Retrieved 1st August 2022
  17. ^ 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 17th August
  18. ^ 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 17th August
  19. ^ Mortimer F (2010) The sustainable physician. Clin Med 10:110–11.
  20. ^ Mortimer F (2010) The sustainable physician. Clin Med 10:110–11.
  21. ^ Mortimer F (2010) The sustainable physician. Clin Med 10:110–11.
  22. ^ Mortimer F (2010) The sustainable physician. Clin Med 10:110–11.
  23. ^ Mortimer F (2010) The sustainable physician. Clin Med 10:110–11.
  24. ^ Quality improvement made simple. The Health Foundation; 2021 (www.health.org.uk/publications/quality-improvement-made-simple) Retrieved 9th of May 2022
  25. ^ a b Mortimer, F.; Isherwood, J.; Vaux, E. (2018) Sustainability in Quality Improvement: Redefining Value. Future Healthc. J. 5: 88–93.
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