Independent consultancy in sustainable management
In 2008 a ‘Health Care and Climate Change’ pilot was funded by Cornwall and Isles of Scilly PCT, and also the NHS Institute, and worked in partnership with Knowledge into Action (KiA) and the Campaign for Greener Health Care. It was designed to use a resource efficiency toolkit developed by Eco-nomic Ltd a few years earlier, in Cornwall and for the NHS, updated for the latest thinking on carbon reduction and the foreseeable effects of climate change on health care delivery.
The project worked with four GP surgeries, two Community Hospitals and a mental health unit, and through RCHT with renal, path labs, outpatients, and a children’s ward,
The plan was for each unit to bring together a multidisciplinary team, and to provide three two-hour workshops. These would (a) identify all the health care and climate change issues relevant to the individual unit, (b) prioritise them down to a few important and manageable issues for now, and some for later, and (c) write an action plan with measurables. Each unit would then ensure its action plan became part of their ongoing management agenda for the long term.
The main results were:
1. There are plenty of potential savings. This pilot turned up c£250,000 potential savings and many more to be costed (ROI approx X 6).
2. Reducing carbon is a better incentive to staff than reducing costs.
3. There are plenty of staff who realise climate change is important and are keen to act. Feedback on this programme was positive. Lack of time, perceived or real, is a problem; and this is not part of performance assessment.
4. Three two-hour workshops proved about right to identify the issues, prioritise them, and write an action plan with measurables.
5. Expertise from outside has to be on hand to solve problems, unblock routes etc. You need your own mafia, a ‘support group’ of other senior managers.
6. As with industry, momentum is easily lost. People only act when someone from outside is booked to come in on a particular day, or when the staff member has to stand up and make a report to a peer group – or a Board of course.
7. Some issues such as pharmaceutical waste and patient transport require new kinds of projects. These can be either at trust level, or multi-trust level, and could be financed through an innovation fund.
8. As NHS Trust boards begin to develop strategies for climate change, the toolkit we developed provides a mechanism for engaging clinical staff and delivering carbon reduction. It will also help future proof the NHS for other changes brought about by global warming.
There are many reasons the NHS should pay attention to climate change, and many ways it could benefit by using resources more efficiently. Energy and therefore carbon is embodied in just about everything we do and use. Reductions in carbon often equate to cost avoidance. Resource efficiency methods had already saved Cornish NHS trusts some significant amounts. Climate change brings many new challenges, not least the 80% reduction in CO2 by 2050 embodied in the Climate Change Act which went through Parliament in the course of this project.
The resource efficiency methods used, sometimes called lean engineering, are based on the best that has been developed in industry, particularly by companies like Toyota. However these need to be adapted for NHS structures, as well as its special culture and language. They are a good way to engage the energies, ideas and enthusiasm of a team drawn from within a unit. By looking at all resource use issues, including processes, they can not only unlock savings and enable the NHS to lighten its footprint, but also make workplaces more enjoyable.
This project started with funding from CIOSPCT and very quickly attracted the attention of Knowledge into Action. KiA was able to bring in the NHS Institute who funded the acute trust work with Royal Cornwall Hospitals Trust. Dr Frances Mortimer of KiA took part in delivery.
Climate change brings risks and opportunities as far as public health is concerned. This project enabled each of the units to identify and consider how it could best address these challenges. One of the obvious plusses is the way in which the agenda to improve healthy living is paralleled by some actionsExperiences of public health action and learning for climate change, contributed to the site by participants. advisable to deal with climate change. Thus a reduction in car miles to reduce CO2 emissions by substituting walking or cycling is also of benefit to public health. This coincidence is true for a range of healthy living actions.
In our project this link was very clear with the GP surgeries, which were keen to find ways to make the links work. The children’s ward identified their involvement with families as an ideal opportunity to raise awareness and achieve changes in living patterns. The same is true for the community hospitals and outpatients.
Most units felt it best to get their own house in order before making too much of this public health connection: rampant overheating was pretty well universal, with other wasted resources being uncomfortably obvious.
This project was all about climate change, how we can help prevent it becoming worse than it has to be by reducing CO2 now, and also how we adapt to the changes already inevitable. For each unit the mix of issues was different.
All found many ways in which energy could be saved, particularly in heating, but also in lighting and equipment use. Significant pieces of work to make building fit for the 21st century and climate change have followed from this project.
Pharmaceuticals appeared to be a big area worth further work. It accounts for some 22% of NHS carbon footprint, and expenditure. GP’s report “50% of patient use is non-complaint.” “Wastage is huge.” “We see the tip of an ice-berg.” An eight week STEP student project found no evidence anybody knew what was in the pharma bins, or whether the returns system was working properly. A project across all three Cornish trusts would be needed to track the flows, measure what is actually happening, identify areas for improvement, and action them. Oxford Radcliffe Hospital saved some £300,000 p.a. by implementing part of such a programme.
Transport is another major issue for climate change. Two STEP student projects enabled us to develop carbon footprints for each of the GP surgeries and the two community hospitals. Two different ways of working out the footprints were trialled. While there are some obvious CO2 savings that could be made by improving staff transport – car sharing, better pedestrian access and street lighting, and links with public transport – the big footprint is patient travel. Tackling this may require systems redesign and structural changes to the way health care is delivered. In our short STEP projects the data gathered from patient survey was too thin to be reliable. This was partly because receptionists did not wish to give out the questionnaires for fear of the response from people who had just gone round and round the car parks trying to find a space.
The effects of climate change on health itself were covered in the workshops. Most units felt these effects – changes is disease patterns, heat waves, flooding etc - were too far off to spend time on now, although two of the GP surgeries had flooding issues. One was being solved with a £10m scheme going on outside in the road, the other had sandbags at the front door. It was put on the PCT risk register and a flood plan devised to minimise impact.
There are many parallel actionsExperiences of public health action and learning for climate change, contributed to the site by participants. required for both health promotion and dealing with climate change.
Reductions in CO2 generally equate to cost avoidance. Such savings could be held in a pot to provide the finance necessary to carry out further actions. Indeed this is what happens in the best of industry. The other lesson from industry is to carry out one action at a time and see it through.
Trusts need a strategy for climate change and carbon reduction. This project ran while the NHS Strategy for Carbon Reduction was being developed (published Jan 2009), and while the Climate Change Act was going through Parliament (Nov 2008). Therefore the trusts concerned in Cornwall had no strategy, and actions on climate change were not in anybody’s performance assessment or job description. A trust strategy would provide a framework into which the actions of the individual units could fit.
Finding the right drivers is important. There is good staff engagement on reducing CO2. Nobody wants the process of delivering health care today to wreck the health of future generations. Resource efficiency, as a tool for tackling climate change issues, causes fewer barriers among staff than simply making cost savings. Most of the savings identified came from process improvements and did not include the big ticket issues of energy, transport and pharmaceuticals. Some £8,000 was saved in renal straight away. Many other actions remain to be costed.
This is not the only NHS initiative to include process improvement. Therefore for the sake of staff sanity it is important we find ways to integrate and join up; for example with the ‘Productive Ward, and Productive Community Hospital’ initiatives.
Finance Directors will have to become carbon literate as a result of the Climate Change Act, and the introduction of the ‘Carbon Reduction Commitment’ cap and trade system which the NHS will probably have to take part in. This CRC system is effectively a tax on carbon emissions. As carbon becomes as much a currency and discipline as £’s the potential of the resource efficiency approach adopted unit-by-unit in this pilot will really come into its own.
We think we did no harm!
An eight week STEP student project on pharmaceuticals drew a blank on pharmaceutical wastage data.
Without a trust strategy staff find it very difficult to give this work the time it needs.
We are happy to share what we have learned.
Meanwhile we are endeavouring to set up a network/group/club for those who have taken part already. This will help to maintain momentum, share what has been learned, and hopefully will give each of the participants encouragement and ideas. Knowing that 'it is possible' and what others are finding can work is important.
While active Board involvement in this work, and a strategy, are essential we do not feel a top down 'this is what you are going to do' approach is the real answer. It certainly has not worked in industry, evidenced by the continued rise in energy intensity and CO2 emissions.
Some kind of 'movement' that releases the energy, enthusiasm and ideas of people at every level of the organisations, that gives them more power to create change than they would have in isolation, may be the key to turning this tide of squandered energy and resources.
As of March 2009 we have funding to start with two further community hospitals in Cornwall; to create the network mentioned above; and to revisit the 2008 pilot units to help them maintain progress. We also plan a workshop with the PCT Board and Executive team in order to start on the road to a trust strategy.
We expect to capture further achieved savings during follow up in 2009. Possible savings identified c£250,000 – not including energy, transport and pharmaceuticals.
It is hard to put a figure on what could be saved if Boards were behind it, if trusts had a strategy, if this was part of performance assessment, if savings were put aside to lever out further carbon reductions. There were opportunities everywhere we looked.
We have shown a useful part of the NHS target 80% reduction in CO2 by 2050 could be tackled through this kind of resource efficiency programme. Other CO2 savings will come through the eco-design of equipment the NHS buys; we started this process by identifying some suitable items of the renal equipment. Further savings will come through systems redesign, and facilities redesign which can be informed by this kind of work, and eventually through changes in the NHS model.
It is therefore important we tease out the carbon and climate change implications of the different possible health care models (e.g. the four scenarios published by NW NHS 'What if?' May 2008) so that we have evidence and knowledge of which are more and less sustainable, and what develops is not a blind reaction to the series of future shocks envisaged.