30 April 2018

Why greening healthcare is essential for health

General practice Public Health

Health planning requires a sustainable basis for service delivery into the future. Our health system is clearly facing mounting pressure from an ageing population, increasing chronic morbidity and increasing costs of new technologies.

Health expenditure in Australia over the decade has been growing in excess of GDP1 and it would be fair to conclude that in its current form is not economically sustainable.

Beyond economic sustainability, our health system is also not environmentally sustainable. Healthcare is one of, if not the largest sectors of the economy, accounting for around 10% of GDP.2 It is resource intensive (in consumables) and produces large quantities of waste.3  

Australia’s health service is also energy intensive and is estimated to be responsible for 7% of our domestic greenhouse emissions:4 hospitals are responsible for 44%, pharmaceuticals for 19%, capital expenditure 8%, community and public health 6% and general practice 4%.

Health and the environment are inextricably linked. Public-health policies in relation to our water, air quality and pollution are a testament to the importance of this relationship. Current resource use, the depletion of freshwater and soils; ecological degradation and biodiversity loss; pollution, including greenhouse gas emissions, are all occurring at unsustainable levels. We are exceeding the capacity of planetary ecological and physical systems that maintain a safe and healthy environment. In 2009, The Lancet singled out climate change as the greatest threat to our health during this century.5

There is good reason, therefore, to include environmental effects in the planning and delivery of healthcare.  It is even more compelling when considering that many of the changes needed to reduce environmental impacts also improve financial and quality outcomes. These are often referred to as health co-benefit.

More judicious use of resources, recycling and reusing materials all reduce waste that is both expensive to process and can produce harmful pollutants. Waste rationing can result in significant cost savings. It is 10 times more expensive to dispose of clinical waste than general waste.6

Energy waste can be reduced using efficiency systems and strategies. The UK’s NHS recently announced £300 million in savings from the deployment of energy conservation measures and the deployment of renewable energy systems.7

Waste is effectively a measure of inefficiency. After studying nine healthcare systems or hospitals that implemented energy- and waste-reduction strategies over the last five years, the authors of a 2012 report concluded that the same sustainability actions taken by all hospitals across the United States would result in savings of more than $5.4 billion over five years and $15 billion over 10 years.8

Time and travel-related emissions can be avoided through teleconferencing. Promoting active travel or public transport for staff results in a fitter, healthier more productive workforce. 

While general practice has a relatively small environmental footprint, its role is important in the broader context of sustainability. International9 and national10 literature suggests that a strong primary healthcare orientation within the health system is associated with reduced costs, increased efficiency, lower rates of potentially preventable hospitalisations and better population health. 

General practice can also be a platform for advocacy through “leading by example”. Within our surgery, over the last decade we have with mixed success attempting to reduce waste and recycle. Initiatives have included purchasing recycled paper, minimising single-use instruments and improved separation of infectious and non-infectious waste.

But with unsolicited marketing material and unnecessary packaging, going “paperless” still seems to result in lots of paper! 

Solar panels installed have greatly reduced our electricity bill and with a short payback period will be a significant cost-saving. The sudden demise of our hot-water system has allowed us recently to install a new solar system. Our front garden across the road from the local primary school is a fruit and vegetable garden and we encourage our neighbours living in apartments to use our composting bins and we have installed a bicycle rack and promoted active transport in our local community.

Sustainability in health is more than just about “greening” the health sector, although environmental sustainability is an important consideration. A sustainable health and care system needs to be able to go on forever within the limits of financial, social and environmental resources.11 It needs to deliver high-quality care and improved public health without exhausting natural resources or causing severe ecological damage.

To do so will involve broadening our view to include a system-wide approach when deciding what we invest in within health services. There is strong evidence for the cost-effectiveness of numerous public-health interventions, especially when considering the long-term return on investments. 12

Finally, if we are actually to stem the demand for medical services we will need to look upstream, beyond current largely reactive health policies, to address the “causes of the causes of ill health” or underlying social determinants of health and the health inequalities that afflict our society.13 

Dr George Crisp and Dr Richard Yin are Perth GPs and members of Doctors for the Environment Australia. 

References: 

 1. https://www.aihw.gov.au/getmedia/3be568f2-d938-4575-bf1f-8742bad4d2ce/ah16-2-2-how-much-does-australia-spend-on-health-care.pdf.aspx

2. https://www.theguardian.com/australia-news/2017/oct/06/australias-healthcare-spending-rises-above-10-of-gdp-for-first-time

3. http://www.hospitalhealth.com.au/content/clinical-services/news/sustainable-perioperative-practices-reducing-reusing-or-recycling-1077048395

4. http://www.thelancet.com/journals/lanpla/article/PIIS2542-5196(17)30180-8/fulltext?elsca1=tlxpr

5. http://www.thelancet.com/pb/assets/raw/Lancet/pdfs/climate-article.pdf

6. http://www.issuesmagazine.com.au/article/issue-september-2010/hospital-waste.html

7. https://www.cleanenergynews.co.uk/news/efficiency/nhs-energy-savings-exceed-300-million-as-efficiency-installs

8. After studying nine health care systems or hospitals that implemented energy- and waste-reduction strategies over the last five years, the authors came to an eye-opening conclusion. The same sustainability actions taken by all hospitals across the United States would result in savings of more than $5.4 billion over five years and $15 billion over 10 years.

9. https://www.ncbi.nlm.nih.gov/pubmed/11965331

10. https://trove.nla.gov.au/work/29254941?selectedversion=NBD44711214

11. http://www.sduhealth.org.uk/policy-strategy/what-is-sustainable-health.aspx

12. https://academic.oup.com/jpubhealth/article/34/1/37/1554654/The-cost-effectiveness-of-public-health

13. http://apps.who.int/iris/bitstream/10665/69832/1/WHO_IER_CSDH_08.1_eng.pdf