Sustainable healthcare is not as clear-cut as it seems

Sustainable healthcare is thought of as the provision of future approaches to health, care and wellbeing in an increasingly environmentally and financially sustainable manner, and one which also makes intelligent use of our abundant social and human resources.

Proponents of the sustainable healthcare approach point out that in our current place in time, and for the future – our future, the future of the generations after us, and the for earth’s future itself – we need to ensure that the healthcare institutions need to make minimal impact on the environment, so that there is an environment for future generations, and not one that has been plundered of its resources.

The thinking behind the sustainable healthcare approach is that in operating with a minimal-impact focus, there is an added benefit in doing so, because operating costs can supposedly be minimised as well. There is a perceived amount of overlap in these two areas, and avoiding unnecessary environmental harm while reducing waste can also save money. One quoted instance of this is how the use of ultra-low energy lighting in hospitals requires less power demands, which means an efficient distribution of electricity at the power plants, and ultimately this all can be traced all the way back to making less environmental impact whilst saving on electrical costs.

But how much of this interest in sustainability is genuine, and how much of this is merely a governmental facade to mask or sidestep the issue of reduced health budgets?

Yes, ultra-low energy lighting can minimise running and environmental costs, but is the manufacturing process of the lighting itself sustainable? And will the ultra-low energy lighting pay for itself over its lifespan?

Let’s consider this example. Suppose it costs £20,000 to replace the outdated lighting systems in a hospital with the new flash lighting. Throw in an added £5,000 for labour costs. Assume the new lighting lasts 20 years before it needs to be replaced. Will the £25,000 costs be significantly made up over the twenty years to warrant its installation in the first place?

Whether or not it is possible to do so, it is arguable that even if it isn’t, it is more PR-friendly for organisations to be viewed in the public eye as sustainable, and they will rush to choose measures which may be seen to be sustainable, rather than carefully evaluate their options. This only opens things up to abuse as suppliers will merely jump on the bandwagon and market products under the guise of being sustainable.

Take for example, the case with Salford City Council. Years ago, when the trend for recycling was at its peak, the council unceremoniously dumped five wheelie bins in every household without consultation. The move was supposedly to encourage recycling. But what resulted was a stealthy method to cut the frequency of bin collections from once every week to fortnightly, as well as cut the number of waste collection workers by forcing residents to sort out the recycling. But where did the money for four extra bins per household come from, apart from through higher council tax charges, and did the extra financial cost, as well as the added time of a rubbish truck emptying five bins instead of one, thereby causing road congestion, save costs in the long run? Probably not. In the rush to be seen as being eco-friendly, it is ironic that it cost more to be viewed as so, rather than to not be eco-friendly at all. The extra cost went into buying a perception. We must not make the same mistake with sustainability.

Proponents of sustainability in healthcare suggest that health is also won or lost outside formal health and social care settings. The hospitals and other care organisations do not govern the lives of individuals. Individuals themselves can empower themselves to live better lives, by making better choices so as to require less medical care and ultimately make less demands on the healthcare system and the environment. Sustainable healthcare, they say, means a thorough examination of how we are living – how we eat better, how we move our own bodies more, how we develop new ways of protecting and improving health. It is about empowering the individual to lead a pro-active lifestyle.

Another idea put forth is that the quality of resilience needs to be imbibed in people, families and communities, especially when you consider the increasingly frequent extreme weather. Is this a subtle way of saying “in times of harsh weather conditions – like extreme cold or heat, instead of getting in touch with your GP, just tough it out?”

It is suggested that what is needed is a collective effort in supporting and growing effective networks within communities so that the health system works to provide support and services alongside people rather than just to people. How does this help the system to be sustainable? The claim is that pre-existing logistical setups are already in place and aid can be delivered swiftly to recipients – the cost of setting up a delivery system is negated by using one that is already in existence.

The proposed sustainable health strategy is based on three principles, and launched jointly by leaders from the NHS, the social care system, local government, and Public Health England.

Firstly, a healthy society depends on a healthy environment: clean air to breath, green spaces for children to play in, safe places to walk and cycle, and a radical reduction in our greenhouse gas emissions.

Secondly, the health and care system is increasingly aware of the benefit of helping to develop resilient communities: resilience that is fundamental to health and wellbeing, both in times of relative stability, and in times of crisis.

Thirdly, the health and care system can take every opportunity to work with people to prevent the preventable and manage the manageable. This means helping us all improve our understanding and control over our own health, illnesses and opportunities and to take pro-active steps over our health, within our homes and communities. The traditional model that exists at this time is of citizens being well, then falling ill, before being treated and getting better is increasingly outdated. This, in essence, is passing on the responsibility for our own health to the state. We need to make increasingly wiser choices over our health and manage ourselves with the support and guidance of the health and care system using improved information, integration, collaboration and technology.

However, this third principle requires a cultural shift for public, patients and particularly professionals. We have business models that are built on the foundations of people getting ill. We pay insurance premiums, private medical treatments, and existing business models rely on poor health to function rather than improved health. What would happen to hospitals and staff if people lived better? We would have a surplus and would have to close them down. Cynics could be forgiven in thinking that sustainability is the guise under which the NHS meets budgets through cuts. The existing models we have depend on certain numbers of people being ill in order to function. But in the light of diminished financial resources, this rethink may come sooner and seen more positively. We may need more diverse business models for providers of care. We could reward care providers for the amount they reduce death rates or health inequalities or survival times or for simply improving the experiences of patients. But will this only complicate matters by only shifting traditional costs elsewhere?

Those who hold responsibility in commissioning healthcare are increasingly choosing to focus on outcomes as the marker for remuneration. There are many examples already in existence in our society already, where care is less focussed on a hospital setting and more in the community. This can be through more programmes which are community based ones. Or it is suggested we could rely on interventions in partnership with the voluntary sector, or – through the use of technological opportunities – even care in the home. And the societal focus of rewarding providers of care for outcomes rather than just activity might uncover methods that are more creative, cost effective, and appropriate ways of keeping people informed, independent, and healthy. It is a way of allocating resources to encourage positive needs. Cynics may suggest that this is a subtle way of shifting government responsibilities lower down to the community, in light of budget cuts, but it remains to be seen whether individuals in need get help more sooner within their community, and the redistribution of care resources down the chain to the community, which is already in place, rather than wait for government initiatives to filter through after legislation and debate, means that a community-based system is more responsive and more agile.

Devolving responsibility and dividing care provision requires overall coordination to ensure facets run smoothly. If what was amalgated under a traditional NHS is now devolved to various third parties, who will be in charge of overall co-ordination? Will the cost of overall co-ordination actually prove to be more expensive in the process? In the latter case, probably not – but why? Because the responsibility for co-ordination will probably fall to a computer system, and any failings of this system will be explained away by traditional excuses we ascribe to technology; and without having a person to blame anyway, we will have to grin and bear it. Be resilient.

This move towards reaching a sustainable health service is partly technological, but other factors such as the economic, social and cultural also come into play. It will only be achievable through various shared values – honesty, partnership, social involvement. Business models and technology widely used outside in other facets of society have to be used creatively in order to deliver a safer, fairer future. One of the challenges is that sustainability and commerce do not easily mix, and the transition must be carefully managed. Sustainable models are efficient and usually low-cost, and as a form of revenue and unemployment do not offer as much as commerce-based models. And as organisations such as the health service move towards a lean, agile and efficient mode of service, unfortunately it is a likelihood that such sustainable models mean that individuals employed in traditional sectors may require re-training to find continual employment.

This strategy for the future has been shaped and supported by partners across the system, not just by a single organisation. This is vital because, although we know much about what needs to be done, we really are not yet certain how to do it together, ensuring our collective efforts add more value than the sum of our individual approaches. Society as a whole needs to move forward together, inching our way collectively so that we can all adapt to the various stages of the transition. Binding all of these approaches into a sustainable approach focusses us on the truth that a liveable community for our children is more important than a growing economy.

The health and care system should not entertain the thought that it is separate from the challenges (and opportunities) that are presented by a rapidly changing world. A future-focused health and care system is the most obvious representation of a collective effort for the common good. But the scale and pace of this move is needs to be realistic and functional, and it extends beyond specific health areas alone. Moving towards a sustainable health model is not just about making the NHS more efficient and environmentally-friendly. It is about creating a sustainable world for future generations through its constituents, and fostering shared capabilities so not only is the sense of community and a shared world an attainable vision, but working demands are shared to minimise wastage and tax on the environment. The NHS is one such constituent to institute this change in thinking and move it forward.

Healthcare is a fine example of a sector to set clear examples of our collective responsibility to the future. In the current financial climate of constraint there is opportunity for this evolution of healthcare to go forward. What is being proposed is good for the purse, good for our families, and good for the future. Ultimately this reduces the cost of state healthcare, empowers individuals to take charge of their own, and whatever resources are available are delivered to those who need it in an efficient way.

What does all this mean for the NHS? Among other things, it means the health service must:

1) Operate sustainably, minimising its impact of the environment. This means the physical infrastructure of the NHS has to be sourced from means that are as environmentally-friendly as possible.

2) Continue to source its needs from sustainably-beneficial agencies. An example of this is that if the NHS has two pharmaceutical companies offering the same drug at similar prices, it engages the one with more environmentally-friendly policies. This is to promote the use of sustainable measures to its partners.

3) Impart knowledge through the use of community-based programmes to encourage personal responsibility for health. The NHS can support local programmes, for example by setting up stalls in school fairs to promote health advice or encourage people to do health testing, among other things, so that tests that are routinely conducted at hospitals or GPs are done elsewhere, resulting in time savings, and also encouraging individuals to maintain responsibly from their health by having constant local reminders within the community framework.

4) Conduct constant research in order to find better medicines – “better” not necessarily in the sense that the cost is lower, but better in the sense that they can be constructed from more natural sources, and hence require less demands on the environment during production. In this, the NHS may have to turn to various alternative therapies such as homeopathy, Chinese medicine, or preventative therapies such as the Alexander Technique.

5) The NHS also has to collaborate with partner agencies that can provide long-term non-medication solutions. For example, research on mental health has suggested that while medication for serious health issues has benefit, milder forms of mental health are equally well-addressed with cognitive therapy rather than medication, and cognitive therapy also has more lasting impact and a lower chance of relapse than medication. In the long run it is not conceivable that a sustainable health service would cultivate a society that is less dependent on medication as a quick-fix remedy, but one that encourages its citizens to closely reflect on how they are living their lives in order to live free of medication as far as possible.

The challenge in implementing all this, as we have previously mentioned, is that as organisations and processes become more streamlined, cost-effective and environmentally-friendly, economies which depend on growth – essentially, ALL of them – and government which raise finance from taxation – again, ALL of them – start to suffer. Sustainable organisations employ less people. And the more sustainable an organisation becomes, the less people it employs. Even the large organisations that focus on saving the environment have a majority of their workforce consisting of volunteers. This means a huge chunk of the government budget attained from working tax is lost, and a equally worrying time-bomb is large numbers of unemployed with no financial means of securing a living property.

Taxes on working profits will fall, because the silent partner is sustainable schemes is low cost. Would you pay more for the same product or service, if the product carries a promise to invest sustainably? Would you pay more for Fairtrade products? Most, apart from those with more disposable income, would probably go cheaper, given that society will have to live with financial constraints for years to come. The tax on a lower-cost product is less than that on a higher-cost product, which means the government has less revenue.

We arrive at a situation where the government has less funds to distribute, organisations that have less funding but have to find ever more ingenious ways to use or grow that forever-dwindling income. At the same time we have a situation where the numbers of jobless will continue to grow, many will remain on low-wage jobs, while property continues to spiral out of reach. It is not an economically-sustaining situation. It begs the question – are we only pushing the demands on the environment that we made, while we were focussed on growth, back to the economy again?

A sustainable health service, and living sustainably, is essentially a dismantling of the economy that we have come to build.

The future is uncertain. It is scary and will require careful negotiation. We’re sure we need to live sustainably and make less demands on the environment, but we haven’t quite worked out fully how to transition there, nor what we will do when we really get there.