This blog will consider some reports that have been published looking at health and public health in relation to climate and sustainability. The blog also serves to introduce a new SPICe Academic Fellowship project which will see a detailed SPICe briefing on the links between the climate change to health and social care, and the NHS in Scotland.
The Chief Medical Officer’s annual report
This year, we have seen an interesting perspective in the annual report from the Chief Medical Officer (CMO), Professor Sir Gregor Smith. He continues the theme of Realistic Medicine that was introduced in the 2014-15 report, by the then CMO, Dr Catherine Calderwood, but takes the theme in quite a new direction.
This year the focus is on ‘care’, in its broadest sense. While the individual remains at the heart of consideration, it is less about a focus on individuals and transactional relationships, and health done to people, and more about kindness and care through what has been dubbed ‘communityship’.
Chapter two of the report is ‘Taking care of our planet’, so is dedicated to considering healthcare in that context. This is novel, and some might say refreshing, in the current gloomy context of ever-growing waiting lists, demand for services and pressure on resources.
The chapter refers to three related aspects:
- The impact of healthcare on the planetary crisis
- The impact of the planetary crisis on health and care
- Mitigation and adaptation
The report provides lots of links to high level information and documents about the impact of climate change, through major events such as extreme weather events, increasing temperatures and rainfall, and food insecurity because of water scarcity. It also points out that invasive mosquito species will bring serious diseases to the UK, as temperatures climb, leading to infections such as dengue and Zika becoming endemic here.
The report identifies NHS National Services Scotland as having the critical role in how the health system adapts.
The second section highlights the impact healthcare has on the climate through emissions. It states that healthcare remains the fifth biggest emitter of carbon dioxide and the Citizens’ Panel, a long-standing group organised by Healthcare Improvement Scotland found that 75% of panel members were very, or fairly concerned about climate change.
The CMO also refers to the Centre for Sustainable Hospitals in Denmark, which is seeking solutions to healthcare generated emissions.
An example is selected – single-use surgical products – which create significant waste, but have become the norm over the years. The growth of single-use products paralleled infection control concerns, but there is a recognition that the ‘old-fashioned’ multi use products tend to be of better quality, and their substitution or reintroduction make no difference to clinical outcomes.
The CMO chooses strong terms to critique some current practice:
“…the most harmful care for our planet is the wasted and futile care that makes no difference to the lives of the people we care for. The Organisation for Economic Co-operation and Development (OECD) estimates that 20% of healthcare spend does not meaningfully improve our health.”
He describes building a culture of stewardship within health and care, whereby all resources, from surgical gloves and aprons and time, are used responsibly and sustainably.
Yes, this is aspirational, in the current climate, where few in the sector would have the ‘headspace’ to turn 180◦ in cultural terms, especially following decades of received wisdom about infection control, and where single-use Personal Protective Equipment, and an increasing number of single use products have become the norm.
What he describes, he says, requires visionary, determined leadership and confidence in health and care public bodies and, in primary care, with GPs potentially taking the lead within their practices and premises over how resources are used, re-used and maintained.
He also recognises the challenges:
“Transitioning towards sustainability can be complicated by hygiene, costs, work environment, cooperation, efficiency, culture and behavioural considerations. While it is easy to feel overwhelmed, we must question established practices and we must take action to reduce consumption in a safe and responsible way.”
The CMO moves onto pollution, perhaps the most obvious and well-publicised impact of industrialisation on public health, that reaches back well over hundred years. Children are disproportionately affected by air pollution because their developing lungs are more sensitive and they tend to spend more time outside, and pushchairs, for instance, are at a height close to passing traffic.
“In Scotland, outdoor air pollution is implicated in approximately 1,800 to 2,700 deaths every year, making it the largest environmental risk to public health. Air pollution is caused by fine particulate matter released from a variety of sources. We have some of the most stringent air pollution regulations in the world – but these fall short of WHO recommendations.”
Again, he brings the issue into sharp relief with local examples, such as a study in Dundee which found that two out of five children admitted to hospital with breathing issues had these because of air pollutant levels.
He ends the chapter with a discussion of food, and community food-growing, and a call for health facilities and hospitals to be ‘anchors of stewardship’ in communities.
NHS Scotland Climate Emergency and Sustainability Strategy 2022 – 2026
There are duties on all public bodies in relation to Climate Change, including health boards, integration joint boards and local authorities, which together make up 43% of the bodies that have to report.
There was correspondence between the Scottish Parliament’s Net Zero, Energy and Transport Committee and Neil Gray, the Cabinet Secretary for Health and Social Care, in the context of the upcoming budget and in the role of the NHS in achieving net-zero by 2045.
A letter sent on 5 July to the Cabinet Secretary for Health and Social Care asked how budget decisions in health would focus on emission reduction, particularly transport.
The response of 26 July refers to the CMO’s report, and also highlights the focus of net-zero aims for NHS Scotland. These include building energy use, waste, fleet fuel use and gases such as anaesthetic gases.
The data on NHS emissions were cited in the response:
“In 2022/23, NHS Scotland’s reported emissions for its 2040 target sources were 571,000 tCO2e of which 407,000 were from building energy use, 84,000 were from meter dose inhaler propellant, 30,000 were from the fleet and 27,000 were from anaesthetic gases.
It is estimated that supply chain emissions make up around 60 per cent of total NHS emissions with medicines, chemicals and equipment making up around 40 per cent of the total. Staff commuting and visitor travel are estimated to make up around 5 per cent of total NHS emissions.”
There is a recognition in the letter that actions are being taken across a number of areas, including procurement, diet and community use of the NHS estate to grow food.
All that said, the letter projects something of a piecemeal approach and only the start of a process of thinking about and addressing all the relationships between climate and healthcare.
Health boards have reported on emissions at least since 2015-16, using a number of measures and these are published in the Annual NHS Scotland Climate Emergency and Sustainability Report. The NHS Scotland climate emergency and sustainability strategy: 2022-2026 sets out the plans to reduce emissions under five themes:
- Sustainable buildings and land
- Sustainable travel
- Sustainable goods and services
- Sustainable care
- Sustainable communities
NHS National Education for Scotland, one of the non-territorial health boards, has published its own Climate Emergency and Sustainability Strategy 2024 – 2027.
The Foreword states:
“NES is a key enabler in supporting the wider NHS and Social Care sector in Scotland. As the principal provider of education and training to the workforce, we will influence how awareness of the climate emergency is raised and understood, and how and when changes to clinical practice are developed and embedded into our education and training programmes and technology development.”
Future scrutiny?
The Health, Social Care and Sport Committee have never explicitly considered our health and care services in relation to the climate and nature emergency. This perhaps reflects that its work programme is always busy with either legislation or scrutiny of more immediate health and care issues.
However, given the known direct and indirect impacts of climate on health, as well as the greater impact on those living in poorer circumstances nationally and internationally, this is surprising, but perhaps speaks to a more general lag in acknowledgement of the most profound effects of the now rapidly changing climate.
There persists a high level discourse which hasn’t wholeheartedly entered the nitty gritty of public consciousness and conversation on a day to day level. In relation to health for example, connections remain to be made between the impact of asthma inhalers, medical waste inherent in single use equipment in the service of infection control, and the increase in global major weather events. It is not an easy leap to make.
With the fast-growing awareness and dot-joining in areas of policy which were previously seen as peripheral to climate change, along with the baseline provided by the NHS Climate and Emergency Sustainability Strategy, there will be an opportunity to consider progress in relation to public as well as planetary health.
Anne Jepson, Senior Researcher, Health and Social Care, SPICe
Blog image from Adobe Stack