Can the NHS ever be green?

Green medicine
Can healthcare ever be sustainable?
Delny Britton investigates the hidden impacts of western mainstream medicine - including pollution from pharmaceutical products, high carbon emissions and adverse drug reactions - and asks whether the healthcare sector can ever be truly sustainable

While slow to enter the choppy waters of sustainable development, the healthcare sector is now making up for lost time by addressing its own contribution to climate change and the pressing need to become ‘future proof’. In February 2011 the NHS Sustainable Development Unit (SDU) for England published its ‘Route Map for Sustainable Development’, a blueprint for a sustainable health service. The Route Map builds on the SDU’s Carbon Reduction Strategy, released in 2009, which sets out ways of meeting the Climate Change Act’s ambitious target of at least a 34 per cent reduction in carbon emissions compared to 1990 levels by 2020 and a massive 80 per cent reduction by 2050.

For an organisation still in its infancy – having formed in 2008 – the SDU has made impressive strides towards visualising a sustainable health system and the components needed to achieve it. Using the Triple Bottom Line (TBL) approach - an accepted way of analysing an organization’s economic, social and environmental impacts and performance as well as its capacity for sustainable growth - it is examining a broad range of areas in which the NHS can become more resource efficient, including buildings that encourage low carbon use, lowering the carbon impact of procurement, minimising the creation of waste, ensuring efficient water use and promoting care closer to home.

It certainly needs to. The healthcare sector based on western, mainstream medicine is not only a significant consumer of resources but one of the highest industry users of energy. The SDU has calculated that the NHS produces 21 million tonnes of CO2 every year, making it the largest public sector contributor to climate change.  Drug production has been estimated to account for four million tonnes of CO2 a year (a fifth of all emissions), the equivalent of an extra 750,000 cars on the road.

Speaking at the launch of the Route Map, Sonia Roschnik, Operational Director at the SDU, said she believed the NHS could be sustainable ‘but it’s going to take a tremendous amount of will and big effort. If we want to introduce a zero tolerance to carbon and zero tolerance to environmental impact we could. It’s up to us.’

Carbon emissions are, understandably, an immediate sustainability concern for the NHS, particularly given such challenging emissions targets. But applying the TBL more broadly across the healthcare sector reveals a system that fails to meet the needs of the present generation, let alone one that enables future generations to meet their own needs. 

Environmental decline

Contribution to climate change is not the only damaging environmental impact associated with western mainstream medicine. In the past decade there has been increasing concern over pollution of the aquatic environment by pharmaceuticals, most visible in developing countries where cheap drugs are produced for the massive Western markets of the US and Europe. One drug manufacturing area in India has been described by scientists as ‘Bhopal in slow motion’.

Away from such manufacturing centres, pharmaceuticals are now a widespread source of chemical pollution and have infiltrated aquatic ecosystems around the globe. This is because bioactive chemicals that are ingested or applied to the skin ultimately enter the water system, either through lavatories or through bathing and showering. Trace amounts of numerous different human and veterinary medicines can now be detected as far afield as the Arctic, while drinking water in major cities around the world is contaminated by low concentrations of sex hormones, antibiotics and antidepressants - all of which have the potential to interfere with complex biological functions.

Aquatic toxicologists have warned that climate change will cause differences in the movement, quality and distribution of water that could affect stream acidity all over the world. This change in pH could increase the toxicity of pharmaceutical contaminants in fresh waters.

The NHS is now working in partnership with suppliers to try to reduce the environmental impact of pharmaceutical production, particularly that of carbon emissions, but ‘the trajectory at which we use and develop them will eventually have to stop’ said Dr David Pencheon, Director of the SDU. ‘There will come a time when we have to revisit where pharmaceuticals sit in the whole healthcare spectrum. It’s in everyone’s interest we make sure there’s a sustainable pharmaceutical industry but at the same time we must make sure we’re doing more good than harm.’

Social ills

Western mainstream medicine is a lifesaver in acute and emergency situations and has improved outcomes for many previously fatal conditions, yet the focus on secondary intervention in the treatment of chronic lifestyle diseases such as diabetes and obesity is ‘simply a quick fix that does nothing to tackle the root causes of ill health,’ according to David Hunter, Professor of Health Policy and Management at Durham University. 

And there is growing evidence that western mainstream medicine puts lives at risk. In the UK more than 250,000 patients are admitted to hospital each year suffering from adverse drug reactions (ADRs) and around 10,000 people die from this cause, according to a 2004 study published in the BMJ. ADRs are thought to cost the NHS a staggering £2 billion per year, and if deaths from hospital acquired infections and surgical and medical errors are added to the equation, the toll - and costs - are even higher.

The ultimate irony is that despite their potential to cause serious harm due to toxicity or misuse, evidence for the efficacy of many ‘conventional’ primary care based interventions is often flimsy, according to Professor George Lewith from Southampton University’s Complementary and Integrated Medicine Research Unit - particularly for chronic benign illnesses such as irritable bowel, asthma, migraine, depression and musculoskeletal pain.

Less carbon-intensive and environmentally damaging healing modalities already exist in the form of complementary and alternative medicine (CAM) but despite ‘substantial’ use of CAM in England, according to a national survey last year, there has been little integration of these modalities into the NHS. ‘We know there are other models of care where the evidence base is as good as some traditional therapies’ said Dr Pencheon. ‘Many of them, like acupuncture for example, are far more sustainable but we wouldn’t trade sustainability for effectiveness.’

Clinicians and PCT managers claim that evidence based research guides their decisions when it comes to CAM, yet many researchers believe the focus on evidence based medicine is too limited for complex systems such as CAM and other approaches to healing. Furthermore ‘GPs generally don’t understand how these therapies work and are guided by tacit perceptions of research literature’ said Dr Lesley Wye, Research Fellow at Bristol University’s Primary Health Care Unit. ‘The real issue here is around power, which GPs are generally reluctant to hand over either to patients or to alternative practitioners.’

Dr Rosy Daniel, consultant in Integrated Medicine and Director of Health Creation, which helps individuals and organisations achieve optimum health through the use of integrated healthcare products and services, views integrated medicine - which combines mainstream medicine with certain CAM modalities and self-help therapies - as the medicine of sustainable healthcare.  ‘It looks at the whole person in the context of community and empowers people to be proactive and responsible for their own health. We cannot go on propping people up with ever more expensive drugs and procedures.’

Economic abyss

Health expenditure in the UK and in all other developed countries around the world has been growing unchecked for decades. We currently spend over £100bn annually on the NHS, roughly ten times in real terms what was spent when the service started in 1948 on a budget of £437m. The health service receives the biggest share of funding of all public sectors, and at a time of swingeing cuts in public spending it has been ring-fenced against them. Yet while the coalition government has pledged to increase NHS funding until 2015, these increases amount to just 0.4 per cent per annum, not the 4.9 per cent needed to keep pace with rising costs.

A growing funding gap between what the NHS needs and what it might get was identified back in 2006 in a study commissioned by BUPA, although the predicted gap of around £11 billion by 2015 appears now to be a huge underestimate. ‘What we couldn’t have foreseen was the financial crisis and the effects of the recession’ said Michael Ridge of Frontier Economics, a co-author of the report. ‘A conservative estimate of the shortfall is now £20 billion, which the government is nervously hoping can be made up by improved productivity and efficiency within the service, but the real figure may be as high as £30 billion by 2015.’

Healthcare costs are being driven up by a toxic combination of increasingly costly medical technologies, an ageing population and a rising tide of preventable lifestyle diseases. Capital and operational costs of diagnostic devices such as computed tomography (CT) scanners and magnetic resonance imaging (MRI) units are high and the rising number of scans performed each year means that overall expenditure has risen sharply. In the US medical imaging is now a $100-billion-a-year industry, and other developed countries are following a similar growth trajectory.
The story is similar for pharmaceuticals, with both the volume of drugs prescribed and their total cost increasing exponentially worldwide. According to Department of Health data, a person in the UK now receives around 16 prescriptions a year on average, twice as many as 20 years ago.

Pharmaceutical drugs are now the first line of defense against preventable lifestyle diseases, many of which - heart attacks, high blood pressure, stroke and diabetes for example - are strongly linked to obesity, a condition most prevalent in deprived areas of the country. NHS costs associated with inequality are now well in excess of £5.5 billion a year according to the 2010 Marmot Review of Health Inequalities, and will rise significantly in future if no action is taken.

Sustainable healthcare

Public expectations of health care continue to increase at a far faster rate than other public services, including education, and consequently medical progress has no obvious endpoints or constraints. ‘No matter how much money is spent, no matter what the health gains, they never seem enough’, observes Daniel Callahan, Director of International Programs at the Hastings Centre, in the forward to his book False Hopes, a sober look at the obstacles to sustainable healthcare systems. 

But tomorrow’s world of limited resources – particularly oil, the energy source that permitted western mainstream medicine to proliferate in the first place – dictates that a linear expansion of medicine’s social and technological complexity is not an option. ‘We are focusing on the efficiency of present business models but also recognise that we have to look at transformational issues in order to achieve a truly sustainable healthcare system’ said Dr Pencheon.
Pouring resources into rescuing growing numbers of people who are leading unhealthy lives is an unsustainable exercise. There is now a wide consensus amongst public health professionals that attention must be shifted upstream in order to address the cause of chronic ill health and health inequalities. 

‘We need to be focusing on things like education, transport, housing, employment – the totality of how the environment could be reshaped to support health’ said Professor Hunter. ‘If spending on the NHS wasn’t ring-fenced we’d be able to take public health and health inequalities more seriously and see resources directed to where the pay-off was highest. Conditions like obesity are a societal problem that can’t be fixed by focusing on individual behavior. The government needs to be concentrating on the structural determinants of health.’

Forum for the Future’s vision of the health system of 2025 sees joined-up policy development as central to the system’s effectiveness. Cross-budgeting between government departments will allow interventions that contribute to sustainable development and improved health to be planned and paid for holistically.  Shorter working hours, greater service accessibility, more contact with the environment, growing localisation of production and consumption and redistribution of wealth towards the poor – all key drivers of health and wellbeing – will produce benefits across the social spectrum and aid the sustainability agenda. The SDU looks, optimistically if perhaps unrealistically, to a time when going to hospital is seen as a failing of the health and social care system.

An integrated, creative approach to health is now the only way forward. Perhaps the real bottom line is whether a society hooked on medical intervention is ready to support such a bold but crucial move towards sustainability.

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