Net Zero Clinical Care 2023

Introduction:

With climate change’s unprecedented threat to human health, the NHS is striving towards net zero carbon emissions [1] . Policies and initiatives are introduced at multiple levels of governance, from NHS England, through NHS trusts, departments, and right down to the individual actions.

The role of the BMA, the GMC and specialty colleges, alongside organisations such as the Centre for Sustainable Healthcare and the UK Health Alliance on Climate Change influence the formulation and uptake of such strategies.

An interconnected system with overlapping jurisdiction will require an approach mindful of its complexity [2].

This research looks at the awareness and attitudes of healthcare professionals in England, and how they view their role within a ‘greener’ healthcare system. It explores the interaction between large-scale policy shifts, individual engagement and external agents/organisations

Objectives:

a) Establish a baseline level of awareness of current climate change policy and sustainability initiatives at different levels of organisation.

b) Identify where professionals find out information on climate change policy in healthcare.

c) Develop an understanding of perceived effectiveness of different policies.

d) Examine professional’s attitudes towards climate change influencing their practice.

Methods:

An online survey of original design was advertised to members of the Royal College of Physicians, Faculty of Intensive Care Medicine, Royal College of Psychiatrists, and the Centre for Sustainable Healthcare. Likert scale and short answer questions addressed the aims of the study. Participants were invited to take part in semi-structured interviews to build on the survey ideas (Figure 2), which were coded into a thematic analysis (Figure 3).

Levels of organisation

·Needs to be governmental (1) (8)

·Needs to be trust level (2) (3) (4) (8)

·Clinicians needs to get on and follow the system change (2) (4)

·Senior hospital are the only ones with any power (5) (8)

·Individual education builds a culture from bottom-up (4) (10)

·It is equally everyone's responsibility (3)

·NHS-wide initiatives are too complex (3)

·In primary care, it is all about the individual (3) (5)

·Levers from the top encourage cultural shift below (5)

·Top and bottom together is needed (6)

The Individual

·Individual action doesn’t work (1) (2) (3) (4) (8) (10)

·Better to mandate them/guideline changes (1) (2) (4) (8) (9)

·Mandating something can just become another chore (3), and it won’t work without buy in (5) (8) (10)

·Despair/powerlessness (2) (10)

·Laziness/not willing to change (4) (8)

·No money (4) (5) / no funded time (8) (9) (10)

·Clinician voice carries weight in the NHS (6)

·Individual education is important (2) (4) (10)

·Can't get cultural shift without energised individuals (5) (6)

The role of individual action

·Helps with engagement (2) (4) (10)

·Important in primary care (3) (5)

·Individuals don't have much power in hospitals (3) (4)

·Individuals will follow system changes (4) (8) (9)

·NHS is too top-heavy for impactful individual action (1) (3)

References:

[1]Improvement, N. E. (2020). Delivering a Net-Zero National Health Service. London: NHS

[2]De Wals, P., Espinoza-Moya, M.-E., & Beland, D. (2019). Kingdon's Multiple Streams Framework and the Analysis of Decision-Making Processes Expert Review of Vaccines, 575-585.

[3]Martin, G. P., Currie, G., Finn, R., McDonald, & Ruth. (2011). The medium-term sustainability of organisational innovations in the national health service. Implementation Science, 6(19).

[4] Buchanan, D. A., Addicott, R., Fitzgerald, L., Ferlie, E., & Baeza, J. I. (2007). Nobody in charge: Distributed change agency in healthcare. Human Relations, 60(3).

[5] Gruen, R. e. (2008). Sustainability science: an integrated approach for health-programme planning. The Lancet , 1579-1589.

[6] Pereira, E., & Dean, B. (2009). British surgeons' experiences of mandatory online workplace-based assessment. Oxford: Royal Society of Medicine.

Results:

There were 137 survey respondents in total, including 95 doctors. The remaining were from nursing and allied health backgrounds. 10 interviews were conducted with healthcare professionals from a variety of specialties.

a) Awareness of issue and current policy/strategies

-Climate change was perceived to impact other parts of the world and future generations more than the individuals surveyed.

-57% and 55% of respondents were aware of the environmental impacts of metered dose inhalers and anaesthetic gases respectively.

-18% were unaware of the environmental impact of anaesthetic gases.

-Action on ‘recycling and waste’ and ‘travel and transport’ were the most frequently mentioned policies/strategies across all respondents.

-35% were aware of ‘green champions’ as a strategy.

-Respondents were marginally less aware of specialty-level action, compared to NHS-level and Trust-level (Figure 5).

b) Sources of information

-Most frequently respondents find out about sustainability and climate change policy through their place of work (Figure 4)

-Colleagues were a common source of information for NHS-level, trust-level and speciality level policies/initiatives

-Healthcare journals were effective for advertising speciality-level policies/initiatives

c) Policy effectiveness

-Policy was thought most effective overall if delivered at an NHS-level, but can be more effectively communicated at a trust-level (Figure 6)

-Departmental-level policy was thought quickest to be impactful

-Interviews thought policy has to come ‘from the top’ and ‘mandated’ (IV1, IV7, IV8, IV10), although noted that NHS-level initiatives were ‘unwieldy’ and ‘complicated’ (IV3).

-33% thought it is equally easily implemented at trust-level (compared to NHS-level), with IV3 noting trust’s ability to ‘enforce’ policy.

-84% thought that helping healthcare professionals understand how it ‘saves time’ and ‘benefits patients’ were effective strategies (60% thought this was the case re: ‘green champions’)

d) Discussions in clinical encounters

-90% thought the climate crisis should influence clinical encounters (Figure 7)

-80% would encourage patients to switch to low carbon treatments in some capacity, and 68% would consider discussing this directly with patients.

-Guideline changes and direction from professional organisations would influence clinicians most when having these discussions (Figure 8).

-Lack of knowledge is a barrier to clinicians introducing such discussions (IV1, 10).

-It is a ‘responsibility’ for clinicians to inform patients about these issues (IV6), although care should be taken for how the issue is ‘framed’ as to ensure the patient doesn’t feel their care is being affected (IV3, IV4). Treating the patient should remain the ‘top priority’ (IV5, IV7)

Discussion and conclusion:

This study showed that many healthcare professionals in England are aware of climate change’s health impacts, but less of what is being done.

‘Top-down’ governmental action was thought the primary mechanism for policy introduction, although only in an organisation whose culture is receptive to the changes [3]. A ‘constellation of leadership’ that distributes responsibility among individuals can help policy be sustained longer term [4].

Colleagues as information sources reinforce the role of clinical leaders to facilitate conversations and initiatives in the workplace ‘from the bottom-up’

Professional organisations and specialty colleges are well placed to advise practice changes ‘from the sides’. This multi-directional tact is likened to an ‘ecosystem’ by Gruen [5]

So-called ‘non-clinical’ actions (recycling/waste and travel/transport) dominate the popular imagination, showcasing the merit of educating healthcare professions about how climate change policy will affect their clinical work. This, however, should be vary of worsening the ‘bureaucratic burden’ of workplace assessment and avoid it becoming a ‘chore’ [6], as well as ensuring the narrative doesn’t infer compromises of patient care.

Net Zero Clinical Care 2023

Understanding healthcare professionals’ perceptions of climate change policy in the UK, and how these can be used to further NHS net zero ambitions.

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