The effect of climate change on public health is becoming increasingly evident, and the need to act is perhaps more urgent than ever. But it’s not just global governments at the COP summits who can influence sustainable change. As the Royal College of Emergency Medicine’s GreenED initiative highlights, all hospital staff can play their part. Katherine Price investigates.
Emergency healthcare systems are already having to manage the consequences of climate change, with associated air pollution and extreme weather events on the rise and increasing pressure on services. The recent catastrophic floods in southeastern Spain and heatwave in the UK in 2022 are just two examples.
While the impact and repercussions of the floods are still being assessed, the UK heatwave caused an estimated 2,985 excess deaths in England alone and also led to IT failures at one of London’s largest NHS hospital trusts, demonstrating a significant logistical and human cost.
Focus groups at the recent European Emergency Medicine Congress rated the severity of the impact of climate change on health systems, and specifically on emergency care, both now and in the future, at an average of seven on a scale of zero to nine. This highlights widespread concern and the need for the emergency medicine community to mobilise around the climate agenda.
‘There’s broad recognition in the health community that climate change is the biggest threat to public health,’ says Dr Zoe Steley, emergency medicine registrar, co-founder of the Royal College of Emergency Medicine’s (RCEM) Environmental Special Interest Group and clinical co-lead of its GreenED initiative. ‘That’s a big part of why GreenED is a priority, because it’s connected to the broader care crisis.’
Launched in September 2023, GreenED aims to measure and reduce the environmental impact of emergency departments (EDs) in the UK, thus driving environmentally sustainable practices within the specialty of emergency medicine and contributing to NHS England’s ambition of achieving net zero by 2040.
Its open-source framework has been designed to hit a ‘triple bottom line’ within secondary care: quantifiable sustainable changes that also reduce costs, improve efficiency and maintain or improve patient care outcomes.
Safely and sensibly decarbonising care
‘Climate change is a health emergency, and the NHS has a pivotal role in tackling this issue for the benefit of our patients,’ says Chris Gormley, acting chief sustainability officer for the NHS. ‘With the dedication of our clinical staff and the collaborative efforts of the RCEM, we are making significant strides towards safely and sensibly decarbonising the care we provide, and we are proud to support this work.
‘Our goal is to ensure that NHS EDs can deliver not only high-quality, efficient and cost-effective care but also environmentally sustainable solutions. We are committed to enhancing patient outcomes while improving health now, and for future generations.’
As part of these efforts, in September 2024, the RCEM awarded five EDs in the UK GreenED accreditation for environmental sustainability. The first accreditations of their kind, these align with the three levels of the GreenED sustainability framework – bronze, silver and gold.
Providing evidence of achieving or sufficiently addressing specific actions across the three levels leads to respective accreditation for 12 months, with an annual £2,000 fee per site to take part in the support and accreditation scheme. According to Dr Steley, accredited sites have, on average, saved around £10,000 per year by implementing the changes.
GreenED: what it takes
For Dr Daisy Stevens, a specialty doctor in emergency medicine and GreenED lead at the newly bronze-accredited Derriford Hospital in Plymouth, keeping the patient front and centre of all sustainability efforts is imperative. ‘[It’s] making sure that everything that we do request for a patient is appropriately indicated, getting rid of any excess or duplication that isn’t going to change patient management or isn’t in their best interests.’
And she advises starting small. ‘Evidence the victories and use this to gain momentum to target some of the bigger actions,’ Dr Stevens says.
Kate Whittaker, a junior sister in the ED at Great Western Hospital in Swindon, which received both bronze and silver accreditation, agrees. ‘It’s just looking at where you can make those small changes first that can make quite a big impact… and then you can start building on it from there,’ she says.
At this Trust, in conjunction with Royal United Hospitals Bath NHS Foundation Trust and Salisbury NHS Foundation Trust, all employees can sign up to ACT – an interactive programme aimed at supporting action on climate change. Staff earn ‘green points’ for registering positive environmental actions on the ACT app, with top scorers receiving rewards such as vouchers, which helps keep motivation high.
‘Persistence is key, especially getting off the ground,’ adds Dr James Walton, consultant in emergency medicine at Northumbria Specialist Emergency Care Hospital, which also achieved both bronze and silver accreditation. ‘Once there’s momentum, it’s been really easy to run with it… Our initial plan was just bronze and then we actually looked and we were 90% of the way to silver.’
Sustainable actions for EDs
The GreenED framework lists 13 bronze, 13 silver and 14 gold actions that EDs can use as starting points on their sustainability journey, which include things as simple as switching off equipment and lighting when not in use and using reusable medical devices where possible.
- Set up a multidisciplinary green team
One bronze action is to set up a multidisciplinary working group. RCEM recommends including a mix of junior and senior, as well as clinical and non-clinical roles. This encourages shared responsibility and accountability, the inclusion of different ideas and perspectives, and creates a space for feedback.
‘If you are making things harder for someone else to do their job, then that’s not a sustainable change,’ points out Dr Stevens. ‘We need to make sure that we’re not doing any harm by the changes that we’re doing.’
For example, ensuring that any sustainable alternatives are suitable for all patient cohorts involves cross-departmental input.
- Offer dry powder inhalers
Another bronze action is to make dry powder inhalers (DPIs) available within the ED. Inhalers contribute to 3% of the total NHS carbon footprint, and DPIs have a carbon footprint 20 to 30 times smaller than metered-dose inhalers. Since introducing DPIs into the ED formulary at Northumbria, approximately a third of dispensed inhalers are now DPIs – a projected saving of 665kg CO2 equivalent (CO2e) per year.
It’s the kind of project that often also has huge potential outside the ED, Dr Steley points out. ‘If you know that not only your successes but the challenges you encounter are going to be informative to unblocking yourself, but also others, that mindset is incredibly motivating,’ she says.
- Review anaesthetic gases and discharge medications
Anaesthetic gases can be a carbon hot spot, but methoxyflurane (brand name Penthrox) has a climate change impact of 117.7 times less CO2e than Entonox. Making methoxyflurane available in the ED and reducing Entonox use by 30% fall under silver actions, while gold involves reducing Entonox use by 60%.
Northumbria has introduced methoxyflurane as its first-line trauma analgesic and turned off nitrous manifolds in the ED, saving 7,200kg CO2e while maintaining excellent patient outcomes. Previously, 38% of patients with shoulder dislocations were discharged within four hours, which has since increased to 75%, and while nearly half of these patients were being sedated, this is now less than 10%.
‘That hits the triple bottom line fully because it’s a shorter length of stay, which is better for the patient; there’s less sedation, which is better for the patient; it’s cheaper; and it’s less environmentally harmful,’ emphasises Dr Walton.
The hospital pharmacy team also reviewed discharge medication to eliminate any unnecessary dispensing – and found very little needed to be changed to maintain sustainable practices.
GreenED challenges to overcome
Despite GreenED involvement being encouraged across all staffing levels, and a statement of support from a clinical lead being a silver action point, the 2022 GreenED pilot report highlighted limited or no senior support as a challenge, particularly sites that did not have consultant involvement.
‘Sites that have senior buy-in from the outset are able to get a lot more done more effectively,’ says Dr Steley. A senior clinician doesn’t have to lead the work, but their support is essential.
A lack of protected time for carrying out the actions was also flagged as problematic, particularly when trying to juggle clinical and other pressures, and the University Hospital of North Tees polit site therefore called for effective resourcing to enable the initiative to progress effectively.
Another key challenge is waste. Having recycling bins throughout Derriford ED saw items ending up in the wrong bins, so instead, a single recycling station has been set up. Northumbria, meanwhile, is conducting bin placement audits.
Also at Northumbria, achieving the bronze action of eliminating single-use plastic cups and cutlery was not as straightforward as hoped. ‘It was really much more complex for patients,’ says Dr Walton. ‘We weren’t able to fully eradicate disposables, but we’ve made a significant improvement.’
There was, however, unexpected success when it came to the logistics of recycling crutches, which had been a concern. Input from the physiotherapy team led to a simple sustainable solution which is expected to become standard operating procedure before the end of the year – ticking off the silver action of creating pathways to return loaned equipment.
Next steps
More than 35 hospitals across the UK have registered for GreenED accreditation – including all EDs in Wales – since it was launched in 2023, and now the first international pilots have also been set up in Australia. ‘The framework itself doesn’t need structural changing really to accommodate different national contexts,’ explains Dr Steley, which means progress in the UK has the potential to be replicated across the world.
Accreditation has been a great motivator, says Dr Walton, with the changes projected to save an estimated 37,500kg of CO2e a year. ‘There’s been a real culture shift and now everybody’s aware of it and knows who to speak to and that it’s everybody’s responsibility to try and make things better. And I think there’s a sense of pride in the whole team,’ he says.
Dr Stevens has a similar sentiment: ‘As a healthcare provider, we have got the ability to deliver this message as a respected member of society. It’s not just altruistically doing it for the environment and for future generations, it’s actually empowering people to see the benefits in their own health care right now.’
