A new role for anaesthetists in environmentally‐sustainable healthcare

‘Climate change is the biggest global health threat of the 21st century’ Costello et al. 1 The new edition of the General Medical Council's Outcomes for Graduates states, ‘newly qualified doctors must be able to apply the principles, methods and knowledge of … sustainable healthcare to medical practice’ 2. In this editorial, we review the context surrounding this recommendation, and reflect on its implementation, as educators and clinicians with an interest in environmental sustainability. We describe the leading role that anaesthetists should adopt in developing and teaching this essential element of the undergraduate medical curriculum, review the available sources of information and support and consider the importance of this topic within the wider context of medical education. Although a universally accepted definition of ‘sustainability’ does not exist, we suggest that sustainable healthcare is that which meets the needs of the present generation without compromising the ability of future generations to meet their own needs 3. This definition is not explicitly environmental, but environmental sustainability is one key factor that must be reconciled together with the social demands and economic constraints of healthcare. Organisations such as the Sustainable Development Unit and the Centre for Sustainable Healthcare make this explicit by considering the costs and impacts of environmental sustainability as part of the ‘triple bottom line’ of social, environmental and financial accountability (‘people, planet, public purse’) 4. Healthcare has a substantial environmental impact. The National Health Service (NHS) is responsible for 5% of traffic on UK roads, generates 4% of the UK's solid waste and accounts for 4% of the UK's national carbon footprint 5, 6. There is a pressing need to reduce the environmental impact of healthcare as part of an urgent and rapid transition to a zero-carbon economy, identified by the UN Intergovernmental Panel on Climate Change as essential to limit global warming to 1.5° above pre-industrial levels. Two degrees of warming would have an enormous impact on species loss, food scarcity and coastal flooding, and would significantly increase the risk of initiating positive feedback loops that drive uncontrolled global warming 7. Globally, the burden of climate change is borne by poorer countries to a disproportionately greater degree 8. However, regardless of locality, the environmental impact of healthcare has the capacity to directly impact the health of service users, for example, cardiorespiratory disease related to air pollution is both a cause and consequence of the increasing work-load of the NHS. In line with the Climate Change Act 2008, the NHS is committed to reducing its carbon footprint by 80% between 2008 and 2050 and currently appears to be on track to meet this ambitious goal, having narrowly exceeded its first interim target reduction of 10% by 2015 9. However, further reductions will be more challenging, and innovation will be required to meet them. Equipping tomorrow’s doctors to innovate for carbon reduction involves integrating sustainability principles into training curricula from an early stage, as set out in the General Medical Council's new guidance 2. Resource procurement accounts for 58% of the NHS carbon footprint 10. This includes pharmaceuticals and equipment, both of which are central to the practice of anaesthesia and contribute to making operating theatres one of the most resource-intensive locations in healthcare. Annually, each operating theatre generates 2.3 tonnes of solid waste and the equivalent of 188 tonnes of CO2 5, 11. Anaesthetists are intimately involved with resource use; the ‘hands-on’ nature of the specialty means that unlike many of our medically-qualified colleagues we administer medications and handle disposables and equipment personally. This experience gives us the credibility to reflect on resource use and healthcare waste. As clinicians, we are also well placed to comment on the compromises and challenges that the healthcare working environment presents. For example, the infection control agenda supports single-patient use equipment, and a busy operating list may not make it easy to engage in waste segregation and streaming. Furthermore, our academic grounding in physical sciences places us in an ideal position to explain the processes that underlie climate change 5. Importantly, anaesthetists are able to modify their practice in ways that can minimise its environmental impacts. Most anaesthetists, for example, are aware of the global warming potential of inhalational anaesthetic agents, which contribute the equivalent of ~5% of the carbon footprint of acute NHS Trusts 12. Of these, nitrous oxide accounts for two-thirds of the contribution; although this is predominantly from sources outside theatre (e.g. obstetric analgesia), it has been estimated that where nitrous oxide is used as part of a general anaesthetic, it often makes up the largest component of the carbon footprint of anaesthesia 13. Of the halogenated hydrocarbons, desflurane has the highest environmental impact due to its atmospheric persistence (14 years), with a 100-year global warming potential (GWP100) 2540 times that of an equal mass of CO2 (sevoflurane 130, isoflurane 510 times) 11, 14. Although there are strategies which can minimise the volume of inhalational agent used clinically, the potency of anaesthetic vapours as greenhouse gases is such that techniques which avoid their use altogether, including regional anaesthesia and total intravenous anaesthesia (TIVA) are likely to be preferable from an environmental perspective. Where an inhaled anaesthetic is required, the carbon footprint can be minimised by avoiding the use of both desflurane and nitrous oxide, monitoring depth of anaesthesia and minimising flow rates. Technologies for vapour capture and resupply are also becoming available and are currently being piloted in NHS Trusts. Life cycle analyses, which account for the impact of the development, evaluation, manufacture, packaging, transport, storage, administration and waste management of drugs and devices rather than simply assessing the pollution directly associated with their use, are required in order that fair comparisons between alternative techniques can be made. For example, the additional use of syringes, pumps and infusion lines in TIVA is anecdotally a source of scepticism regarding its environmental benefits over inhalational agents. This issue was investigated in a life cycle study by Sherman et al. 13 which indicated that propofol TIVA has a life cycle carbon impact orders of magnitude less than volatile anaesthesia, with the greatest single contributor being the electricity required to run the infusion pump. More studies such as this are urgently required in order that anaesthetists can make appropriately informed decisions. Although carbon impact is the predominant concern in the assessment of the environmental effects of anaesthesia, there are other important considerations. For example, when disposable plastics, anaesthetic drugs and their metabolites are released into the environment they may accumulate in organisms with varying toxic effects 15, 16. Reducing the introduction of these pollutants into the ecosystem requires a responsible approach that prioritises the reduction in resource use, maximises the opportunities for recycling and emphasises the appropriate handling and disposal of waste that cannot be otherwise avoided 17. The contribution of anaesthesia to the environmental impact of healthcare is significant and visible, but amenable to change. We believe that this places anaesthetists in an ideal position to lead educational initiatives on environmental sustainability. This is already occurring at Keele, Southampton and Brighton Medical Schools. At our respective institutions, we have explored various forms of sustainability teaching, including plenary lectures 18 and interactive workshops 19. In these settings, we have found that the use of personal narratives which emphasise our own experiences of attempting to provide sustainable healthcare to be more effective than a dispassionate explanation of scientific principles. Student projects, although more limited in their reach, have the potential to allow individual students to take an in-depth approach to a certain topic. We have found sustainability to be a fertile source of ideas for student-led research and quality improvement [e.g. 17, 20], and suggest that readers may draw inspiration from the work of colleagues to develop such projects. The February 2019 edition of Anaesthesia News, for example, contains reports of several practical environmental initiatives that could be easily adapted for this purpose. Our experience suggests that confining sustainability teaching within ethics or global/public health curricula limits its incorporation into routine clinical practice. Instead, we contend that sustainability principles should be integrated across teaching domains, including clinical teaching and quality improvement 4. For example, anaesthetists might teach students about how TIVA and regional anaesthesia can not only improve patient outcomes when used appropriately but can also reduce the environmental impact and financial cost of anaesthesia when compared with using inhalational agents 21, 22. Such practical and routine institution of the ‘triple bottom line’ offers students a clinically-relevant example of how they might think about, and implement, sustainability principles into their own developing practice. Furthermore, anaesthetists might use teaching opportunities to role model or discuss the ‘triple bottom line’ through personal behaviours, such as eating a predominantly plant-based diet 23, commuting by walking, bicycle or public transport, reconsidering conference attendance (e.g. accessing by webinar) and adopting a minimalist lifestyle. A number of frameworks for identifying opportunities in sustainable healthcare teaching and implementation are available. The Centre for Sustainable Healthcare advocates a model that reduces environmental impact without reducing health, by decreasing both (wasteful) activity and carbon intensity (Fig. 1) 24. A 6R ‘waste hierarchy’ model can focus first steps towards sustainable practice, emphasising the importance of using fewer resources over their re-use or recycling, together with rethinking, researching and taking responsibility 17. There is ample opportunity for medical students and junior doctors to become involved in analysing current practice, improving its clinical, environmental and financial quality 4 and presenting potential changes to clinical and managerial colleagues, as indicated within the current General Medical Council guidance 2. Professionally, ‘Anaesthesia UK’ increasingly promotes an active sustainability agenda. The Association of Anaesthetists, for example, recognises sustainability and climate change as key strategic issues, and established an Environmental Task Group in 2013. This committee hosts an ‘Environment’ session at the (sustainable) Winter Scientific and Annual Congresses, encourages sustainability through prizes and awards and maintains a web page with practical advice, suggested research priorities and links to evidence and resources (www.aagbi.org/about-us/environment). In partnership with the Centre for Sustainable Healthcare (sustainablehealthcare.org.uk), the Association also supports a fellowship in environmentally sustainable anaesthesia 25; in turn, the Centre for Sustainable Healthcare offers training on integrating sustainability into education and quality improvement, and hosts a number of sustainable healthcare networks, including those with a focus on the operating theatre environment and medical education. Anaesthetists are well placed to act as role models, advocates and educators in the field of sustainable healthcare. Given the immediacy of climate change and its impacts on health, it is vital that the profession pursues the opportunity presented by the new General Medical Council guidance to engage with this topic at the earliest stage of medical training. We endorse the professional example being set by the Association, and strongly encourage the inclusion of the principles and practices of sustainable healthcare within continuing professional development, and the new Royal College of Anaesthetists core and specialty training curricula when they are published next year. FM is the medical director of the Centre for Sustainable Healthcare and SW is an editor of Anaesthesia. No other conflicts of interest declared.