Beyond destruction and scarcity, aspects of climate change have a widely reported yet under-appreciated association with human health outcomes1. Climate change and human health are inextricably linked, with increased temperatures and humidity associated with an increase in infectious disease prevalence and high temperatures associated with an increase in mortality and poor cardiovascular, respiratory, and neurological health2,3,4. In order to avoid the worst impacts of climate change, healthcare providers must significantly adapt their service models, particularly around long-term conditions, in order to reduce emissions and ensure the survival and prosperity of health services.
Climate change and human health are inextricably linked.
Scope of the NHS response to climate change
As the largest employer in the UK and a significant contributor to national emissions, the NHS recognises the role it must play in tackling climate change and has a ‘net zero NHS’ commitment in place consisting of two related targets5:
- To be net zero by 2040 for emissions from directly controlled or NHS-owned sources. This includes emissions from the generation of purchased energy, and from producing/transporting services and goods. Emissions covered within these limits are referred to within the NHS as the ‘NHS Carbon Footprint’.
- To be net zero by 2045 for the sources mentioned previously, as well as for patient/visitor travel, and home-use medications. Emissions covered within these limits are referred to within the NHS as the ‘NHS Carbon Footprint Plus’.
What has been done so far?
Over the past decade, the NHS has taken significant steps to reduce its environmental impact. Considerable progress has been made with material reductions in emissions and movement towards both net zero targets (see Table 1). Whilst acknowledging this progress, it is important to be realistic about the considerable challenge that is reaching net zero from current emission levels.
|NHS Carbon Footprint (MtC02e)||16.2||8.7||7.4||6.1|
|Carbon Footprint reduction vs 1990||NA||46%||54%||62%|
|NHS Carbon Footprint Plus (MtC02e)||33.8||28.1||27.3||25.0|
|Carbon Footprint Plus reduction vs 1990||NA||17%||19%||26%|
|Table 1 – Adapted from: Delivering a ‘Net Zero’ National Health Service, NHS.5|
Challenge and opportunities
Meeting net zero commitments will demand action, significant investment and expertise. The NHS must work collaboratively with suppliers and collaborators to deliver innovation at the rate of change required, improve efficiency, and enhance patient experience by moving towards a model of proactive out-of-hospital care.
Role of Virtual Care Models and Digital Pathways
As the NHS faces unprecedented demand, the healthcare service has identified some key commitments to guarantee its viability and shape its future. This includes the promotion of ‘out-of-hospital' healthcare, which aims to provide patients with improved access to clinical care teams and facilitate a more proactive approach to disease management. In addition to these benefits, out-of-hospital healthcare is significantly more sustainable than traditional service pathways due to multiple factors.
Virtual care models can reduce unnecessary travel
In England, around 3.5% of all road travel is accounted for by patients, visitors, staff, and suppliers to the NHS. This contributes to around 14% of the emissions covered by the NHS ‘Carbon Footprint Plus’ within NHS England6. To reduce these emissions, it is essential to adapt current models of outpatient care and reduce emergency hospital admissions where possible.
Lenus Health can offer patients the opportunity to attend outpatient appointments outside of a hospital setting at whatever location is most suitable to them through the Lenus Appointments service. The asynchronous structure of the appointments provided through this service allows patients to interact with their clinician over an extended window of time, allowing for a more robust patient-clinician interaction and reducing travel costs and time pressures. As a result, a channel shift to digital appointments has the potential to reduce emissions whilst improving patient experience.
The below projections show the resulting reduction in emissions from a channel shift of traditional face-to-face outpatient appointments to the Lenus virtual consultations service. The projections assume that 70% of journeys are made by car and with emissions calculated using the Sustainable Healthcare Collation’s carbon footprint calculator7. Within the table the emission reductions are contextualised by the distance that would have to be travelled by the average car on UK roads to produce the equivalent CO2 emissions and the number of UK homes that could be provided with electricity for a year whilst producing the same CO2e emissions.
|Appointments||Car journeys||Kg C02e avoided||Equivalent km driven *||Equivalent annual electricity usage (UK homes)|
|Table 2 – CO2e emissions saved from channel shift to asynchronous virtual consultations from face-to-face outpatient attendances. *CO2 emissions only. Emissions per km driven calculated from European Automobile Manufacturers Association8 and Society of Motor Manufacturers and Traders9 data. Average CO2e emissions per kWh10 and average kWh electricity usage11 determined from UK government data.|
Remote monitoring can reduce admissions and emissions simultaneously
Not only do hospital admissions cause significant anxiety for patients and their families, but they are also financially and environmentally costly. Reducing the number of days individuals spend in hospital is key to improve long-term health outcomes and increase the efficiency, prosperity, and sustainability of the NHS. To tackle this, a proactive, personalised, and preventative approach to healthcare is required.
Lenus Health can offer clinically evidenced remote patient monitoring tools as a workable means of implementing preventative care within the NHS. This technology enables the consent driven transfer of patient-generated data from web applications, wearables, and medical devices to clinical care teams who can then identify individuals whose health is deteriorating and proactively intervene.
To maximise the efficiency of this process, there is considerable interest in integrating machine learning models into remote monitoring tools to stratify individuals at risk of clinical events. Through an NHS Artificial Intelligence in Health and Care Award, work is currently ongoing to integrate risk scores underpinned by explainable AI into the Lenus COPD service’s clinician dashboard. Patent pending 2208262.2.
The utility and effectiveness of the Lenus COPD service was evaluated in a prospective clinical trial (RECEIVER). The trial demonstrated a greater reduction in admissions and occupied bed days (OBDs) in those onboarded onto the service compared to a control cohort matched by time and COPD severity and managed under standard care pathways. The mean reduction in OBDs per patient per year was reported to be 4.53 days greater in the RECEIVER cohort than the control cohort. This represents a substantial reduction in annual emissions associated with COPD management. Additionally, the investigators estimated that the mean face-to-face outpatient appointment requirements were reduced by 3 per patient onboarded to the Lenus COPD service per year due to improved disease management, further reducing the emissions profile of COPD patient management.
The below projections show the resulting reduction in emissions from a channel shift from existing COPD support services to the Lenus COPD support service. These projections assume that 70% of all journeys to hospital are made by car and include return travel to outpatient appointments and assume one visitor return journey to hospital per occupied bed day. The emissions profile per occupied bed day and car journey to hospital were determined using the Sustainable Healthcare Collation’s carbon footprint calculator7.
|Individuals onboarded||Kg C02e avoided||Equivalent km driven*||Equivalent annual electricity usage (homes)|
|Table 3 - Projected CO2e emission reductions resulting from onboarding 500 individuals with severe COPD onto the Lenus COPD support service. This reduction is a result of a decrease in admissions and outpatient appointments. *CO2 emissions only. Emissions per km driven calculated from European Automobile Manufacturers Association8 and Society of Motor Manufacturers and Traders9 data. Average CO2e emissions per kWh10 and average kWh electricity usage11 determined from UK government data.|
Preventative care can reduce medication requirements
Medicines account for a quarter of the NHS Carbon Footprint. A high percentage of these emissions are accounted for by a few medicine groups with particularly detrimental environmental impacts, including inhalers which currently account for 3% of the NHS ‘Carbon Footprint Plus’ emissions5. This is largely a result of traditional pressurised metered dose inhalers (pMDIs) containing highly environmentally damaging hydrofluorocarbon propellants11.
Consequently, there have been increasing efforts to move away from traditional pMDIs and shift respiratory care to lower carbon alternatives such as dry powder inhalers (DPIs) as well as increase access to self-management resources to optimise disease management and reduce reliance on inhalers. The Lenus COPD service provides easy access to a range of self-management resources and has the potential to contribute to significant reductions in inhaler-associated emissions through improved disease management. As a follow-up to the RECEIVER trial analyses, prescriptions data will be analysed to determine the change in inhaler usage in the RECEIVER cohort in the year before and year after onboarding onto the Lenus COPD support service.
Commitment to the sustainable improvement of healthcare service pathways
Digital service models are a transformative approach to healthcare delivery which improve access to outpatient care and empower people to actively participate in improving their health. Critically, the digital adaption of service models will also play a significant role in reducing emissions. Evidence reported in the RECEIVER trial has already shown that implementing a sustainable virtual care model for long-term conditions, such as COPD, into the NHS can support net zero targets by reducing traditional outpatient appointments and improving disease management. Additionally, virtual asynchronous appointments have shown to be a feasible alternative to traditional outpatient appointments and can have a substantial combined impact on reducing travel related emissions.
With thousands of virtual consultations already completed and hundreds of patients onboarded, Lenus Health is committed to offering the NHS sustainable improvement and continues to develop and scale its digital services to new sites in order to further reduce occupied bed days, hospital travel, and healthcare resource utilisation. The Lenus Appointments service, which took home the 2021 HSJ Award in Digitising Patient Pathways, is available for several specialities including dermatology, rheumatology, orthopaedics, gastroenterology, sleep apnoea, and pain management with more under development.
To find out more about how Lenus can deploy digital pathways in your organisation to contribute towards achieving a net zero NHS, please get in touch. The authors, Andrew Cushing and Morgan Dow, are Data Analysts at Lenus Health.