9. Sustainability should become a more explicit consideration
Important sustainability issues are peak oil, the physical environment, and air and land pollution. The public health sustainability agenda cannot be separated from climate change and the detrimental effect this will have on population health. These effects include: changes in disease patterns, such as food poisoning, insect-borne disease, cancers and cataracts, water and sanitation issues; drought and extreme weather events such as more frequent and severe heat waves that could result in heat-related deaths, accidents and trauma; environmental inequalities, which could widen the health inequalities gap; and the reduction of carbon emissions, which is a legitimate priority for public health and the NHS.
The policy drivers of the sustainability movement in the NHS include the document Choosing our Future (67), the strategy for sustainable development for Scotland issued by the then Scottish Executive. This framework sets out a common goal for sustainability, which is defined as: enabling all people throughout the world to satisfy their basic needs and enjoy better quality of life without compromising the quality of life of future generations. Figure 9.1 shows the context for this framework and challenges public health to make the well-being of Scotland’s people a key priority, following a set of principles that include a commitment to a strong, healthy and just society and a sustainable economy.
How NHS Greater Glasgow and Clyde and its partners are responding
Glasgow City Council has made a commitment to sustainability and health through Agenda 21(68) and Local Agenda 21 (69), which were developed through the Healthy City movement. NHS Greater Glasgow and Clyde is the biggest NHS employer in Scotland, employing more than 44,000 staff, and it has the potential to strengthen the NHS commitment to sustainability through collaborative and partnership working with local authorities within the policy context of Choosing our Future.
The Sustainable Development Commission’s report Sustainable Food Procurement in the NHS gives recommendations for food procurement in the NHS (70). Because they are equally relevant to other public bodies, they may support collaborative approaches to sustainable food procurement. The commission has identified four other areas in which the NHS can promote sustainability: facilities management, community engagement, new buildings and travel.
NHS Greater Glasgow and Clyde’s policy on procuring food has the potential to deliver sustainable development because large-scale procurement can send powerful messages up the food chain to wholesale producers. In addition, it can support the local economy and the food it serves has a direct and indirect impact on population health.
On a smaller scale, Have a Heart Paisley funded a pilot commercial fruit shop in the Royal Alexandra Hospital in Paisley in 2002. The shop was a response to the growing rates of cardiovascular disease in an area with high levels of deprivation. The shop, which is in the hospital foyer, gives patients, staff and visitors access to good quality, fresh fruit and vegetables at reasonable prices.
These policies and examples demonstrate that NHS procurement activities can make a considerable impact on health and the sustainable environment. The size of the NHS food shopping list shows the potential for influencing food production and distribution methods across the health system. Current procurement arrangements for the NHS address sustainability and carbon footprints through a national weighting score and using Commodity Advisory Panels to award contracts.
NHS Greater Glasgow and Clyde is currently updating its food, fluid and nutrition policy to include a wider range of issues related to food and nutritional care. The revised policy will also emphasise the Community Planning Partnership role of the organisation in influencing the awareness, affordability, availability and accessibility of healthy foods in other agencies and for communities. The policy will identify and address the nutritional needs of the most nutritionally vulnerable groups. It will also take a comprehensive approach to nutritional assessment, monitoring and care for all in-patients. The policy will address the provision of nutritional support for patients in hospital and community services, as well as considering on-site catering for hospital and residential patients, members of staff and visitors. The policy will also consider vending and provision for clients and staff in all outlets, as well as catering provided by either internal or external contractors.
In terms of food partnerships, the current review of Glasgow City Council’s food and health policy offers an opportunity for NHS Greater Glasgow and Clyde to work with and influence its partners on the affordability, availability and accessibility of healthy foods. The organisation also has the opportunity to influence the new Food and Health Frameworks, which are being devised by local authorities. This gives us a chance to promote healthy eating and to ensure that sustainability is on the agenda. This integrated approach was advocated by the report, the Footprint of Scotland’s Diet (71).
An environmental public health framework would consider land use, supported growing initiatives, recycling, waste management, distribution and transport, reduction of carbon emissions, reduction of water consumption and the reduction of the ecological footprint.
Hungry for Success – the first UK national nutrient-based standard for school meals – was published by the then Scottish Executive in 2002 (72). The NHS could develop further opportunities such as this, to adopt integrated policy approaches developed by local authorities on food procurement and sustainability.
In addition, the National Institute for Health and Clinical Excellence (NICE) produced guidance in 2006 that demonstrated the importance of involving workplaces in the prevention of obesity (73). NHS Greater Glasgow and Clyde agrees that workplaces are an important site for promoting health and its workplace health promotion team, Health at Work, provides prevention programmes to workplaces. These are designed to challenge obesity, which is a priority in the Scottish Government’s policy on workplace health, Healthy Working Lives (74). The workplace team’s programme includes: the Get Fit Nutrition IT pilot, the Food and Health Action Plan, the Healthy Eating Strategy, the Healthy Living Award promotion, Cycling and the NHS, Physical Activity Strategy work, environmental criteria and an environmental audit and action plan.
The NHS can use its facilities management function to practice sustainable working, and to encourage others to do the same. For example, NHS Scotland’s annual expenditure on waste disposal is more than £8 million, equal to the cost of 400 full-time equivalent staff nurses. NHS Scotland disposes of 45,000 tonnes of waste each year - 15,000 tonnes of it clinical and 30,000 tonnes domestic. The award winning approach to waste management adopted by the acute sector in NHS Greater Glasgow and Clyde is a shining example of sustainable development in action.
For example, NHS Greater Glasgow and Clyde recently conducted an options appraisal on plans to centralise six existing decontamination units in the acute sector in a single industrial unit in north-east Glasgow. This is a new development for the NHS, since the size and scale of throughput (12 million instruments a year) would make it the largest of its kind in the UK. The organisation involved the Carbon Trust at all stages of the development; its recommendations included reducing energy, carbon emissions and waste. This would not only reduce costs, but limit the carbon tax payable. An important part of the appraisal was to identify appropriate machinery that can do the job, be environmentally and ecologically friendly and use the minimum energy. The project team applied the principles laid down in the Green Code to all aspects of the design and commission of the new plant.
The NHS can also show leadership in applying sustainability criteria to its employment policies. Chapter two of this report highlighted how the NHS can help overcome the social and economic causes of ill health through increasing employability. This agenda aligns with sustainability, and the NHS responsibility for integrating employability into all new-build projects can be replicated in current approaches across the health system. This agenda can contribute to social and economic regeneration when hospitals are being built or redesigned, by actively engaging with national initiatives to improve access by small businesses, including the social economy sector.
For example, the Acute Community Engagement Team in NHS Greater Glasgow and Clyde has commissioned a socio-economic impact study of the new South Glasgow Hospitals, and will engage with regeneration agencies to develop the potential of redevelopment locally, regionally and nationally. The organisation is also developing a Recruitment and Rehabilitation Policy that supports and complements current work to increase access to NHS jobs by the long-term unemployed.
This work links to the Scottish Government’s policy A Smart Successful Scotland (75), and demonstrates NHS Greater Glasgow and Clyde’s commitment to closing the opportunity gap by tackling poverty and disadvantage and by increasing opportunities for sustainable employment at a local level.
The NHS can also increase its sustainability through progressive policies on transport and travel. NHS Greater Glasgow and Clyde is introducing Green Travel Plans at its largest sites and has developed a green travel policy that encourages all staff to reduce their car use by choosing other forms of transport, including walking and cycling. The organisation is working in partnership with Scottish Passenger Transport, local authorities and the Scottish Government to improve public transport services in the area (76).
Another area in which the NHS faces a challenge is how it deals with climate change and air quality. Public health in Scotland faces two environmental challenges: temperatures are becoming steadily warmer and levels of air pollution are still unacceptably high. According to figures from the then Scottish Executive and the Met Office, temperatures in Scotland in the years 2003, 2004, 2005 and 2006 were the highest since records began in 1914. By the end of the century, they are predicted to increase by up to 3.5°C in summer months and 2.5°C in winter. The implications of climate change for Scotland include increased flood risk and impacts on water resources, agriculture, transport, tourism and disease.
Air quality is defined by the levels of pollutants, particularly particulate matter, ozone, sulphur dioxide, and nitrogen oxides.
The Committee on the Medical Effects of Air Pollution has concluded that long-term exposure to air pollutants decreases life expectancy. The committee suggests that particulate air pollution, in particular, has a greater effect on mortality than previously thought, with a small increase in fine particles being associated with a 6% increase in risk of death from all causes. The committee’s report on air pollution and cardiovascular disease (2006) (77) concluded that there is a clear causal link between both daily and long-term average concentrations of air pollutants and effects on the cardiovascular system, including risk of sudden death and hospital admission for acute cardiac events.
All local authorities in Scotland are required by law to monitor air quality in their areas and to prepare an annual report on this for the Scottish Government. All local authorities in the NHS Greater Glasgow and Clyde area are actively monitoring air quality and taking action in locations where the level of pollutants is particularly high.
For example, a number of councils have introduced random vehicle emission testing, campaigns to persuade drivers to switch off their engines when stationary and schemes to reduce high concentrations of traffic at particular pollution “hot spots”.
Key public health messages and priorities for action
In order to address sustainability issues the following need to happen:
Partnership work through community planning should focus on improving public health, the local economy, social cohesion and the environment. Examples of this approach include the following:
All public sector organisations in the Greater Glasgow and Clyde area should adopt a leadership role in promoting sustainability. Examples of this approach include: