Over diagnosis – a new frontier in green and carbon

I got asked a q re my thoughts on greening health care

I think the asker was expecting me to mutter something about light bulbs

They were surprised to see I had no real interest in light bulbs

We’ve all said warm words (pun not intended) on carbon and stuff. 

Climate change is perhaps the key deal breaker for all of us. But perhaps the most invisible and intangible…..

Maybe the courgette crisis is as good indicator we can actually touch, rather than polar bears and melting ice caps.

Maybe the courgette crisis is a good indicator we can actually touch, rather than polar bears and melting ice caps. BUT terminology “climate change” not used so people may think flooding in England and snow in Spain is freak weather rather than incremental global climate change

Any cities ecosystem is the answer, not the individual actions of one all seeing controlling mind or large powerful organisation. i.e. ALL our individual behaviours matter, and matter a lot. Prevention paradox maybe? The notion that if we all make moderate changes to our behaviour that this may collectively have greater impact than big change in a few areas?
You’ll all have clocked the requirement on NHS organisations to have a Board approved sustainable development management plan. Yes, I thought not. 
Mention the word green to most NHS organisations and they will likely yawn and say “yea we changed the light bulbs last year”. 

Most NHS sustainability leads are in facilities management and are focussing on the cashable benefits of being operationally leaner and greener (carbon effective + cost effective) but where action is carbon effective but cost neutral then this economic driver isn’t enough. This is where leadership is required…

But overall, there is some, but not much, progress. Mostly it’s a case of “see me after class”. We aren’t on track, carbon wise.

 
New ideas are needed. 




Overdiagnosis, green and carbon.

Here’s an idea…..lots of people are sweating, a lot, about overdiagnosis and overtreatment. Diagnosis (and thus subsequent treatment – ‘we must do something’) is often low value, can do harm and wastes resources. It also uses carbon needlessly.

This is NOT  about “what happens in the boardroom”, it is about what happens in day to day clinical practice. 
I accept that it’s challenging to many. I gave a room full of 150 GPs a lot of grief on this ealier in the week and lots of eyebrows were raised (“oh but this isn’t something to do with me is it”)….. but that’s not a reason to do nothing…..

There are some notable exceptions, most visible renal medicine whom are mostly busy ripping up the rule book and resetting the mould in a lower carbon alternative. There’s cold hard cash here. Estimates vary widely. Far more important is the notion of doing the right thing.

Some factoids 

  • 61% of NHS’ carbon footprint with pharmaceuticals and medical instruments as the largest component
  • 80% of pharma footprint relates to primary care and community services
  • Never mind the carbon….prescription medicine waste in the community is high and costing £300m per year
  • Notes food waste in hospitals, particularly unserved or untouched meals. 6% meals unserved cost £28m in 2013-14
  • there are no targets on water consumption reduction and water demand is increasing by more than 10% in 2 NHS regions

So……..green is not just about the lightbulbs!

Health care is a big carbon generator. Does the diagnostic label, then the (hopefully) benefits from the downstream treatment justify the expanse, carbon, potential clinical harm that will be done.

 

 

We will definitely prescribe drugs. These are big part of the carbon chain.


 

The carbon footprint is in general practice


 

Where to look

Maybe it doesn’t matter that much. Start somewhere and keep going……
We all have our favourite targets for “overdiagnosis and over treatment”

Mine are-:

  • Poly pharmacy, esp in the elderly. No brainier.
  • Over-treatment of diabetes. Don’t get me started. 

More complex and nuanced:

  • Over medication of low level mental health problems (anti depressant prescribing growing by 10% a year, need is not). lots of studies comparing efficacy of exercise on depressive symptoms to SSRIs (Oxford Study which I can’t track down looked at exercise in green space and near water) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3674785/ What Social Prescribing was a first line treatment for early mild-moderate depressive symptoms
  • Choice in maternity care?  C section and technology assisted births becoming the norm in some areas because there isn’t choice of GP or midwife led assisted delivery units or home birth. How much of this is because this level of intervention (& carbon) is the right approach and how much is it because we haven’t commissioned the models of care that allow for alternatives. Is this level of intervention in routine presentation clinically, carbon and cost effective? Is it too hard to change because we have become too risk averse/litigious?

All of the above things are doubtless good examples of over diagnosis and over treatment where we may do more harm than good, and certainly use a lot of carbon. You’ll doubtless have many more. The Sustainability triple bottom line here is that the intervention is good for us/good for the economy/ good for the planet.
 
Here’s just one unpacked and simple example that isn’t necessarily over diagnosis related, but IS in the realm of day to day clinical practice. – respiratory inhalers….the fastest growing class of medicine in the NHS

MDI inhalers contribute a huge chunk of GHG emissions from the NHS 

This isn’t widely available but GSK have given it to me so I’m sharing it. It shows the carbon-trust-certified carbon footprint of their inhalers.

Headline figures are:

30 days of seretide 250 evohaler (pMDI) = 20kgCO2e

30 days of relvar ellipta 92/22 = 750gCO2e
http://networks.sustainablehealthcare.org.uk/networks/sustainable-respiratory-care/carbon-footprint-gsk-inhalers

So there are a bunch of places to look….. but looking carefully at overdiagnosis and carbon should be a new front

What if


 
I might (probably should) develop a chapter on Sustainability in HWB strategy and JSNA- watch this space.

Here are some other egs and links:

So…….Green and sustainable health care. Yea yea yea…. it’s more than about changing the light bulbs. Yet many stop there. Don’t. Go further. Much further

It’s a challenging one, but more interesting and novel than the normal “change lightbulb” line….

With thanks to Rachel Stancliffe from Centre for Sustainable Healthcare who let me borrow some SDU  slides. 

thanks to Rachel and Magda Boo for comment on the draft 

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