Healthcare Leader’s Editor Victoria Vaughan interviewed the head of sustainability at NHS Supply Chain Heidi Barnard and Director of SEE Sustainability, Dr Matthew Sawyer to learn what work can be done at ICB and practice level in primary care to support reaching the NHS Net Zero target by 2045.
Victoria Vaughan (VV): What is the role of NHS Supply Chain in reaching Net Zero?
Heidi Barnard [HB]: A big part of what we’re doing is educating and informing ICBs to understand who, and what NHS Supply Chain is and what we do along with building on work we’ve done. I often get asked about making swaps and changing from product A to product B. But it’s often not as simple as that, there’s a whole clinical pathway involved and it has knock on impact.
A classic example of that is the switch from single use items to reusables, you’ve got to think about the mechanism for cleaning it, managing it and bringing it back into stock. That is part of what we can support with but it requires a broader set of stakeholders to implement it. That’s the conversation we’re trying to have, so we can support people when they do want to make changes in a way that’s actually going to have lasting sustainable benefits.
VV: What are some of the barriers you face when trying to implement switches? Do people worry about infection control?
HB: We start by thinking about the perceived barriers to this? Why wouldn’t somebody do it? And the first one tends to be around infection control. We’ve got good links with the Infection Prevention Society and they have a sustainability working group. They’re keen on working on some of these things as there’s a perception that infection control is a barrier while actually, they’re some of our biggest supporters. If you get hand hygiene right, if you get your practices right, actually, you don’t need half the stuff we’re doing.
We actually link it back to some of the healthcare issues and concerns that clinicians and practitioners have. One of the big things around glove use in particular, is poor hand hygiene and poor glove use and you end up with a huge amount of dermatitis issues. But if you get proper usage, you drive down usage. If you get proper hand hygiene in place you drive down dermatological issues. So it’s not just a sustainability benefit it has practice benefits as well.
VV: Does NHS Supply Chain have a role when it comes to an ICB wanting to work with its partner trusts and implement a change?
HB: Getting the behavioural change right is the biggest part of this. We have a supporting role in terms of availability of product, but actually it needs to come from the ICS/ICB leadership and the practitioners within the ICB because so much of it is behaviourally driven. They are closer to the individuals involved they know what will work for them. We can support and provide them with the things they need. But actually, for it to really land and to be meaningful it has to come from local leadership.
VV: Are ICBs actively seeking out NHS Supply Chain for this advice?
HB: The 42 ICSs are all at different stages in terms of how they are developing and they have all got slightly different priorities. What we’re seeing is we do have trusts, ICSs and NHS regions all reaching out.
In particular, Greener NHS and sustainability procurement leads. It depends on where they are in their journey and what they’re trying to achieve. If they start right at the beginning, they often want to kind of understand what’s been done, and what are some of the quick-win projects that they could do. You’ve then got those that are more mature who are looking to the next thing.
VV: What are the quick-wins for systems and trusts?
HB: There’s things like switching from primary virgin materials to reusable, this is often in the non-clinical space. That’s things like paper, cartridges, all of those consumables that an organisation goes through a lot. They are products on our catalogue that people procure through us.
Then you’ve got the medical side of it. From a practice point of view, what single use items have they got that can be replaced with reusable so things like switching a single use tourniquet to a reusable one. We’re doing a lot more around reusable continence products, particularly in the community. In primary care, and when we start looking at things like enteral/tube feeding, we’ve been looking at how you package up those products and how you deliver them into people’s homes. Historically they’ve been quite bulky and take up a lot of storage space. So how can you do something different with that?
VV: You’ve mentioned infection control and behavioural change but are there other common challenges that come up when you’re trying to make a change in this area?
HB: The other one is financial payback. A lot of the time this is actually an invest to save option, because obviously a reusable device, it tends to be more expensive than a single use item. So you’ve got that initial outlay of more cost. But actually, it’s a one off cost. Having finance directors and procurement directors and teams that understand that there will be a saving that is realised over time, is really important.
VV: What support are you able to provide ICBs in this area?
HB: We can give them the principles almost a bit like a formula which looks at what they are spending currently and the cost benefit of swapping something out, which can help build the business case. It gets complicated, though, as often those costs are seen in different budgets, and different departmental budget lines. You’ve got to be able to kind of pull together different budget lines to demonstrate it.
The other area is challenging people’s custom and practice and getting them to think about why they do the things they do. If you ask in a non-judgmental, non-confrontational way ‘why do we do it that way?’ you can find in some cases it is no longer relevant. Everybody is so busy, they don’t have always have the headspace to be able to take that step back and think about ‘why’ we do things a certain way.
VV: Have you found that post Covid bad habits have developed in terms of waste?
HB: It’s not something we’ve been able to quantify, specifically, but anecdotally we get that feedback, particularly when I speak to sustainability managers and waste managers, who are obviously seeing the volumes of waste within their particular organisation not coming back down to where they were pre pandemic. Then it’s about how we work with infection control and make it part of ongoing training around best practice.
VV: How are you working with your suppliers on sustainability?
HB: This is what I spend most of my time doing. The first thing is to be really absolutely clear what it is we want from them. So we came up with the five asks approach last year which is around sustainability for any supplier, on any contract, irrespective of whether it’s medical consumables, office supplies, whatever it is, what are the bare minimum basics that we’re after.
It comes down to a carbon reduction plan. Every supplier has to have one. And we ask two social value questions at a minimum on any contracts. And that has a minimum 10% weighting. We’ve got the requirement for an evergreen assessment. So this looks at the suppliers approach to sustainability and where they are in maturity.
We ask them to be aware of and reference the longer-term supplier roadmap from NHS England. It looks at horizon scanning during the course of the contract for regulatory changes. We’ve know we’ve got some milestones coming up from NHS England, but we also know in the kind of the regulatory world around plastics, around packaging, around batteries, there’s all sorts of regulations that are changing and evolving. So are they aware of that? And are they on top of it? The final piece is around modern slavery and the due diligence approach to how we treat modern slavery and what we expect from suppliers on that.
VV: How’s it being received among your suppliers?
HB: We work with around 1,500 suppliers. The big medical suppliers have been really receptive to it, they like the fact it’s clear and concise. It means they tell the NHS once about their work in this area, they don’t have to repeat it for different parts of the NHS. They are more concerned about not getting the highest levels of maturity. And we remind them this is about the 2045 target, we’re not expecting you to be there yet. If you’re at level one and two, you’re doing amazingly. So we’re looking at how we support and enable them and those that are not there yet.
VV: And are suppliers penalised if they don’t work on sustainability?
HB: Yes. At tender submission, they have to have a carbon reduction plan and evergreen assessment and a modern slavery assessment. It they don’t answer the social value questions, which are a weighted scoring, they’ll get 0% for those questions. The fifth question on the roadmap isn’t a scored criteria, but they have to include that sort of information in their social value response. So there are consequences if they don’t of engage with the things we need them to do. But actually we’ve not had to go down that route.
VV: In October 2020, NHS England launched its Greener NHS programme and all ICBs have green plans. But do you think more is needed?
Dr Matthew Sawyer: I’m not employed or accountable to Greener NHS, but I do keep saying ‘ primary care’ to them because I think they are missing a trick.
ICBs have a green plan because all were mandated to have one. However, almost all of them are secondary care focused. There are very few with even a mention of primary care and, if they do, they really only talk about general practice.
The problem, I think, was that it was a bit of a rush job. They were told to get a green plan by the end of tomorrow and they’re like, ‘Oh, what are we going to do? I know, we’ll talk to the hospitals because they already have green plans and departments and people’. And so primary care got missed out.
VV: If primary care has been overlooked, what opportunities have been lost?
MS: I’m a GP by background – I was a GP partner then a salaried locum before I went back to university to do environmental science and environmental sustainability.
A decade or so ago, I realised that being a GP meant spending my time ‘fishing people out of the river’, rescuing them after they’d become ill.
Primary care does the bulk of patient contacts a year across GPs, pharmacies, dentists and so on. And so, I do think that we have a great opportunity in primary care to help structure some of the changes needed which in turn will help with the prevention agenda so that people don’t ‘fall in the river’.
VV: Are there examples of ICBs getting it right with primary care sustainability? And, if so, what are they doing?
MS: Some ICBs and PCNs are incentivising practices to do environmentally sustainable actions.
For example, Gloucestershire ICB set 15 different environmental actions and they had an incentive scheme where practices chose three of them and there was some money that went with it to help them to do those actions. There were some around energy and estates, travel, medicines and inhalers.
But there’s a lot of ICBs where primary care and environmental sustainability are not even on the agenda.
VV: What can primary care do to be more sustainable?
MS: The first is reducing activity. So, when it comes to prescribing, don’t prescribe if it’s not needed. From a sustainability perspective, the best thing is to prevent people from getting illnesses.
Second is the environmental impact of primary care. When it comes to the carbon footprint, there is clinical and non-clinical. There is a carbon footprint of the medicines that are prescribed and there are non-clinical carbon emissions, which are from running the practice – the energy, the gas, the electric, and the travel from patients and staff. And it’s not just carbon. There’s plastic, pharmaceutical pollution into waterways and all sorts of other environmental impacts, which can be quite hard to measure.
Then there are goods and services. For example, if you buy a minor surgery kit, how much of it is just going straight in the bin? So, we then need to be working with the suppliers to say, ‘Can you stop? We don’t use them so why are you putting them in a pack for us to buy? That doesn’t make any sense’.
And then there is how we can use our medical and health knowledge to influence things like how many fast-food chains there are. We may be able to use our knowledge and our experience to influence others to make decisions that are best for the community in the long run.
VV: Some of that is at a system level, then?
MS: A GP practice will not and cannot do these things on their own. That’s really where the system needs to change. It’s where the ICS, ICB, PCN and local authorities all come together and we need to get the staff, the patients, and the practices to be able to feed this back up to the ICS.
For example, creating low traffic neighbourhoods is better for social cohesion, there is less air pollution and it’s far better for kids getting into school. If you do it in towns, people are more likely to visit shops because they’re out walking rather than driving down the high street. And then we get other benefits such as money in the pockets of local businesses.
So, from a sustainability point of view, we can make the argument that if we improve travel and traffic options, we get lots of benefits. We’re not just doing it because it’s environmentally good to get people out of cars, but because the knock-on effects are even greater.
VV: What can individual practices do to be more sustainable?
MS: In general practice, we don’t always recognise that the way we do things might be environmentally harmful, or that it might be affecting our patients. And if a GP practice doesn’t recognise where the harm is coming from, they’re not going to make any changes.
So for example, I did a travel survey with a practice and asked staff how they got to work – how far they travelled and what mode of transport? Prof Mike Berners Lee has estimated how much time is lost from a human life by one mile travelled by different vehicle types. And in that one practice, we could calculate that the patients and staff who are travelling to either deliver or receive healthcare services took away about eight years of life from the community.
Then there are things like decarbonising the heating of a practice. If your boiler has got another 10 years of life left in it, use it for 10 years – then once you can’t use it anymore, go for the alternative. Using air source heat pumps and running it on electricity, rather than gas, makes a big difference to the carbon footprint.
VV: Primary care medicines account for most if the carbon footprint in primary care how can practices help in addressing that problem?
MS: Rough figures are 48% of the carbon footprint of primary care – that is, general practice – is medicines and four areas – inhalers, energy, travel, and goods and services – are all 13%. Yet everyone focuses on inhalers. If we’re putting a lot of effort into inhalers, we should be putting the same energy into reducing our carbon footprint in travel and goods and services.
We’ve known about the carbon footprint of inhalers because of the prepared gases, but we’ve not known it for medicines. Now we do because of an app that was launched about a month ago. Anybody can go online and have a look at the carbon footprint of an aerosol, a fibrate, a statin, antibiotic or whatever. You can see whether it’s low, medium, or high in terms of carbon footprint.
Until now, we’ve only had clinical and financial data. So, this is just another piece of research that gives a bit more information. It means that we can start to say that if we have got something which is good for patients and it’s cheap – realistically, that’s the way that some of the NHS decisions are made – and it’s less harmful for the environment, then that medication is going to get three green ticks.
VV: Do you think that practices should be making prescribing decisions around this?
MS: At the moment, the medicines management committee in an ICB are making decisions based on two bits of information – the NICE clinical guidelines and the financial indication. This is just a third piece. So that when it comes to the local guidance or regional guidance, it will be incorporated into that process of producing that formulary in the same way as we have now: this is your first choice, your second and this is your third choice on the formulary.
VV: The NHS set quite ambitious Net Zero targets. Do you think they will be met?
MS: I think that if we continue to provide services in the way that we do at the moment, I don’t know that we will meet the targets.
However, if there’s a change of focus to say that this is not about disease, but about preventing people from getting the illness in the first place then that’s the most sustainable thing we can do and we have a very powerful opportunity to provide great outcomes for the whole population as well as individual patients.
And we can do it within the financial budget that the NHS is always constrained by, and without causing anywhere near as much harm to the natural living world as we are at the moment. So, I am optimistic.
