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In 2014, The Lancet published a Series about the waste that occurs throughout biomedical research.1 Awareness is also increasing about the waste that occurs in clinical care. Last year, the Academy of Medical Royal Colleges published a report stating that the National Health Service (NHS) could save more than £2 billion if doctors reduced their overuse of tests, interventions, medications, and hospital beds.2 This wasteful use of clinical resources suggests a need to improve sustainability in health care, given the current context of constrained resources. The sustainability framework, initially developed by Elkington for a corporate context,2 when applied to health care can help to ensure that high-value care will continue into the future despite increasing financial and environmental constraints.

Reduction of waste in clinical care is desirable for several reasons. First, it allows the money saved to be better spent elsewhere to improve patient outcomes. Second, it can also reduce the social cost of care for patients, such as those who have to give up half a day of work for an unnecessary review by their care team. Third, every clinical activity has a carbon footprint, and a decrease in the unnecessary use of clinical resources would reduce the highly significant environmental impact of the NHS.

Health care is a carbon-intensive industry; in the UK, it is the largest contributor of greenhouse gases in the public sector3 and has a carbon footprint larger than that of some medium-sized European countries.4 In the USA, it contributes 8% of annual national greenhouse gas emissions.5 Mental health services account for 1·47 million tonnes of carbon dioxide emissions in the UK; however, they out-perform other services in terms of carbon footprint per pound spent.3 The single largest component of the carbon footprint of mental health care is pharmaceuticals, followed by medical equipment and clinically related travel.3 In fact, clinical factors account for most of the carbon footprint of health care, whereas buildings and energy use contribute only around 17%.3 The NHS has signed up to meet the Climate Change Act targets of an 80% reduction of their carbon footprint by 2050.3 Carbon reductions need to be in the order of 20 million tonnes, of which about 1·2 million tonnes will need to come from mental health.3 Unless psychiatrists engage in designing and implementing less carbon-intensive care pathways, only marginal reductions of mental health care's large carbon footprint will ever be achieved.

Psychiatrists are already accustomed to dealing with low financial resources—now they need to be aware of the finite environmental resources, and develop the perspective of a wise steward of clinical resources. This concept lies at the heart of sustainability in health care.

Medication waste is an obvious area that needs to be assessed. In view of the low rates of adherence in those with long-term mental illness, improved prescribing practice could potentially reduce the carbon footprint of mental health care in the UK by 10%.3 Importantly, however, how care is provided also needs to be reviewed. How can we provide high-quality care that is less financially and environmentally resource intensive and that can restore social capital? Examples might include reducing impact from travel by encouraging active travel methods or empowering patients to self-manage by using community support groups or online educational materials. Sustainable interventions that have a low carbon footprint and also provide social value might include group therapy, horticultural therapy, art groups, or social prescribing services.6 Through the use of standard NICE treatment regimes7 and carbon conversion factors,3 the carbon footprint of depression treatments can be estimated. Calculations show that the carbon footprint of cognitive behavioural therapy (16 sessions and two follow-ups; 1100 kg carbon dioxide emissions) is larger than that of antidepressant treatment with psychiatrist follow-up (900 kg carbon dioxide emissions). This difference is because the carbon footprint for each therapy session, including the travel and the energy it takes to heat and light the room, outweighs that of medication. By contrast, the estimate for the carbon footprint of video-linked face-to-face cognitive behavioural therapy is much smaller, at around 230 kg carbon dioxide emissions. Similarly, telephone-based cognitive behavioural therapy and online-based cognitive behavioural therapy also have much smaller carbon footprints (230 and 110 kg carbon dioxide emissions, respectively). Given the significant differences in carbon footprint between these options, further thought needs to be given to the management of depression. Use of natural settings such as outdoor mindfulness groups or social prescribing could potentially maintain the quality of care while reducing the carbon footprint, without losing the important aspect of face-to-face interaction.6

On a global scale, the UN Sustainable Development Goals will be launched later this year, following the Millennium Development Goals programme. These sustainable goals focus on ecosystems, natural resources, water availability, and agricultural practices rather than the simpler health outcomes of the Millennium Development Goals. Furthermore, a new goal has been added: “Take urgent action to combat climate change and its impacts”.8 This progression towards a sustainable agenda by the UN is a result of the acknowledgement that human health is far more likely to be affected in the future by these more complex global factors, mainly because of continued population growth and the increasing prevalence of consumption-oriented ways of living.9 In fact, the Lancet Commission on managing the health effects of climate change and WHO have both stated that climate change is the largest threat to human health in the 21st century.10, 11 This threat extends to mental illness, with increasing evidence that unstable weather patterns—a direct consequence of climate change—can have harmful effects on mental health.12 Secondary effects can also occur, such as an increased prevalence of psychosis following climate-induced migration and increased urbanisation.12 Crucially, people who are socially disadvantaged, have poor social connections, and live in rural areas are most vulnerable to the effects of climate change.12 Limiting the environmental effects of mental health care and addressing the social determinants of mental illness are both crucial to the sustainability of mental health care, both in the UK and worldwide.

Changes in mental health services will help to mitigate against climate change and will also help to deal with the damage already done. As psychiatrists, we are accustomed to dealing with individuals, not the bigger picture. However, given this very real threat to human health, there are increasing calls for doctors to advocate for a satisfactory response from governments and international organisations about climate change.10 The first step should be to try and reduce the large carbon footprint of mental health care. If doctors, who remain the most trusted professional group,13 can lead the way by actively engaging with this distressing and complex issue, then perhaps internationally we can begin to develop an adequate response to the serious threat that climate change poses to health.

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Ashley Cooper/Science Photo Library

We declare no competing interests.

References

  1. 1Macleod, MR, Michie, S, Roberts, I et al. Biomedical research: increasing value, reducing waste. Lancet. 2014; 383: 101–104
  2. 2Maughan, D and Ansell, J. Protecting resources, promoting value: a doctor's guideto cutting waste in clinical care. http://www.aomrc.org.uk/dmdocuments/Promoting%20value%20FINAL.pdf; November, 2014. ((accessed Feb 2, 2015).)
  3. 3NHS Sustainable Development Unit. Goods and services carbon hotspots. http://www.sdu.nhs.uk/documents/resources/Hotspot_full.pdf; Dec 3, 2013. ((accessed Dec 12, 2014).)
  4. 4Steen-Olsen, K, Weinzettel, J, Cranston, G, Ercin, AE, and Hertwich, EG. Carbon, land, and water footprint accounts for the European Union: consumption, production, and displacements through international trade. Environ Sci Technol. 2012; 46: 10883–10891
  5. 5Chung, JW and Meltzer, DO. Estimate of the carbon footprint of the US health care sector. JAMA. 2009; 302: 1970–1972
  6. 6Yarlagadda, S, Maughan, D, Lingwood, S, and Davison, P. Sustainable psychiatry in the UK. Psychiatr Bull. 2014; 38: 285–290
  7. 7NICE. Depression. http://pathways.nice.org.uk/pathways/depression; 2010. ((accessed March 5, 2014).)
  8. 8United Nations. Outcome Document – open working group on sustainable development goals. http://sustainabledevelopment.un.org/focussdgs.html. ((accessed Oct 8, 2014).)
  9. 9Intergovernmental Panel on Climate Change. Climate change 2013. Intergovernmental panel on climate change, United Nations. http://www.ipcc.ch/pdf/assessment-report/ar5/wg1/WG1AR5_SPM_FINAL.pdf; 2013. ((accessed Oct 26, 2013).)
  10. 10Costello, A, Abbas, M, Allen, A et al. Managing the health effects of climate change. Lancet. 2009; 373: 1693–1733
  11. 11Chan, M. The impact of climate change on human health. World Health Organization, ; Apr 7, 2008http://www.who.int/mediacentre/news/statements/2008/s05/en/. ((accessed Dec 13, 2014).)
  12. 12Berry, HL, Bowen, K, and Kjellstrom, T. Climate change and mental health: a causal pathways framework. Int J Public Health. 2010; 55: 123–132
  13. 13Royal College of Physicians. Doctors in society. Medical professionalism in a changing world. http://www.rcplondon.ac.uk/sites/default/files/documents/doctors_in_society_reportweb.pdf; December, 2005. ((accessed March 26, 2014).)