Positive steps are being taken to reduce the carbon footprint of the Australian health system, but many challenges and questions remain, according to presentations to the recent National Medicines Symposium.
Alison Barrett reports below for the Croakey Conference News Service.
Alison Barrett writes:
In an Australian first, the Western Australian Department of Health removed one of the most polluting anaesthetic gases, desflurane, from public hospitals in October.
This move – which was applauded at the National Medicines Symposium last week – was “part of a comprehensive effort to reduce the carbon footprint of the State’s health system”, WA Health said in a statement.
It followed the longstanding efforts of a “committed body of clinicians” who had worked for several years to remove desflurane from individual anaesthetic departments across WA, Dr Emma-Leigh Synnott told Croakey prior to the symposium.
“It was a demonstration of collaboration and how people can come together to create change,” said Synnott, Medical Advisor at WA Health’s Sustainable Development Unit.
Desflurane has 2,540 times more global warming potential than an equivalent mass of carbon dioxide, with the emissions from one hour of desflurane anaesthesia being equivalent to driving 320 kilometres in a combustion engine car.
The National Medicines Symposium, hosted online by the Australian Commission on Safety and Quality in Health Care on 8 November, profiled the role and insights of a range of stakeholders in addressing the carbon footprint of pharmaceuticals – 19 percent of total carbon emissions from Australia’s health system.
A total of 1,730 people joined the symposium broadcast, with presentations by the Commission’s CEO Conjoint Professor Anne Duggan, community pharmacist and Deputy National Rural Health Commissioner Faye McMillan AM and Professor of Evidence-Based Medicine at Bond University, Paul Glasziou.
Dr Kate Charlesworth, Medical Director for the Climate Risk and Net Zero Unit in NSW Ministry of Health, told symposium attendees that “WA is to be congratulated” for removing desflurane from their state-wide formulary.
While WA is the first Australian jurisdiction to stop desflurane use in public hospitals (although it can still be made available, where clinically indicated and if no alternative anaesthetic agent can be used, through the individual patient approval process), earlier this year Scotland became the first country to ban the anaesthetic gas, removing it from use in hospitals across NHS Scotland.
In recognising the important role of clinicians, NSW Health runs a Net Zero Leads program where staff coordinate Net Zero programs in their service of specialty, focusing on known carbon hotspots, such as anaesthesia.
Anaesthetists play an important role in this work by understanding the environmental impact of desflurane. Charlesworth said they are “to be congratulated for shifting away from desflurane towards clinically equivalent alternatives”.
Wiradjuri woman and Deputy Chairperson of the Metropolitan local Aboriginal Land Council Yvonne Weldon delivered the Welcome to Country, reminding the audience of the long-standing traditions and wisdom of Aboriginal and Torres Strait Islander people.
“My people are the oldest living culture of the world and as we all gather online and in person, reflection and remembering is important,” she said.
Weldon called for us to share what we know, so we “can make a difference to the lives of so many”.
In his address, Chief Medical Officer Professor Paul Kelly thanked Australia’s health sector for the role they have already “played in galvanising action on climate change in this country”.
Kelly said the Federal Government’s forthcoming National Health and Climate Strategy aims to address the “significant challenges” of climate change by establishing a plan of action “to build a sustainable net zero health system, strengthen the health system to protect the health and wellbeing of people in Australia from the impacts of climate change, and mobilise whole-of-government climate action for healthy and resilient communities”.
The Strategy – expected to be released by the end of 2023 – appears to be following a Health in All Policies approach, as many stakeholders have urged, with Kelly saying it will engage with other sectors on mitigation and adaptation policies that have implications for human health and wellbeing.
The Strategy will build on the work already underway to “transition Australia to net zero emissions by 2050” across various Commonwealth portfolios, as well as the medical colleges, state and territory governments, he said.
The Strategy would establish a three-year plan to measure and reduce greenhouse gas emissions from the health system, as well as identifying responses to the health impacts of a changing climate, he said.
One of its key priorities would be to support the provision of appropriate and value-based care to improve patient outcomes and environmental sustainability, “optimising the use of medicines to reduce low-value care”, Kelly said.
The Strategy is expected to outline specific actions to be taken to reduce greenhouse gas emissions from the use of medicines, including promoting a move to the use of clinically safe alternatives with lower emissions, according to Kelly.
While it appears the National Health and Climate Strategy will acknowledge the current carbon footprint of the healthcare sector, and actions will be included to measure and reduce emissions, it was not clear from Kelly’s presentation and others at the symposium how much we should be aiming to reduce the use of pharmaceuticals and other healthcare activities to reach net zero by 2050.
Following the symposium, Croakey asked Assistant Minister for Health and Aged Care Ged Kearney – who is leading the Strategy’s development – if it will include emissions reduction targets for the health sector.
Her office provided this reply (which did not address the specific question):
“Australians are already experiencing the impacts of climate change on their health and wellbeing. That’s why the Albanese Government is developing Australia’s first National Health and Climate Strategy.
“The Strategy is being informed by an extensive engagement and consultation process involving researchers, clinicians, First Nations people and the wider public.”
Transition to a lower carbon footprint
One of the key symposium themes is the critical need to reduce the use of medicines and address polypharmacy – where an individual takes multiple medicines.
Dr Alpana Mair, Divisional Head of the Effective Prescribing and Therapeutics Division of the Scottish Government, told Croakey that inappropriate polypharmacy – where an individual is taking medicines that may no longer be needed – is a “global health challenge”.
She said one way this and medicines waste could be reduced is through a “sustainable, person-centred approach to medicines reviews” involving shared decision-making.
Mair told Croakey the Scottish Government is producing updated editions of its National Quality Prescribing Guides. The Respiratory and Diabetes guides are due to be published by the end of this year, with a Polypharmacy guide to follow in 2024. Each guide is supported by data and indicators that are openly available to drive improvement and improve safety, she said.
At the symposium, Mair shared information about the Scottish initiative, seven steps to appropriate prescribing, which centres around what matters to the patient. Interim findings showed the project delivered in improving the appropriate use of medicines, Mair said.
Professor Nick Watts, Former Chief Sustainability Officer of the NHS in the United Kingdom, told the symposium that “by far the most important thing is the need to make sure that we are all out there asking questions”.
“This transition is going to be big, it’s going to be complex,” said Watts, who is now the Director at the Centre for Sustainable Medicine at the National University of Singapore.
The transition will require considering “every single thing that we do in medicine”, including the use of medical devices, medicines and patient pathways.
We need to ask if there are better ways for our patient, as well as better ways that we can do this for the planet, Watts said.
Glasziou spoke about antibiotic stewardship, critically important given overuse of these medicines – he was co-author of a 2017 study that found antibiotics were prescribed for acute respiratory infections at rates four to nine times as high as those recommended by Therapeutic Guidelines.
Effective methods for reducing antibiotic prescribing may include delayed prescribing, shared decision making with the patient and a nudge poster, but different interventions may work better in combination, he told the symposium.
Some research has been done to determine which combination works best, but Glasziou said more research is needed.
“No one has yet found a magic bullet that will turn off the prescribing overnight. What is clearly needed is a sustained program of implementation, but also a sustained program of research into implementation to find out what the most effective combinations are,” Glasziou said.
The Commission is due to release the latest national data on antimicrobial use and resistance this Thursday, 16 November.
Addressing the broader determinants of health and equity considerations is another way to promote sustainability in healthcare and medicines, according to some of the health experts at the symposium.
Wiradjuri yinaa (woman) Professor Faye McMillan AM told the symposium that “when we look at a system as a whole, we can begin to build protective qualities and safe mechanisms that reduce risk and improve health outcomes for communities where and when they need them”.
This requires looking at policy and workforces, including growing the rural and remote health workforce. It is particularly important for Aboriginal and Torres Strait Islander peoples that they see “Indigenous leadership at every level of our systems and structures”, McMillan said.
McMillan said pharmacists are often the only accessible health professional in rural and regional communities. “It is necessary to establish new standards to ensure the quality training programs will support pharmacists expanding their scopes of practice,” she said.
Darlene Cox, Executive Director of Health Care Consumers’ Association, told the symposium that, based on many conversations with consumers and carers, she recommends four areas for action to improve sustainability in healthcare:
- Keep people healthy so our need for healthcare reduces
- Reduce low value care
- Prioritise quality use of medicines and diagnostic technologies
- Decarbonise the healthcare system.
Cox said the health sector needed to “change the way we do things” – for example, by holding conferences, meetings and healthcare consultations online to reduce unnecessary travel.
This comes with a “critical caveat about equity” though, she told the symposium. While virtual healthcare can help consumers receive more appropriate and timely care, “it can worsen existing health disparities”.
“Not all consumers have access to the technology or broadband” and/or may not have the “digital literacy required to engage effectively”, Cox said.
Digital literacy and accessibility will vary across individuals and communities and it is something to be mindful of, Cox told the Symposium.
Determinants of health
The cost-of-living pressures that many Australians are experiencing now are also impacted by climate change, CEO of Consumers Health Forum Dr Elizabeth Deveny said.
For example, someone living in rental accommodation who has no control over energy efficiency may not be able to afford sufficient heating or cooling. Deveny added that the people who are worst affected by climate change have fewer resources to “cope, adapt and recover”.
Deveny also said one of the key ways to improve sustainability is to do more to “integrate prevention” into all healthcare services.
“Improving prevention, reducing the burden of disease has a lot of benefits for us in maintaining the sustainable use of medicines,” Deveny said
For example, addressing social determinants of health, such as the cost of living, and improving prevention means that people living in lower socioeconomic areas or experiencing poverty will have improved health outcomes.
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