Abstract
Climate change has been termed the greatest threat to human health of the 21st century. Older people and those living with frailty are more vulnerable to the effects of climate change including heatwaves and extreme weather events, and therefore, we have a responsibility to advocate for action on the climate emergency and take steps to reduce the environmental impact of our care provision. The NHS contributes 5.7% to the carbon footprint of the UK, and by reviewing the financial costs associated with frailty, we estimate the carbon footprint of frailty to be 1.7 MtCO2e, or 7% of the total NHS carbon footprint. Resource use also increases with age with particular interventions and medical equipment such as hearing and mobility aids being predominantly associated with the care of older people. The NHS has committed to net zero carbon emissions by 2045 and in order to achieve this we all need to act—balancing the triple bottom line of environmental, social and financial impacts alongside outcomes for patients and populations when making decisions about care. The principles of sustainable healthcare are already embedded in the geriatrician’s holisitic approach to the care of older people and those living with frailty, and the imperative to reduce the carbon footprint of healthcare should add weight to the argument for extending the role of the geriatrician into other specialties. It is time to begin our journey to net-zero geriatric medicine.
Key Points
Older people are particularly vulnerable to the effects of climate change.
Frailty is associated with significant resource use and has a large carbon footprint.
We have a responsibility to act to reduce the impact of healthcare activity on the environment and on our long-term health.
Introduction
Anthropogenic climate change has already caused global warming of 1°C above pre-industrial levels, and without immediate and decisive action, this is projected to continue, leading to severe, pervasive and irreversible impacts for the planet through changing weather patterns, rising sea levels, and damage to biodiversity and ecosystems [1]. These changes will affect human society, through impacts on food and water supply, security and economic growth. Climate change has been termed the greatest threat to human health of the 21st century [1, 2].
While this has led many of us to make changes to reduce the carbon footprint of our personal lives, this should also extend to our working lives taking into account the wider influence and responsibility we have as healthcare professionals. Older people, particularly those living with frailty, are at greater risk from the changes arising due to climate change, which behoves us to advocate for action on the climate emergency [3]. Correspondingly, meeting the healthcare needs of older people has a large carbon footprint and we have a responsibility to examine what we can do to reduce environmental harms in our provision of care.
The climate emergency is a health emergency and older people are particularly vulnerable
Extreme heat, natural disasters (including floods, typhoons and hurricanes) and changing patterns of infection due to climate change are predicted to lead to an additional 250,000 additional deaths a year worldwide from 2030–2050 [4]. The physiological changes of age, accumulation of co-morbidites and presence of frailty negatively impact on ability to thermoregulate and adopt adaptive behaviours in changing environmental circumstances, and therefore, older people are likely to be more vulnerable in extreme temperatures and weather events [3].
There has been a more than 50% increase in heat-related mortality in people over the age of 65 in the last 20 years, with populations in Europe and the Eastern Mediterranean particularly vulnerable through ageing and increasing urbanisation [2]. The decade 2010–2020 was the hottest on record, with heatwaves in England in summer 2020 leading to a record 2,244 excess deaths in the over 65 age group (88% of heatwave-related excess deaths), and of these, 1,173 were in the over 85 age group [5]. During and immediately after hurricane Katrina in New Orleans in 2005, 75% of deaths were in people over the age of 60, despite this age group comprising only 15% of the local population [6]. Burning fossil fuels not only generates carbon dioxide and other greenhouse gases but also particulate air pollution, which is known to increase the risk of cardiovascular and respiratory mortality; again risks that increase with age [4].
Actions to mitigate the effects of climate change and to reduce carbon and other greenhouse gas emissions will potentially have major co-benefits for health across all age groups, including older people, and for future generations—what is good for the environment is good for our health [7].
Frailty has a large carbon footprint
A simplified metric of climate change impact is the ‘carbon footprint’: a measure of carbon dioxide equivalent (CO2e) generated by a process or activity. A carbon footprint includes carbon dioxide generated from fossil fuel combustion but also incorporates an equivalent value for other greenhouse gases such as methane, nitrous oxide and fluorinated gases [1]. Estimating the carbon footprint of healthcare activity is important to illustrate that healthcare provision does have an impact on the environment and provide a means of measuring this impact and efforts to reduce it.
The carbon footprint of the NHS is estimated to be 24.9 Mt CO2e which comprises ~5.7% of the UK’s total carbon footprint [7, 8]. The NHS also contributes significantly to air pollution, water usage, and plastic and other waste [7]. Available data on the carbon footprint of the NHS are apportioned by types of activity (for example travel, energy and equipment) but not by clinical specialty, and therefore, we do not have a direct estimate of the carbon footprint of geriatric medicine [7]. However, carbon costs correlate very closely with activity, and therefore, NHS activity related to the care of older patients is a good proxy of the scale of associated environmental impact.
Health expenditure rises in the 7th decade of life and continues to increase with age (Figure 1). Frailty is associated with increased rates of emergency and elective hospital admission, length of hospital stay and general practitioner attendances, with an estimated financial cost to the NHS of £5.8 billion per year [9]. Thus, care of older people and those living with frailty is associated with substantial resource use, including energy, medical equipment and pharmaceuticals, and we can be confident that the attributable carbon footprint is huge. While work continues on detailed carbon footprint calculations for individual components of care pathways, estimates of carbon cost can be made based on carbon intensity per £ spend or per unit of activity [10]. The carbon intensity of the NHS is 0.3 kgCO2e/£, making the carbon footprint of frailty an estimated 1.7 MtCO2e, or 7% of the total NHS carbon footprint [10].
UK healthcare spending by age (adapted from Licchetta M, Stelmach M. Fiscal sustainability and public spending on health. Office for Budget Responsibility. 2016).
Estimates of the carbon footprint of some components of care can be made on the basis of bed occupancy. In 2019, the mean number of geriatric medicine beds occupied per day in the NHS in England was 16,337, comprising 13% of all NHS inpatient beds [11]. With an inpatient bed day apportioned an average carbon footprint of 83.9 kgCO2e, this equates to 1,370 tonnes CO2e per day, equivalent to driving a petrol car around the circumference of the Earth 195 times [11].
This estimate does not also take into account frail patients occupying hospital beds under other specialities such as patients with hip fractures, the most common serious injury in older people, or having treatment not in a hospital bed such as those undergoing cataract surgery, the majority of whom are older patients; 1,100 cataract operations per day are carried out in the NHS with an estimated carbon footprint of 182 kgCO2e per operation [12].
It is also worth recognising that medical devices comprise 58% of the carbon footprint of purchased goods in the NHS, and equipment predominantly used in the care of older or frail patients, including disposable continence products, mobility aids and hearing aids, are among the top 20 contributing items [13].
As well as highlighting some of the ways in which the care of older people and those living with frailty contributes to the carbon footprint of the NHS, these examples also offer opportunities to rethink how we can deliver care to benefit both patients and the environment.
The sustainable geriatrician
In December 2020, the NHS made a historic commitment to become the world’s first ‘net zero’ health service, with a target of achieving net zero carbon emissions for all activities directly controlled or influenced (the ‘NHS carbon footprint plus’) by 2045 and an interim reduction of 80% by 2036–2039 [7]. The NHS called upon all who work in the health service to support that ambition. Because care of older and frail patients makes a large contribution to that carbon footprint, it is incumbent on all of us to examine our practice and actively seek opportunities to reduce the environmental impact of the care we deliver. We need to consider the ‘triple bottom line’ when making decisions about care—balancing the outcomes for patients and populations with the environmental, social as well as financial impact of that care.
The principles of sustainable healthcare are preventative medicine, patient empowerment and self-care, lean service delivery, and choosing low-carbon treatment options [14]. Resource use and waste reduction can be simplified to the maxim ‘reduce, reuse, recycle’ with most environmental gains to be had from reducing and reusing resources. These principles are to some extent already embedded in the geriatrician’s holistic approach to the care of frail, older people which allows resource-intensive investigations and interventions to be avoided if they are not aligned with patient-centred goals, medication review and deprescribing of inappropriate drugs, and supporting older people to maximise independence and avoid unnecessary hospital admissions. The imperative to reduce the carbon footprint of the NHS should empower geriatricians to extend their roles in, for example surgical liaison, perioperative care and promoting advanced care planning.
In terms of reuse of resources, much of what is discarded is due to poor systems. For example, mobility aids are made of aluminium, a metal for which the extraction and processing is highly carbon intensive. Such aids are too often treated as single use items due to a lack of resources to check, clean and store them for reissue, yet they could potentially be reused for years if looked after properly. As well as addressing systems, we should be asking industry to explore environmentally preferable solutions for the other equipment or medications we use from continence products to hearing aids.
Conclusion
The current and impending impact of climate change on human populations, and in particular the patient population we serve, means we have to act now on our journey to net zero geriatric medicine. We can start by informing ourselves and our patients about climate change, promoting the health benefits of a low-carbon society and leading by example. We are at the beginning of this journey and there is much scope for research and quality improvement. But begin we must.
Declaration of Conflicts of Interest
None.
Declaration of Sources of Funding
None.
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