Educating for Sustainable Healthcare –
Priority Learning Outcomes (1st draft)

 
The doctor as scholar and scientist 


 1.Ecosystems and human health 
 The doctor will demonstrate an understanding of the functioning of the natural systems underpinning human health. These ”ecosystem services” include oxygenated air, fertile soils, adequate clean water, carbon-based and renewable energy sources and a stable climate.(1) In addition urban and rural green spaces contribute to physical health and mental well-being. Though freely available and easily taken for granted these services are of incalculable value to human health.

Curriculum links: wider determinants of health, nutrition, basic human needs (Maslow’s hierarchy), health economics

2. Human impact on ecosystems 
 The doctor will be able to describe the ways in which human activity is having a major impact on the global ecosystem. The system is robust but can only allow life to flourish within “planetary boundaries” such as those scientifically established for atmospheric carbon dioxide, biodiversity loss, and ocean acidification. (2) These boundaries have been surpassed or are threatened as a result of human activity since the industrial revolution, resulting in adverse conditions such as global warming, glacial melt and the threat of sea-level rise.(3)

Curriculum links: wider determinants of health, global health, population studies, dealing with uncertainty and complexity

  3. Health effects of ecosystem stress 
 The doctor will recognise the direct and indirect effects of ecosystem stress on human health. (4) Direct effects include the impact of air pollution on cardiorespiratory disease. Indirect effects include the impact of global warming on drought and flood and hence on food security. The increasing frequency of extreme weather events, water scarcity and seawater inundation will have unequal social distribution, with poorer, older and immune-compromised populations worst affected, but will ultimately affect everyone, for example via mass migration and resource depletion.  

Curriculum links: environmental medicine, clinical epidemiology, risk management, global health, health inequalities

4. The Sustainability Paradigm
The doctor will understand the concept of sustainability which acknowledges planetary boundaries and seeks ways for humans to thrive within them - looking after things now so that they can be enjoyed by future generations. The emphasis is on the appropriate use of resources and the minimisation of waste. In healthcare this equates to preventative medicine, lean system design, building resilience and promoting virtuous cycles that sustain both human and planetary health. (5) For example active travel (walking, cycling) reduces obesity and carbon dioxide emissions.

Curriculum links: public health, preventative medicine, sociology of health, psychology of behaviour change

5. Measuring the environmental impact of health services
The doctor will understand and quantify the ways in which health services impact on the environment. (6) For example, sources of greenhouse gas emissions may be divided into transportation, energy use in buildings and supply chain activities (such as the manufacture of drugs and equipment).  In addition, release of gases such as inhaled anaesthetics and hydrocarbons used in respiratory inhalers contribute directly to atmospheric warming.  The graduate will demonstrate “carbon literacy”, understanding how their own clinical services impact in these domains, including an understanding of tools such as waste and energy audit.(7)

Curriculum links: health economics, economic prescribing, epidemiology, reflective practice, audit.

The doctor as practitioner


 6. Fostering self-care and resilience
The doctor will support individual and community resilience. This includes promoting patients’ ability to understand, prevent, self-treat or appropriately seek treatment for health problems(8); educating patients about health and the environment; and promoting health-related behaviours that benefit both. The doctor will recognise that the most deprived patients are likely to have the least resilience to adverse effects of ecosystem stress.

Curriculum links: health promotion, supporting patients caring for themselves, communication skills.

7. Lean clinical care pathways
The doctor will be able to design and deliver “lean” clinical care pathways that optimise value to patients and populations.(9) Lean clinical care is shaped by patients’ own priorities, avoids unnecessary clinic visits, only orders investigations likely to lead to patient benefit and scrutinises all prescriptions for current necessity. Advanced care planning at the end of life exemplifies this approach. Lean care pathways deliver on the triple bottom line of improved clinical outcomes (including fewer adverse events), reduced cost and reduced environmental impact.

Curriculum links: prescribing economically, reflective practice, end-of-life care, patient safety, quality.

8. Resource management
The doctor has a duty to make the best use of resources for financial and environmental reasons.  Wasted resources – such as money, water and fuel - accrue a cost to the wider society, since they cannot be used to promote health in other areas.   Energy management will be a particular challenge if energy prices continue to rise as predicted.(10) The graduate should be able to include environmental indicators in healthcare management and seek ways to improve the use and prioritisation of resources.

Curriculum links: doctor as manager, audit, clinical governance, health economics

9. Healthy spaces and healthcare environments
The doctor will be aware that the buildings in which healthcare takes place contribute tangibly to the therapeutic environment. Those with access to daylight and outside spaces reconnect staff and patients to the environment and thus meet important psychological needs.(11) Buildings also consume energy as we 
heat, cool and light them, and doctors should understand the principles of building design, energy efficiency and how to promote healthy environments in their workplaces and in wider society.(12)

Curriculum links: environmental hazards, wider determinants of health, psychological factors in health

The doctor as professional 

 10. Ethics and values
 The Hippocratic Canon offers the twin injunctions to do good and not to do harm. These ethics apply not only to individual patients, but to those systems that sustain human health, and not just to the current but to future generations. Sustainability also highlights prevailing tensions between freedom of action (autonomy) and the ethic of justice, as those most affected by harms to the global environment are those least responsible for causing them. The doctor will be able to recognise and articulate his or her own values and principles in relation to sustainability and, by upholding these values, to act with integrity.(13)

Curriculum Links – ethics, respect for all, rights of all, acting with integrity

11. Policy and law
Doctors working in the NHS share their institution’s legal duty to reduce greenhouse gas emissions as part of the public sector’s responsibilities outlined in the Climate Change Act of 2008 which set out a mandatory 80% reduction in carbon emissions by 2050.(14) The doctor will be able to understand their institution’s sustainability policies and to work with colleagues to achieve mandatory and voluntary goals.

Curriculum Links – Legal responsibilities , knowledge of laws

12. Improvement science
The doctor has a role as  team manager and as a leader of public opinion to promote appropriate action within their organisation.  The doctor will understand behaviour change and change management and will explain how promoting sustainability of care systems and of healthcare organisations relates to other drivers for service improvement and organisational change. The doctor will work with colleagues in various disciplines to achieve common objectives. 

Curriculum Links – Doctor as manager, team-working, behavioural change.



References

1.             Ecosystems and Human Well-Being: Health Synthesis from the Millennium Ecosystem Assessment. [Internet]. World Health Organisation; 2005. Available from: http://www.who.int/globalchange/ecosystems/ecosys.pdf

2.             Rockström J, Klum M. The Human Quest: Prospering Within Planetary Boundaries [Internet]. Princeton University Press; 2012. Available from: http://www.ecologyandsociety.org/vol14/iss2/art32/main.html

3.             Climate change: a summary of the science [Internet]. The Royal Society; 2010. Available from: http://royalsociety.org/climate-change-summary-of-science/

4.             Costello A, Abbas M, Allen A, Ball S, Bell S, Bellamy R, et al. Managing the health effects of climate change: Lancet and University College London Institute for Global Health Commission. Lancet. 2009 May 16;373(9676):1693–733.

5.             Schroeder K, Thompson T, Frith K, Pencheon D. Sustainable Healthcare. Wiley-Blackwell; 2012.

6.             NHS England Carbon Footprint (published 2012) [Internet]. NHS Sustainable Development Unit; 2012. Available from: http://www.sdu.nhs.uk/documents/publications/NHS_Carbon_Footprint_Published_2012.pdf

7.             Connor A, Lillywhite R, Cooke MW. The carbon footprint of a renal service in the United Kingdom. QJM. 2010 Dec;103(12):965–75.

8.             Bodenheimer T, Lorig K, Homan H. Patient Self-management of Chronic Disease in Primary Care. JAMA: The Journal of the American Medical Association. 2002;288(19):2469–75.

9.             Kim CS, Spahlinger DA, Kin JM, Billi JE. Lean health care: What can hospitals learn from a world-class automaker? Journal of Hospital Medicine. 2006;1(3):191–9.

10.          Raffle AE. Oil, health, and health care. BMJ. 2010 Sep;341(sep01 2):c4596–c4596.

11.          Maller C, Townsend M, Pryor A, Brown P, St Leger L. Healthy nature healthy people: “contact with nature” as an upstream health promotion intervention for populations. Health Promot Int. 2006 Mar;21(1):45–54.

12.          Guenther R, Vittori G. Sustainable Healthcare Architecture. 1st ed. Wiley; 2007.

13.          Stott R, Godlee F. What should we do about climate change? Health professionals need to act now, collectively and individually. BMJ. 2006;333(7576):983–4.

14.          Climate Change Act 2008. [cited 2012 Apr 19]; Available from: http://www.legislation.gov.uk/ukpga/2008/27/part/1

15.          Sustainable Healthcare Education | Centre for Sustainable Healthcare [Internet]. [cited 2011 Sep 25]. Available from: http://sustainablehealthcare.org.uk/sustainable-healthcare-education

16.          Welcome to the World Café! [Internet]. [cited 2012 Apr 19]. Available from: http://www.theworldcafe.com/

17.          Gore’s climate film has scientific errors - judge | Environment | The Guardian [Internet]. [cited 2012 Apr 19]. Available from: http://www.guardian.co.uk/environment/2007/oct/11/climatechange

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