At the Conference of Parties (COP21) in December 2015, the leaders of 187 countries agreed to limit average global temperature increases to below two degrees Celsius compared to pre-industrial levels. The fact that such an agreement could be achieved across this large number of parties is encouraging, but much work will need to follow to achieve the ambitious aim. Are the effects of climate change starting to become more apparent in many countries, with changes in weather patterns, floods and draughts and the acidification of oceans?
It is also increasingly recognised that the health of our populations will be strongly linked to climate change and its effects. The 2015 Lancet commission on health and climate change identifies a number of potential dangers to human health and wellbeing from climate change:1
- Under-nutrition following reduced fishery as a result of ocean acidification as well as a reduction in agricultural productivity through biodiversity loss, ecosystem collapses and pests.
- Increased vector-borne diseases and harmful algal blossoms from increases in temperatures and changes in rain fall patterns.
- Droughts and fires resulting in ozone and particulate pollution of the air as well as higher pollen allergenicity burdens, all of which may increase respiratory diseases.
- Cardiovascular diseases and excess summer deaths from heat waves.
- Impacts on mental health, amongst others from loss of habitation, poverty, mass migration and the associated loss of community resilience as well as an increase in violent conflicts.
Reducing carbon emissions from healthcare
In the face of these risks to the health of current and future generations, the management of their own carbon emissions is becoming increasingly important for many organisations within the healthcare sector. Strategies to reduce the carbon footprint of the health service are numerous and include reductions in emissions from procurement, travel and the energy use of buildings. While general practitioners may best contribute through preventing the need for resource intensive treatments, acute hospitals were recognised to have significant potential to reduce building energy consumption by cutting unnecessary energy services and increasing energy efficiency.2
Furthermore, building energy use is important for hospitals in view of rising energy costs, the need to ensure a secure and resilient energy supply in health critical environments as well as given increasing energy demands across the world. The 2010 European Energy Performance of Buildings Directive also explicitly encourages reductions in the energy demand of all buildings, while some countries (amongst them the UK) also publish carbon reduction targets specific to the healthcare sector.
Reducing hospital energy use
Acute hospitals are complex buildings with unique energy requirements: they are occupied 24/7 by a large number of people, many of whom are vulnerable and require a strict control of the thermal environment. Medical requirements further necessitate the control of indoor air parameters, especially in operating theatres and treatment rooms. Specialist medical equipment, sterilisation, laundries and food preparation also contribute to a hospital’s substantial electricity use.3 Going forward, further increases in energy consumption are expected from innovative new therapies such as proton beam therapy, but also from higher cooling loads as well as rising hospital admissions in an ageing population.
Many different strategies may result in reductions in hospital energy use. Primarily, they include technical measures such as the retrofitting of fabric insulation to older buildings and updates to lighting installations as well as to pumps, motors, lifts and space conditioning equipment. Salix Finance (a government arm’s length organisation providing much of the funding for energy-saving projects to hospitals in England, Scotland and Wales) list combined heat and power (CHP), heat recovery and LED lighting as most commissioned energy technologies in the National Health Service between 2012 and 2014.4
A marginal cost abatement curve outlining carbon abatement potentials and the cost of measures within healthcare in England also expects large, cost effective carbon savings from CHP plants in acute hospitals as well as from improvements in heating and lighting controls and the installation of more energy efficient lighting.5
To help healthcare organisations manage the energy use of their buildings, the UK Department of Health publishes and regularly updates the guidance document EnCO2de6 (in 2006, latest version from 2015). In addition, many other non-government bodies offer advice for hospital energy managers, in the UK notably through the Carbon Trust’s Carbon Management Programme and previously the Building Research Energy Conservation Support Unit. A plethora of both historic and current Carbon Management Plans of individual trusts are also available as exemplars, if not as best practice examples. In other European countries, comparable guidance documents exist such as in Germany,7 in Austria8 or in the US.9
In the design of new hospitals, the appreciation of future climate scenarios is crucial. In the UK, the overheating of buildings is a growing concern, especially in urban areas experiencing heat island effects. While avoiding any risk of airborne cross-infection has long been a major driver for the blanket provision of fully mechanically ventilated health environments, this is increasingly questioned in the context of ambitious energy reduction programmes. A modelling exercise in the UK suggests that 70% of the net floor area of small-to-medium-sized acute hospitals could be naturally ventilated without any concern for patient safety.10 Carefully questioning the requirement for and the specification of all building services hence needs to be part of all attempts at low carbon hospital design.
The role of clinical staff in reducing hospital energy use
Aside from design and technical measures, all healthcare staff can further contribute to reducing their organisation’s energy use while ideally improving their working conditions as well as the healing environment for their patients.11 Money saved through energy efficiency measures may at best be redirected to delivering healthcare, for example, to alleviate prevalent staffing pressures. Some measures such as training for the use of heating controls may further improve the thermal comfort of both patients and staff.
In the UK, Operation TLC (initially trialled at Bart’s Health NHS Trust) has been one example of a successful campaign that has managed to reduce the hospital’s energy use while improving the interior conditions for staff and patients.12 The awareness campaign asked staff to turn equipment off when not in use (T), switch lights off when possible (L) and close doors and windows while heating or cooling was active (C). It focused on wards as 24-hour areas, but included some offices and clinical day areas. Rewards within small teams and improving patient experience were identified as central motivators for clinical staff and consequently stressed in communicating the campaign. While the engagement of staff with the awareness campaign varied throughout the hospital, some departments achieved substantial reductions, especially in after-hours energy use and patients reported to sleep well on wards engaged with the campaign.
More recent research looking beyond individual members of staff and at how clinical processes relate to hospital energy use13 further highlighted the important role of clinicians and clinical management in championing reductions in hospital energy use. Fundamentally, a good working relationship with the estates and facilities management team was recognised as mutually beneficial. The facilities management (FM) teams of large hospitals are in charge of a huge number of different spaces and areas, with differing operating hours, temperature requirements and special needs. As technical experts, their knowledge on clinical processes is necessarily limited. A close working relationship between the clinical management of each department and the FM team may therefore help to ensure that the departmental needs and requirements are met, while avoiding a somehow wasteful blanket provision of services ‘just in case’.
A simple example of this relates to the use of IT equipment. Many hospitals feature automated PC power down software, which automatically switches off workstations in non-clinical areas in the evenings and restarts them in the morning. This feature, which is often well received by staff as reducing the chores needing to be remembered, can be extended to clinical areas – but only if the central IT department is aware of workstations that are not needed during the night. By communicating and updating actual working hours of departments and spaces within departments, clinicians may hence contribute to maximising the energy savings from a customised IT power down. Clarifying actual operating hours also helps to enable heating and cooling energy savings by allowing for nighttime temperature setbacks, a potentially impactful measure given that up to two thirds of hospital energy use can be for heating and cooling.
More fundamentally, an increased clinician input into the detailed specification of building services required to ensure optimal patient outcomes could be beneficial. This may range from the required colour rendering properties of lighting installations to help diagnosis over the need for ventilation to reduce infection rates to future scenarios of health care provision and how hospital buildings may best support these. Naturally, such collaborations take time, a commodity traditionally sparse in healthcare organisations. Mutual benefits at the local level as well as the input of professional organisations such as medical associations and long-term planning more generally may be helpful here.
Energy costs, particularly electricity costs, are a growing concern for many acute hospitals. In response, many now have carbon, environmental or energy managers in place. They have an enormously challenging task, often hindered by the complexity of hospital operations and the low priority energy issues have in the face of the organisational core task to provide healthcare to our populations. With the increasing realisation, however, that climate change will fundamentally affect human health, there may be scope for this to change while – in the words of the 2015 Lancet commission – “tackling climate change could be the greatest global health opportunity of the 21st century”.
- Watts N et al. Health and climate change: policy responses to protect public health. Lancet 2015;386:1861–914.
- NHS Sustainable Development Unit, Sustainable, resilient, healthy people & places. A sustainable development strategy for the NHS, public health and social care system. Report, NHS Sustainable Development Unit, 2014. Available at: http://www.sduhealth.org.uk/policy-strategy/engagement-resources.aspx. Accessed March 2016.
- Carbon Trust, Hospitals. Healthy budgets through energy efficiency. Technical report, Carbon Trust, London, UK, 2010.
- Salix Finance. Salix working within the NHS. Briefing, 2014. Available at: http://www.salixfinance.co.uk/system/public_files/nhs_briefing_final.pdf. Accessed March 2016.
- NHS Sustainable Development Unit, Save Money by Saving Carbon. Decision Making in the NHS using Marginal Abatement Cost Curves. Technical report, NHS Sustainable Development Unit, 2010.
- Department of Health, EnCO2de- making energy work in healthcare: environment and sustainability. Technical report, Department of Health and Carbon Trust and Building Research Establishment and NHS Scotland Property and Environment Forum and Welsh Health Estates and Northern Ireland Health Estates, 2006.
- Tippkötter R, Wallschlag B. Leitfaden. Energieeffizienz für Krankenhäuser. 2. Auflage. EnergieAgentur. NRW, 2009.
- Benke G et al. Das energieeffiziente Krankenhaus. Realistische Ansatzpunkte und Massnahmenidentifikation (in German). 2009, Bundesministerium für Verkehr, Innovation und Technologie: Wien.
- Singer BC et al. Hospital Energy Benchmarking Guidance – Version 1.0, in LBNL Report 2009, Berkeley CA: Lawrence Berkeley National Laboratory.
- Short CA, Al-Maiyah S. Design strategy for low-energy ventilation and cooling of hospitals. Build Res Inf 2009;37(3):264–92.
- Short CA et al. Health Technical Memorandum 07-02: EnCO2de 2015 – making energy work in healthcare. 2015, Department of Health: London.
- NHS Sustainable Development Unit, Changing Energy Behaviours in the NHS: Operation TLC, 2013. Available at: http://www.sduhealth.org.uk/news/214/barts-health-nhs-trust-saves-100000…. Last accessed March 2016.
- Morgenstern P. Understanding hospital electricity use: an end-use(r) perspective. 2016, PhD thesis. University College London, London.