Measuring carbon in healthcare

1. Measuring carbon in healthcare Dr. Frances Mortimer, Medical Director Centre for Sustainable Healthcare National Workshop - Carbon Modelling within Dentistry 17th February 2015

2. Measuring carbon in healthcare • Why measure carbon? • How do we do it? • Carbon measurement examples: • The whole NHS • Dorset renal service – a clinical service • Antipsychotic depot injection – an intervention • Respiratory inhalers – a product • Overview

3. Why measure carbon – how does it help? Carbon will be as important as money – you can’t commission if you can’t cost… • Policy development: setting targets, tracking progress • Service redesign: identifying carbon hotspots, evaluating innovations • Comparing higher and lower carbon interventions and products • Engaging public, staff, suppliers /providers carbon cost per QALY

4. Carbon footprint - The sum of greenhouse gas emissions released in relation to an organisation, product or service, expressed as carbon dioxide equivalents (CO2e).

5. Carbon footprint: what is included?(operational boundaries) Can be expressed in carbon dioxide equivalents (CO2e)

6. Steps involved • Define the goal and scope of the study • Identify the resources used (set boundaries, create inventory) • Measure the resource utilisation (collect data) • Attribute a carbon cost or footprint to the resources used (x carbon intensity)

7. Bottom-up versus top-down SDU. (2013). Goods and services carbon hotspots

8. Example 1 Carbon footprint of NHS England Motive: policy development, engagement Method: Scope 3 (consumption-based), mixed top-down / bottom up

9. NHS England activity data SDU. (2013) Carbon footprint update for NHS in England 2012

10. Climate Change Act 2008 targets SDU. (2013). Goods and services carbon hotspots,

11. SDU. (2013). Goods and services carbon hotspots

12. Example 2 Carbon footprint of Dorset Renal Service Motive: identify carbon hotspots, policy development/ engaging staff and others Method: Scope 3 (consumption-based), mostly bottom-up

13. Steps involved • Define the goal and scope of the study • Identify the resources used (set boundaries, create inventory) • Measure the resource utilisation (collect data) • Attribute a carbon cost or footprint to the resources used (x carbon intensity) Renal procurement data not available at national level

14. Dorset renal service • Six service components: inpatient, outpatient, haemodialysis, peritoneal dialysis, transplantation, administration • (Slices of) five sites Detailed knowledge needed for bottom-up study The Carbon Footprint of a Renal Service in the United Kingdom. Connor A. et al. QJM (2010) 103 965 – 975

15. Dorset renal service activity data The Carbon Footprint of a Renal Service in the United Kingdom. Connor A. et al. QJM (2010) 103 965 – 975

16. Discussion • Total GHG emissions from Dorset renal service = 3007 tonnes CO2e per year • Supply chain emissions contribute 72% (pharmaceuticals 35%, medical equipment 25%, waste 10%) • Carbon footprint of dialysis = 7.1 tonnes CO2e per patient per year The Carbon Footprint of a Renal Service in the United Kingdom. Connor A. et al. QJM (2010) 103 965 – 975

17. Example 3 Carbon footprint of antipsychotic depot injection Motive: service redesign: carbon modelling a service change Method: Scope 3 (consumption-based), mixed bottom-up / top-down

18. Best Practice • There is no clinical improvement from doses of Flupentixol Decanoate higher than 50mg every 4 weeks The average dose prescribed in the UK is 60mg every 2 weeks

19. Activity data / emissions factors

20. = building blocks for carbon modelling Goods and services carbon hotspots, NHS Sustainable Development Unit (2013)

21. Top down methods of carbon footprinting clinical activity • Method 1. Total NHS carbon emissions per pound total expenditure apportioned on the basis of unit costs of each activity • Method 2. Total NHS carbon emissions for secondary care (based on share of secondary care spend out of total spend) apportioned on the basis of shares of total activity for each service area • Method 3. Total NHS carbon use for inpatient and outpatient care (based on share of inpatient and outpatient spend out of total spend) apportioned on the basis of shares of total activity • Method 4. NHS Building energy use carbon emissions apportioned on the basis of inpatient activity (not applicable for outpatients)

22. Discussion Currently, being on depot causes a significant increase in a person’s total carbon footprint of 6% per year, from 7.9 tonnes CO2 to 8.4 tons per year. This could be reduced by over 50% Maughan, D., Lillywhite, R., Cooke, M. The economic cost and carbon burden of long acting injections. (submitted for publication)

23. Example 4 Carbon footprint of inhalers Motive: internal product appraisal; public reporting on carbon impact of alternative devices Method: product life-cycle, bottom up

25. The relationship between the Corporate, Scope 3, and Product Standards for a company manufacturing product A Source: GHG Protocol Product Life Cycle Accounting Reporting Standard

26. Setting boundaries

27. Discussion Inhalers contribute 5% of NHS carbon footprint Ventolin (100mcg) 200 dose Evohaler 29kg CO2e per pack144g CO2e per actuation Ventolin (200mcg) 60 Dose Accuhaler 0.8kg CO2e per pack 13g CO2e per actuation • Per actuation, MDI emissions are 11x DPI emissions • The propellant HFA134a contributes >99% of the carbon footprint of the Evohaler (MDI) • For a 200 dose Ventolin Evohaler, 88% GHG are released on inhaler use, the rest in manufacture Source: GSK, by personal communication

28. Overview • Carbon footprinting is easy: just multiply activity data x carbon intensity factors… • Understand the goals of the study when setting scope & method – will you want to compare findings or monitor impact of changes? • Data quality / access may limiting • Methodology is increasingly standardised • Be transparent about (look carefully at) boundaries and assumptions

29. frances.mortimer@sustainablehealthcare.org.uk