Hello Rachel, thank you for posting this. I enjoyed reading your blog.

Here’s a provocative question for you 🙂 It’s a no brainer that projects which reduce environmental impact at the same time as improving care processes or outcomes are a good thing — these are win-win situations and it is great that you have been able to identify such clear examples of this.

But what about when sustainability and other healthcare values come into tension with one another? When is it ok to implement policies and programmes which have a significant positive environmental impact but which require higher expenditure (and so have associated opportunity costs), or which will make outcomes for patients a bit worse? Or should sustainability always be treated as a secondary value in healthcare, i.e. we should only pursue sustainable solutions when this is compatible with other improvement aims?

(For context, I’m part of a group thinking about the philosophy and ethics of healthcare improvement. We are interested in highlighting and unpacking some of the value tensions that arise in healthcare improvement. And it strikes me that sustainable healthcare is an area where really important (and urgent) questions arise about the relative priority of healthcare aims and outcomes vs wider social aims.)

Hi Polly,

Thank you for your interesting question and I apologise I didn’t see this sooner. This is a great question and one really important to address (though there is no short or easy answer!)…

By using the sustainable value equation our aim is to consider and measure all elements to better understand the true impact of services and potential improvements. This means we can make balanced decisions taking different factors into account, which traditionally improvement work hasn’t always done, which in some cases may worsen inequalities (e.g., by focusing on easy to reach patients first).

In response to the patient care/ outcomes element…
Patient /populations are depicted as the ‘top line’ of the sustainable value equation as we should never be making changes for environment impact at the expense of worsening patient care. If we do worsen care, we will likely be less environmentally sustainable anyway, as the patient will need even more care / intervention / resources long term. We use the principles of sustainable clinical practice when thinking about implementing change – the first and most important is prevention, followed by patient empowerment and self care – this highlights that environmental sustainability and better health for populations are interconnected.

There can sometimes be perceptions from staff that changes will negatively impact patients, as was the case when the HIV project in the blog post was first proposed to the nursing team. However, when patients were engaged, they wanted the change to happen. This further reinforces the importance of engaging patients in shared decision making, but also in long term measurement. Often by looking at improvement through the lens of SusQI, we can see improvement in many areas at once.

Regarding expenditure…
Financial costs of course need to be considered and balanced. There may be times where the cost / benefit is neutral. When there is an investment, you can think about balancing this with a reduction in costs from low value / unnecessary costs (that are not adding value to patient outcomes – such as the HIV appointments in the blog piece). When an investment is for long term gains and betters patient care – there is likely additional savings elsewhere from a reduction in healthcare activity and associated costs down the line, ensuring a financial stable model. Whilst QI work is often a short term burst initially – the methodology encourages us to monitor impact over time, and so we must consider long term outcomes.

I agree sustainability is absolutely vital to be considered within your thinking around this subject of ethics and value tension. This is what SusQI is really about – whatever the key aim/scope of the project, whether improving patient safety, reducing waiting times, etc… we should be looking at the issues through a sustainable value lens. We cannot continually make improvements that benefit a minority (has a social impact elsewhere) or harms the environment / natural world (on which we rely for health), or have exponential cost.

For these reasons I don’t believe that environmental sustainability should always be treated as a secondary value, as from a broader perspective, the health of people and populations is dependent on a healthy planet – and we know the negative impacts of climate change are already exacerbating and widening inequalities.

We’re hoping in the new year they’ll be some opportunities hosted by the sustainable healthcare SIG to bring people together across the community to discuss some of these issues and tensions – so I hope we can speak further soon.

Best wishes,
Rachel