The NHS is, as we know, currently under immense pressure. There are more patients than ever waiting for treatment in England, while NHS staff are still recovering from the stresses of the COVID pandemic and a real-terms pay cut during a cost-of-living crisis.
Within this context it might seem ambitious to expect staff to engage in sustainable transformation. However, SusQI has been shown to inspire and motivate staff while also achieving changes that have real potential to reduce service delivery pressures.
In addition to the environmental and financial benefits, SusQI has wider potential benefits for staff, students, and NHS organisations.
As part of my work at the Centre for Sustainable Healthcare, I’ve had the privilege of running our Green Team competition. Last year, we worked with 35 different health care teams across seven organisations to plan, run and measure the impact of SusQI projects. I look at two projects in more detail below.
Collectively, the initiatives have projected annual savings of 7,196,265 kgCO2e per year. That’s the equivalent of driving over 20 million miles in an average car! There were also impressive anticipated financial savings of over £780,000.
What is SusQI?
‘It just changes the way you look at things forever.’ – Student, SusQI Education Pilot project
SusQI is a framework that supports health workers and multi-disciplinary teams to embed sustainability at the heart of their quality improvement (QI) work. It is not about rewriting quality improvement but about adopting a sustainability perspective within improvement methodologies.
Often, QI projects will consider measurement for clinical and financial outcomes. SusQI integrates environmental and social sustainability measurements within our understanding and definitions of quality and value. It takes a holistic approach to health care improvement using the principles of sustainable health care:
- prevention
- patient partnership, empowerment and self-care
- lean clinical pathways
- low-carbon alternatives.
Additional benefits of SusQI
‘You could see from the beginning … [students] were nodding and thinking yeah, this is exactly the thing we should be talking about’ – Educator, SusQI Education Pilot Project
In addition to the environmental and financial benefits, SusQI has wider potential benefits for staff, students, and NHS organisations. An evaluation of SusQI education (see link below) demonstrated that including sustainability in QI motivated students and health workers to engage in the QI process. It was felt to be rewarding and transformative.
SusQI examples from the Green Team Competition
The two projects I want to focus on use a patient-centred approach to care. The first, to reduce low-value testing and appointments; the second, to prevent disease complications. Their results are transferable to a wide range of health and care services and settings.
Project 1: Reducing low value testing and appointments
Northamptonshire Integrated Sexual Health and HIV Services looked at changing their clinical pathway for very stable HIV patients to reduce testing and face-to-face appointments.
Improvements in HIV treatment over the last decade mean that most patients adhering to treatment are now physically stable, living normal lives and with low risk of transmission. However, across the UK, most stable HIV patients attend NHS services with the same frequency as those HIV patients who are relatively newly diagnosed or considered unstable. Patients in the Northampton service would attend six-monthly appointments with blood testing as a minimum, regardless of their stability.
Across the UK, where in 2019 nearly 99,000 HIV patients are accessing care, the potential impact is significant.
Consultant Lynn Riddell led this project to engage patients alongside key junior and senior team members. The country consultants agreed upon a definition of a very stable HIV patient and developed a new annual review pathway. All patients received a letter about the new care pathway, which explained this would be discussed in more detail at their next scheduled appointment. It emphasised that no patient would be moved to the annual pathway without shared decision making and patient consent.
Results from a survey of 100 HIV positive patients showed a clear and strong patient voice in favour of reduced attendance. This increased staff engagement in the change. Patients were also asked about the importance of the environment to them, the distance travelled to appointments, the impact of attendance on employment and salary, and communication preferences.
Approximately 90% of HIV patients met the criteria for being moved to the very stable pathway. 855 patients moved to annual reviews, resulting in:
- 30 kgCO2e saved per appointment (including patient travel, consumables and blood test processing), equating to an annual saving of 25,958 kgCO2e, equivalent to 74,763 miles in car journeys
- £52.52 saved per appointment (including consumables and blood test processing), equating to an annual saving of £44,905.
- staff time savings of approximately 350 Band 6 nurse hours and 200 doctor hours, which can be redirected to higher value work.
The clinical team noted that explaining the new pathway to patients who were not currently eligible appeared to motivate them to improve their medication adherence so that they would become eligible for reduced attendance.
Across the UK, where in 2019 nearly 99,000 HIV patients are accessing care, the potential impact is significant.
The solutions to the problems lie within the staff that run the services. Enable them!
Lynn Riddell, Consultant Physician and Countywide Clinical Service Lead said:
‘If a small department can make such a significant environmental impact, what could we all achieve across the NHS if Integrated Care Boards, the Department of Health and the Commissioning bodies put their support behind initiatives such as this. The solutions to the problems lie within the staff that run the services. Enable them!’
The project will be presented at the BMJ Net Zero clinical care conference in October.
Pathway re-evaluation such as this does not need to be limited to HIV and sexual health services. There are multiple outpatient pathways seeking to manage chronic conditions where reducing or eliminating low-value testing and appointments could bring patient, staff, environmental and financial benefits.
Preventing hip fractures in oncology patients
The Christie NHS Foundation Trust’s endocrinology team ran an exploratory project to assess the impact of screening and treating patients at high risk of fracture on an acute oncology ward. The aim was to reduce hip fractures and the associated clinical, social, environmental and financial impacts.
Patients with an oncology diagnosis are likely to be at higher risk of fragility fracture. In 2020/21, six inpatients at The Christie sustained hip fractures and resulting disruptions to their oncology management. All six died within 12 months of sustaining the fractures. A retrospective review suggested that these patients had a high risk of fracture. There is a possibility that earlier screening and treatment may have been an opportunity to intervene to potentially prevent the fracture. However, screening is not routine practice.
There is much potential for prevention of painful and debilitating fractures. This could bring vast benefits to patients and their families.
The team used information from the six hip fracture patients from 2020/21 to model the likely incidence of hip fracture and the associated costs in an oncology population. They then screened a small cohort of 13 acute oncology patients (who had not had a fracture) using the screening assessment, extrapolating potential treatments and costs for 100 patients.
While a larger patient sample size would be required to increase the accuracy of the data, the results suggested that for every 100 patients screened, one fracture could be prevented, leading to:
- an estimated carbon saving of 316 kgCO2e, equivalent to 911 miles driven in an average car
- financial savings of £3,500
- prevention of hip fractures, pain and deaths while also preventing the distress associated with these for patients, their family and staff.
The benefits above are likely vastly underestimated. The project concluded that there is much potential for prevention of painful and debilitating fractures. This could bring vast benefits to patients and their families, while lowering environmental and financial costs of care. However, more work with a larger group of inpatients/outpatients is needed to create an optimal fracture screening strategy. The team plans to work with the Trust’s Frailty team to progress this work.
Learn more
Read the full case studies here:
SusQI Project report: A Novel Care Pathway for Very Stable HIV Patients Sustainable Healthcare Networks Hub
SusQI Project Report: Stop the fracture SusQI project | Sustainable Healthcare Networks Hub
You can read additional Green Team Case studies in the CSH Resource Library.
Join our Sustainable Healthcare Special Interest Group to share your success stories and connect with colleagues on SusQI, sustainability and quality improvement.
Further resources
Sustainability in Quality Improvement website
Green Team competition
SusQI education project evaluation
BMJ Net Zero clinical care conference