Professor Gillian Leng CBE Deputy Chief Executive, NICE National update Professor Gillian Leng CBE Deputy Chief Executive, NICE © NICE 2018. All rights reserved. Subject to Notice of rights

The UK health system NHS: sees one million patients every 36 hours 5th largest employer worldwide 39% of public sector emissions 9.1% of GDP (2014) NHS: sees one million patients every 36 hours Top health care system: Commonwealth fund, 2017 Patient contacts - https://www.nhs.uk/NHSEngland/thenhs/about/Pages/overview.aspx NHS – 1.3 million people http://content.digital.nhs.uk/workforce Adult social care – 1.34 million people https://www.nao.org.uk/wp-content/uploads/2018/02/The-adult-social-care-workforce-in-England-Summary.pdf GDP https://data.worldbank.org/indicator/SH.XPD.TOTL.ZS

Wider impact – determinants of health NHS has biggest impact of any organisation Staff Local communities Local employment opportunities Environment - air, water, green space Due to its scale of staff, infrastructure, travel and expenditure in local economies, the NHS also has more impact through the way it works, travels and spends its money on the wider determinants of health than any other single organisation in England.

What do people think - public and staff Parliamentary survey - public 18-40 years old: climate change and health 18-24 years old: climate change SDU NHS staff survey 98%: important for H&SC to support the environment 71%: own organisation actively supports environmental sustainability 6200 staff responded Top two issues Full report to be launched later but supports the demand and expectations that our staff have about corporate behavior and the willing to support orgs to address the challenges we face in reducing carbon emissions, plastics waste and air pollution Local ambassadors, keen to support local progress in their area Top issue

Overall goal – NHS, public health, social care Reduce carbon dioxide equivalent emissions by 34% by 2020 NHS, public health and social care system: reduce carbon dioxide equivalent emissions across building energy use, travel and procurement of goods and services by 34% by 2020. SDU strategy 2014 – document here https://www.sduhealth.org.uk/policy-strategy/engagement-resources.aspx

How is this being achieved ALBs + DHSC joint statement: secure the environmental, social, and economic sustainability of the health and care system, for the health of the population Commitments from national organisations £90m saved Waste, water and energy costs And environmental benefits…

What is NICE doing?

NICE’s role The national point of reference for advice on safe, effective and cost effective practice in health and social care, providing guidance, advice and standards aligned to the needs of its users and the demands of a resource constrained system. Evidence Guidance Quality standards Improved outcomes

Relevant guidelines Guidelines on environmental issues: 2 published 2 in development Can register as a stakeholder

CEO of the National Institute for Health and Care Excellence Could NICE do more? The NICE sustainability steering group is chaired by Sir Andrew Dillon and is exploring what NICE could usefully contribute to promote the environmentally sustainable development of the health and care system beyond the development of guidance. Sir Andrew Dillon CBE CEO of the National Institute for Health and Care Excellence

Current NICE resource impact assessment CG180 Atrial fibrillation: management Treatments and adverse effects People (per 100,000) Unit Costs (£) Cost (£) Current treatments   Warfarin 549 283 155,000 Aspirin 360 32 12,000 Dabigatran etexilate 76 802 61,000 Rivaroxaban 767 58,000 Apixaban No treatment 464 Strokes 59 12,228 719,000 Major bleeds 12 1,173 14,000 TOTAL COST 1,080,000 Future treatments 748 212,000 40 1,000 186 150,000 143,000 253 41 495,000 15 18,000 1,168,000 NET COST/SAVING 88,000 £ NICE produces a resource impact assessment for all of its guidance. This currently accounts only for financial resource impact. Example – atrial fibrillation

Future NICE resource impact assessment? £ + + + Could a future NICE resource impact assessment take into consideration greenhouse gas emissions, water usage and waste consumption alongside financial impact?

Coalition for Sustainable Pharmaceuticals and Medical Devices Guidance GP CONSULTATION PATIENT TRAVEL EMERGENCY DEPARTMENT VISIT INPATIENT BED-DAY SURGICAL PROCEDURE CONDITION SELF-MANAGEMENT The pathways guidance from the Coalition for Sustainable Pharmaceuticals and Medical Devices (CSPM) is a method for assessing the environmental cost impact of a care pathway. It breaks down care into six modules… Each module has an associated average value for greenhouse gas emissions, fresh water consumption and waste production. A care pathway is assessed as to the number of each of the modules that an average patient would encounter and then these are simply added together to give totals of greenhouse gas emissions, water and waste per care pathway. = 1.14 kg CO2e = 7.9 kg CO2e = 13.8 kg CO2e = 89.5 kg CO2e = 35.1 kg CO2e = 1.6 kg CO2e = 2.28 m3 = 25.8 m3 = 20.9 m3 = 137.5 m3 = 61.8 m3 = 0 m3 = 1.14 kg = 0.13 kg = 0.29 kg = 0.41 kg = 0.41 kg = 0.016 kg

A potential final product ? Medicines optimisation guideline Potential savings of: 0.5% of the annual carbon footprint of the health and social care system in England 179,133 million litres of fresh water 4.4% of the NHS annual waste Feedback: Local resource calculator time intensive Resource Impact Analysis CG 180 £ + 88,000 - 102 kg CO2e What we may end up with is a resource impact statement which gives the above Refined methodology and repeated for medicines optimisation guideline. Feedback from end-users was that local resource calculator was time intensive to use. + 23 m3 - 50 kg

Next steps Preference sensitive decision points Shared decision making Inhaler use in asthma Providing environmental impact information at key decision points “The negative impact on the environment is 10 times worse from inhalers that use a propellant”.