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

2. CENTRE for SUSTAINABLE HEALTHCARE Measuring carbon in healthcare 1.Why measure carbon? 2.How do we do it? 3.Carbon measurement examples: The whole NHS Dorset renal service – a clinical service Antipsychotic depot injection – an intervention Respiratory inhalers – a product 4.Overview

3. CENTRE for SUSTAINABLE HEALTHCARE Why measure carbon – how does it help? Carbon will be as important as money – you can’t commission if you can’t cost… 1.Policy development: setting targets, tracking progress 2.Service redesign: identifying carbon hotspots, evaluating innovations 3.Comparing higher and lower carbon interventions and products 4.Engaging public, staff, suppliers /providers carbon cost per QALY

4. CENTRE for SUSTAINABLE HEALTHCARE 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) Scope 3: Indirect emissions (other) Scope 2: Indirect emissions (electricity) Scope 1: Direct emissions Supply chain Travel Waste disposal Electricity use Energy generation Vehicle emissions HFCs, N 2 O, etc. Can be expressed in carbon dioxide equivalents (CO 2 e)

6. CENTRE for SUSTAINABLE HEALTHCARE Steps involved 1.Define the goal and scope of the study 2.Identify the resources used (set boundaries, create inventory) 3.Measure the resource utilisation (collect data) 4.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. CENTRE for SUSTAINABLE HEALTHCARE Example 1 Carbon footprint of NHS England Motive: policy development, engagement Method: Scope 3 (consumption-based), mixed top-down / bottom up

9. CENTRE for SUSTAINABLE HEALTHCARE NHS England activity data CategoryData source Direct energy use of coal, oil, gas and renewables ERIC returns Direct release of anaesthetic gases & nitrous oxide Suppliers’ figures Electricity useERIC returns Procurement spendNational accounts expenditure for government expenditure on health, HM Treasury PESA, NHS Shared Business Services (Trust level data) Staff, patient and visitor travelNational Travel Survey SDU. (2013) Carbon footprint update for NHS in England 2012

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

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

12. CENTRE for SUSTAINABLE HEALTHCARE 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. CENTRE for SUSTAINABLE HEALTHCARE Steps involved 1.Define the goal and scope of the study 2.Identify the resources used (set boundaries, create inventory) 3.Measure the resource utilisation (collect data) 4.Attribute a carbon cost or footprint to the resources used (x carbon intensity) Renal procurement data not available at national level

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

15. CENTRE for SUSTAINABLE HEALTHCARE Dorset renal service activity data CategoryData source Buildings energy useCalculated from ERIC returns for each site, based on the proportion of the floor space occupied by the Dorset renal service Staff and patient travelTravel surveys Visitor travelEstimated from National Travel Survey 2006 Procurement dataExpenditure data for pharmaceuticals, medical equipment, paper, food, sanitation products and IT were collected from relevant departments Numbers of radiological and laboratory investigations were taken from IT records Water consumption taken from meter readings Linen usage determined per patient Waste amounts and disposal route were estimated from published reports The Carbon Footprint of a Renal Service in the United Kingdom. Connor A. et al. QJM (2010) 103 965 – 975

16. CENTRE for SUSTAINABLE HEALTHCARE Discussion Total GHG emissions from Dorset renal service = 3007 tonnes CO 2 e per year Supply chain emissions contribute 72% (pharmaceuticals 35%, medical equipment 25%, waste 10%) Carbon footprint of dialysis = 7.1 tonnes CO 2 e 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. CENTRE for SUSTAINABLE HEALTHCARE 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. CENTRE for SUSTAINABLE HEALTHCARE 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. CENTRE for SUSTAINABLE HEALTHCARE Activity data / emissions factors

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

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

26. Creating inventory: process map for inhaler production Source: GHG Accounting Sector Guidance for Pharmaceutical Products and Medical Devices Global warming potential of HFA 134a = 1430 x CO 2 Inhalers contribute 5% of NHS carbon footprint

27. Setting boundaries

28. 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 Ventolin (200mcg) 60 Dose Accuhaler 0.8kg CO 2 e per pack 13g CO 2 e per actuation Discussion Ventolin (100mcg) 200 dose Evohaler 29kg CO 2 e per pack 144g CO 2 e per actuation Source: GSK, by personal communication Inhalers contribute 5% of NHS carbon footprint

29. CENTRE for SUSTAINABLE HEALTHCARE 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

30. frances.mortimer@sustainablehealthcare.org.uk