William Beharrell

In my last blog, I outlined some of the ways in which Dr Fiona Brennan and her colleagues have been embedding sustainable healthcare within the practices and procedures of the anaesthetic team at Cardiff and Vale University Health Board. However, systemic change relies upon education and requires dedicated time and concentrated efforts. With this in mind, Dr Brennan and Opthalmology Consultant Dan Morris worked with the senior management team to agree a three-year partnership with the Centre for Sustainable Healthcare: CAVUHB would host  three consecutive clinical fellowships with the assistance of the HEIW Clinical Leadership programme. Our first fellow in this role is Dr Amarantha Fennell-Wells, a dental surgeon, who, eight months ago, was working as a dental core trainee in oral and maxillo-facial surgery with regular on-calls in the Emergency Department.

Within a few minutes of speaking to Amarantha, discussion had covered both laughing gas and the prospect of Penylan, Penarth and other parts of Cardiff being underwater in eighty years’ time. If this sounds rather far-fetched, it is worth noting that the five hottest years on record have occurred consecutively since the Paris Climate Accord in 2015. The threats to health caused by natural phenomena such as flooding, extreme weather and heatwaves, as well as population-driven poor air and water quality, zoonotic disease and a loss of biodiversity, are all examples of what has been termed “planetary health”. Planetary health is an emerging and multidisciplinary field; its fundamental premise is that the health of human civilisation cannot be separated from the health of the natural systems on which we depend.

Not long before our conversation, the Welsh Government had published the NHS Wales Decarbonisation Strategic Delivery Plan 2021-2030 in response to the 2017 commitment to a carbon-neutral Welsh public sector by 2030. One of the Strategic Delivery Plan’s key initiatives is to monitor nitrous oxide use and waste as a direct result of Amarantha’s work: project design and management, data collection and analysis, stakeholder engagement, and medical education. Her contribution sits alongside similar projects at 50 acute sites across Scotland, England, Northern Ireland, and Republic of Ireland, and forms our main contribution to this task. Nitrous oxide, perhaps more widely known as ‘laughing gas’, is a medical, or ‘anaesthetic’, gas used for its analgesic and anaesthetic properties across many different clinical services.  It is also a powerful climate pollutant, occupational health hazard and recreational drug.  She has been supported in this task by Dr Fiona Brennan, NHS Lothian pharmacist Alifia Chakera, and also by the Centre for Sustainable Healthcare.

Amarantha tells me that using the only available benchmark supplied by NHS Lothian, which is likely an underestimate, CAVUHB infrastructure may have wasted nearly 4 million litres of nitrous oxide, and over 14 million litres of Entonox® over the last three financial years. “This total waste equates to an environmental impact reaching nearly 10,000 tonnes of CO2e, a financial waste of potentially £55,000, and a theoretical ‘social’ cost of around £700,000.”  Research conducted by Alifia Chakera, who is mentoring Amarantha through management within CAVUHB, shows that at least 80% of nitrous oxide and 30% of Entonox is wasted before it even reaches patients. She also informs me that, in comparison to the mean carbon footprints per maternity episode for NHS Scotland and NHS England, CAVUHB births are 40% and 47% more carbon intense respectively when considering consumption of Entonox via piped infrastructure alone.

Talking to Amarantha, it is clear that she brings not only passion, but also focus to this role. The former she ascribes to a growing sense of social justice, personal and professional responsibility, and an aspiration to use her position of relative privilege to help others.  A range of skills nurtured through many years of dental and postgraduate training are being demonstrated throughout the variety of projects she has tackled this year.  In the eight months or so since she joined CAVUHB, she has already developed and presented teaching material to medical undergraduates, submitted her thorough report on the systemic waste of nitrous oxide, and set up a national conference to help healthcare personnel in Wales run sustainable healthcare projects.

In shining a spotlight on an otherwise inaccessible topic, Amarantha has helped us all to understand the potential savings to be made from careful scrutiny of our medicines management and procurement practices.  None of this has been possible without collaboration across departmental boundaries: clinical teams, administrative and support services have all contributed to systemic understanding of just one medicine. More importantly, Amarantha has demonstrated the harm caused by the waste and disposal of greenhouse gases like nitrous oxide and, our obligation as healthcare personnel to do what we can to minimise that harm.  In this, she is exemplifying the principles of sustainable healthcare, which are worth repeating here: (1) Prevention (2) Patient empowerment and self-care (3) Lean systems and (4) Low carbon alternatives.

For more information, Amarantha has recommended the following two videos:




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