William Beharrell

On the day I spoke to Dr Fiona Brennan, consultant anaesthetist at Cardiff and Vale University Health Board, the UK government had announced that they had just passed into law a new target to slash emissions by 79% by 2035.  What was different about this sixth carbon budget was the inclusion of aviation and shipping emissions, which together bring the UK, in theory, more than three-quarters of the way to net zero by 2050.  It is interesting to consider that NHS emissions are often described as being equivalent to those produced by the aviation industry. This is a point that Fiona mentioned as we began to discuss her own work to reduce greenhouse gas emissions from her particular part of the NHS: operating theatres at the University Hospital Wales, in Cardiff.

When Fiona began her training as an anaesthetist in 2005, the environmental impact of anaesthetic gases was not widely acknowledged, and certainly not included in any training syllabus. Sixteen years later, and we, as clinicians, are increasingly being expected to reduce our carbon footprint as part of a system-wide effort to be carbon-neutral by 2030.   Anaesthetic gases from our operating theatres and maternity wards are estimated to account for 5% of the total NHS Greenhouse gas emissions. This is on a par with patient travel, water and waste but a fraction of the emissions caused by procurement, which account for 60-70% of the total.

So, why start with anaesthetic gases? By the time Fiona qualified as a consultant in 2013, she had worked in numerous hospitals, sometimes as many as five different hospitals in one year. This rapid succession of jobs makes its very difficult to enact any kind of lasting change. But with the stability of her new role in Cardiff and Vale UHB, Fiona began to realise that as anaesthetists, they had relative control over how anaesthetic gases were procured; how they were used; and when it might be beneficial not to use them. She also learned that the most harmful gases, such as Desflurane, were often the most expensive and that their atmospheric concentrations were increasing.

Along with other colleagues in Cardiff & Vale, Fiona was instrumental in launching Project Drawdown in 2018 with the aim of educating colleagues about the ozone depleting properties of Nitrous Oxide and the global warming potential (GWP) of different gases, some of which have significantly greater impact than the others. Within six months, they had reduced their emissions by 50%.  And in 2019, Fiona co-founded the Welsh Environmental Anaesthetic Network (WEAN), setting themselves the target of reducing their greenhouse gas emissions by 80% by 2021. With more than half the year remaining, they have already reduced their emissions by 70%.  In demonstrating how simple educational interventions can lead to significant and rapid savings, Fiona is one of a group of clinicians leading the way in sustainable healthcare.

With success like this on a small-scale comes the inevitable question of how one might increase the impact of such intervention. With support from the Centre for Sustainable Healthcare, and in coordination with colleagues from other health boards, Fiona has organised the inaugural conference for the Green Health Wales which will take place on June 29th.  There are some immediate challenges which this network will look to address including the use of single use plastics in theatres, replacing metered-dose inhalers with dry powder inhalers, and establishing a network of sustainable healthcare fellows across NHS Wales.   Given the scale of the challenge ahead – i.e. to be carbon neutral in nine years – these pioneering feats are being conducted by small agile teams well in advance of those gathering at base camp. If we stand a chance of meeting the 2030 target, then it is going to take the traditional hierarchies of the NHS to think and act in radically new ways: to learn to balance the immediate risk of infection with the environmental risk of single-use instruments and plastics; to reconsider the nature of the doctor-patient relationship in the context of fewer in-person consultations and travel-miles saved; make bold commitments to switch to green energy sources using renewable tariffs and on-site renewable energy; and invest in shorter supply-chains despite the short-term increase in cost.

The lessons learned from focusing on anaesthetic gases are applicable to every part of our system, and complementary with the principles of prudent healthcare. For example, prescribing antibiotics according to local guidelines, directing patients for the appropriate treatments on the first attempt, investing in preventive approaches, listening to patients attentively to make sure we’re responding in ways that make sense to them.  If you feel moved to make a difference in your particular part of the health board, then do contact us and we would be delighted to direct you to any learning from Fiona and her colleagues in the Green Health Wales network to assist you in your work.