Increasing life expectancy is putting our health and social care systems under more pressure than ever before as more people need continuous care and support, with the right systems and resource in place to enable it. Many people are living longer but with complex conditions – like diabetes, asthma or heart disease – that need constant care and attention. Children born with complex conditions are now living to adulthood, while those with learning disabilities and other groups have lifelong needs.

In the first ever system-wide ‘shared commitment’, twelve national lead organisations in health and care have come together to build a system of integrated care that can provide care and support built around the needs of the individual, their carers and family and that gets the most out of every penny spent. By helping to prevent illnesses, properly manage complex conditions, avoid falls and other accidents, an integrated approach can offer better care for the individual with less pressure on the system.

The ultimate aim is to improve the outcomes and experiences of individuals and communities through personalised care and support, an increased focus on primary and community care, and population-based public health.

Defining integrated care

With over 175 different definitions of “integration” in the published literature, a common language and a shared understanding of the term “integrated care and support” is essential.

National Voices, a national coalition of health and care charities, developed an agreed definition or ‘narrative’ of integrated care to provide a guide to the sort of things that integrated care will achieve, such as better planning, more personal involvement of the person using services, and free access to good information. The headline definition aims to describe something that an individual person would recognise as integrated care and support:

“I can plan my care with people who work together to understand me and my carer(s), allow me control, and bring together services to achieve the outcomes important to me.”
Narrative of integrated care, National Voices

A more detailed understanding of this headline definition describes an individual’s experience of person-centred, coordinated care and support using a series of generic “I” statements, such as ”I tell my story once”.

Committing to integrated care and support

Integrated Care and Support: Our Shared Commitment sets out how local areas can use existing structures like Health and Wellbeing Boards to bring together local authorities, the NHS, social care providers, education, housing services, public health and others to make further steps towards integration.

The plans, which will be delivered by national leaders and local areas working closely together, include:

• An ambition to make joined-up and coordinated health and care the norm
• The first ever agreed definition of what people say good integrated care and support looks and feels like, developed by National Voices
• New ‘pioneer’ areas around the country to be announced in September 2013
• New measures of people’s experience of joined-up care and support by the end of this year

Partners involved in this initiative include the Association of Directors of Adult Social Services (ADASS), the Association of Directors of Children’s Services, the Care Quality Commission, Department of Health, Local Government Association, Monitor, NHS England, NHS Improving Quality, Health Education England, the National Institute for Health and Care Excellence, Public Health England, the Social Care Institute for Excellence and Think Local Act Personal in association with National Voices.

Putting people first

The commitment recognises that national and local organisations need to take urgent and sustained action to make integrated care and support happen.

The focus is on person-centred coordinated care and support as key to improving outcomes for individuals who use health and social care services, in the context of recent reforms to the health and care system, which have enabled local communities to increase focus on commissioning and ensure the kind of care and support that best meets their needs, with local practitioners at the fore.

Launching the commitment Care and Support Minister Norman Lamb explained:

“People don’t want health care or social care, they just want the best care. This is a vital step in creating a truly joined-up system that puts people first. Unless we change the way we work, the NHS and care system is heading for a crisis. This national commitment to working together is an important moment in ensuring we have a system which is fit for the future.”

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• Consulting on a new sustainable development strategy for health and social care
• Adapting to tomorrow’s climate in health and social care

The NHS Sustainable Development Unit’s consultation and engagement programme on a Sustainable Development Strategy for the Health, Public health and Social Care System for 2014-2020 was launched on 29th January and is open until 31 May 2013.

In their joint foreword to the consultation document, NHS Chief Executive Sir David Nicholson and Public Health England Chief Executive Duncan Selbie describe the scale and importance of the challenge:

“Assuring a sustainable health, public health and social care system is one of the greatest and most important challenges of our time and our vision and ambition should match the scale of these. We have a clear responsibility to take a leading role in tackling climate change and have a genuine opportunity to influence change for our patients, service users and the public. We must align, integrate, and coordinate a whole system approach to health and care which ensures the future is more environmentally, financially and socially sustainable.”

The consultation

The new strategy will be launched in January 2014 and will cover the period 2014 to 2020. Building on the Carbon Reduction Strategy the new strategy is not just for the NHS but embraces the whole health, public health and social care system. It will define where we need to be on the path to sustainable health care by 2020 and the measures and targets against which progress will be measured.

The consultation poses seven core questions with the opportunity to add general comments:

1. Is a new strategy for sustainable development needed to coordinate and guide the next phase of action to 2020?
2. Which elements of the health and care system should be included in the scope of the next strategy?
3. Should the health and care system set itself challenging ambitions with regard to sustainability?
4. Should sustainable development be measured more broadly than through carbon reduction only?
5. What areas of sustainable development need to be prioritised in the next strategy?
6. What areas of research need to be prioritised to enable a more sustainable health and care system?
7. Are there any questions, issues and opportunities missing from this consultation document?

An introduction to the consultation outlines the questions in more detail and provides additional context for the consultation

Responding to the consultation

The NHS SDU is looking for a broad response from individuals, groups and organisations across all parts of the health and care sector. This includes patients, service users and communities, health and care partners in local authorities, and the third sector.

Respondents can complete an online consultation questionnaire available on the main consultation webpage.

Alternatively responses and comments can be submitted:

• By e-mail to info@sdu.nhs.uk
• In writing to Sustainable Development Unit, Victoria House, Capital Park, Fulbourn, Cambridge, CB21 5XB

The SDU also invites examples of best practice or case studies that respondents feel should be implemented.

Engaging as broad a range of people as possible

The SDU is keen to ensure that the consultation reaches throughout the NHS and welcomes support and input to ensure that this happens. Respondents are encouraged to involve as broad a range of people as possible in developing organisational, network or sector responses. Individual responses are also welcome.

Running an event or several events will help people engage in the debate and feed into the process. This is a great opportunity to discuss these issues and to keep making progress towards a more sustainable health system. It is also an ideal opportunity for every organisation and system to revisit what sustainable development means for their set up and to take further pledges for action.

A range of materials is available to help communicate within organisations and encourage stakeholders to engage and respond.

Further reading

• Sustainable Development Strategy for the Health and Care System 2014 – 2020 : Consultation: full details, consultation document and online consultation questionnaire

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• Adapting to tomorrow’s climate in health and social care
• Consulting on new sustainable development indicators

The second NHS Sustainability Day follows on from last year, which saw over 100 Trusts participate in a varied set of events and initiatives up and down the country with further engagement online.

The brainchild of Trevor Payne, Director of Estates and Facilities at Barts Health NHS Trust, NHS Sustainability Day is hosted by Barts Health NHS Trust. He described its relevance:

”Ensuring sustainability is fully integrated within the NHS is paramount to securing the future of healthcare in England. NHS Sustainability day allows individuals and organisations working for and with the NHS the opportunity to take action to make positive changes to behaviours which can minimise their impact on the environment. Everyone can be involved and no action is too small. Together we can make a significant difference to our future.”

Support for NHS Sustainability Day

Prime Minister David Cameron has given his huge support for the forthcoming NHS Sustainability Day and outlined the importance of sustainability in the NHS:

“The NHS Sustainability Day is a very important intiative that alignswith this Government’s ambitions for a low-carbon and eco-friendly economy. I am encouraged by the scale of reduction in carbon the NHS is contributing towards the UK’s target and the acknowledgement that there is more to do”

Stephen Fry has also given his support for the day, saying:

“The NHS is one of the greatest institutions in the world-helping look after us while doing no harm. But its very size means it can harm the world it shares with us. So it needs to be more sustainable. Support the NHS and participate in NHS Sustainability day on the 28th March. It’s a fabulous opportunity to make a difference and make healthcare more sustainable.”

Carbon and sustainability in the NHS

Carbon reduction within the NHS may not be on the top of most Boards to do list. However the 2010 update on the NHS Carbon Reduction Strategy for England calculated the carbon footprint of the NHS in England at 21 million tonnes per year, making it one of the biggest emitters of carbon in Europe.

The Sustainability Health Check 2012 report showed how sustainability is viewed by leaders in the health service, and demonstrated the public’s desire for a more sustainable healthcare system. The aim of the report was to help NHS organisations and their leaders save money by being more sustainable, particularly with the support of the public.

Getting involved

The NHS Sustainability Day website is up and running with plenty of ideas, event information and case studies. NHS organisations and stakeholders can register their participation and upload event ideas. The website will close around 20th March to allow time to evaluate the winners of the NHS Sustainability Day Awards.

Many companies are signed up to offer their services free of charge for the day, with full details on the website.

NHS Sustainability Day Awards

Nine awards will be given for NHS Sustainability Day events and projects, in categories including clinical engagement, biodiversity, sustainable travel and sustainable food.

Entries will be evaluated by a panel of experts and the winners announced at the event of 28th March.

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A growing aging population means greater demand for residential care services. Is the notion of an environmentally sustainable care home realistic? What is the current environmental impact of the residential care sector? Can reducing environmental impact have cost, health and wellbeing co-benefits?

These questions are explored in a recent study, Sustainable Care Homes, carried out by NEP Energy Services in 2012, a charity-owned social enterprise funded by NHS East Midlands Regional Innovation Fund.

Key findings of the research were:

• The residential care sector accounts for at least 3.4 million tonnes of CO2e each year and £1.07 billion in natural resource costs. The social cost of carbon adds a further £76 million in costs to the economy per year.
• In 2008/9 energy use in residential homes accounted for around £468.5 million in utility costs and around 2.3 million tonnes of CO2e, representing 0.42% of the 2009 UK carbon footprint (National Statistics, 2012)
• In 2008/9 residential homes also accounted for around £505 million in food costs generating around 622,250 tonnes of CO2e.

Besides waste, the costs of energy and food are major areas for change and likely to rise significantly. With increasing competition for natural resources, there is clearly a need to prioritise these areas for reasons of both cost and carbon management.

Waste

The research investigated both pharmaceutical, offensive and commercial waste, finding significant opportunities for carbon and cost savings.

Pharmacy waste

Annual pharmacy waste from UK care homes amounts to £49 million in value and corresponds to up to 28,764 tonnes of CO2e. Opportunities to reduce this waste are identified in other reports, particularly Evaluation of the Scale, Causes and Costs of Waste Medicines by Trueman Taylor et al 2010). Care home pharmacy waste only represents a fraction of care home pharmacy consumption, but there is scope for carbon and cost saving in reducing pharmacy waste through better communication between GPs homes, residents and pharmacies. Good medicine management and capping over-prescribed drugs makes sense in terms of both cost and health.

Laxatives, Paracetamol, Aspirin and calcium supplements represent the most significant areas of waste, cost and carbon emissions, representing around 40% of all care home pharmaceutical waste and 27.5% by both value and carbon emissions.

In research visits for this report, two managers identified that a well managed 28-day prescription cycle with better communication and cross checking between home, GP and pharmacy, has been effective in reducing unnecessary over prescription from repeat prescriptions. Central treatment rooms, with fewer goods in residents’ rooms, were also identified as having been effective in aiding better management of stocks to prevent over-ordering.

A major issue identified was that pharmaceutical interventions were paid for by the GP prescription budget, while non pharmaceutical interventions, such as additional sensory stimulation as an alternative to antipsychotic drugs, had to be paid for by the home, despite NICE recommending these alternate therapies over drugs.

Another issue is that the disposal of drugs waste through pharmacy returns is paid for by the Primary Care Trust and that comprehensive records of reasons for drugs wastage are not usually available. As waste and returns are not visible to or paid for by GPs, there is less incentive at practice level to evaluate and address how and why this waste occurs.

Offensive waste

Offensive waste is mainly hygiene and continence waste. In 2008 a staggering 50% of the UK‘s 217,000 tonnes of non-hazardous healthcare and biological waste was generated by care homes (calculated from Defra data). Offensive wastes from UK care homes have an estimated cost of £29.3 million per year and give rise to more than 30,724 tonnes of CO2e, assuming disposal to landfill.

Offensive waste was analysed in some detail, as a key component of care home waste disposal costs and carbon emissions. If offensive waste were incinerated using energy from waste locally, rather than disposal through landfill, at least 66,750 tonnes of CO2 would be saved every year, equivalent to the carbon footprint from energy use of 13,350 houses in the UK.

Support and funding for continence care, to move residents off continence pads, along with better care in hospitals to ensure residents stay off pads when admitted, has benefits for resident dignity, health and wellbeing. This also offers significant potential for carbon and cost savings across the whole lifecycle of a continence product’s manufacture procurement, delivery and disposal. Procurement of continence contracts that favour more sustainable, lower weight products with user controlled delivery, to avoid over supply, also has a huge potential to cut waste and emissions.

Clinical Commissioning Groups will be taking on this responsibility from Primary Care Trusts and should consider employing sustainable procurement practices in addressing these contracts.

Commercial and Municipal Waste

Care home municipal waste disposal is likely to cost around £19.5 million across the UK and result in around 427,000 tonnes of CO2 emissions from disposal to recycling and landfill.

Up until April 2012, councils were only able to charge for collection of waste from residential homes or premises forming part of a hospital or nursing home, but not disposal, meaning that councils effectively had to offer a subsidised waste service. As of April 2012, a charge for collection can still be made for waste from such premises, but a reasonable charge for disposal of that waste may also be made (although such waste is classified as household waste, it is treated as commercial waste for the purposes of disposal charge powers in the Environmental Protection Act 1990). This change could lead to increased costs to homes using local council waste services which no longer include free waste disposal, and in some cases already has (commercial waste service providers were always able to charge for collection and disposal).

Care homes should explore the potential for alternate collaborative arrangements around waste management, possibly in partnership with GPs or local health centres. Where possible, these contracts should look to favour providers who:

• Offer good data weight of waste collected
• Additional off-site segregation and recycling of municipal waste
• Energy from Waste for offensive waste

Energy

The study showed energy use and consumption in the four case study homes could be cut by an average of 11% if recommendations were implemented. Nationally, this could save £52.8 million in energy costs and 220,000 tonnes of CO2e each year.

The easiest way to achieve savings is by empowering site staff to identify areas of waste. The simplest way to do this is to provide care home managers with access to smart meter data. Three of the four homes had smart meters, however none of the care home staff were given access to the half hourly data, or trained on how to spot trends and energy waste. Educating the home managers is key to reducing energy consumption, they are better placed and are more likely to be aware of the local causes of energy waste, given the right training.

A national programme of better metering and training alone could potentially save £12million and 50,000 tonnes CO2e per annum.

Renewables

If a care home site is suitable for a ground sourced heat pump energy system, this is an option worth considering. Two of the homes studied in detail were fully or partially heated with heat pump systems and under floor heating. Both of these homes should be able to achieve near zero carbon heating by 2050. Heat pumps also have the capacity to offer low-cost low-carbon cooling in heat wave conditions. Ground sourced heat pumps also offer long-term income in terms of the renewable heat incentive, with one home having the potential to earn £10,000 per annum from this route.

Encouraging the inclusion of ground sourced heat pumps in new build care homes, and gas combined heat and power (CHP) for retrofit, would help ensure care homes contribute to the UK’s carbon targets, offer a better environment for residents and protect homes against rising energy costs.

Community, environment and food

The links each home formed with their local community were found to have helped improve the care home grounds and their local environment, and ensured residents had regular and varied external contact, improving the capacity to carry out activities that kept residents physically and mentally active. These sorts of relationships play a critical part of a healthy sustainable care home and should be valued and encouraged.

The use of care home grounds to grow food, particularly in raised beds, animals and use of suitable tools provides both diversion and stimulation for residents, helping them to maintain an active lifestyle. Three of the homes visited were growing food on-site. This approach involved engaging residents, staff and external community groups. In one case a city farm supported the home by cultivating the grounds. The cost savings are fairly small but the health and wellbeing benefits more significant. Producing food on-site also provides an incentive to compost uncooked food wastes rather than dispose of them to landfill or incineration.

Conclusion

The study’s assessment of the national picture and the four case study care homes shows significant shortfall in support and information; this currently makes it very difficult for this sector to make an active contribution to the UK carbon reduction targets. This is increasingly critical given the need to protect the sector and vulnerable older people from rising natural resource costs.

Pockets of good practice notwithstanding care home managers do not seem to be regularly encouraged by operators, Local Authorities or health trusts to engage with environmental sustainability, even where they are keen to contribute.

The costs and carbon emissions associated with residential care are high. The benefits of addressing these issues are not just financial and environmental, but a key component of high quality care.

Care Quality Commission (CQC) inspection reports deal with quality of care, life, environment and management. While recent issues raised by the CQC around medicines management and record keeping have some cross-over, there is little that clearly addresses the issues of environmental sustainability dealt with here. Consideration could be given to broadening inspection criteria to also include resource efficiency and environmental impacts of care.

A home that manages its natural environment and its environmental impacts, through a more holistic approach, can benefit residents in terms of wellbeing and home operators in terms of running costs while reducing impacts on the local and global environment.

With an aging population and rising natural resource costs, it is essential that this sector is supported and encouraged to take an active role in resource efficiency and carbon reduction. This will be critical in both safeguarding affordable care for vulnerable elderly people, maintaining dignity and social participation in old age and in achieving carbon, waste and energy targets.

New public health guidance from the National Institute for Health and Clinical Excellence (NICE) examines how – and why – to increase the level of walking and cycling in the UK, detailing the multiple, overlapping benefits that increases in exercise can yield in many different areas of public policy.

The new guidance complements previous NICE guidance in this area, covering the changes needed in the national physical infrastructure, national fiscal measures and injury-reduction strategies.

Accessible health benefits

NICE recommends targeting walking and cycling as an efficient way of accessing the health benefits of exercise because they are already, respectively, the first and fourth most common recreational activities undertaken by UK adults and are thus already familiar to most people. Walking and cycling are also free or cheap forms of exercise that are widely available.

Small increases in physical activity are strongly positively linked with a wide range of health benefits, the most prominent being reduced risks of coronary heart disease, strokes, cancer, obesity and type 2 diabetes. In addition, exercise has been shown to provide well-being benefits for individuals. Despite this, a small minority of the population achieves regular exercise.

‘Only six per cent of men and four per cent of women achieved at least thirty minutes of moderate or vigorous activity on at least five days…’

The case for increased exercise levels as a major source for improving public health has been incorporated into new national physical activity guidelines issued by the Chief Medical Officers of England, Scotland, Wales and Northern Ireland in 2011.

Social and environmental benefits

Increasing walking and cycling rates offers a wide range of other social and environmental benefits and can create virtuous cycles of outcomes.
Perhaps the most obvious are reductions in car use and corresponding environmental gains. These gains can be split broadly between reductions in carbon emissions which help to deliver on climate change mitigation, and air pollution reductions that significantly improve localised air quality, particularly in urban areas where human populations are more highly concentrated. This air quality improvement then feeds back into further health benefits for populations who spend a much of their lives in those environments. And this may be a significant gain; the report notes that air pollution probably reduces UK average life expectancy by 7-8 months and causes 50,000 premature deaths per year.

‘‘Unless otherwise stated, the recommendations will benefit everyone”

Economic gains

The publication points out that there is no conflict between the health benefits of the policy and its economic outcome, indeed there seem to be some clear economic gains from reductions in road traffic. For example the DfT estimates the cost of road congestion to be over £10billion per year. There is also evidence that improvements in the walking environment leads to increases in economic activity and resulting increases in commercial rents and local property prices.

At the same time as providing clear gains in the spheres of health and environment, and offering some potential economic gains, the guidance argues that increased levels of walking and cycling can also improve the social quality of public spaces by increasing the numbers of people using them. This not only makes streets safer but increases the feeling of safety, another virtuous cycle of increased use, especially for vulnerable groups. The report also highlights some of the smaller gains such as a reduction in noise to be had from quieter roads.

‘‘Bicycles are used for around 2 % of journeys in Britain – compared to about 26 % in the Netherlands… Yet of all trips made in Great Britain in 2009, 20% covered less than one mile…”

Ten detailed recommendations are set out, taking a detailed route through various elements of implementation. Recommendation 2 (“ensuring all relevant policies and plans consider walking and cycling”), for example, includes a list of 20 agencies or stakeholder groups who need to be considered when pushing through a plan to increase walking and cycling and 15 issues that they will need to take into consideration or that may be effected by the issue. All this is augmented by substantial appendixes providing information on cost effectiveness and gaps in the research picture.

Fighting the “inactivity pandemic”

Countless bodies have come out on the side of active travel as the healthy way to go, not least the medical journal, The Lancet, which last year pointed to the global ‘inactivity pandemic’. NICE’s latest authoritative and comprehensive examination of the importance of activity in preventing ill health gives us all the evidence we need to start the activity revolution.

Implications for health, transport, planning, neighbourhood design and air quality

NICE was formed to standardise health policy in the UK and its solidly empirical approach wields considerable power. The NHS in England and Wales is legally obliged to provide funding for medicines and treatments recommended by NICE’s technology appraisal board.

NICE guidelines are based primarily on evaluations of efficacy and cost-effectiveness in various circumstances, in three areas;

1. The use of health technologies within the NHS (such as the use of new and existing medicines, treatments and procedures)
2. Clinical practice (guidance on the appropriate treatment and care of people with specific diseases and conditions)
3. Guidance for public sector workers on Health promotion and ill-health avoidance.

This publication on walking and cycling falls into the third category above and speaks directly to public health professionals. However its comprehensive nature and the stature of NICE guidance means that this publication has value for those working in transport, planning, neighbourhood design and air quality as well as those with a focus on the health co-benefits to be gained from behaviour that benefits the environment.

Further reading

• Walking and Cycling, local measures to promote walking and cycling as forms of travel and recreation (NICE Public Health Guidance 41)

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The Doha declaration on climate, health and wellbeing highlights the effects of climate change on both current and future health, the cost to health of carbon, and the immense health and economic ‘co-benefits’ of meaningful climate action.

The signatories – over 80 health medical organisations, including the UK’s Royal College of Physicians and Royal College of General Practitioners, alongside over 1,200 individuals – are seeking the protection and promotion of health as a central priority of global and national policy responses to climate change, calling for:

• The health impacts of climate change to be taken into account domestically and globally
• Investment in climate mitigation and adaptation to be significantly increased on a rapid timescale
• The health sector and the community to be engaged and informed on climate action

Calling for action

Speaking at the launch of the declaration Dr Cecil Wilson, President of the World Medical Association, set out its importance:

‘The declaration is an important statement from leading health organisations around the world and builds on last year’s successful climate change health summit. The statement illustrates why we are extremely worried about the slow progress at the international climate change negotiations and it highlights the health benefits of tackling climate change.

‘The world’s leaders still do not appear to recognise the impact on health as a result of climate change. If these health implications continue to be overlooked, the world population will be exposed to serious consequences. It is time for the world’s leaders to show leadership and to act now before it is too late.’

Health as a driver for mitigation and adaptation

The declaration asserts that the impact of climate change on health is one of the most significant measures of harm associated with our warming planet, and argues that protecting health is one of the most important motivations for climate action.

Climate change is affecting human health in multiple ways: both direct – through severe weather events, food and water insecurity and infectious diseases – and indirect – through economic instability, migration and as a driver of conflict. Direct health impacts like vector-borne diseases, heatwaves, drought or flooding, are relatively widely recognised, but severe weather events can also cause food insecurity, leading to increased migration and even civil conflict.

The declaration argues that urgent and sustained emissions reductions as well as effective adaptation are needed to counter the risks to health from climate change, which will particularly affect children, women and poorer people and those in developing nations.

Climate action for health benefits

The declaration offers a positive message that climate action has the potential to deliver many benefits to health worldwide:

“Reducing fossil fuel consumption simultaneously improves air quality and improves public health. Shifting to cleaner, safer, low carbon energy systems will save millions of lives each year. Moving to more active lifestyles and expansion of and access to public transport systems can improve health through increased physical activity and reduced air pollution. Improving insulation in homes and buildings can protect people from extreme temperatures and reduce energy consumption. All of these changes will provide significant economic savings.

“Climate action that recognises these benefits can improve the health of individuals and communities, support resilient and sustainable development, and improve global equity.”

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Building the UK’s resilience to climate change is an economic, social and environmental challenge that cuts across every sector of society. To help meet this challenge Defra is developing the National Adaptation Programme (NAP).

NAP will address the risks from climate change set out in the first UK Climate Change Risk Assessment.

From our archive
» UK Climate Change Risk Assessment: The UK Climate Change Risk Assessment (CCRA), published on 25 January 2012, builds on the 2009 UK Climate Projections to develop our understanding of climate risk and provide detailed analysis of the practical implications of climate change across all sectors of the economy and society.

The first NAP is due to be published in 2013, with subsequent reviews every five years, and will focus on helping UK businesses, local authorities and civil society to become more resilient to climate change impacts, working towards a “Climate Ready UK”:

“A society which makes timely, far-sighted and well-informed decisions to address the risks and opportunities posed by a changing climate.”

NAP will reflect new and current or ongoing policies within Government which are being proofed against climate risks, but equally Defra wants to encourage awareness and action beyond central government players. Working alongside businesses, local authorities and civil society, Defra hopes to stimulate innovative policymaking and to empower a wide variety of non-government organisations to take responsibility for finding the best solutions for their sector.

Social vulnerability and community resilience

Health and wellbeing is one of five core themes in the National Adaptation Programme, and includes building community resilience and addressing social vulnerability:

“Climate change could have significant implications for the health and wellbeing of the UK population. There are implications for public health, the continuity of health and social care services both within the NHS and beyond, the resilience of local emergency services and the impact on the most socially vulnerable. Although there may be some extremely welcome benefits, these are projected to be outweighed overall by a range of negative effects.”

Proposed aims for this theme are to create:

“A health service, public health and social care system resilient and adapted to a changing climate”

And:

“Local resilience structures and capability take account of, and are resilient to, a changing climate”

Defra is already working in partnership with local authorities and civil society groups to support projects championing resilience to climate change impacts for the most vulnerable in society by strengthening capacity, capability, tools and guidance.

Mapping the needs of BME communities in Manchester

MC-UK is leading a project to map the needs of BME (Black and Minority Ethnic) communities impacted by changing climate across Greater Manchester, focusing on two particularly vulnerable communities: older people and the refugee and asylum community.

In its first phase the project will map the needs of BME older people and refugees and asylum communities to understand concerns, difficulties and solutions relating to the impact of changing climate on them and their families and friends in their countries of heritage.

The project will subsequently work to build capacity, raise awareness and empower the communities to address climate change impacts, through a creative toolkit and practical workshops. A final report will gather feedback from the project to offer recommendations for future action.

Building social resilience to heat and flooding in Islington

The Climate Resilience Islington South Project (CRISP) will explore the level of social resilience against climate impacts and principally heat and flooding, alongside education elements addressing vulnerability to air pollution and sun exposure. The project will investigate and ‘market-test’ a number of solutions around the optimisation of social capital, community resilience and enhancing the responsiveness of the statutory and voluntary sectors. The findings of the project will inform a new Community Climate Resilience Toolkit and Islington’s local extreme weather risk and resilience plan, as well as being replicable across urban local authorities.

The project will focus on areas identified as strongly subject to the urban heat island effect, with little green space, large concentrations of properties whose residents could be at particular risk of excess heat and a number of areas prone to flooding. Such areas also have considerable concentrations of tenants, both social and private, without the means to improve the resilience of their properties, and experience significant deprivation, poor physical and mental health, and generally increased risk.

The most significant challenges are to help people realise that they are vulnerable, to inform residents and service providers that heat waves constitute genuine health risks, and to improve understanding of the behavioural aspects of heat exposure. Whilst focussing primarily on behaviour adaptation and service preparedness the project will also identify buildings and estates that are the least climate-resilient and seek to identify fabric measures for future implementation.

Mapping vulnerability in Leeds

Leeds City Council is working to directly build climate resilience within vulnerable groups by developing a spatial tool allowing partners to map the most vulnerable residents of Leeds, overlaid by their relative exposure to severe weather events. The project aims to combine the most appropriate data sets, including work done in other cities and by the Environment Agency, with detailed data about the whereabouts of vulnerable people to develop a GIS tool.

The tool will help keep front line workers up to date with the severe weather risks of their clients and to assist in both longer term planning for severe weather events as well as the short term response when these events occur. Initially based in Leeds, the project will aim to develop a tool with practical applications for other Local Authorities.

Building resilience for people with mental health and substance misuse problems

Equinox is an organisation providing support and care for people with mental health and substance misuse problems who are often overlooked by mainstream services and marginalised by society.

Equinox will be working through peer led consultation with people who have experience of alcohol and drug problems and/or with mental ill health to gauge how to build resilience to climate change issues. The findings will inform the production guidance leaflets, appropriate to service users who are often outside the main target audience for such support.

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Equinox provides support and care for people with mental health and substance misuse problems who are often overlooked by mainstream services and marginalised by society. Equinox works across London and the South East with a range of housing, outreach and day services, all of which aim to assist their users in engaging with the communities around them and finding effective strategies to deal with the challenges they face in their lives.

Defra support to help vulnerable groups affected by climate change

One of only two charities nationally to be awarded a grant by Defra to improve knowledge of how “vulnerable groups” will be affected by climate change and how best to respond to its impacts, Equinox will focus on extreme weather events such as heatwaves, severe cold snaps and flooding, and associated risks specific to Equinox service users.

Defra’s grant recognises the commitment and prior achievements of Equinox in engaging with climate change as an issue where we all have responsibilities and can all make a difference.  Led by service users acting as peer mentors, the new project will raise awareness of climate change among people with drug, alcohol and mental health needs and consult on practical tools to help them adapt.  It will also give Equinox a platform to influence national policy and local government, especially emergency planning.

Service User Involvement Manager, Earl Pennycooke, describes how Equinox service users are central to the project:

“The Defra award to Equinox represents a first for people with mental ill health, drug dependence and alcohol dependence.  Service users from Equinox and other organisations are coming together to discover how extreme weather conditions affect these under-represented groups. We are proud that Equinox service users are leading this pioneering project – from focus groups through to final designed information leaflets.”

Chief Executive Bill Puddicombe explains how the project aims to reach groups often missed by existing advice and support:

“Our experience is that local authorities issue helpful guidance leaflets for voluntary organisations to distribute to the vulnerable, for example, about keeping warm in winter or cool in heatwaves. This is commendable but this vital information is not always relevant to our service user groups, as it tends to be aimed at the elderly.”

How Equinox got started with climate harm reduction work

Around the same time Equinox began to develop its Service User Involvement (SUI) Strategy in 2008 (Breaking Down Barriers, published 2009), the organisation started to think about its sustainability policy and also got involved in the Big Response initiative exploring the role of civil society organisations with respect to climate change.

Sharon Bye, former operations director at Equinox, describes Equinox’s involvement in The Big Response project to explore how climate change could affect its work

This was the perfect opportunity to model emerging SUI principles, and a working group of service users, staff, directors and trustees came together to think and act upon what climate change means to Equinox.  It soon became clear that everyone, whatever their role, wanted to relate the Big Response to what is important to Equinox.  This meant Equinox as a sustainable “business” in the long-term, the efficiency and resilience of everyday operations, and the place of Equinox in the wider community, as well as the wellbeing of service users.  In one of a series of workshops, facilitated by the Big Response team and involving people from across the whole organisation, the term “climate harm reduction” was coined to link the commitment to tackling climate change with the “harm reduction” risk management concept familiar to people in the sector.

Beyond mitigation and adaptation to resilience and recovery

Early on in its thinking about sustainability, Equinox had committed to a number of short and longer term actions to reduce carbon emissions which would also benefit the organisation in other ways, including smarter energy use, promoting walking and cycling, and food growing at some services.  For example, Equinox has vegetable gardens at Equinox Aspinden Wood, a care home in Bermondsey for people who have long term problems with alcohol, mental health and homelessness, and Equinox Southampton Way, self contained accommodation for men with enduring mental health problems, in Peckham. 

Equinox recognised the “win wins” in this kind of behaviour change, as being more active is good for physical and mental health, and contributing to the community engenders a sense of purpose which can in turn aid recovery.  Energy efficiency is also good for our pockets.  These things are important to Equinox as a charity, to staff and to service users alike.

With the Big Response, Equinox turned its attention to actions to adapt to climate change, including thinking differently about how to keep services open whatever the weather, and the kinds of messages for service users to share.  It was this which drove home the fact that information and support is not currently well suited to Equinox service users.  Issues identified included the importance for people on medications like methadone to keep hydrated during heatwaves; the possibility that extreme weather could cause or increase side effects for people taking medication; the increased risk of food poisoning due to scavenged food spoiling more quickly; and service users on benefits being less able to afford bottled water when fresh water is not available.  The Defra grant allows Equinox to test and expand this list with a wider group of stakeholders – and to do something about it.

Life experience and life skills:  climate harm reduction and “personalisation” in social care

The grant from Defra is part of the National Adaptation Plan (NAP), which includes a section on health and wellbeing, and the Climate Ready implementation programme.

Equinox’s information leaflets, with practical suggestions to help manage the risks identified, will be shared with the NAP team, with local authorities and the NHS, and groups like the London Climate Change Partnership so that they can be promoted more widely.

Equinox itself will feed its learning into service user support planning, for example, coping with severe weather as an essential “life skill”.

Last but not least, the project will demonstrate the know-how and creativity of our service users, who say they consider themselves “forgotten people”.  Equinox hopes this will help combat stigma in general and give people with drug, alcohol and mental health problems the confidence to work alongside commissioners and decision-makers on a global challenge which affects us all.  This aspiration is central to the Personalisation Strategy, co-produced by staff and service users, which includes objectives for Equinox to make the most of the skills of its service users, ensure they have a real say over the resources of the organisation, and encourage and support service users to influence the world around them.

Further reading

• National Adaptation Plan: addressing the risks set out in the first UK Climate Change Risk Assessment
• SCIE resources on personalisation in social care: thinking about social care by taking the person and their individual circumstances as the starting point, rather than the service
• London’s Changing Climate – In Sickness and In Health: London Climate Change Partnership tool to aid health and social care commissioners and providers as they begin to design and shape their services in the new delivery landscape.
• Vulnerable People and Climate Change: NCVO project building on the Big Response and involving VCS organisations working with older people in London, disabled people and those with mental health needs in London, black and minority ethnic communities in Greater Manchester, and people on low incomes in Hull & East Riding and Portsmouth.

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• The National Adaptation Programme: building climate change resilience among vulnerable groups
• Adapting to tomorrow’s climate in health and social care

For a while now the changing British weather has been making some of us sick and some of those already ill even more so.

In 2002 the Department of Health (DH) produced one of the first country-specific reports detailing the impact climate change is having and is likely to have on the health of UK citizens. Produced jointly by the DH and the Health Protection Agency, The Health Effects of Climate Change in the UK 2012 is the third edition of this very valuable work and includes new chapters on aeroallergens, the indoor environment and health co-benefits to be reaped from action on climate change.

Establishing exactly what climate change is and will be responsible for, and when, is a complex research area. Despite its technical detail and length (230 pages), this report deserves a broad audience as it offers clear explanations of the scientific data, probable clinical implications and straightforward public health recommendations.

This peer-reviewed document provides a point of reference for health and climate change for professionals in the health and social care sectors charged with delivering and planning care. For academics and policy professionals, each chapter sets out the complexity of the current research picture and the evidence gaps.

Being too hot and being too cold

Currently, a 1°C change in temperature brings about changes in mortality figures of around 2%. It is tempting to hope that as deaths from heat wave increase fewer older people will be lost to the winter cold, but global warming will not protect us from exceptionally cold winters. The health risk from extreme temperatures is still much greater from cold than heat and this is projected to be the case for the first half of the century despite steep hikes in heat related mortality. The authors predict that those dying as a result of extreme heat will rise by 70% in the 2020s, then up to 260% during the 2050s and 540% in the 2080s. Age is a key factor and those over 85 years are the most vulnerable to extreme temperatures.

‘Very few of these deaths will arise as a direct result of hyperthermia or hypothermia, but rather from temperature effects on disease, especially cardiovascular and respiratory.’

Recommendations for reducing vulnerability include dehydration prevention and temperature management at household level. Interventions need to target older people, those with a pre-existing condition and – on account of urban heat island effect – those living in large cities.

Air quality

Health impacts in this area are difficult to assess without making assumptions about level of global future greenhouse gas emissions. Ground level ozone (the central focus of this chapter, which also covers particulate matter and nitrogen dioxide) has significant health impacts principally as a respiratory irritant which is expected to lead to between 14,000 and 15,000 premature deaths during the 2030s. This burden is expected to fall unevenly across the UK, affecting London, the South East and Eastern regions to the greatest extent. The key public health tools to fight these effects are the provision of education about possible impacts and warning systems providing information on changes in air quality.

Allergens in the air

Those with conditions like asthma and hayfever are likely to experience onset of symptoms from pollen and fungal spores earlier in the year and over a longer period. Also expected are changes in the prevalence and diversity of flora. Recommended public health measures include ensuring that good information on aero-allergens is available to health care professionals and those with respiratory conditions. This, it is hoped, will enable sufferers to limit their exposure and manage their symptoms. Further measures, such as controlling the invasive spread of problematic plants like ragweed, will also be of value.

Staying indoors

This new chapter focuses on areas such as flood damage, overheating indoors, possible changes to concentrations of indoor pollutants and biological contamination.

Those living in the UK and other developed countries spend, on average, an astonishing 90% of their time indoors. This may be higher for young children, older people and those with poor health. The air indoors is of course also mixed with air from outside and the aero-allergens it may contain and this may be of particular importance to those with some respiratory, cardiac and skin conditions. Homes and health care buildings including pharmacies will require assessments on ventilation and risks of overheating. Support to those living in top floor flats, the elderly and those in low income and/or overcrowded households should be a priority. The report also encourages vulnerability assessments to be completed prior to building adaptations such as thermal insulation as this may seal in indoor pollutants.

Going outside

Skin cancer is one of the commonest forms of cancer in the UK. As average temperatures rise this may lead us to spend more time outside in the summer. UK Ultraviolet radiation levels may be affected by climate change but risks of skin cancer rest predominantly on behavioural changes. Increased summer temperatures may well draw us to the garden and the beach but if better weather and emissions mitigation drives stop some of us travelling abroad then this may actually reduce the amount of malignant melanomas in the UK. Well targeted information striking the balance between vitamin D benefits and risk of burning is recommended.

Health effects of flooding

According to Environment Agency 2009 figures, 7% of hospitals and 9% of surgeries and health centres are in flood risk areas. Flooding is not only devastating for homes but also to the delivery of health care services. It may disrupt power and water supplies, damage patient records, impede ambulance work, cause staff absence and increase patient loads. This is before we consider the increased patient load that may occur as a result of patients being flooded. The health impacts may be both immediate and long-term and include drowning, fatal and non-fatal accidents, poor mental health and a possible increased risk of mortality some time after the waters have subsided. The authors urge that a ‘cross government flood plan’ that includes health impacts – akin to that of the Heatwave Plan for England (DH, 2011) – be developed.

Bites and stings

This is a complex area but the authors are able to predict that the activity and range of disease vectors like ticks and mosquitos is likely to increase in the UK. In this case rates of Lyme disease infection will rise and the transmission of diseases like West Nile virus may occur. Public health and veterinary health sectors are encouraged to work together more closely to improve preparedness in this area. This is one of the areas where action on behalf of the environment may carry public health risks:

‘… there exist possible future conflicts between biodiversity-enhancing strategies and vector-borne disease’.

Substantial sets of appendices accompany this chapter, detailing trends and future scenarios.

Water and food

The way that changes to the climate impact on food and water pose a range of potential risks to health ranging from pathogens in the food we eat and the water we bathe in to changes to food consumption behaviour bought about by food price rises. This is another area where predictions are complex but maintaining and improving public health resources in relation to food and water contamination is likely to be critical to ensuring that the rates of diarrhoeal disease do not increase.

Co-benefits: the good news

Global warming poses a significant threat to health. Many mitigation policies bring such important public health benefits that they may pay for themselves. However the negative impacts such as energy policies that make fuel less affordable to low income households need careful attention. Among other recommendations the authors encourage better policy join-up to ensure co-benefits are realised. The also advocate that the health impacts of climate change feature in the education and training of public health professionals.

Further information

• The Health Effects of Climate Change in the UK 2012: full report available to download
• World Health Organisation factsheet on global health impacts
• NHS Route Map for Sustainable Health: slides, graphs and pictures

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• Adapting to tomorrow’s climate in health and social care
• Preparing communities for climate change

Desired outcomes for public health

The Public Health Outcomes Framework set out the desired outcomes for public health over a 3-year period, and how they will be measured, concentrating on two high-level outcomes to be achieved across the public health system:

• Increased healthy life expectancy
• Reduced differences in life expectancy and healthy life expectancy between communities

These outcomes reflect a focus not only on how long people live but on how well they live at all stages of life. The second outcome focuses attention on reducing health inequalities between people, communities and areas. The framework uses a measure of both life expectancy and healthy life expectancy to draw on the most reliable information available to understand the nature of health inequalities both within and between areas.

Shared responsibility

The framework stresses that responsibility for public health is shared and sets out how its intergration into local government will address the many factors involved:

The responsibility to improve and protect our health lies with us all – government, local communities and with ourselves as individuals.

There are many factors that influence public health over the course of a lifetime. They all need to be understood and acted upon. Integrating public health into local government will allow that to happen – services will be planned and delivered in the context of the broader social determinants of health, like poverty, education, housing, employment, crime and pollution. The NHS, social care, the voluntary sector and communities will all work together to make this happen.
Executive summary, A public health outcomes framework for England, 2013-2016

Public health and sustainable development

The public health agenda is fundamental to sustainable development because it can deliver long-term environmental and financial benefits to society. For example, measures to reduce obesity levels can not only make people healthier, but can reduce environmental impacts, by reducing consumption levels and encouraging active travel, and also mitigate future costs to the NHS.

From the archives
» Healthy lives, healthy people: Department of Health strategies on public health and mental health recognise the role of health in sustainable development, delivering long-term environmental and financial benefits to society.

Refreshing the Public Health Outcomes Framework

The technical update to the Public Health Outcomes Framework, which reflects technical developments since the framework was first published in January 2012, together with the recently published Adult Social Care Outcomes Framework and NHS Outcomes Framework, constitute a structure for measuring improvement across the system and ensuring we meet the health and care challenges we are facing. How these frameworks will work together to improve health outcomes across the system is set out in Health and Care; the role of the Outcomes Frameworks.

Indicators and data tool

A set of public health indicators supports the two high level outcomes of the framework by helping to focus understanding of progress year by year nationally and locally on those things that matter most to public health. The indicators, which cover the full spectrum of public health and what can be realistically measured, are grouped into four ‘domains’:

• Improving the wider determinants of health
• Health improvement
• Health protection
• Healthcare public health and preventing premature mortality

A new interactive Public Health Outcomes Framework Data Tool, allowing local authorities to assess their own outcomes against the various indicators, has also been published with a first set of baselines for over half the indicators. Outstanding baselines will be added to the tool as definitions are finalised and they become available. The tool also currently includes a number of indicators broken down by some of the equalities and inequalities breakdowns – the intention is to expand the number of indicators presented in this way and the range of equalities breakdowns presented over time.

Further reading and resources

• Healthy lives, healthy people: Improving outcomes and supporting transparency: Public Health Outcomes Framework
• Update to the Public Health Outcomes Framework
• Public Health Outcomes Framework Data Tool
• Adult Social Care Outcomes Framework
• NHS Outcomes Framework
• Health and Care; the role of the Outcomes Frameworks

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• Adapting to tomorrow’s climate in health and social care