To survive and prosper long term, health systems must be financially, socially, and environmentally sustainable. All health systems face a challenge in being sustainable in that costs rise ahead of inflation; patients and citizens can lose confidence in systems that offer poor quality care, are hard to access, and feel unresponsive; and most health systems have rising emissions of greenhouse gases and generate a huge amount of waste, including leaking pharmaceuticals into the environment. Digital health has an important contribution to make to the financial, social, and environmental sustainability of health systems.
I want to concentrate in this piece on the role of digital health in environmental sustainability, but I also want to write a few words on financial and social sustainability—not least because the three forms of sustainability are intertwined, actions that benefit one often benefit the other two.
Expenditure on healthcare in Britain has risen from 25% of public expenditure to 40% in two to three decades—and it will have risen still higher with pandemic. The rise is partly caused by aging of the population, but the main driver is that healthcare can offer much more. Ironically the higher spend on healthcare (which is mostly sickness care) crowds out expenditure on education, housing, and the environment, which are more important for health than is healthcare. (There is a widespread almost irresistible tendency to conflate health and healthcare, but they are quite different: the best estimate is that healthcare accounts for about 10% of health, with the environment, lifestyle, and genes accounting for 90%.)
Most of the expenditure of the health system is on hospital care, with community care having a falling proportion. Despite the increase in expenditure on healthcare, most commentators insist the NHS is underfunded, and the backlog in care resulting from the pandemic has caused further strain.
There is increasing consensus that “more of the same” will not keep the NHS financially sustainable and that a different model is needed. The main change that is needed is to move from a model of the “NHS fixing people’s problems” to one of the “NHS supporting people to stay healthy and then cope with—or self-manage—problems when they do become sick.”
This change is necessary, not just for financial sustainability, but also because of the change in disease patterns: in the early days of the NHS people presented with infections and trauma, problems that could be “fixed” in short episodes; now people mostly have long term conditions, often multiple conditions, that cannot be “fixed.” If patients have meningitis, then whether they live or die depends mainly on the clinical teams, but if patients have diabetes, chronic obstructive pulmonary disease, heart failure, arthritis, or depression then how well they do depends primarily on them and their families not on the doctors and nurses. This is not an ideological statement, but simply a fact when patients may spend three hours a year with clinicians and the other 8757 living with and managing their conditions.
Making such a fundamental change is not easy for either health professionals or citizens and patients, but digital technology can help—and giving patients full access to and control of their health records, as Patients Know Best (a company I chair—see competing interest statement) does, is a necessary but not sufficient step.
When the NHS began patients and citizens were extremely grateful that access to care was free and that the anxiety of not being able to access or afford care had gone. But over 70 years people have come to expect much more than simply access. We live now in a consumer-driven world where a huge range of services are a “click away.” People, particularly younger people who have always known the NHS and don’t have the same “gratitude” for it, expect services as good as those available from the best retailers. The social sustainability of the NHS depends in part on being able to meet those expectations—and so must include better digital access to information and services.
Social sustainability also depends on the NHS being able to provide good access to high quality care and being responsive and humane. One way that the NHS would fail is if the middle classes were to desert because the service did not meet their expectations. This fear has receded with the pandemic and the mass vaccination programme, but could return if the NHS fails to catch up with the huge backlog of work left after responding to the pandemic.
The NHS did perhaps not worry much about environmental sustainability until recently. Like most of the rest of the world it took the environment for granted and didn’t think that its limits could be reached. Growing recognition of the gravity and urgency of climate change and ecological destruction has changed that. NHS England has become the first health system in the world to have a detailed plan for achieving net-zero by 2040 for all it controls and 2045 for all that it procures. The health and social care system accounts for about 5% of the UK’s greenhouse gas emissions, and if healthcare across the world were a country it would be the fifth largest emitter of greenhouse gas emissions.
Increasing digital healthcare is an important part of reducing the carbon footprint of the NHS, and carbon and cost are closely related. Even in a world without a substantial carbon tax (and such a tax will have to come soon) savings in carbon usually mean savings in cost.
Some of the savings in carbon are straightforward. Substituting electronic messages for paper letters means savings in paper, emissions from transport, and cost. Letting patients book appointments online is a small step along the road that banks followed many years ago of getting customers rather than staff to do much of the work. Allowing people to consult online can provide a better service and also save the 10% of the NHS carbon footprint that is accounted for by patient and staff travel: one in 20 journeys on Britain’s roads is associated with the NHS. Optimal online consulting depends on the consultations being incorporated into health records with both patients and clinicians having access to them, as Patients Know Best allows.
But, as the NHS net-zero plan makes clear, changing buildings, using renewable energy, and introducing electronic vehicles will not be nearly enough to get the NHS to net-zero. Everything, including clinical practice and pathways, has to change. This reality is only just beginning to sink in with many health professionals.
The real power of digital comes from empowering or activating patients, and to be much more active in their own health and care patients must have access to their own records and results and high-quality information. They must also have the chance to share data they collect themselves with health professionals. Care becomes a partnership that recognises that patients know best what matters to them.
An example of change is recognising that the widespread routine six-month follow-up of patients with long-term conditions is inefficient. The pattern of most long term conditions is that patients are stable for much of the time but then have flare-ups when they need professional care. If patients are given access and control of their records and test result and “put in charge” then they can keep themselves stable, feedback to clinicians that they are well and don’t need to be seen, and then request to be seen as a flare-up begins. A study of using a pathway along these lines with patients with inflammatory bowel disease showed that visits to outpatients and the emergency department and admissions fell and that patients with flare-ups were seen within a week rather than usual six weeks.
Redesigning pathways in this way can reduce cost and carbon consumption. The changes that occurred at the beginning of the covid-19 pandemic illustrated how quickly and extensively clinical pathways can change when it’s essential, and pathways have to change to keep healthcare financially, socially, and environmentally sustainable. The need may not feel as urgent as with the start of the pandemic, but the need is just as urgent. We are running out of time to keep the global increase in temperature at less than 1.5C above pre-industrial levels, and increases above 1.5C open up the possibility of a rapid descent into chaos.
A leak from the near-final draft of the 2022 report of the Intergovernmental Panel on Climate Change (IPCC) made clear how little progress is being made and how “Species extinction, more widespread disease, unliveable heat, ecosystem collapse, cities menaced by rising seas—these and other devastating climate impacts are accelerating and bound to become painfully obvious before a child born today turns 30.”
Digital health, including all patients having access to and controlling their records through Patients Know Best, is an essential component for sustainability, but ultimately patients and health professionals working together have to innovate using the technology.
Richard Smith was the editor of The BMJ until 2004.
Competing interest: RS is the unpaid chair of Patients Know Best but has equity in the company. He is also the chair of the UK Health Alliance on Climate Change and the Point of Care Foundation, which works to humanise health and social care.