Minimising the impacts of climate change is a huge challenge, one that requires both individual actions and system changes. This can be explored through our circles of influence, our networks, and our roles as resource stewards, improvement agents, and advocates for health promotion.

Circle of influence. The climate emergency is a concern to us all; within that larger ‘circle of concern’ lies both a smaller ‘circle of control’ incorporating the immediate actions we can individually take; and a mid-sized ‘circle of influence’ where we can positively effect change indirectly. Challenges beyond our control and influence are where we risk wasting effort, and where acceptance may be our only option if we are to avoid eco-anxiety and burn-out. This echoes the mantra of the Serenity prayer, that we express the courage to change that which we can, the serenity to accept the things we cannot, and the wisdom to know the difference.

We lead by example from within our own ‘circle of control’, from the active commuter, to those promoting healthy lifestyles among their patients, to the colleague moving their banking to divest from fossil fuels. Impact from behaviours and choices made in our professional capacity far outweigh that of our personal lives, for example the surgeon recycling at home, but generating kilograms of clinical waste for incineration in the hospital. This puts us in a position of both power and professional responsibility to act and expand our circles of control and influence, including how we engage and communicate with others on environmental issues…

We lead by connecting people and resources within our ‘circle of influence’. Generally speaking, we are all keen to live and work more sustainably, but best intentions can easily be de-railed by demand outstripping supply, or any number of other competing pressures. Conversations engage others and are the first step to building environmental sustainability into the workplace; they also keep the momentum going when initial enthusiasm is eroding. Conversations within networks of engaged individuals share not only ideas, resources and practical advice, but also positive reinforcement and collective motivation, transforming the circle of influence into a multi-directional web, sustaining all involved. Conversations may integrate environmental considerations into everything from corridor conversations and grass roots quality improvement, to advocacy that can influence the higher level agenda, such as service delivery planning or organisational strategy. Leadership and expertise are however vital at these higher levels to provide vision and oversight, as assessment of environmental impact is complex and good intentions driving change can have unintended negative consequences if the full breadth of stakeholders are not involved.

I found my networks locally through setting up a departmental sustainability committee; on social media and online platforms such as the Centre for Sustainable Healthcare through a national specialty working group, and through a cross-discipline group within my health board. Most Universities, Royal Colleges, and international societies now also have sustainability groups which illustrates the progress that we are slowly making in building communities of practice. The structure of these groups may differ, so long as the community and conversations are there.

We lead through stewardship. Building such networks of stakeholders and engaged individuals, we can promote sustainable practices and normalise resource stewardship within our circles. Healthcare professionals focus on symptoms and pathology; we deliver patient-centred care, and their care is within our circle of control.  In the UK, many of us are fortunate enough to work in systems where there are almost no constraints on how much healthcare a patient can receive, on how much equipment or medications can be ordered. We are however also familiar with a finite amount of appointment slots, hospital beds, or theatre space.  We need leadership to apply the same principals of ‘resource stewardship’ to all aspects of healthcare, as our ‘circle of concern’ is the finite amount of resource at a planetary level; resources we are consuming beyond our ability to regenerate, leading to climate change, biodiversity loss, and catastrophic consequences as we push beyond earth’s ability to maintain homeostasis.

Leadership similarities can be drawn with the concept of microbial stewardship, constraining the use of antibiotics to allow us to treat infections and offer high quality care to an individual, whilst future-proofing and preserving anti-microbial sensitivities at a population level.  We must similarly shift the narrative of diagnostic events and finance-based healthcare, to a much broader interpretation of health and wellbeing of the patient, the community, and environment. As for antibiotics, this will be achieved by normalising resource stewardship into everyday practice; reflecting that it is the investigation and management decisions of healthcare professionals that drive health systems’ contribution to climate change – each intervention having required energy to extract resource, to process, manufacture, transport, package, deliver and so on. Returning to our ‘circle of control’, leadership starts by critiquing our own daily practice; identifying the low value activity that consumes resource without contributing to patient care. Removing these low value activities through sustainable quality improvement we can improve efficiencies in patient pathways, save money, and reduce environmental impacts.

Achievable Sustainable Quality Improvement. Quality Improvement (QI) approaches provide structure when implementing change and are widely understood in healthcare. Sustainable QI reflects the ‘shift of narrative’ mentioned above by including environmental, financial, and social outcomes in addition to patient outcomes. Projects should be assessed on their potential impact and feasibility; implementing changes being much easier within ones’ ‘circle of influence’ than projects quarantined in the ‘circle of concern’ due to their dependence on supply chain, procurement, or estates departments, which require additional effort to build into our networks and to overcome regulations. High level leadership must create a working environment that facilitates sustainable QI work across this traditional silo working through empowering network building, including open access platforms.

Prevention is also critical, but does it fall in our circle of control, influence, or acceptance? The well-used metaphor of stopping people falling in upstream being preferable to pulling them out downstream is never more fitting than for sustainable healthcare. The metaphor applies on several levels, e.g. preventing use of consumable items having greater impact than recycling the components after use, or preventing disease states from emerging through reducing exposure to risk factors such as low physical activity, diet, and smoking. Unless you work in Public Health or Health Policy, a focus on prevention poses greater challenges as it may lie beyond our ‘circle of control’, but greater too are the potential impacts if we can extend our ‘circle of influence’ to incorporate ‘upstream’ determinants. We need strong cross-disciplinary clinical leadership, public health, primary care, and political commitment to prevent disease incidence and progression upstream, reducing demand on downstream services.

To conclude, sustainable leadership comes in many guises and operates at all levels of an organisation. We can all choose to engage, to act, to grow and develop our circles of control and influence; inaction is the only option we cannot afford.

I would like to acknowledge the RCPSG and University of Glasgow Leadership Development Scholarship Programme in supporting me 2022.

Author

Eleanor Murray

Eleanor is a Nephrologist working in the West of Scotland, with an active involvement in healthcare-related Environmental Sustainability at a local and national level, and a previous position as Sustainability Scholar for Scottish Government and RCPSG.

Declaration of interests:

I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: none.