Environmental sustainability and quality care: Not one without the other

Abstract

There are increasing calls for attention to environmental sustainability within health systems and healthcare. This is essential given their environmental impact, their need for climate resilience and their role in managing climate-mediated conditions [1]. Quality of care, or the ‘degree to which health services for individuals and populations increase the likelihood of desired health outcomes’, is similarly a key health systems goal given the huge human suffering and mortality associated with care that is not effective, safe or people-centred [2, 3]. As health systems pursue these dual objectives, we must understand the interface between them, conceptually and operationally. Environmental sustainability and quality of care are extensively linked. As health services are scaled up in pursuit of Universal Health Coverage, it is vital that they are both high quality and sustainable. The health sector is a major polluter, generating an estimated 4.6% of global emissions [4]. Improving quality of care has potential bidirectional impacts on pollution: improving quality can reduce adverse impacts, for example, as preventative and patient safety measures reduce unnecessary hospital procedures [5]. Conversely, if quality improves without attention to environmental factors, this may increase adverse impacts on the environment, for example, as improved access to chronic disease medication increases pharmaceutical pollution [6] or as enhanced Infection Prevention and Control (IPC) increases the use of single-use personal protective equipment, especially apparent during the corona virus disease 2019 (COVID-19) pandemic [7, 8]. An increase in healthcare-mediated pollution as quality services are scaled up is not a certainty: these footprints vary considerably by country, with many countries expanding healthcare while maintaining or decreasing carbon outputs [9]. Efficiency is already a widely recognized domain of quality health services [10]; as the costs of inaction on environmental sustainability become ever more stark, the case for its inclusion as a key determinant of efficiency is clear. From an environmental perspective, quality care is associated with more than emissions. Healthcare requires safe and clean environments, including water, sanitation and hygiene (WASH), clean energy and good, ideally locally sourced, food; climate change poses major risks to supply, quality and access—in these ways environmental sustainability is a pre-requisite for quality. Quality of care is closely linked to the views and expectations of patients, their families, the public and communities: their satisfaction is an important metric for quality [11]. Coproduction of health and healthcare, or the involvement of service users, providers, professionals and others in shaping their health and care, is increasingly recognized as important in improving services [11, 12]. As such, quality improvement efforts should recognize existing community demand for environmental sustainability and can also leverage community knowledge and assets in designing environmentally sustainable improvements [13]. Here, quality and sustainability have joint roots and outcomes. Ultimately, the aim of quality care is to improve population health; yet, if health systems fail to simultaneously address environmental sustainability, this will limit improvements in the health of the communities they serve. These cyclical relationships demonstrate the mutually reinforcing impacts of environmental sustainability and quality: we shouldn’t be thinking of one without the other. How do we align action on quality and environmental sustainability? Firstly, recognizing these interlinkages and advocating for those leading quality initiatives across the health system to incorporate environmental sustainability as a quality pre-requisite, goal and outcome. This has been previously highlighted by leaders in this field [13–15], yet is not widely enough recognized and is particularly relevant as health systems ‘build back better’ post-pandemic [16]. Secondly, analysing action on quality through an environmental sustainability lens, for example: exploring the integration of environmental factors within quality interventions (such as accreditation, WASH or IPC) [17]; considering links between workforce, environment, health and quality [18]; coproducing services incorporating community and patient views on quality and environment [11, 12] and the inclusion of environmental sustainability when defining value in quality or resource use [13]. Thirdly, pursuing health systems transformation that intentionally accounts for these inter-related goals of quality and sustainability. This could include utilizing national strategic direction on quality of care [19] supporting infrastructure for environmentally sustainable healthcare (such as quality telemedicine programmes), improving logistics and supply chains and developing performance metrics that measure healthcare sustainability [15, 20]. Fourthly, joint advocacy efforts are required to leverage political attention in support of these complementary—and critical—agendas for sustainable improvements to health and care. Finally, there should be an emphasis on shared inter-disciplinary and bidirectional learning, using the skills and expertise of the quality and sustainability communities, including patients and the public, taking learning from different contexts, at different points of their healthcare quality or sustainability journeys, across the world [21]. Quality of care is a dynamic concept, requiring continual refinement as health systems and population needs evolve; better incorporating environmental sustainability can be viewed as a part of this evolution of a concept vital to promote and protect health [11]. None. No funding is associated with this comment. Not required. N/A. Contributorship: N.P. and M.N. contributed equally to the inception, development and writing of this comment.

Topics & Concepts