Mapping Greener HealthcareMapping Greener Healthcare

Team Members:

• Cleone Pardoe – Clinical Teaching Fellow, Post-IMT2 Doctor, 
• Alexander Strother – Clinical Teaching Fellow, Post-FY2 Doctor, 
• Linh Mao – Undergraduate Medical Education Clerical Officer & Receptionist, 
• Amanda Shotton – Undergraduate Medical Education Service Manager

Project Aims:

1. Reduce the impact of our self-directed practice (SDP) rooms across the triple bottom line, by streamlining equipment packs for our 5 most popular skills: NGT, ABG, cannulation, venepuncture and catheter skills. 
2. Empower students to be conscious of the financial and environmental cost of items they use in the SDP and clinical environments. 
3. Save the Undergraduate department money, that can be better invested into improving the student experience and promoting sustainable healthcare. 

Background:

Based at St James’s Hospital, the ‘Hub’ represents the heart of Undergraduate Medical Education at LTHT. We consist of a diverse education and administration team and are committed to being a place of teaching excellence to the roughly 200 MBChB and Physicians Associate students rotating through our department every month. Further, not only do we facilitate teaching sessions on countless topics, we deliver simulation training, run mock examinations and have two dedicated ‘self-directed practice’ (SDP) rooms, equipped with everything students need to hone their clinical skills independently.

As a Medical Education team, we believe we are uniquely placed to promote ‘greener’ healthcare systems by preparing future clinicians to deliver first-class care to an ever-more complex patient population. As individual clinicians, we will likely care for thousands of patients throughout our career. But as educators, we play a role in training hundreds of students every year, who will in turn care for hundreds of thousands of patients. We believe that by educating future clinicians at this early stage in their training on the importance of sustainable healthcare, we can support delivery of truly holistic care that both protects and promotes the health of current and future generations.

Approach:

Studying the system: A review of the booking system identified which skills were most popular in the past 12 months as well as then process students would go through to use the room. This process involved an online booking system where students detailed when and what skill/s they wished to practice. Upon arrival at the hub students were given equipment they needed in the form of a specific ‘pack’, according to a list that had been in use for many years. A baseline audit of storeroom inventory and SDP room use audit identified items that were

• Not required (unnecessary to the student experience nor reflective of real-life clinical practice) 
• Required and potentially reusable 
• Required and single use (needs to be replaced and purchased each time) 
• Damaging to expensive equipment (e.g., alcohol-based cleaning solutions damaging to material of training arms, reducing their life span) 
• Missing from the packs, which would be beneficial for student experience (e.g., gauze).

Engagement: Students were engaged to ensure a balance between sustainable changes and keeping an authentic and realistic experience for the students to practice their skills. A brief electronic questionnaire accessible via QR codes provided insight into why current students were using the SDP rooms, what an ‘ideal’ SDP was for students, and their thoughts on sustainable practice. This also supported us in developing our change ideas.

Changes implemented: We created new, sustainable ‘packs’, that could be collected by students when they arrived for their session. Metal trolleys were added to each SDP room, stacked with repurposed, labelled containersfor students to put their unused and potentially reusable equipment in when finished. Each label included the price of the relevant item, demonstrating how much money their simple actions could save, empowering students to take their learning into the clinical environment. The sustainable packs are remade at the end of each week with the reusable items students have placed in the trolley, with single use items (e.g., canula) added as needed. Each skill pack has a clear, illustrated document of what needs to be included to facilitate this process. A running total of CO2e savings with equivalent to miles driven in a car is shared on each room whiteboard and will be updated at the end of each month highlighting the environmental savings from their actions.

Measurement:

Financial: Price per unit was obtained from a comprehensive costing list from the Trust Supplies and Procurement team. We calculated savings by reviewing what we had saved through: a) removing unnecessary items; and b) reusing items that were previously thrown away. We added an additional cost to purchase cannulas, which were previously included as part of a larger pack (given free to the hub) that had contained several unnecessary items.

Environmental: CO2e were calculated for every piece of equipment based on the item cost or weight with the relevant emissions factor from the Carbon factors Greener NHS Team 2020-21. We used our audit to compare how many items were required pre and post introduction of our new sustainable packs.

Social: A questionnaire to collect both qualitative and quantitative data from our students ensured their voices were heard and at the heart of our initiative. This questionnaire sought to determine a number of important variables, including the students’ wider views on the importance of sustainable healthcare as discussed above. It could be completed quickly and easily by scanning one of QR codes found in each SDP room, which would direct students to our Google form. These QR codes will remain available to the students beyond the Green Ward; we are always open to ideas on how we can improve these spaces for their learning and the planet. Informal, qualitative data from the wider education team on how they have been inspired by the project and how they might change their practice as a result.

Results:

The balance for each ‘pack’ was calculated and used to predicted savings over 12 months, based upon the previous 12 months’ usage of the SDP room.

Environmental benefit: The total predicted savings amounted to 538.16 kgCO2e. This is the equivalent to 1,544.12 miles driven in an average car.

Financial benefit: The new packs will save our department £623.39 per year.

Clinical and health outcomes: The potential clinical impact is vast due to the huge number of students who come through our SDP rooms and already work in clinical environments on their placements. Our student feedback questionnaire identified 42.9% students had never previously considered the environmental impact of their clinical skills. When asked whether students had changed their practice to reduce waste, their responses were again encouraging:

“Yes - not using what is not necessary to practice examination”

“After this, I will be more mindful of how much equipment I take out of their packets on the ward”

Social sustainability: We were pleasantly surprised by how engaged students were in this process; the trolleys were overflowing with unused and potentially reusable equipment, and everything was in its correct tray. In response to asking if there was anything more we could do in addition to our current, thoughtful changes, the students responded positively:

“Not based on the environmentally friendly packs given today. They were sufficient for practicing the technique”

Without the engagement of our students in this culture change, the remaking of the kits at the end of each week would be time consuming to our staff. Fortunately, we found that both staff and students have very willingly engaged, and there have been no issues in terms of compliance for students to return equipment as requested, and no complaints from staff into the time taken to remake packs at the end of the week.

Our project has also sparked enthusiasm and conversation for sustainable medical education not only within our own team, but across the student cohort, management and Postgraduate teams. Amanda, Undergraduate Medical Education Service Manager, attended regular meetings and updated key stakeholders throughout the project which was vital to this engagement. Please see below some reflections from the Undergraduate team:

Ellie (CTF): “This project has changed my clinical practice - I now ensure I only take the equipment I need for each clinical skill”

Jordan (Medical Education Administrative Coordinator): “The whole project has been eye-opening. It has been great to see how much the students have got on board with the initiative”

Steps taken to ensure lasting change and conclusion:

We believe the ongoing success of this project is possible due to the positive engagement and dedication of staff and students alike. Through our discussions with staff, clinicians and students, one thing is clear: people genuinely care about sustainability, especially students. We believe we have empowered students to be more mindful of the financial and environmental impact of their clinical practice. Both ‘mindful’ and ‘conscious’ were words used by our students in their questionnaire responses. This will ensure not only that our SDP room changes continue, but that students will move on to clinical work with both competence in their skills and awareness of environmental impact of their care.

We have further ideas to further enhance our sustainable teaching including going paperless via use of QR codes to share information, a digital educator platform, and use of iPads which have recently been funded (saving 26,280 sheets of paper and additional 113.72KgC02e per year). We are also working on delivering an interactive workshop on sustainable healthcare to newly graduated junior doctors, on the principles of sustainable care and how we can integrate these with practice.

Our project has sparked enthusiasm and conversation for sustainable medical education across the student cohort, management and Postgraduate teams. We are motivated to ultimately extend this platform to those involved in medical education across the region and are equally inspired by our interactions with students from the Leeds Healthcare Students for Climate Action (HESCA) and Planetary Health Report Card; two student-led initiatives which seek to inspire medical institutions to adopt and promote sustainable healthcare practices in the UK and worldwide.

Summary

Southampton offered a student selected unit (SSU) for 4 students in year 3. The unit covered sustainability within the NHS and climate change in a global context. The course took place over 2 and a half months and was varied in pedagogical formats using lectures, seminars, group projects and field trips to local areas of interest. The students that took part in this SSU stated that the course broadened their horizons and that they really enjoyed escaping the norm of sanitised medical education where answers are right or wrong.

Course description:

The first session covered the science of global warming, taking the students back to chemistry and physics that they may have come across in school.  Other sessions, run by a variety of facilitators and lecturers, covered a huge range of topics:

• The potential health impacts of rising temperatures – Prof S. Padmadas, Professor of Demography and Global Health, University of Southampton
• Waste management at University Hospital Southamton (UHS) - Mr Andrew Hatcher, Head of waste management, UHS
• Sustainable transport at UHS - Mr Rui Marcelino, Sustainable Transport Manager, UHS
• What should we leave our grandchildren – Dr Robin Stott, Climate and Health Council
• Energy consumption and management - Mr Mark Bagnall, Head of estates, UHS
• Demographic and population changes resulting from rising sea levels in low lying and delta regions in the world – Prof S. Padmadas, Professor of Demography and Global Health, University of Southampton

There were two field trips, where students visited:

• University Hospital of Southampton’s Combined Heat and Power Plant
• Ordnance Survey headquarters in Southampton to see an environmentally sustainable building design, including ground-source heat pump.

The practical application of sustainability was woven through the course,  the final session quantifying the CO2 emissions for a DC cardioversion, bringing together resource use and energy consumption. The students presented their own project work during the final session which included topics such as:

• Edible cutlery
• The carbon intensity of beef rearing
• The impact of rising sea levels in Southampton on healthcare delivery

The students went on to present their findings on DC cardioversion at the Sustainability Symposium in Brighton on 22nd June.

Lessons Learned

Educators leading this SSU have reflected that the initial lesson on the science of climate change would benefit from the production of a glossary of terms before the session.

Feedback on the sustainability teaching evidenced a positive experience for staff and students alike. Students’ feedback stated that they were never bored and that the variety of subjects covered was broad but not exhaustive. Student engagement in the project to carbon footprint the DC cardioversion pathway was particularly well received, suggesting that practical projects that enable students to apply their learning can stimulate engagement.

Course or session dates: 15/01/2016 until 01/04/2016 

Number of students taught: 4

Pedagogical format: Lectures, Seminars and Project-based

Teaching time: 30 hours

Curriculum area: Public Health

Sustainability learning outcomes addressed:

• PLO 1 - Describe how the environment and human health interact at different levels
• PLO 2 - Demonstrate the knowledge and skills needed to improve the environmental sustainability of health systems
• PLO 3 - Discuss how the duty of a doctor to protect and promote health is shaped by the dependence of human health on the local and global environment

Summary

Kings College London (KCL) has taken a novel approach to including sustainability in their curriculum, and has developed Quality Improvement Projects (QIPs) for 4th year medical students.  This approach has been steadily growing since 2015 with each year seeing more students engaging in sustainability-focussed QIPs, and all students (even those whose focus is not on a sustainability QIP) now evaluate the sustainability aspects and implications of their QIP. The majority of sustainability QIPs  are in General Practice (GP), but students carrying out QIPs in hospitals can also choose a sustainability focus.

Course Description

In 2015/16, six selected GP practices and 18 allocated students were involved in the KCL pilot project. Students undertook a modified Health Promotion review, which involved collecting baseline quantitative data to inform a Plan-Do-Study-Act (PDSA) cycle as part of a QIP.

GPs were offered written information and one face-to-face briefing session about sustainability and quality improvement in 2015/16. The GP practices specified the focus of the QIPs. In 2018/19 the pre-project clinical educator training is being adapted to make it more accessible to GPs, and will comprise e-learning and a webinar.

The pilot project benefitted students and GP practices alike. Students gained research experience and learnt more about sustainability in the workplace. Clinical educators also learnt about sustainability, and many cited improvements in sustainability in their workplace. The project was therefore expanded in 2016/17 and 2017/18 so that all fourth year students (not only those allocated to certain GP practices) now have to report on the sustainability aspects of a QIP carried out in a group of five in either a hospital or a GP setting.

Examples of projects completed by students are facilitation of a move from paper to electronic prescribing in a GP practice, and establishment of diabetic support groups which has stimulated members to change their dietary habits and physical activity. The electronic prescribing had been available to GPs, but not achieved sufficient uptake until the student project evaluated and acted to support uptake. The diabetic support groups instigated by the students remain active, welcoming new members, and were re-audited by the 2017-18 student cohort.

Course or session dates: 11/12/2015 until 29/04/2016, and in subsequent years

Number of students taught: 18 in 2015-16, expanding to 430 in 2017/18 

Pedagogical format: Project Based 

Teaching time: 8 hours. Self-directed learning: 6-12 hours 

Teaching time for sustainable healthcare (hours): 2-3 hours

Curriculum area: General Practice

Sustainability learning outcomes addressed:

      PLO 2 - Demonstrate the knowledge and skills needed to improve the environmental sustainability of health systems

      PLO 3 - Discuss how the duty of a doctor to protect and promote health is shaped by the dependence of human health on the local and global environment

Lessons learnt

• Educators at KCL reflected that this type of project needs significant pre-project briefing to ensure that both students and staff understand sustainability concepts and are prepared to design and run a QIP. The attendance of GPs at a face-to-face briefing was low, hence the decision to move to e-learning and a webinar. Educators also emphasised that it is important that all the GPs in the practices are on board to support the project’s success.
• Overall, students valued and embraced the project. Since the project is time intensive, informing students early on about their allocation and giving them time to get to grips with the pre-reading and e-learning early is very beneficial.

A GP said:

“Enthusiastically engaged with whole practice team to implement the change to electronic prescribing with a realistic target and using a variety of ideas to educate and encourage change in both staff and patients without causing significant extra work for staff and educating patients positively to encourage compliance with good effect.” 

Students said (focus group):

“I’d never really thought about this kind of thing before, so it was good to see how these projects work from a smaller scale just so that it was something that we could do in a short space of time, but as [I] said, just quite useful to understand ‘cos it would be quite useful in our future practice if we wanted to improve certain aspects of it.”

“…overall I thought it… the practice was great in terms of letting us do what we needed to do, the project itself I think is a good idea, just with the issues we had and I think the timeframe it could be improved, with how it’s implemented.”

“…maybe sometimes it’s hard to link sustainability with the quality improvement project you’re trying to do, like ‘cos for us sustainability wasn’t a focus in terms of trying to implement, or design our project, and I mean it could have been a bit more I guess, but they’re two different things to think about at the same time I guess.”

“I think for me it highlighted that this is kind of going to be the new, not craze, but the new focus for the NHS to be more environmentally friendly and green.”

Summary

“Introduction to sustainable health” is a 1.5 hour interactive workshop now scheduled for its second year in the Patients, populations, policy (P3) module. The workshop is a required experience for all first-year medical students (~200) and begins with a definition of environmental health, followed by an introduction to the overall causes, mechanisms and impacts of climate change.

Background

The faculty member who developed this session looked at the courses run by her department and identified those most amendable to climate-change topic related insertions. Because she has a relationship with her departmental colleagues, she was allowed to include these topics without adding substantially to the curriculum. Specific sustainability learning objectives were added to the P3 workshop, linked to the overall teaching goals of the course.

Course Description

The session addresses the following questions:

1. What are the mechanisms and impacts of climate change?
2. What are some of the barriers to implementing sustainable behavioral and institutional practices?
3. What are some commonly identified strategies to reduce greenhouse gas emissions?
4. What actions can doctors take to improve sustainability?
5. What effects does climate change have on air quality and by what mechanisms do increased temperatures affect air quality?
6. List common air pollutants. By what mechanism do they harm health?
7. What are the health effects/outcomes of air pollution?
8. Which populations are the most vulnerable and what environmental conditions increase individual vulnerability? How might lower SES influence exposure or susceptibility to air pollution?
9. What is the air quality in dc today and what does it mean? What advice would you give your 16-year-old asthma patient if the air quality index is 130? What are your options in counseling your vulnerable patients? How useful are face masks?

After listening to an introductory summary outlining the mechanisms and impacts of climate change, students identify their degree of concern about climate change through clicker voting, which is then compared to US percentages (‘6 Americas’) and their political affiliations, and discuss barriers to addressing climate change in their personal and professional lives.

Students also calculate their carbon footprint. They then are given a case study which links air pollution and climate change. The students form small groups to answer questions such as how to look up air quality, how to address the impact of air pollution on respiratory disease, what travel advisories would they give restricting travel to areas with high levels of pollution, and how to use an app to detect wildfires.

Year group taught: 1st years

Status of this teaching within the curriculum: Core

Curriculum area: P3 is an existing introductory course aimed at familiarising students with the US health care system (and comparing it with other systems), financial structures and health care coverage, and addressing issues important to population health, including a focus on social determinants of health.

Pedagogical format: lectures interspersed with interactive learning activities

Teaching time: 1.5 hours

Number of students taught: 200

Materials used: PowerPoint slides; background articles

Session dates: Takes place in October, has so far run in 2017 and will run in Fall, 2018

Sustainability learning outcomes addressed:

• PLO 1 - Describe how the environment and human health interact at different levels (“Explain the causal relationship between climate change & health”
• PLO 3 - Discuss how the duty of a doctor to protect and promote health is shaped by the dependence of human health on the local and global environment (“Identify personal, professional and global solutions to atmospheric carbonization”)
• Other: Advise patients on monitoring air quality to minimize respiratory and cardiovascular effects of air pollution

Lessons Learned

• Based on reactions from students, the session lead found that to enhance effectiveness of the teaching, there needs to be more emphasis on solutions and more follow-up to support the learning. In the next iterations there will therefore be more focus on solutions available to students, and opportunities for follow-up will be provided e.g. research projects, service projects or support for advocacy.
• The educator recommends forming alliances with faculty in other departments and working with them to take a similar approach, consistent with previous recommendations on an integrated climate change curriculum.

An educator (small-group leader) new to teaching the course said:

“Yesterday's content on PCMH and community-focused/patient-centered care, using asthma as the example but then expanding the view by bringing in climate change and environmental impact on individual and community health is just plain genius. Over the course of the morning, the learning was just at optimal level. This session is a beautifully-designed flow and weave of content and teaching method.”

Summary:

Dundee included sustainability as an option for their Student Selected Component (SSC) modules throughout the medical school year-groups and included some lectures on sustainability in their core lectures.

Course and lecture details:

First-year students received two lectures that were specifically focussed on sustainability. The first was an introductory lecture on “How to live forever” aiming to show the bigger picture of healthcare. It included information on climate change and the environment, as well as slides from Hans Roslin’s work on life expectancy. The second, later on in the year, was integrated into respiratory lectures with an hour being dedicated to learning about the environmental causes of lung disease (in 2016, the lecture was expanded to include health impacts of water pollution also).

First year students were also able to choose “Sustainable Healthcare” as an SSC topic. This involved  40 hours of project-based work for 5 students in a student-led module. The students and the tutor initially met for a chat about the overall learning objectives and the students subsequently submitted essay titles and brief abstracts for their proposed essays. Essay outlines were submitted half-way through the SSC (limited to an A4 sheet of paper) and then at the end of the four-week period submission of a 10 page essay was required.

A lesson learnt from student feedback is that students may have preferred a more structured start to the module, such as a seminar to introduce the topics. The tutor plans to replace the informal discussion based on pre-reading with a short seminar and discussion group to explore ideas for projects, which is slightly different from most SSC modules in Dundee which are usually entirely student-led.

A four-week SSC on sustainability is also planned for second and third year students. Fifteen students will be given the option to attend seminars followed by project-based work on sustainable healthcare. This SSC will be enhanced by combining seminars with other SSCs that run simultaneously, therefore getting a broad mix of engagement from students throughout the medical school.

Pedagogical format: Seminar, lectures and project work

Assessment: Assessment of the SSCs was completed by educators who marked the students’ written submissions and / or presentation of their project work 

Sustainability learning outcomes addressed:

• PLO 1 - Describe how the environment and human health interact at different levels
• PLO 2 - Demonstrate the knowledge and skills needed to improve the environmental sustainability of health systems
• PLO 3 - Discuss how the duty of a doctor to protect and promote health is shaped by the dependence of human health on the local and global environment

Summary

Brighton and Sussex medical school incorporated sustainability into their core curriculum by giving a one-hour lecture to their 4th year medical students during their Primary Care block. The teaching was arranged by a lecturer in public health and was delivered together with a local GP who is the lead for sustainability at the CCG.

Sustainability learning outcomes addressed:

• PLO 2 - Demonstrate the knowledge and skills needed to improve the environmental sustainability of health systems
• PLO 3 - Discuss how the duty of a doctor to protect and promote health is shaped by the dependence of human health on the local and global environment

Experience and Lessons Learned

Educators received positive feedback about the session. That teaching was delivered by a clinician gave the students a “hook” that engaged them and made the teaching relevant to their practice. Meeting with the module leader in the preparation phase for this session ensured that the teaching on sustainability was in line with the rest of the teaching on the primary care module. Ensuring that the content had examples of local practice in primary care helped to link this lecture to the rest of the module and to the students’ future roles.

One problem highlighted by the educators was that the lecture was given at the end of year 4 therefore introducing the “language of sustainability” too late for many students;  it might have better results if incorporated earlier on in students’ medical education. A further concern was that a stand alone lecture such as this in the primary care unit may imply to some students that sustainability is only relevant to primary and not secondary care.

Reflecting on the teaching, the organiser felt that it would have been better managed in small groups and in seminars rather than large groups – however BSMS had a limited capacity of teaching staff with the appropriate expertise at the time of the teaching.

Lecture date: 17/06/2016

Pedagogical format: Lecture

Number of students taught: 140

Teaching time:  1 hour

Curriculum area: Primary Care

Summary

This fourty-five hour optional module for professionals from a variety of health and health-related disciplines formed part of the Public health postgraduate course. The seven-week module brings together postgraduate students from medicine, nutrition, social work, psychology, pharmacy, administration and law.  

Course details:

This was an optional module, which brought together postgraduate students to learn about sustainability in healthcare. This course has been running since 2012 and there has been increased uptake of the course year on year.

The course consisted of weekly seminars on the following topics:

1. Introduction to environment and health
2. Introduction to chemical toxins and health, including ‘Stolen Future’ film
3. Theory and practice of environmental health surveillance
4. Genetically modified organisms and their health impacts
5. Health threats from climate change
6. Pesticides and their health impacts
7. Discovery trail and presentations of project designs

Students also took time to study each topic before the session and collected resources in a shared online portal (dropbox). Sessions were interactive, including group discussion and peer-led learning.

Course dates: every year from 2012 to present, for example 13th March 2017 - 24th April 2017

Pedagogical format: Lectures, seminars including using materials such as videos to stimulate discussion, peer-led learning, practical outdoor sessions including sustainability walk and green space walk and picnic

Seminars ranged in style from a very interactive session with students sitting in a circle and contributing throughout, to a more didactic session with questions asked of the group to stimulate engagement.

Teaching time: 7 x 4 hours = 28 hours of contact time all focused on sustainable healthcare + 17 hours of self-study.

Number of students taught: 20 per year on average

Materials used:

1. Video, “Futuro roubado” (Our Stolen future), BBC documentary about endocrine disruption caused by man-made chemical contaminants that interfere with hormones in humans and wildlife to stimulate discussion about environmental  risks and health
2. A professor from the Toxicology centre of UNESP gave a talk on pesticides  and public health
3. A researcher at the Brazilian Association of Biodynamic Agriculture gave a talk on genetic modification and its known and unknown health impacts
4. Local case studies and spaces in Botucatu, such as green hospitals, agroecological food baskets and edible gardens, which were used for the green walk and as discussion topics. The Botanical Garden of UNESP is used as a setting for an environmental trail, reflecting on theoretical content presented in the module. A picnic demonstrates and stimulates reflection on sustainable eating and the students present and share their intervention projects.

Assessment

The students were assessed on the following:

• Attendance at and participation in seminars
• Group presentations in the fourth week of the programme
• A written report about a practical project that each student should design for their own work place.

Sustainability learning outcomes addressed:

      PLO 1 - Describe how the environment and human health interact at different levels

• Reflect on the interactions between the environment and health using an ecosystems framework.
• Discuss the impacts of climate change on health.
• Discuss the main problems of Environmental Health, and its interfaces with Public Health, through different approaches and proposals. (LO written specifically for this course)

      PLO 3 – Discuss how the duty of a health professional to protect and promote health is shaped by the dependence of human health on the local and global environment

• Discuss how environmental health can be used as an instrument to build citizenship, quality of life and sustainable communities. (LO written specifically for this course)
• Explore the concept ad practice of environmental health surveillance in the SUS (Brazil’s public health system). (LO written specifically for this course)

Lessons Learned

• Engagement of students was excellent and the course stimulated deep reflection and ongoing engagement. There was lively discussion during the sessions and a range of perspectives provided by the interdisciplinary group. This highlights the value and depth of engagement and learning that can be achieved in an optional and interdisciplinary course. Students are already reporting implementing changes in their own lifestyles and efforts to implement the intervention project that they designed for their module coursework.
• Student presentations were very effective at stimulating learning. Students were very respectful of each other’s work and learnt both through preparing and observing presentations.
• Covering a range of topics with a range of pedagogies and media helped to maintain students’ interest.

Summary

Following on from a university wide pledge to, “promote environmental sustainability in all that we do”, Keele Medical School has been running teaching sessions as part of the core curriculum for all 3rd year MBChB students to increase awareness on sustainability within the workplace. These teaching sessions consist of a lecture by a doctor working in the NHS followed by small working groups discussing case studies on waste in the NHS.

The lecture focusses on the doctor’s reflections on his/her clinical practice and how it can conflict with his/her personal beliefs and actions on environmental sustainability. Overall, the students have been very positive about both sessions considering them  relevant to their future practice and increasing their knowledge. The students especially enjoyed the style of delivery and the enthusiasm of the facilitators. Many also agreed that these sessions were likely to influence of their future practice. These teaching and learning sessions have since become embedded in the MBChB curriculum.

Course Description

Keele introduced a whole-cohort introductory lecture during central teaching, delivered by a consultant anaesthetist. The clinician reflected on how his clinical practice often contradicts his personal beliefs in, and personal practice of, environmental sustainability. This didactic lecture-based teaching was followed by breakaway group discussions in which students were facilitated to think further around sustainability in the workplace using four case studies based around prominent types of waste within the NHS. The groups were facilitated by enthusiastic and knowledgeable staff including the Head of sustainability and energy Officer from the local University Hospitals of North Midlands Trust (UHNM).

Course or session dates: This teaching and learning event runs once a year (usually in March) for all 3rd year medical students.  

Number of students taught:  130

Pedagogical format:  Lecture & Case-based learning and discussion

Teaching time: Total student teaching time for this course or session: 2 hours

Materials used:  Keele educators have developed their own cases based around four prominent types of waste within the NHS: food, pharmaceutical, clinical and fuel. Each case is accompanied by targeted questions to guide students’ discussion and help them brainstorm potential solutions  and the barriers and opportunities of their implementation.  Students are also provided with supporting information for each case based on the published scientific literature, NHS Sustainable Development Unit (SDU) documents and figures, videos, relevant case studies from the SDU and / or Centre for Sustainable Healthcare (CSH) and local initiatives.

Curriculum area: Public health. Development of leadership skills.          

Sustainability learning outcome addressed:

PLO 2 - Demonstrate the knowledge and skills needed to improve the environmental sustainability of health systems

• Existing learning objectives were identified in the Keele curriculum which encompassed the learning objectives for these new sessions on environmental sustainability, hence the listed Keele ILOs were not modified.

Lessons Learned

Since implementing the first year three intervention Keele has recognised that earlier exposure to sustainability topics would be beneficial to enhance engagement and understanding amongst the medical student cohort. Subsequently, they have introduced the topic of environmental sustainability and healthcare earlier on in the medical course, as part of the introduction to public health lecture. They have also generated a variety of literature review topics for first year medical students to choose from for their SSC. Several students in the subsequent cohort have selected sustainable healthcare-related topics for their SSC from the list, or self-generated.

Based on third year medical students’ feedback and the facilitators’ own experience, the following points have been identified as being critical for the success of their teaching and learning interventions about environmental sustainability and healthcare:

• Small yearly cohort size (120-130 students) allows delivery of a whole cohort intervention so that all medical students gain an understanding of environmental sustainability in healthcare
• Involvement of a mixture of enthusiastic clinical “role models”, relevant stakeholders such as local hospital trust sustainable development team and academic staff
• Use of realistic case-based scenarios for interactive sessions
• Small group, facilitated discussion
• The scheduling of the teaching and learning sessions at an appropriate time in the academic year is also important for student engagement.

Summary

The University of Bristol Medical School has been running a student selected module in Sustainable Healthcare for the past five years. Although the content and structure has changed and adapted over this time, the course continues to have significant impact onstudents’ understanding of sustainability, and their role in creating sustainable healthcare systems. The course combines theoretical study, active learning and self-reflection to enable students to realise the practical implications of the concept of sustainable healthcare. The students have been taught by specialists from the Centre for Sustainable Healthcare and the NUS’ Department for Sustainability. Their learning is complemented by a placement in a local GP (general practice) surgery or NHS trust, where they deliver, monitor and evaluate a project designed to improve sustainability and quality of care, which may be linked to actions within the RCGP’s Green Impact for Health toolkit.

Course description

2nd year students are given the opportunity to engage in this student selected module which uses the SusQI framework for integrating sustainability in quality improvement and Green Impact for Health. The module engages students at the beginning of their career, enabling them to promote sustainable behaviours to contribute to a new, more sustainable culture in healthcare organisations.

The module gives students a background in sustainable healthcare, climate change, quality improvement and change management; issues that all practitioners in health and social care require an understanding of. Students are then placed within a healthcare organisation to develop and complete a project addressing an area that they feel particularly strongly about, using a simplified quality improvement approach. Projects have ranged from reducing disposable glove use, streamlining referral and support streams for obese children, establishing new exercise classes for social prescribing and creating awareness videos for patients about air quality.

Sustainability learning outcomes addressed:

• PLO 1 - Describe how the environment and human health interact at different levels
• PLO 2 - Demonstrate the knowledge and skills needed to improve the environmental sustainability of health systems
• Understand the wider concept of sustainability including social, economic and environmental sustainability and how it relates to healthcare
• PLO 3 - Discuss how the duty of a doctor to protect and promote health is shaped by the dependence of human health on the local and global environment

Of course, there are other lessons learnt and feedback from students suggests the module also enhances confidence, soft-workplace skills, change-make skills, systems-thinking and critical-thinking.

The details

• Teaching time has varied based on the medical school’s requirements. For the firstfour years the students had 30 hours spread across a ten-week period. Of these, 9 were used specifically for teaching and c. 8 were spent in practice. In the latest iteration of the module, students had 14 consecutive days to work on the module.

• 2-12 students have been taught per module although this could be extended to 20.

• The pedagogical format has been a mixture of lectures, seminars, community project visits, self-facilitated learning, peer-to-peer learning and a practice based project. A course handbook is also produced.

• Assessment for the module has varied across different years but has included verbal presentations, learning reflections, poster presentations and project reports.

• Impact assessment is undertaken with both the host GP practices as well as the students, so we can understand how the module is influencing activity, learning, and attitudes and behaviors relating to sustainable healthcare. Feedback from those involved also helps shape then next iteration of the module.

Lessons Learned:

• Using external experts to deliver the module (Charlotte Bonner from the National Union of Students and Dr Frances Mortimer from the Centre for Sustainable Healthcare) has presented both an opportunity and a challenge. The opportunity arises from their perspective and experience of practicing and teaching about sustainable healthcare; the challenge is ensuring alignment of their teaching both in terms of logistics and in terms of the aims and pedagogies of the module and the medical school.
• Student feedback suggests that students want to learn about sustainability if it is framed such that they can relate it to other core curriculum topics, particularly clinical care, and to their own personal interests, such as social justice and the future of the NHS.
• Tasks that seem doable to practitioners with experience of integrating sustainability into healthcare practice may be incredibly difficult for students just starting out on the journey – we have learned to reign in our expectations and take into account the other pressures students are experiencing! Similarly managing student expectations as to what is achievable in a few weeks needs to be done carefully.

Student feedback:

“This SSC was a great addition to my medical course, it was a lot of work at times, but I felt like I have really made a difference, and due to the nature of my project I felt like Iwas acting a professional in the NHS which was very exciting and rewarding.”

“This SSC has been a great opportunity...I have thoroughly enjoyed exploring a subjectoutside of the normal curriculum and it has been hugely valuable to experience thechallenge of making sustainable changes in the NHS.”

“Overall, I think the sustainability SSC offers a different but very relevant and animportant outlook on how healthcare is delivered.”

“I learnt a great deal within this course. I already had an understanding of sustainability but had not applied it to a healthcare setting.”

"The topic was very interesting and a good extra to our course as it is not covered but a vital part of working in the NHS and being a doctor. I believe it is a part of our educationthat is missing.”

“A doctor has a responsibility as someone who is respected by the community to pioneerchanges in practice and influence others to do the same...I think it will change the way Iwill practice medicine and will inform many decisions I make in the future.”

“I thought being a doctor was going into a surgery and talking to people but it’s helpedme realise that ... sustainability is a thing that as a doctor you can push forward and people will listen – you don’t realise how big your voice is until you use it. “

The Scholarship Programme is run by the Severn Deanery School of Primary Care (SoPC), NHS Education – South West. The purpose of this programme is to offer high performing GPST3 trainees the opportunity to develop skills in sustainable healthcare within the context of the NHS.  Such skills will help equip them for future appointments within clinical commissioning groups and the NHS as a whole.  

Trainees on the programme have 20 days of study leave over 13 months, during which to learn about sustainable healthcare and to design and complete a relevant project, with educational support from the Centre for Sustainable Healthcare (CSH) and others.

Picture: Our second scholar with Dr Clare Gerada, the Chair of the RCGP, whom she interviewed for her article on cycling among GPs. Photo taken by Heather Whitney.

Educational Opportunities

1. Strategic educational input from the CSH  – possible attendance at an introductory workshop on sustainability in healthcare in Oxford. 
2. Educational support from the Sustainability Lead of NHS South West.
3. Local mentorship from the Royal College of General Practitioners’ Climate Change and Sustainable Healthcare Lead.
4. Regular guidance and support from national experts in the field of sustainable healthcare.
5. Project work as directed by sustainability mentor/ experts, for example in: Prevention; Patient-centred care and patient partnerships; Leaner care pathways; Low carbon treatment options.    
6. Network with other sustainability scholars and other ‘green’ organisations. 

The scholars are expected to write a final report and a briefer report to go on the SoPC website. They are encouraged to submit posters for conferences such as the RCGP Annual Conference and also to write articles for publication.

Skills and personal development

The project work is designed and supported to help meet educational goals set by the Scholar. Trainees develop specific experience in: Problem analysis, business planning, project management, critical review of success and failure, preparation of report, paper or presentation. 

Funding and practicalities

Appointees extend their period as a GPST in year 3 from 12 to 13 months, allowing them the opportunity for specific sustainable healthcare training and experience, while continuing on the GP training pathway. The additional month works out as 20 working days  (40 sessions) additional study leave which may be taken at any point across the year. Funding for this is provided by the Deanery.  In addition, educational supervision from CSH has been funded by Wiltshire PCT.

Selection

The selection process is competitive. Invitations to apply for the post are circulated to all ST2 doctors in the February prior to the start of the appointment in August of each year.  The application process is by CV, covering letter, and requires the written support of the doctor’s educational supervisor (trainer) and a member of their local patch educational team. 

Aims and Objectives of Recent Scholars

Sally’s aims:

Knowledge regarding:  

1. The relationship between climate change and health 
2. Sustainability – at home, in the community, at work/in the NHS 
3. The broader perspective of the role of doctors in society 
4. The balance between a doctor’s responsibilities to the individual and to society  
5. How to facilitate rather than dictate change

Skills in:

1. Project management: analysis of problem, evaluation/critical review, report writing            
2. Presentation             
3. Advocacy 

Sally’s main outcomes:

Sally spent the first month reading various books and journal articles on of climate change, sustainability and sustainable healthcare and met with Dr Maggie Rae, Corporate Joint Director of Public Health and Wellbeing NHS Wiltshire, and the team at CSH including Sir Muir Gray, Dr Frances Mortimer and Rachel Stancliffe.  She then devised her plan for a project. The formal outcomes are divided into a practice-based project – the production of a Sustainable Action Planning (SAP) “How-to Guide” and “SAP in Practice”, as well as a considerable amount of advocacy work.

Annie’s aims:

1. To promote cycling amongst GPs and GP registrars
2. To research the evidence base behind the benefits and risks of cycling to work
3. To learn about writing skills and improving my copyrighting
4. To get some work published 

Annie’s timeline and outcomes:

Over the initial months (August 2011– February 2012) Annie educated herself about Sustainable Healthcare through reading, browsing the key internet sites and networking via telephone and email.  She identified potential interview candidates and lined up interviews with them.  She emailed a list of questions to the interviewees prior to the meetings. Her outcomes included some publications – an 800 word article, "On Your Bike!" published in the Review section of the BJGP, and a 500-word article published in RCGP News.  She was also awarded the Green Practice Award by Dr Tim Ballard, after delivering a 5-minute presentation (an overview of her cycling work.)

Quotes from the scheme’s organisers and the first two scholars: 

“It was interesting to see how both scholars’ knowledge and plans for the scholarship developed along quite similar patterns over the course of the scholarship, both following almost a cycle.  They both started with a big wave of enthusiasm; they had lots of ideas and wanted to pursue them all, in many different directions.  We helped them to narrow these down towards something practical but also matching their interests.

“In both cases there was point when they experienced a dip, having thought a given plan was going to work really well and convinced themselves of how much sense it made.  When things didn’t go to plan – as happened in both cases – the scholars were disappointed and lost some of their confidence.  That was when they needed some more support and encouragement from us to help them get back on the bike, as it were, and keep going.  I think the whole process, including the low points, was really important in terms of their personal development.”

 Rachel Stancliffe, Director of the Centre for Sustainable Healthcare

“I have learned so much this last year about the relationship between climate change, health, and sustainability...  I have gained skills in project management, including analysis of problems, evaluation/critical review and report writing, as well as presentation and advocacy skills. I now have valuable experience in trying to make a change.”

 Sally Aston, Scholar and GP trainee

“The Scholarship was interesting and a challenge.  I learned a great deal and developed some useful skills.  ...  Things did not run smoothly, but I was able to identify the reasons for this and was pleased to be able to demonstrate change …  I hope that my advocacy work made people think, at least a little, about sustainability and that with time, this gains a greater role in future general practice.

 “I feel it has been a valuable year …I now have a much greater understanding of the importance of sustainable healthcare and hope that when I am a salaried GP/partner I will make the sustainable agenda an integral part of practice decision-making. …I hope that this year has been just the beginning of my role as an advocate for sustainable healthcare and intend that practising sustainably will be an intrinsic part of my career.” 

 Annie Elkins, Scholar and GP trainee

Acknowledgements

Thanks to CSH intern, Isobel Braithwaite, for her help in preparing this case study.