Amarantha Fennell-Wells is the first Welsh Clinical Leadership Fellow focusing on sustainable healthcare, during the first year of a three-year collaboration between Cardiff and Vale University Health Board, Health Education Improvement Wales, and the Centre for Sustainable Healthcare. Over the past year, Amarantha has led a pilot project to increase the efficiency of nitrous oxide provision throughout CAVUHB hospitals; supporting a wider UK initiative recently nominated for the BMJ Environmental Award 2021. She is also a founder member of the Green Health Wales network. In this blog, Amarantha will discuss key aspects of her year.
“Before embarking on this clinical fellowship, I was working as a third-year dental core trainee in oral and maxillofacial surgery (OMFS), with regular on-calls in the Emergency Department. I hadn’t decided upon a dental specialty at this point and was open to any career opportunities which might become available. I prefer hospital-based dentistry and I enjoy working with special care patients, doing specialist treatments in specialist centres.
When working in Prince Charles Hospital for Cwm Taf Morgannwg University Health Board (CTMUHB), I received an email about a leadership training programme offered by Health Education Improvement Wales (HEIW). Initially I wondered whether it had been sent to me by mistake, as I assumed the position was only available to medical trainees. I was thrilled to realise it was a multi-disciplinary programme open to medics, dentists, pharmacists, and optometrists. Dentistry feels like an isolated specialty, but we need to “put the mouth back into the body” and working with a dynamic group of colleagues keen to lead their professions seemed too good an opportunity to overlook. I believe the future of the NHS will rely upon adaptive, compassionate and strategic leadership, requiring a plethora of different career experience. Upon applying for the role, I was invited to interview and was delighted to come top of this process, which gave me first choice of the projects.
Earlier on in my career, I had no real thought for the environmental impacts or “sustainability” of healthcare, as I was trying so hard to find my feet in clinical dentistry/surgery and simply look after my patients well. Continuing with the CTMUHB OMFS team for a second year, I began to feel much more confident in my abilities, and was able to recognise how inefficient some processes could be. As I became more confident in my clinical care ability, I began to notice and become increasingly aware about the serious waste I was witnessing on a daily basis.
I became acutely aware of the number of single-use items on pre-made surgical trays and theatre kits, and how many of these were thrown away untouched. Serendipitously, this was the first year to offer my chosen project, Sustainable Healthcare, and I remember saying to myself ‘that’s it, that’s the project I want.’
A crucial issue highlighted this past year is how little our complex health system values its global impact. Creating more sustainable health systems involves reconsidering and redefining what value means to us. ‘Sustainable value’ explicitly considers the environmental, social and financial impacts in relation to health outcomes for both patients and populations. The difficulties of the past year (COVID-19, isolation, burnout) have definitely helped me reconsider how I value things. The “Bottom Line” is the key financial phrase within the NHS: how much money will something cost? In reality, we need to think of the triple bottom line: we are equally reliant on social assets (the networks, such as staff, carers and patients) and environmental resources (Image 1).
The different work streams I have focussed on during my fellowship have gone far beyond the very visible issue of clinical waste. While it is a conspicuous problem, it does not take into consideration the bigger picture: the climate is becoming more unstable, the effects of which are becoming more evident closer to home in the form of extreme weather events and overwhelming pressure on health and healthcare services. Cardiff is the 6th most susceptible city in the world to the effects of climate change because half of it will be underwater by 2100AD. The University Hospital Wales site will have a sea view. We are destroying our natural habitat: we’re suffering through a global pandemic as a result of biodiversity disruption… And we ship everything around the globe twice!
When presenting new arguments, especially within healthcare, morally and ethically you put the patients and staff first. It is a misconception that considering climate change and sustainability within the context of healthcare means neglecting patients or denying patients the care they need. If we don’t make the climate crisis an urgent priority, we will have more patients with problems as a result of climate issues (image 2).
A fantastic start to this fellowship came in the form of introductory courses provided as part of the funding by the Centre for Sustainable Healthcare (CSH). The CSH offers strategic input and consultancy on sustainable healthcare research and practice to national and local programmes. I vividly remember leaving PCH dazed after my 7th nightshift to make it back in time to attend a carbon footprinting course that morning! These courses were fantastic and provided me with essential understanding of sustainable healthcare concepts and tools.
I was a little overwhelmed at the start of the year, but having the support of my supervisors and other like-minded healthcare colleagues gave me inspiration and made me more determined. Within CAVUHB, these colleagues were Dr Fiona Brennan (Consultant Anaesthetist and Educational Supervisor), Mr Dan Morris (Consultant Ophthalmologist and Educational Supervisor), Ed Hunt (Programme Director for Strategic Planning) and Jon McCarrigle (Estates Energy Advisor). It was invaluable having key people in the health board who had already commenced work on sustainability; they believed in me and my plans, and encouraged my efforts with kindness and enthusiasm. Approaching a system from a new and novel perspective can mean that your beliefs, values, and evidence is questioned, so it is important to have the courage of your convictions.
The Nitrous Oxide Project was formed as a result of my advocacy for the initial research conducted in Scotland. Understanding the situation within CAVUHB accounted for a significant proportion of my fellowship, and I wrote my evidence-based report alongside several other work streams including: sustainable quality improvement education; building a national sustainable health network; studying for a postgraduate certificate, and attending two leadership courses provided by HEIW and the Faculty for Medical Leadership and Management.
My evidence-based report was met with some resistance and was heavily scrutinised and questioned by the many stakeholders involved with the provision of nitrous oxide. However, my report was robust and supported by both external specialists and medical suppliers. CAVUHB then established a working group, inviting key stakeholders to discuss the results of my investigation: in short, the results suggested a significant portion of piped gas is unaccounted for and is not reaching patients. The working group has formulated a pilot intervention to provide the Children’s Hospital for Wales with anaesthetic nitrous oxide gas via portable cylinders instead of the piped medical gas systems. We are hoping to demonstrating substantial environmental and financial savings by changing delivery systems.
Another main aim of the fellowship was to set up a national, environmentally-conscious healthcare network. Along with some of my colleagues in North Wales, who are also leading their own fantastic sustainable healthcare initiatives, we established Green Health Wales: a network of people in/around/supporting healthcare across Wales, who recognise that the climate and ecological emergency is a health emergency. I managed the first national conference in June 2021, aiming to connect likeminded people across Wales via educational talks and workshops to discuss how we can transform healthcare within Wales. We hope that by nurturing Green Health Wales we’ll see exciting ideas come to fruition and show how these can be adopted and scaled quickly and effectively.
I will remain in touch with these wonderful colleagues who made my fellowship so worthwhile, including the progress of the nitrous oxide mitigation strategy. I hope that the trial proves we can significantly reduce environmental and financial waste – ultimately shrinking our carbon footprint. It is ever important that patients can still receive the care they need and that clinicians continue to have the flexibility to provide the best service that they can.
The highlight of my year has most definitely been having the opportunity to work so closely with Dr Fiona Brennan. She’s female, she’s at the top of her clinical game, her passion for this work is infectious, and most of all she was incredibly supportive of my decisions in relation to my fellowship.
Advice? Well, the first thing I’d say is it’s not just all about bins!
Take full advantage of all the resources that are out there. The Green Health Wales resource page has all the information that I would recommend, including a 15-minute video on the impact of healthcare on the environment in Wales. It’s also important to look through the infographics in the NHS Wales Decarbonisation Strategic Delivery Plan document.
Lastly, it’s vital to remember that healthcare is evidence-based, and the evidence for the climate crisis is irrefutable. We are experiencing its effects right now, so question your personal and professional choices with curiosity and urgency.
The 3 main things that I would say to do would be:
Cardiff & Vale University Health Board is an active entity continually improving. As a health board, we aim to exceed our responsibilities by delivering more than healthcare. We are always striving to be better. By continuing to make a difference not just for today, we hope to leave a lasting example for future generations to follow.
If you wish to contact the Sustainability Team, please email firstname.lastname@example.org