06/04/2013

Dear Sir/Madam,

I am writing with some feedback on the Health Education England's Strategic Intent document on behalf of a student group called Healthy Planet, which I currently coordinate; please accept my apologies for the late submission. Healthy Planet is affiliated to the registered student-led charity Medsin - a network of students, primarily medical students, from across the UK. We have a committee made up of students from Brighton, Manchester, Keele, KCL, UCL and Queens' Belfast, and we work closely with several members of the Medsin National Committee and with Medsin groups at branch level. The incorporation of sustainability a term with many meanings, but by which we essentially mean a more future-oriented, more equitable and more global approach to health into medical education is a particular area of interest for both Healthy Planet and Medsin, and has been the focus of quite a lot of our work, alongside organisations such as the Sustainable Healthcare Education Network. The HEE Strategic Intent document discusses the central importance of compassion and the statement that everyone counts, as well as the need to shape the future , and we are wholly on board with these intentions. However, precisely what is meant by these statements for example, whether everyone is taken to include people in the future or in the countries most vulnerable to climate change - isnt entirely clear, although from the reference to the needs of current and future patients, it seems that the HEE recognises the importance of future patients. We would very much welcome the incorporation of some more specific detail, for example with reference to what shaping or future-proofing the NHS might mean re. climate change and energy security. The importance of and opportunities created by environmental sustainability for the NHS would also be worth some discussion; implemented well, these can include both financial savings, a better patient experience and the reduced risks to peoples health in the future that results from reducing emissions and so helping to tackle climate change. Thanks to a series of talks, workshops and the use of social media over a number of years, awareness of the current and future health impacts of climate change is now relatively high amongst Medsin members. As a result, many members feel that the

formal education we are receiving is not preparing us at all adequately for what this means and that there is a need for a much greater focus on these subjects. At Medsins Autumn General Assembly, we secured an almost unanimous vote for a new Medsin policy statement on incorporation of content on Climate Change, Health and Sustainable Healthcare into UK Medical Education. This can be found at http://www.healthyplanetuk.org/policy-statement-on-education.html as well as on the Medsin sitei. We are pleased that the document mentions the objective of future-proofing the NHS, although it does not go into great depth on what is meant by this. As the Health Education England document highlights, those who graduate from medical school this year will still be practicing in 2050. By 2050, the world's population will be larger, more globalised, and facing a different global burden of disease with significant rises in many chronic and non-communicable diseases. Another relevant difference between now and 2050 is that current projections and emissions trends suggest that the world will be at least ~1.5C warmer by 2050 based on business-as-usual emissions scenariosii, and will very likely be in transition to a world 4C warmer than now or more without urgent actioniii. This may be a very difficult change for human and natural systems to adapt to; it is comparable to the average temperature difference between now and the last ice age. Moreover, it will have multiple consequences for human health, some of them potentially very large in magnitude - in an increasingly globalised and inter-dependent world, these are unlikely to be restricted to developing countries iv. In addition, policies and lifestyle changes that improve home insulation, reduce air pollution, increase active travel and reduce the consumption of red and processed meat can have significant health and environmental co-benefitsv. At present, however, students only have the opportunity to learn about these risks and opportunities if they happen to be at one of the few Universities which incorporate teaching about them, and usually only through optional modules taken by a small number of studentsvi. If Health Education England were to make the case for such content to become part of core teaching, we could start to end this illogical situation. We see it as a natural corollary to our interest in the health consequences of climate change that we want the NHS to lead in the delivery of sustainable healthcare, especially given that innovation for sustainability can also be a valuable driver for better, more patient-centred care and significant cost savings, which are both valuable in their own right. Medsin and Healthy Planet have been active in promoting NHS sustainability day vii,viii and raising awareness among students locally of what NHS sustainability means. In addition, a number of students have been working with their medical schools to secure more teaching on these subjects, which is an ongoing process in most cases. Others have undertaken internships with the SHE Network, written in the Student BMJ ix,x, and delivered many peer-to-peer workshops through Medsin for a such as its regular conferences. The GMC has been proactive in requesting the development of learning outcomes for sustainable healthcare by the SHE Network, and Health Education England has a real opportunity to help set direction towards a more sustainable NHS. Ultimately, we feel

that this will probably depend much more on a sustainability-literate workforce than on purely technological measures, which is why bodies such as HEE have such an important role to play. A significant number of our members have recently contributed responses to the Consultation on Proposed Learning Outcomes for Sustainable Healthcare which have been compiled by the Sustainable Healthcare Education (SHE) Network, and we also ran an online focus group to capture students views through the slightly different fo rmat of group discussion. The outcomes of this are summarised below: A number of points were made about how the current draft of the Learning Outcomes could be improved and made more accessible, but all of the students thought the lack of coverage of these subjects was a key failing in their medical education, and one likely to impede the NHSs ability to respond to the various challenges it will face in the future. Of the students who took part, climate change had been mentioned in teaching at only two of the six medical schools represented in spite of the evidence presented by the UCL-Lancet Commission that it may well be 'the greatest threat to health of the 21st century'. This is a problem beyond the confines of the NHS because doctors are a well-trusted group with a strong influence on public opinion. None of the students participating had had any teaching on the NHS's environmental impact, carbon footprint or use of resources, even though the NHS is becoming a world leader in the field, with the Sustainable Development Unit (SDU), whose work is specifically focused on measuring and reducing these impacts.

Often, the links between the challenges facing the NHS and sustainability are less obvious, but already, rising costs, including for energy, tighter budgets and a wave of non-communicable disease are straining the system. These are all part of a larger set of global process and cannot be tackled effectively unless the system they are part of is understood by those in positions of responsibility and influence. Future healthcare professionals will need to be able to connect the dots between the global and local contexts which create these problems in order to respond to them effectively, and to be a force for organisational change towards a more sustainable and resilient healthcare system. This is especially true given the increasing managerial responsibility currently being given to clinical staff. The extensive and varied work done by the NHS SDU and Centre for Sustainable Healthcare highlights the significant untapped potential for changes that can simultaneously bring about emissions reductions, service improvements including a better patient experience, and cost savings. However, such changes will not happen spontaneously. Building the capacity needed to realise these benefits will likely require a sustainability strand or theme running throughout under- and postgraduate medical and nursing education and continuing professional development, and that of other healthcare professionals. Such a change, which Health Education England has the chance to help bring about, would be a valuable investment in the future of the NHS and of the population it serves. We would be very pleased to work with Health Education England in order to build on the work already being done to integrate sustainability into medical education, and to help

introduce more students and educators to these issues; please dont hesitate to get in touch if this would be of interest, or if you have any questions.

With best wishes, Isobel

Isobel Braithwaite National Coordinator, Healthy Planet UK (www.healthyplanetuk.org) Email: healthyplanet@medsin.org or Isobel.Braithwaite@lshtm.ac.uk

References
i

Medsin-UK Policy Statements and Guidance Statements - September 2012 http://www.medsin.org/public/resources/secretarial/MedsinUK%20Policy%20and%20Guidance%20Statements%20Sept%202012.pdf (pp. 20-23) and http://www.healthyplanetuk.org/policy-statement-on-education.html ii IPCC, 2007: Summary for Policymakers. In: Climate Change 2007: The Physical Science Basis. Contribution of Working Group I to the Fourth Assessment Report of the Intergovernmental Panel on Climate Change [Solomon, S., D. Qin, M. Manning, Z. Chen, M. Marquis, K.B. Averyt, M.Tignor and H.L. Miller (eds.)]. Cambridge University Press, Cambridge, United Kingdom and New York, NY, USA. http://www.ipcc.ch/pdf/assessment-report/ar4/wg1/ar4-wg1-spm.pdf iii World Bank. 2012. Turn Down the Heat: Why a 4C Warmer World Must Be Avoided. Washington, DC: World Bank. https://openknowledge.worldbank.org/handle/10986/11860 iv Costello, A. et al (2008) Lancet and University College London Institute for Global Health Commission: Managing the health effects of climate change http://www.ucl.ac.uk/globalhealth/project-pages/lancet1/ucl-lancet-climate-change.pdf v Ganten, D. (2010) Health co-benefits of policies to tackle climate change http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)62139-3/fulltext#article_upsell vi SHE Network: Teaching Sustainable Healthcare in English Medical Schools Survey 2010 - summary of results http://sustainablehealthcare.org.uk/sites/default/files/she_deans_survey_summary_of_results_14_ feb_2010.doc vii http://www.medsin.org/news-and-events/news/healthy-planet-and-nhs-sustainability-day viii Healthy Planet NHS Sustainability Day video http://www.youtube.com/watch?v=l6XU6aS9PVk ix Braithwaite, I (2013) Climate change, health, and the NHS. Student BMJ 2013;21:f1755 http://student.bmj.com/student/view-article.html?id=sbmj.f1755 x Das, A. (2009) Climate change: a global health emergency. Student BMJ 2009;17:b2484http://student.bmj.com/student/view-article.html?id=sbmj.b2484