EHJ March 2003, pages 80-82 The NHS is wasting an opportunity to make significant health improvements by failing to exploit its ‘leverage capital’. Time for a re-think says Dominic Harrison

Almost any sensible discussion of sustainable development and the NHS will reveal the worrying symptoms of “systems agnosia”. Reducing waste, traffic, pollution, energy consumption, water use and food miles are all examples of sustainability objectives with obvious connections to health improvement. Almost all clearly function as early interventions in managing population health risk exposure in relation to the root causes of heart disease, cancer, asthma and many other diseases that the NHS is charged with preventing and treating as set out in the NHS Plan.

The management of the NHS could encompass sustainable development, but only if the chronic disease of systems agnosia is adequately diagnosed and managed.

In his book, The man who mistook his wife for a hat, Oliver Sacks strikingly describes a case of visual agnosia: “The otherwise highly talented musician in question, Dr P, had responses which were very curious. His eyes would dart from one thing to another, picking up tiny features, individual features...a striking brightness, a colour, a shape would arrest his attention and elicit comment – but in no case did he get the scene as a whole. He failed to see the whole, seeing only details which he spotted like blips on a radar screen...it was precisely this...that rendered him incapable of judgement.”

So it is with NHS planning and performance management in relation to sustainable development. In April 2002, NHS Estates issued a new environmental strategy that contained guidance on sustainable development. The document set targets for NHS trusts to produce their own strategies for energy, waste, water, transport and procurement, which should have been met by the end of last October.

The guidance targeted themes that generally focus on risk reduction and cost containment in relation to environmental impacts, but still neglect the available asset maximisation possibilities. However, they do not appear anywhere in the NHS Priorities and Planning Framework 2003-2006 (or PPF, the NHS deliverables bible) or its Physical Facilities objectives (appendix C).

So, while the PPF has 24 pages listing important things against which the performance of NHS trusts will be assessed, sustainable development is not one of them. This is despite the fact that most sustainable development interventions advocated by NHS Estates would save money, protect the environment and improve health.

For some reason the NHS seems to struggle to develop systems capable of aligning its services, structures and performance management to meet its stated objectives. This leads the NHS to squander vast amounts of “leverage capital”, failing to recognise that this could be used to pay a substantial “health dividend”.

As a result, it may be unnecessarily degrading the environment, wasting money and perhaps risking lives. The failure to connect and integrate NHS sustainability targets within the performance management of the health outcomes of NHS investment, as reflected in the PPF, is a massive wasted opportunity.

The concept of sustainable development can seem infinitely expandable. Business and industry generally equate it with “sustainable economic development”, while others often simply see it as a synonym for “environmentally friendly”.

For now, let us assume that while sustainable development is certainly about managing population risk exposures it is also about maximising human development opportunities, both in terms of the environment and the economic and social experiences of communities. From this perspective, we can begin to see the possibility of adding value to existing NHS investment through considering wider social and economic objectives.

In July 2002, the King’s Fund produced a report, Claiming the health dividend: Unlocking the benefits of NHS spending (www.kingsfund.org.uk). This demonstrated the potential for the NHS to become a good corporate citizen – in the domains of employment; purchasing policy; child care; food purchasing; waste; travel; energy; and building – while using its power to influence markets and communities to improve health from an institutional perspective.

The report emphasised that the health care sector is currently failing to exploit clear opportunities to make a significant contribution towards improving population health (and sustainable development).

The most significant is probably the nascent economic and social “leverage capacity” which results from the market dominance inherent in consuming 7 per cent of the nation’s gross domestic product (GDP). It is important to note that throughout Europe public sector expenditure is a consistent 38-43 per cent of GDP.

For instance, the UK health care sector is responsible for sustainably generating more than 9 per cent of all the country’s jobs and is the largest employer at regional and national levels. At local government level, NHS employment can be as high as 26 per cent of all those employed in an area.

In London, the NHS contributes 10 per cent (£10bn) to the GDP of the region when the indirect effect of spending by health workers is taken into account.1 This percentage will be larger outside the capital. The total NHS cash spend in the capital is £7bn. The health service is one of the most significant sources of employment in poorer areas, which makes it a leading agent of sustainable social and economic regeneration.

These figures support theoretical work done by the World Health Organisation, suggesting that an annual increase in global health investment of $66bn (£42bn) above current spending over 2015-20 would generate at least $360bn a year of sustainable economic growth, representing a sixfold return on investment.2

But the health and sustainable development “leverage capital” of NHS spending goes well beyond sustainable growth in employment. The table on page 82 illustrates some of the key assets that remain part of the health care system’s unutilised leverage capital. The squandering of this institutional resource raises serious issues for the NHS modernisation programme and the management of the health care system – issues of equity, sustainability, social inclusion and health. It is salutary to reflect that a multinational company would have “sweated” (realised) this hidden leverage capital years ago.

The wider (deeper?) notion of sustainable health and health care systems is not well addressed in NHS policy and planning, and not really tackled in the NHS Estates work.

A sustainable health and health care system would view health as an “added value” outcome of social organisation and explore the co-production of health within health care services. We are now experiencing a so-called cost containment dilemma in all European health care systems, given the view that there will never be enough money to satisfy the “infinite demand” for care. To some this implies that, in the long term, health care systems that cater for everyone are simply not sustainable.

This confusing and sometimes pernicious perspective arises because the idea of “resources for health” has become infected by neo-liberal (classical) concepts of wealth and capital, which separate citizens into producers and consumers.

Referring to issues of autonomy, power, professionalisation and the production of health, Thompson argues: “I would say that the notion of treating patients as consumers or customers, far from being empowering, actually uses neo-classical discourse to place patients in a position of being able to only choose from a limited range of services over which they have no say. A more liberating model would place patients in the role of health producers, who on occasions require assistance in meeting their needs through co-operative working with health professionals, or what has been labelled a co-production model, or collaborative autonomy.”3

This view has profound implications for the way that health system resources might be conceptualised in future. Co-production of health is a key strategy for developing sustainable health and health care systems. Here, the production of health is not seen as a product or an activity to be purchased. Health is seen as integral to social organisation as a whole, dependent on the total impact of social systems on individuals.

Health investment arises as a consequence of the impact on populations of sustainable housing, nutrition, transport and income policies, and so on, with health investment viewed as an integral part of those policies. The neo-liberal model (“we cannot afford now what we could in 1948”) might support the maintenance of health-damaging social systems, but then go on to purchase marginal health improvement programmes “in addition” to ameliorate their effects. Modernised and sustainable services need to move on from that paradigm.

With a sustainable health care system, significant health improvements and health promotion could be achieved without large additional financial resources. What is needed most is the commitment and participation of non-health care sectors, and a change in the power relationships and professional cultures within the health care system itself.

The concept of sustainable development throws out a fundamental challenge to the NHS. It challenges the health service to act as a good corporate citizen and to review and overhaul its systems, “theories of purpose” and professional cultures.

As everyone will tell you, this could take a generation – up to 25 years – to achieve. All the more reason to get started right away.

References

1. Travers T, Glaister S, Graham D. Capital asset: London’s healthy contribution to jobs and services. London: NHS Executive, 2000.
2. World Health Organisation. European perspectives on the macroeconomics and health. Copenhagen: WHO, 2001.
3. Thompson A. Patient expectations, satisfaction and outcomes. Paper to the International Workshop on outcome governed health care, Linkoping , Sweden, 12-13 June 1997.

Dominic Harrison is an associate director of the Health Development Agency.

This article was originally published in Health Matters, issue 50, winter 2002/03