Creating sustainable psychiatric services

Dr Guy Harvey looks at four ways of making environmentally-friendly interventions in mental health services and how such interventions can lead to benefits for patients and the environment.

The NHS Net Zero report was published in October 2020 and contains a commitment that the NHS is to become carbon neutral by 2045. This is the most ambitious carbon reduction plan of any healthcare system in the world. Alongside this, each NHS Trust and Health Board is now required to develop a Green Plan which sets out how these reductions can be achieved. 

Our Green Plan contains sections on the efficiency of our buildings and energy use, waste, water management and travel, but what about the actual care and treatments we provide? How environmentally friendly and sustainable are they? What can we say in our Green Plans about this?

The Centre for Sustainable Healthcare (CSH) has produced a document that describes the key elements of sustainable mental health services. It turns out that a lot of what we already do and a lot of what we would call good practice is sustainable psychiatry. Take prevention for instance. If we can prevent people becoming ill or deteriorating that’s good for service users and it’s also low carbon, sustainable care.

The CSH document talks of four main groups of environmentally-friendly interventions and to make our services more sustainable we should develop along these lines.

Prevention 

There are several good examples of preventative services in Psychiatry.

Early intervention in psychosis for instance. They support people at high risk of psychotic illness and work with them to keep them well. By engaging in treatment early, they can avoid the most serious effects and lengthy hospital admissions. Likewise hospital liaison. They identify those with mental illness in general hospitals and can reduce time in hospital and improve outcomes. Crisis teams provide an alternative to admission and Home Based Treatment services help get people out of hospital earlier. 

Also, if we want to prevent mental illness we must work with our partners. Public health, social and education services are all vital. For instance, early years support for children, education, employment, good housing, healthy living, and active travel; we all know these help to prevent physical and mental illness.

Service user empowerment

The second aspect of sustainable healthcare services is the empowerment of service users. If we can teach patients about their illness and about self-monitoring, teach them self-care and treatment interventions they can use themselves, then they can make less use of the most carbon-intensive parts of the service. We can do this through high-quality peer support and truly collaborative shared decision making.

High-value Care, not wasteful care

A sustainable service delivers high-value care by providing the right care at the right time and reduces waste.  

We have blogged about pharmaceutical waste before. Half of all medicines dispensed are not taken as directed and lots of effort goes into encouraging patients to follow prescribers’ advice. But what interests me most is why is it people don’t take it? Maybe because the doctor and patient haven’t understood each other?

In psychiatry, many people are reluctant to reveal they don’t take their medicines. Perhaps this is because of shame or embarrassment or fear of being reprimanded by their clinical team. Improving collaborative shared decision making could overcome this and lead to a deeper understanding of the patient’s goals, the risks, benefits and harms of treatments. Maybe for these people, an alternative non-pharmacological treatment plan could be found that better meets their needs and doesn’t waste valuable medications.  

I think in some situations even, we may be able to continue to support people with severe mental illness who choose to not take medications at all. This would be a big shift in our thinking. It’s been referred to as managed non-concordance.

So through real collaborative care, we can create treatment plans that genuinely meet the patients’ needs; that are not judgmental if patients choose not to have drugs, and that make the best use of low carbon alternatives. This might lead to fewer tablets collecting in bathrooms or being flushed into the sewers or dumped into landfill.

Low carbon interventions

The pharmaceutical industry is a large producer of CO₂. Even though mental health services have lower medication carbon footprints relative to other services our influence over what is prescribed in primary care is significant. Low carbon prescribing uses the lowest effective dose for the shortest period of time and makes the best use of alternatives such as psychotherapy, social prescribing and green care. Optimising medications through Structured Medication Reviews could save a lot of waste and carbon.

It would help if we knew which treatments have the biggest carbon footprint. We don’t yet have this in psychiatry but it is beginning in other areas. Asthma inhalers are an example. Aerosol inhalers contain gases many hundreds of times more harmful than CO₂, and dry powder alternatives are the same price and as effective. Some anaesthetic gases are similar and many centres are now phasing these out. If we knew which of our medicines are the most carbon-intensive we could find alternatives.

Summary

So if in our Green Plans we aim for services that focus on prevention, empower service users, use more evidence-based treatments, reduce waste and offer low carbon alternatives, we can have mental health services that are both good for the patients and the environment.