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Carbon, cost and care: what makes a sustainable care home?

Jerome Baddley, Sustainability Services Manager at the Nottingham Energy Partnership, describes the findings of research into sustainable care homes, considering whether environmentally sustainable care services are possible and even offer cost, health and wellbeing co-benefits.

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A growing aging population means greater demand for residential care services. Is the notion of an environmentally sustainable care home realistic? What is the current environmental impact of the residential care sector? Can reducing environmental impact have cost, health and wellbeing co-benefits?

These questions are explored in a recent study, Sustainable Care Homes, carried out by NEP Energy Services in 2012, a charity-owned social enterprise funded by NHS East Midlands Regional Innovation Fund.

Key findings of the research were:

  • The residential care sector accounts for at least 3.4 million tonnes of CO2e each year and £1.07 billion in natural resource costs. The social cost of carbon adds a further £76 million in costs to the economy per year.
  • In 2008/9 energy use in residential homes accounted for around £468.5 million in utility costs and around 2.3 million tonnes of CO2e, representing 0.42% of the 2009 UK carbon footprint (National Statistics, 2012)
  • In 2008/9 residential homes also accounted for around £505 million in food costs generating around 622,250 tonnes of CO2e.

Besides waste, the costs of energy and food are major areas for change and likely to rise significantly. With increasing competition for natural resources, there is clearly a need to prioritise these areas for reasons of both cost and carbon management.

Waste

The research investigated both pharmaceutical, offensive and commercial waste, finding significant opportunities for carbon and cost savings.

Pharmacy waste

Annual pharmacy waste from UK care homes amounts to £49 million in value and corresponds to up to 28,764 tonnes of CO2e. Opportunities to reduce this waste are identified in other reports, particularly Evaluation of the Scale, Causes and Costs of Waste Medicines by Trueman Taylor et al 2010). Care home pharmacy waste only represents a fraction of care home pharmacy consumption, but there is scope for carbon and cost saving in reducing pharmacy waste through better communication between GPs homes, residents and pharmacies. Good medicine management and capping over-prescribed drugs makes sense in terms of both cost and health.

Laxatives, Paracetamol, Aspirin and calcium supplements represent the most significant areas of waste, cost and carbon emissions, representing around 40% of all care home pharmaceutical waste and 27.5% by both value and carbon emissions.

In research visits for this report, two managers identified that a well managed 28-day prescription cycle with better communication and cross checking between home, GP and pharmacy, has been effective in reducing unnecessary over prescription from repeat prescriptions. Central treatment rooms, with fewer goods in residents’ rooms, were also identified as having been effective in aiding better management of stocks to prevent over-ordering.

A major issue identified was that pharmaceutical interventions were paid for by the GP prescription budget, while non pharmaceutical interventions, such as additional sensory stimulation as an alternative to antipsychotic drugs, had to be paid for by the home, despite NICE recommending these alternate therapies over drugs.

Another issue is that the disposal of drugs waste through pharmacy returns is paid for by the Primary Care Trust and that comprehensive records of reasons for drugs wastage are not usually available. As waste and returns are not visible to or paid for by GPs, there is less incentive at practice level to evaluate and address how and why this waste occurs.

Offensive waste

Offensive waste is mainly hygiene and continence waste. In 2008 a staggering 50% of the UK‘s 217,000 tonnes of non-hazardous healthcare and biological waste was generated by care homes (calculated from Defra data). Offensive wastes from UK care homes have an estimated cost of £29.3 million per year and give rise to more than 30,724 tonnes of CO2e, assuming disposal to landfill.

Offensive waste was analysed in some detail, as a key component of care home waste disposal costs and carbon emissions. If offensive waste were incinerated using energy from waste locally, rather than disposal through landfill, at least 66,750 tonnes of CO2 would be saved every year, equivalent to the carbon footprint from energy use of 13,350 houses in the UK.

Support and funding for continence care, to move residents off continence pads, along with better care in hospitals to ensure residents stay off pads when admitted, has benefits for resident dignity, health and wellbeing. This also offers significant potential for carbon and cost savings across the whole lifecycle of a continence product’s manufacture procurement, delivery and disposal. Procurement of continence contracts that favour more sustainable, lower weight products with user controlled delivery, to avoid over supply, also has a huge potential to cut waste and emissions.

Clinical Commissioning Groups will be taking on this responsibility from Primary Care Trusts and should consider employing sustainable procurement practices in addressing these contracts.

Commercial and Municipal Waste

Care home municipal waste disposal is likely to cost around £19.5 million across the UK and result in around 427,000 tonnes of CO2 emissions from disposal to recycling and landfill.

Up until April 2012, councils were only able to charge for collection of waste from residential homes or premises forming part of a hospital or nursing home, but not disposal, meaning that councils effectively had to offer a subsidised waste service. As of April 2012, a charge for collection can still be made for waste from such premises, but a reasonable charge for disposal of that waste may also be made (although such waste is classified as household waste, it is treated as commercial waste for the purposes of disposal charge powers in the Environmental Protection Act 1990). This change could lead to increased costs to homes using local council waste services which no longer include free waste disposal, and in some cases already has (commercial waste service providers were always able to charge for collection and disposal).

Care homes should explore the potential for alternate collaborative arrangements around waste management, possibly in partnership with GPs or local health centres. Where possible, these contracts should look to favour providers who:

  • Offer good data weight of waste collected
  • Additional off-site segregation and recycling of municipal waste
  • Energy from Waste for offensive waste

Energy

The study showed energy use and consumption in the four case study homes could be cut by an average of 11% if recommendations were implemented. Nationally, this could save £52.8 million in energy costs and 220,000 tonnes of CO2e each year.

The easiest way to achieve savings is by empowering site staff to identify areas of waste. The simplest way to do this is to provide care home managers with access to smart meter data. Three of the four homes had smart meters, however none of the care home staff were given access to the half hourly data, or trained on how to spot trends and energy waste. Educating the home managers is key to reducing energy consumption, they are better placed and are more likely to be aware of the local causes of energy waste, given the right training.

A national programme of better metering and training alone could potentially save £12million and 50,000 tonnes CO2e per annum.

Renewables

If a care home site is suitable for a ground sourced heat pump energy system, this is an option worth considering. Two of the homes studied in detail were fully or partially heated with heat pump systems and under floor heating. Both of these homes should be able to achieve near zero carbon heating by 2050. Heat pumps also have the capacity to offer low-cost low-carbon cooling in heat wave conditions. Ground sourced heat pumps also offer long-term income in terms of the renewable heat incentive, with one home having the potential to earn £10,000 per annum from this route.

Encouraging the inclusion of ground sourced heat pumps in new build care homes, and gas combined heat and power (CHP) for retrofit, would help ensure care homes contribute to the UK’s carbon targets, offer a better environment for residents and protect homes against rising energy costs.

Community, environment and food

The links each home formed with their local community were found to have helped improve the care home grounds and their local environment, and ensured residents had regular and varied external contact, improving the capacity to carry out activities that kept residents physically and mentally active. These sorts of relationships play a critical part of a healthy sustainable care home and should be valued and encouraged.

The use of care home grounds to grow food, particularly in raised beds, animals and use of suitable tools provides both diversion and stimulation for residents, helping them to maintain an active lifestyle. Three of the homes visited were growing food on-site. This approach involved engaging residents, staff and external community groups. In one case a city farm supported the home by cultivating the grounds. The cost savings are fairly small but the health and wellbeing benefits more significant. Producing food on-site also provides an incentive to compost uncooked food wastes rather than dispose of them to landfill or incineration.

Conclusion

The study’s assessment of the national picture and the four case study care homes shows significant shortfall in support and information; this currently makes it very difficult for this sector to make an active contribution to the UK carbon reduction targets. This is increasingly critical given the need to protect the sector and vulnerable older people from rising natural resource costs.

Pockets of good practice notwithstanding care home managers do not seem to be regularly encouraged by operators, Local Authorities or health trusts to engage with environmental sustainability, even where they are keen to contribute.

The costs and carbon emissions associated with residential care are high. The benefits of addressing these issues are not just financial and environmental, but a key component of high quality care.

Care Quality Commission (CQC) inspection reports deal with quality of care, life, environment and management. While recent issues raised by the CQC around medicines management and record keeping have some cross-over, there is little that clearly addresses the issues of environmental sustainability dealt with here. Consideration could be given to broadening inspection criteria to also include resource efficiency and environmental impacts of care.

A home that manages its natural environment and its environmental impacts, through a more holistic approach, can benefit residents in terms of wellbeing and home operators in terms of running costs while reducing impacts on the local and global environment.

With an aging population and rising natural resource costs, it is essential that this sector is supported and encouraged to take an active role in resource efficiency and carbon reduction. This will be critical in both safeguarding affordable care for vulnerable elderly people, maintaining dignity and social participation in old age and in achieving carbon, waste and energy targets.


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