Sustainability Indicators

Sustainability Indicators Contents Introduction...2 Background...2 Objectives...2 Process used to identify these metrics...3 Next steps...3 Appendix 1 - Driver diagram overview...4 Appendix 2 - Driver diagram for sustainability...6 Appendix 3 - Driver diagram for improving sustainability summary of indicators 12 Appendix 4 - Metrics used in existing NHS sustainability frameworks... 14 Appendix 5 - Defra Sustainable Development Indicators... 19 1

Introduction Without measurement monitoring progress on sustainability will not be possible. Carbon emissions are often used as an indicator of sustainability however this captures only some of the impacts on sustainability. Incorporating economic, environmental and social considerations will capture more of the impacts. This document pulls together information on three themes. Firstly, the document provides the context of a driver diagram. Secondly the driver diagram is used to give an overview of sustainability metrics for the health system. Thirdly, metrics and action are linked with a map of metrics already identified through various guidance documents. Metrics, measures and indicators are provided to support a balanced consideration of sustainable development in a health context. Background Some areas of sustainability are already being measured across the health system however some areas are easier to quantify than others. The Public Services (Social Value) Act 2012 1 requires all commissioners of public services to consider taking into account economic, social and environmental value, not just price, when buying goods and services. Many NHS organisations are already incorporating measurement of sustainable development into their annual reports 2, Sustainable Development Management Plans 3 and using the Good Corporate Citizen assessment model 4. Measures include carbon, waste, water and some process measures. The Public Health Outcomes Framework 5 includes an indicator of Sustainable Development Management Plans across public sector organisations. The NHS England carbon footprint provides an overview of carbon impacts from buildings, travel and procurement. Objectives Measurement of sustainability in the health system can be improved through: Quantification of the link between sustainability and health Comprehensive metrics and indicators covering the breadth of sustainability Alignment of indicators across different settings 1 HMSO: Public Services (Social Value) Act 2012. Available at: http://www.legislation.gov.uk/ukpga/2012/3/contents 2 Nottingham Energy Partnership analysis of published data on sustainable development for NHS organisations. Available at: http://www.nottenergy.com/consultancy/energy_carbon_intelligence/nhs_carbon_reduction 3 Sustainable Development Management Plans map of regions. Available at: http:///sd_and_the_nhs/sdgovernance/sdmp.aspx 4 Good Corporate Citizen regional performance. Available at: http://www.corporatecitizen.nhs.uk/ 5 Public Health Outcomes Framework 2013-2016. Available at: http://www.dh.gov.uk/en/publicationsandstatistics/publications/publicationspolicyandguidance/dh_132358 2

The NHS Sustainability Metrics Steering group prioritised the project to review the existing indicators and summarise the current metrics and measures covering the breadth of sustainability. Using a balanced approach to sustainability these indicate action across the healthcare system on high quality health, social, environmental and economic considerations. Through reviewing and summarising a standard set of metrics these indicators can be aligned across different settings. Indicators have been identified both where they already exist and where measurable actions are clear but not measured. Process used to identify these metrics Driver diagrams are a powerful tool to translate high level improvement goals into action and measurement. In our case the goal is a high quality, sustainable, affordable healthcare system more for less forever. Further information about driver diagrams and their use is available in Appendix 1 - Driver diagram overview. Using the framework of the driver diagram the metrics steering group identified existing metrics and measures where applicable. Measures were aligned with Outcomes Frameworks, sustainability indicators and existing measures for the NHS. Measures which are already available were identified for the sustainable development scorecard. Mapping of metrics across guidance, route map for sustainable health is available in Appendix 4 - Metrics used in existing NHS sustainability frameworks. Next steps Development of metrics for sustainability in the health system can be improved in a number of ways. These include identifying measures in different categories: priorities and core measures; hierarchy and demonstrating progress; and missing indicators and duplication of topics For many of the indicators identified in this document there is yet to be determined the data flows and frequency of expectations on reporting. 3

Appendix 1 - Driver diagram overview A driver diagram is an immensely powerful tool that helps you to translate a high level improvement goal into a logical set of underpinning goals and projects. It captures an entire change programme in a single diagram and also provides a measurement framework for monitoring progress. It is your theory about how the system you are working in and wanting to improve actually works. The layout of a driver diagram is most easily explained via a simple example. Imagine your personal goal was to reduce the amount you spend on petrol (i.e. decrease fuel costs ). The diagram below shows a part of a typical driver diagram constructed around this goal. Aim Primary Secondary Tertiary Actions/ Interventions Reduce price per litre 2 Decrease fuel costs 1 Reduce miles driven 3 Increase mpg 4 Improve car efficiency 5 Limit speed 7 Buy a diesel car next time Stick to 70 mph on motorway Improve driving patterns 6 Use appropriate gear 8 Get into highest gear more quickly Drive smoothly 9 Accelerate more slowly Book onto AA course Driver diagram goal The driver diagram starts with a clearly and measurable goal (box 1). Often these come with a numeric target but it is not necessary to have one for the diagram to work. Primary The overall goal is linked here to three factors that are believed to have a direct impact on it. We assume that fuel costs will go down if you find cheaper fuel (box 2), reduce the number of miles you drive (box 3) or increase your fuel efficiency (box 4). This first set of underpinning goals are referred to as primary because they drive the achievement of your main goal. These may act independently or in concert to achieve the overall goal. 4

Lower level The process of breaking down a goal can continue to lower levels to create secondary or tertiary. Here it is done for one of the primary increase mpg (boxes 5 to 9). Actions or interventions The ultimate aim of a driver diagram is to define the range of actions or interventions that you may want to undertake. These can appear anywhere in the hierarchy of the driver diagram but are usually shown on the right hand side. Driver diagrams therefore help to break down an overall improvement goal into underpinning goals (i.e. ) to the point where you can easily define the actions that you need to make. How to create a driver diagram Start with a clearly goal Brainstorm potential - the areas where change will impact on your aim. Concentrate on generating ideas for at this stage, don t try to allocate into primary or secondary straight away. Once you ve completed the brainstorm then cluster the ideas to create an agreed set of - make sure you use language like improve or decrease and that each driver is clearly (and potentially measurable) Now you can identify the links between the creating primary, secondary and tertiary and set these out in the diagram format. Add actions or interventions for each driver. Finally, decide which and interventions that you want to measure and add those to the diagram. Tips and tricks Driver diagrams are a live tool. They will change over time as you make changes to your system. If you can make your measurable you have created a measurement framework for determining progress towards your overall goal Creating a driver diagram with a team ensures that everyone understands your goal and how they can contribute towards achieving it Driver diagrams will vary from place to place - there is no definitive right answer as your local situation may be very different from other parts of the country NHS Institute for Innovation & Improvement, May 2012 What do people think of driver diagrams? It took us a few times to get it refined, we changed it six times; it was an intuitive process. But it really is the backbone of our strategy. We re now hanging project measures on to it. Driver diagrams are something that can be applied to any environment, any situation It gets you into a structure of thinking where even with a very complex and complicated programme, you can put that into context to another person. It enables us to move from a concept or an idea into starting to execute a programme and delivery very quickly. That has been a major difference to the way we work... 5

Appendix 2 - Driver diagram for sustainability Aim Primary Secondary Indicator Governance Use of resources Increased quantification in sustainability for health Models of care and technology See following pages Adaptation Behaviours 6

Aim Primary Secondary Indicator Organisation Sustainable Development Management Plans (SDMPs) Board approved SDMPs for healthcare organisations GCC assessment performed Good Corporate Citizen Increased quantification in sustainability for health Governance GCC score Presentation of information Benchmarked indicators available for organisations Setting goals and quantifying scale of change Not 7

Aim Primary Secondary Indicator Measure carbon reduction Monitor electricity use Monitor fossil fuel use Water use reduction Monitor water use Waste reduction Monitor waste to landfill Monitor clinical waste Increased quantification in sustainability for health Use of resources Reduce impact of procurement Assessment of procurement carbon impact (e.g. SCO2PE tool) Assessment using P4CR Flexible Framework Ethical Procurement BMA guidance Reduce environmental impacts Sustainability impact assessment included in service configuration decisions 8

Aim Primary Secondary Indicator NHS uses effective treatments and reduces ineffective treatments Effective treatment Treatment accreditation considers sustainable development Care closer to home Percentage of people who die at home Increased quantification in sustainability for health Models of care and technology Effective delivery Percentage of people with long term conditions supported to manage their condition Use of appropriate telehealth Emergency admissions for acute conditions that should not usually need hospital admission Commissioning support Partnership working to roll out low carbon models of care Low unplanned admissions Preventing ill health Healthy life expectancy 9

Aim Primary Secondary Indicator Adaption planning Board approved Adaption Plan for healthcare organisations Reduced dependence on resources Transparency in energy dependence Increased quantification in sustainability for health Adaptation Capacities for adaptation Emergency planning Climate Change Risk Assessments PAM SAQ Effectiveness - Handling capacity and throughput demands under unexpected circumstances Adapting to models of treatment PAM SAQ Effectiveness - Anticipating future adaptability Business continuity PAM SAQ Finance&VFM - Asset improvement, disposal & business continuity strategies 10

Aim Primary Secondary Indicator Legislation Society Increased quantification in sustainability for health Behaviours Health and Social Care Operating frameworks Staff green workplace Individuals Job descriptions include SD 11

Appendix 3 - Driver diagram for improving sustainability summary of indicators Primary Drivers Secondary Drivers Indicator Status Governance Use of resources Models of care and technology Organisation Sustainable Development Management Plans (SDMPs) Board approved SDMPs for healthcare organisations Indicator Good Corporate Citizen GCC assessment performed Good Corporate Citizen GCC score Presentation of information Setting goals and quantifying scale of change Measure carbon reduction Measure carbon reduction Benchmarked indicators available for organisations Not Indicator not Monitor electricity use Indicator Monitor fossil fuel use Indicator Water use reduction Monitor water use Indicator Waste reduction Monitor waste to landfill Indicator Waste reduction Monitor clinical waste Indicator Reduce impact of procurement Reduce impact of procurement Reduce impact of procurement Reduce environmental impacts Effective treatment Assessment of procurement carbon impact (e.g. SCO2PE tool) Assessment using P4CR Flexible Framework Ethical Procurement BMA guidance Sustainability impact assessment included in service configuration decisions Treatment accreditation considers sustainable development Indicator not Indicator not Effective treatment NHS uses effective treatments Indicator not and reduces ineffective treatments Effective delivery Care closer to home Indicator not 12

Primary Drivers Secondary Drivers Indicator Status Effective delivery Effective delivery Percentage of people who die at home Percentage of people with long term conditions supported to manage their condition Effective delivery Use of appropriate telehealth Indicator not Effective delivery Emergency admissions for acute conditions that should not usually need hospital admission Commissioning support Partnership working to roll out low carbon models of care Indicator not Preventing ill health Low unplanned admissions Indicator Preventing ill health Healthy life expectancy Indicator Adaptation Adaption planning Board approved Adaption Plan for healthcare organisations Reduced dependence on resources Transparency in energy dependence Capacities for adaptation Climate Change Risk Assessments Emergency planning PAM SAQ Effectiveness - Handling capacity and throughput demands under unexpected circumstances Adapting to models of PAM SAQ Effectiveness - treatment Anticipating future adaptability Business continuity PAM SAQ Finance&VFM - Asset improvement, disposal & business continuity strategies Indicator not Behaviours Society Legislation Indicator not Society Health and Social Care Operating frameworks Individuals Staff green workplace Individuals Job descriptions include SD 13

Appendix 4 - Metrics used in existing NHS sustainability frameworks Existing measures were reviewed to align were possible both in terms of frameworks and indicators. Colour coding from the Route map http:///sustainable-health/route-map.aspx Route Map Societal behaviours Health system explains the case and how it s taking sustainability forward Integrated sustainability in products, services and places We embed true value in society with a life time consideration Individual behaviours You understand, act and know you can make the difference You make choices based on sustainability and health criteria You demand zero tolerance of unsustainable behaviours System Governance Responsibilities, mechanisms, measures and incentives are agreed Sustainability is accounted for in decision making including the life cycle cost System uses self regulation and feedback across the health system Use of resources Models of care Technology Identify, prioritise and address gaps in knowledge through research Entire resource impact (including full life cycle carbon and sustainability costings) are used in health decision making All resources including people s time and natural environment are accounted for, enabling a no waste approach Explore sustainable models of care including reducing ineffective care and increasing prevention of illness Collaborate to prevent illness, promote health and develop joint service plans Tailor healthcare so it s closer to home, working together to reduce inequalities Adopt and invest in sustainable technologies and welcome innovation Enable and support technology to allow the empowerment, equality and wellbeing of individuals Require and expect low carbon technologies to be incorporated in all healthcare services and products 14

Sustainability reporting framework Energy and carbon management Energy cost Energy use Renewable energy Emissions from electricity Emissions from gas Emissions from business travel Emissions from other activities inc. procurement Finance Use of resources Workforce Adaptation Organisation Governance NPV of sustainability savings CRC expenditure Expenditure on business travel Waste and recycling volume (weight) Water volume Water cost Waste cost Finite resource use Sustainable development included in every job description Staff energy awareness campaigns Adaptation of models of care Adaptation of buildings Sustainability issues in risk management Board approved SDMP Policies to deliver sustainable procurement Board level lead for SD Sustainable Transport Plan 15

Carbon Reduction Strategy Energy and carbon management Procurement and food Low carbon travel, transport and access Water Waste Designing the built environment Organisational and workforce development Role of partnership and networks Governance Finance Board approved SDMP Renewable energy Measure and monitor whole life cycle costs Behaviours and energy use Minimising wastage at the buying stage Partnership working with suppliers Whole life cycle cost Promoting sustainable food Review the need for travel Monitor business mileage Incentives for low carbon transport Promote care closer to home, telemedicine and home working Measure and monitor water usage Design for low water use Quick response to leaks Avoiding bottled water Water efficient technologies Monitor and set targets for waste Review single use and decontaminatio n options Built environment encourages sustainable development Resilience to the effects of climate change Energy management Broad approach to transport, service delivery and community engagement Encouraged and enabled workforce Awareness and behaviour change programmes Encourage home working and low carbon travel Include sustainable development in every job description Consolidate partnership working in local area Regional networks with a broad, consistent approach Sign up to Good Corporate Citizenship assessment model Board approved Sustainable Development Management Plan Interim target for CR 10% by 2015 on 2007 baseline Carbon literate including NPV of sustainability savings Prepare for carbon taxes including CRC and EUETS Partnership working with appropriate incentives 16

Good Corporate Citizen Travel Procurement Facilities management Workforce Community Engagement Buildings Travel policies and performance Area planning for improved travel Service delivery Active travel Business travel Traffic management Procurement policies and performance Procurement skills Procurement processes Engaging suppliers Minimising waste Ethical procurement Facilities policies and performance Energy use and carbon Waste Water Hazardous substances Green space Workforce policies and performance Diversity and inclusion Valuing workforce Healthy workplace Childcare and carer support Learning and development Community engagement policies and performance Local partnership and planning Community participation Healthy and sustainable food choices Assets and resources Communication Buildings policy and performance Planning Design Sustainable procurement Energy and carbon Green Space 17

SDMP checklist Governance Action Plan Monitoring and reporting Sections Board approved SDMP Governance arrangements for monitoring progress and assurance Sustainability mission statement in line with core business List of sustainability objectives Board level lead for SD Encourages sustainability in other organisations Sustainable development included in every job description Actions including timeframes and milestones Named person responsible for delivery Reporting arrangements Quantitative measures Baseline figures and performance targets Responsibilities/ accountabilities for development, implementation and monitoring Monitoring building energy use, waste and water Outlining compliance with HM Treasury sustainability requirement Setting an absolute carbon reduction target of 10% by 2015 on a 2007 baseline Setting annual targets for absolute Outlining the specific metrics used to monitor progress and provide assurance Outlining public reporting arrangements e.g. what s included in annual reports Monitoring carbon related to procurement and travel Risk assessment and mitigation plan Section on adaptation Plan of action for compliance with the CRC Coverage of the 10 areas of the Carbon Reduction Strategy 18

Appendix 5 - Defra Sustainable Development Indicators Economy Society Environment Economic prosperity Healthy life expectancy* Greenhouse gas emissions Long term unemployment Poverty Social Capital Social mobility in adulthood Natural resource use Wildlife & biodiversity Knowledge & skills Housing provision Water availability Economy Society Environment Population demographics Total population Population Demographics - Households Avoidable mortality Obesity UK CO2 emissions by sector Energy consumed in the UK from renewable sources Debt Lifestyles Housing energy efficiency Pension provision Infant health Waste Physical infrastructure Air quality Land use & development Climate change adaptation Noise Origins of food consumed in the UK Research & development Fuel poverty River water quality Environmental goods & services sector Fish stocks Status of species & habitats UK Biodiversity impacts overseas Available at: http://www.defra.gov.uk/consult/2012/07/24/sus-dev-indicators/ NHS Sustainable Development Unit NHS England carbon footprint update 19