Environmental sustainability in hospitals - a systematic review and research agenda.

OBJECTIVES: Hospitals are significant contributors to natural resource depletion and environmental change. Our objective was to establish the extent to which hospital environmental sustainability has been studied and the key issues that emerge for policy, practice and research. METHODS: The PubMed, Engineering Village, Cochrane and King's Fund databases were searched for articles relating to hospital environmental sustainability published in English between 1 January 1990 and 1 October 2013. Further studies were found by review of reference lists. One hundred ninety-three relevant articles were found and 76 were selected for inclusion in the review. RESULTS: Common research themes were identified: hospital design, direct energy consumption, water, procurement, waste, travel and psychology and behaviour. Some countries (particularly the United Kingdom) have begun to invest systematically in understanding the environmental effects of hospitals. We found large variability in the extent of the evidence base according to topic. Research regarding the architectural fabric of hospital buildings is at a relatively mature stage. Similarly, there is a developed research base regarding devices and technologies used within hospitals to reduce the environmental effects of direct hospital energy and water use. Less is known about the clinical, psychological and social factors that influence how health care professionals use resources, travel to/from hospital, and interact with the buildings and technologies available. A significant part of the environmental footprint of hospitals relates to clinical practice, e.g. decisions regarding the use of pharmaceuticals and medical devices. Medical 'cradle to grave' life cycle assessment studies have been published to understand the full financial and environmental costs of hospital activities. The effects of preventive or demand management measures which avoid unnecessary hospital procedures are likely to be much greater than incremental changes to how hospital procedures are performed. CONCLUSIONS: There remain significant gaps in the evidence base on hospital sustainability. Assessments of environmental impacts and natural resource use are beginning to be produced, both at the level of individual hospitals and at the health system level. These are an important start, but in many areas do not yet provide sufficiently detailed information to guide decision-making. There are many areas where the interests of patients and the environment coincide, but others where tensions exist. Rising resource costs and climate change mitigation measures are likely to create an increasing stimulus for research on hospital sustainability. Such research will benefit from inter-disciplinary coordination across research funders and countries.

The use of external consultants by NHS commissioners in England: what lessons can be drawn for GP commissioning?

OBJECTIVES: To describe the current use of external support by commissioners in the English NHS; assess what impact it is having; explore the factors influencing effectiveness; and draw out the implications for the future of NHS commissioning. METHODS: (1) Two national surveys of primary care trust managers. (2) Qualitative interviews and focus groups with representatives of 12 firms providing support services to commissioners. (3) Focus groups in three primary care trusts and interviews with representatives of two strategic health authorities (SHAs). RESULTS: The majority of survey respondents reported using external support (89% in 2010). Satisfaction levels were reasonably high, with most rating the service received as excellent or good. Perceived impact in the case study sites was mixed, but benefits were reported in a number of areas. There were cases where external support had not achieved its goals. Several factors contributed to success or failure, including difficulties around procuring external support; building effective working relationships; and implementing the ideas generated by external partners. There was evidence that commissioners do not always use support in a way that takes full advantage of the skills existing in external organizations. There was also some evidence that poorer performing organizations may be less successful in using external support effectively. CONCLUSIONS: External support can play a role in improving the quality of commissioning. However, certain pitfalls must be avoided if it is to be used effectively. The role of external support will evolve (and may expand) as commissioning responsibilities are transferred to general practice consortia.

Reducing health inequalities in priority public health conditions: using rapid review to develop proposals for evidence-based policy.

BACKGROUND: In November 2008, the Secretary of State for Health (England) commissioned an independent review to propose effective strategies for reducing health inequalities. Review task groups were given just 3 months to make preliminary evidence-based recommendations. In this paper, we describe the methodology used, and the recommendations made, by the group tasked with inequalities in priority public health conditions. METHODS: A series of rapid literature reviews of the policy-relevant international evidence base was undertaken. Quantitative studies of any design, which looked at the effects on health inequalities, the social gradient or overall population health effects, of interventions designed to address the social determinants of selected public health priority conditions were examined. Recommendations were distilled using a Delphi approach. RESULTS: Five key policy proposals were made: reduce smoking in the most deprived groups; improve availability of and access to healthier food choices amongst low income groups; improve the early detection and treatment of diseases; introduce a minimum price per unit for alcohol and improve the links between physical and mental health care. CONCLUSION: The combination of rapid review and Delphi distillation produced a shortlist of evidence-based recommendations within the allocated time frame. There was a dearth of robust evidence on the effectiveness and cost-effectiveness of the interventions we examined: our proposals had to be based on extrapolation from general population health effects. Extensive, specific and robust evidence is urgently needed to guide policy and programmes. In the meantime, our methodology provides a reasonably sound and pragmatic basis for evidence-based policy-making.

Young people at risk of offending: their views on a specialist mental health service in south east London.

This article explores the views of young people regarding their involvement with a specialist mental health service for adolescents who offend or are at risk of offending. The main aims are to shed light on means of engaging this group in therapeutic work, and to illustrate the use of qualitative techniques in the evaluation of health services. Twenty clients and ex-clients were interviewed using a semistructured schedule. Responses were analysed using a thematic indexing technique. Findings show that the majority felt the service had helped them to some extent, despite initial resistance to referral. Five factors which helped practitioners overcome this resistance were identified: (1) A manner which demonstrates respect and commitment; (2) being able to operate flexibly and offer outreach appointments; (3) clinical effectiveness; (4) making therapeutic sessions seem personally relevant; and (5) explaining clearly the role of the service. Attention should be paid to these areas if mental health services are to support this challenging client group.

Simultaneous release of metals and sulfide in lacustrine sediment.

A single DGT (diffusive gradient in thin films) probe that could measure metals and sulfide simultaneously and at the same location was deployed in the surface sediment of a productive lake (Esthwaite Water). It contained a layer of AgI that binds sulfide overlying a layer of chelating resin that binds metals. Analysis for sulfide in two dimensions showed local sources of sulfide, 1-5 mm in diameter, at 8-11 cm depth within the sediment. A transect of trace metals measured at 100-microm intervals through the largest sulfide "hot spot" demonstrated concomitant release of Fe, Mn, Cu, Ni, and Co. Substantial supersaturation with respect to metal sulfides was observed for Fe and Co at the site of metal generation, but at a distance of less than 1 mm, solution concentrations were consistent with equilibration with amorphous FeS and CoS phases. Simple mass balance calculations were consistent with Fe being supplied from reductive dissolution of its oxides and with sulfide being supplied from reduction of sulfate. The observed concentrations of Cu, Ni, Co, and Mn could be accounted for by their release from iron oxides without invoking Mn reduction. The metals are removed rapidly (approximately 1 min) at the edge of the hot spot. These first observations of the simultaneous release of trace metals and sulfide are consistent with the known removal of metals by formation of their insoluble sulfides if the in situ kinetics of metal sulfide formation is on this time scale. The coproduction of reduced Fe and S suggests that iron- and sulfate-reducing bacteria may exist together in the same localized zone of actively decomposing organic matter.