“Sustainable Health”; Individual, Structural or Planetary Health

There are different types of change to consider when thinking about ‘sustainable health’, they are connected, but not really interchangeable. Discussions at the Royal Society of Medicine highlighted the differences that the term 'sustainable health’ meant to different people, but the conversations could be grouped into three broad themes.

Individual what people can do differently, how they can keep well and maintain their own health, and ‘be healthy’ throughout their lives. Structural change is the set of conditions that shape risk, access, and opportunity; and therefore shape inequalities, including the fundamental future of the NHS and wider healthcare services under current financial, workforce, and patient / client pressures. Planetary Health is the footprint of care itself; the carbon, the waste, and the resource intensity of how healthcare is delivered and supported.

Individual health and individual level changes work, evidence supports behaviour change approaches. Particularly where they go beyond information and include active participation, goal settings and action points. This can be seen in the success of some smoking cessation services which offer wider physical and mental health support to quit.

The limit is that people’s choices are shaped by the conditions they live in; resources and risks are not distributed evenly. Public health approaches can argue people's free choices are taken away from them by addiction, aggressive targeted marketing, and their economic environment. For example, calorie dense food is usually cheaper than fresh fruit and veg for a family.

The NHS has net zero targets for 2040 for emissions it controls. There is a larger footprint that sits in the supply chain which can influence overall planetary health. To address these the social value element of the procurement contracts could be enforced more stringently so more progress could be made.

If we push only on the individual lever, you risk blaming people for barriers. If you push only on structural reform, the people, quality, and equity elements of the quadruple aim can be forgotten in the pursuit of a financial position. If you treat planetary health as a side programme, we are building up problems for future generations.

The art in such complex systems such as health and care is to ensure our work includes considerations across the board. Designing services that make healthier choices realistic, prioritising upstream interventions that reduce demand over time, treating waste, duplication, and poor pathway design as systemic issues should be what we are working to always improve as our work and the evidence internationally evolves.

Individual change, Wellness and a Healthy Lifestyle

Individual level interventions matter. Behaviour change approaches can be effective, and individual change sits inside a context. If the system makes the healthy option hard, expensive, unsafe, or unrealistic, then the impact is low.

This is why the social determinants distinguish downstream behaviours from upstream conditions. It is now known that unequal outcomes are driven by unequal distribution of health promoting resources and opportunities.

This is why the debate about funding GLP 1 medications vs upstream prevention action matters. It is not either / or, it is how we balance immediate support for individuals with structural changes that make healthier options easier, more accessible, and more affordable. Reformulation, regulation of advertising, and fiscal measures such as the sugar tax all sit in the structural space that supports individual action of healthy weight.

Structural Sustainable Healthcare

Structural change sounds slower, harder, and political, it arrives in England as ‘Can the NHS survive in its current form?’

When resources, environments, and opportunities are distributed unevenly, we should not be surprised that outcomes vary, this is the fundamentals of work from the Institute of Health Equity and Marmot, and the impact of the Inverse Care Law.

Structural change does not need to be abstract or the exclusive remit of departments of health. It is where stewardship matters. In complex systems you do not make one large change and expect a predictable result. You set direction, align incentives, and create the conditions for multiple actors to move together. This is why it is quoted ‘Culture eats Strategy for breakfast’, the feeling, the culture, which allows people to work differently to achieve a wider goal is more successful that top down mandates. Look at the Wigan Deal for evidence of this.

Free at the point of care for the NHS, Yes, with the delivery of care as close to home as possible, Yes. If England is to make the proposed change to neighbourhood health a success, its lots of smaller changes across the system and its pathways to achieve this. It's the trust and acknowledgement of local leaders' expertise to achieve the goal in their local context. Guidance such as NICE, Yes, but guidelines supported with accountability to achieve outcomes over outputs.

It's difficult and long term, I hope the government has the patience for a long term plan to come to fruition. (and the funding resilience).

The Planets Health

No Planet, no healthcare … lets ensure we are reductive in our energy and carbon consumption.

A large portion of the carbon and energy footprint sits in how healthcare is organised and what it buys. Indirect emissions, largely the supply chain, are around half of the NHS total footprint. NHS England’s progress reporting also puts the NHS at around c.5% of the UK’s total carbon footprint. So we (the whole system) need to be smarter about the decisions we make. Single use items cannot be avoided in healthcare, for example gloves, but we can choose where we buy those gloves from using the social value part of procurement contracts to ensure quality, footprint, and good work practices flow through the supply chain.

A significant amount of healthcare's carbon footprint is encapsulated into medications, including R&D, manufacturing, and unfinished medication courses; how do we address each step? Encourage people to finish their antibiotic course, which would also help with AMR, and prescribe well in the first place, for example multiple unsuccessful prescriptions to tackle a UTI.

Think of planetary health as a system design constraint, but If we reduce avoidable admissions, duplication, low value activity, and poorly joined-up pathways, we can improve quality and reduce carbon at the same time. This is not about adding another programme. It is about building sustainability into the definition of quality. Consider the wider impact of high waste, or high energy consumables, and if there are alternative organisations which can supply an equivalent product.

The NHS can set the market conditions.

What is ‘Sustainable Health’?

If we over focus on individual change, we risk blaming people for structural barriers. Structural change without lived experience, risks losing momentum, quality and trust. If we treat planetary health as separate we are knowingly creating problems and pressures for future generations, the problems are global, but we can each act local.

Consider “sustainable health” in plain language; What are we asking individuals to do differently? What structural barriers are we removing? How will we see inequalities narrow? What changes are offered to reduce waste and reduce carbon from a product of better design?

Sustainable health becomes real by individual enablement, structural fairness, and our planetary responsibility, joined through the way care is designed and delivered.