Is it time to rethink health-economics?

Updated: Apr 19

How one little girl challenges the health service to redevelop health-economic modelling with climate targets appropriate, for our health, our planet and our wallet



The landmark Coroner's ruling on the tragic death of 9 year old Ella Adoo-Kissi-Debrah of South London, confirmed a recording of air quality as a cause of death for the first time in the United Kingdom. A legislative bow tied on top of repeated public health calls for a reduction in climate impacts to save health.


Air quality is a proven, direct contributor to the health and economic cost of respiratory conditions. Per year, it costs the NHS £345 million to treat and lowers a sufferer quality of life to the point that 40,000 tragically die.


In young Ella's case, she was admitted to hospital 27 times in 3 years having suffered multiple seizures and finally succumbed to acute respiratory failure caused by asthma, contributed to by exposure to excessive air pollution and died on the 15th February 2013.


Adoo-Kissi-Debrah's second coroner's enquiry since her death not only highlighted gross social inequity, given the disproportionate proximity of inner city BAME families to toxicity risks like roads, it also highlighted how far behind evaluation and operating models are from the reality of their own effects on air pollution contained in each buying decision.


7 years is not only a long wait by Ella's mother for justice, it's also a long time to continue emitting dangerous Nitrogen Dioxide into a municipal air space. Much at a time when Diesel was still wrongly considered the "greener choice" of fuel.


Despite this, diesel continues to power every single freight, haulage and logistics platform around the world. Enabled and necessitated by the UK's public procurement sector. Every kilo of food; every mass manufactured care product. All with an 'on-cost' in health impact and finance.


Current Health Economics

Health-economic models are the gold standard of evaluation. All HealthTech, MedTech, medicines and medical practise evaluation undergoes a risk appropriate level of health-economic evaluation that seamlessly applies all the way up to NICE's medical efficacy evaluations. It also aligns procurement with the makings of outcome focused purchasing and supply. Introduced through the new Category Towers. Fundamental to this, is the evaluation of total lifetime cost and total quality of life benefits which a health establishment must consider.


The 13 NHS Category Towers
NHS Supply Chain, Category Towers


Climate factors clearly influence both of those primary dependent variables within health economic models that vector into every respiratory patient and out again through health and through public money.


The health impacts of plastic care products are not limited to the direct effects of delivery emissions and plastic.


For the UK NHS, 133,000 tonnes of plastic waste goes through this process. The weight of almost 4,000 average UK houses or 400 Boeing 747 commercial aircraft. Some of which degenerating into microplastics and making their way to waterways to be eaten by fish, which in turn, are consumed by humans. Microplastics as large as 5 um in size have now been found in human placenta.

The climate and health effects of plastic stretch far beyond the plastic itself. More plastic delivered, means more emissions from haulage and logistics which means a greater respiratory impact. Every 1Kg of Polypropylene tubing clamps, is the sum of energy consumed processing 4kg of oil into petroleum and then on to ever-refined plastic products. Add to that the transportation to and from intermediary chains by haulage and logistics (at circa 190g CO2/Kg/km) before getting into the hands of care workers, only to be processed through the expulsion of energy for storage and then on through waste disposal trucks and industrial reprocessing, to be burnt for energy or disposed of in landfill, releasing the carbon or simply being disposed of in landfilled. Every 1kg of plastic is accompanied by more than 20Kg of CO2 added to it in that lifecycle, through energy, freight, logistics and disposal.



Lifecycle impact of carbon on health and populations
The lifecycle impact of Carbon on the NHS


There is hope. This effect is invertible. These nonlinear relationships can be exploited to yield a similar degree of Carbon saving per 1kg of plastics.


What should this all mean? How does a healthcare organisation move to evaluating climate criteria in the context of health-economics?


It's a Journey

Firstly, score climate questions. The lowest hanging fruit. Many tenders ask for "consideration" of environmental effects and social good, but do not score them. The only scoring criteria remain cost and "quality".


Yet, climate needs to be a first class citizen to full appreciate the mutually recurrent effect it has on both cost and health. Strategically, all that needs to happen is simply to score climate evidence and questions with the same veracity as cost and quality. Otherwise, all that's left is promises, waste and broken hearts.


The Trinity, always!

Commissioning and procurement rarely adequately score environmental evidence. Most tenders refuse to consider their parity with cost and health indicators, despite organisational claims to the contrary and the inexorable link. Without it, the effects of medical equipment disposal fail to be recognised in supplier appointments. Often appointing climate hostile suppliers and placing disproportionate disadvantage and burden on sustainable suppliers, that similarly shifts into existing disposal costs operated by facilities and different supplier relationships in a different tower. A factor rarely considered in health-economic models because it's regarded as the problem of someone else, in a different silo.


Health-economists with solid mathematical skills are well aware that introducing a third dependent variable can radically model behaviour and equally, provide insight into normally invisible factors. Yet in practise, it raised the NHS' expectations of suppliers. Crucially, giving them less disposal surprises as reward.


However, it also introduces commissioning complexity and a need for a new way to evaluate suppliers that many won't be keen to see.


There are several ways to proceed. In any evaluation model, parametric or transformation systems can be used to map the climate effects into other relevant variables. However we in the mathematics world already transform complex, nonlinear multidimensional evaluations in (n) projections into a set of n-1 dimensional projections.


This is a very abstract statement. So consider:

  1. Climate-economic evidence and health-economic evidence separately, then combine them through the economic dimension

  2. Health-climate and climate-economic evidence, then combine through the climate dimension

  3. Health-economic and health-climate models, combined through the health dimension

  4. All 3 dimensions of health, climate and economics in one.

Each of these considers different primary variables and extrapolates the other from the connecting factors. All at the mercy of time.



Full-Lifecycle Considerations. (aka "manufacturers: take away your rubbish")

Full lifecycle suppliers can demonstrate end-of-life disposal process and recycle consumables. Circularity is a feature in the best examples which are more complex considerations for limited health-economic evaluations, since the benefit is exponential over time.


Circular economies create recurrence relations, where prior batches of supply, impact the health of current patients, who are treated with current plastic equipment, manufactured and delivered at a prior time, setting a precedent for future patients that must be treated using the plastic equipment delivered now, ad infinitum.


Suppliers taking over waste disposal can save NHS establishments between £70 and £3,000 per tonne and crucially, do this without significantly adding to the emissions footprint, as long as it's taken away during delivery or maintenance activity. Saving some of the 5.7 billion miles driven by NHS Supply Chain and £345 million spent on respiratory treatment, which ultimately prevents many of the 40,000 annual deaths.


Worth repeating: Consider systemic evidence

Benefits derived through the category towers are aligned well with health economics but are counterproductive to climate models because of the missing upstream and downstream manufacturing and freight data. Weakening the claim each tower has and causes a front-facing silo, which doesn't observe the systemic flow of medical products through the system.


For example

  1. A mass manufactured Polyurethane mallet splint is bought by the NHS through NHS Supply Chain

  2. It is delivered to the hospital 8 miles from the supplier

  3. This is fit to the patient with plasters, Velcro and and sleeves, each of which also delivered with or, or separately through another supplier

  4. Once recovered, the splint is removed and discarded

  5. A different refuse collection agency collect the waste in amongst other plastic medical, but not clinical, waste

  6. If it is not one of the vast majority of unrecyclable single use plastics in health, it is still placed in landfill, or incinerated for energy (releases stored carbon). In other industries, it is segregated from other different plastics, shredded and recycled into raw materials used for carpet rebond, clothing and mattresses.

Several steps are unnecessary in this process that lead to savings for the healthcare service, by considering the systemic effects of supply.


  • Polyurethane can be substituted with bioplastics using novel designs to maintain performance, allowing multiple remanufacturing cycles from the same kg of material.

  • Mallet splints can be 3D printed on-site (edge manufactured). Removing all delivery emissions and dramatically reducing climate costs per kilogramme of material

  • Warm-water formable bioplastics, like our folded face visor designs, remove the need for as much plastering and velcro attachments

  • Material collected by the manufacturer is segregated through special bins. Saving money and time in plastic segregation and costs for the NHS.

  • There is also no need to procure separate waste management service as the manufacturer removes (and recycles) their supply. Reducing the cost of procurement


Summary

It's clear that health and social care needs to reconsider new evaluation to meet all the targets for health and climate, while also reducing costs. The ambitious Net Zero plan set climate targets the NHS has to meet to become a new-zero health service and this forces environmental considerations never previously considered.


That oversight wasn't harmless. The most sustainable suppliers were not only bypassed, they were repeatedly disadvantaged. Evaluations focusing on the manifestation of front-side cost factors and ignoring disposal effects at the back.


And it is that one 9 year old former patient, Ella Ella Adoo-Kissi-Debrah, who holds the key to closing the gap left between the two factors in patient-centric care.


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