Striving for sustainability

Professor Dame Carrie MacEwen's speech at NHS Highland's Medical Education conference in Inverness on Thursday 30 May 2024. The conference was titled Striving for Sustainability: Medical Education in a changing climate.

Thank you for inviting me to speak here today.

The global climate and ecological crisis is one of the greatest threats to human health that we face. It impacts health and wellbeing in the UK in multiple, significant ways. The healthcare system is a significant contributor.

At the General Medical Council, we recognise that we can make an important contribution to creating a more sustainable healthcare system in the UK, both in our role as a regulator and our role as an employer.

Some of the contribution we can make falls within the scope of our statutory duties, other things we can do sit outside that, such as using our influence to help convene power, or to use our data and insights to inform and influence and provide important context to discussions.

Considering workforce sustainability, while we have no statutory responsibility for this, we do see it as a significant priority, and it forms a key part of our current strategy. Awareness of climate change needs to be part of this thinking.

A robust medical workforce is going to be needed to cope with the changing health needs of the population, and at the moment, much work is required to be in a position where we can be confident about that future.

On paper, in the UK, we have the largest medical workforce we’ve ever had. Since 2019, the number of doctors joining the workforce each year has been increasing at a rate of more than double the number who leave. However, the number of those leaving is also growing, and we can see from our data an increase in intention to leave to take up another career or to practise abroad. The annual Barometer survey asks doctors what steps they may have taken to leave UK practice, and analyses the strength of these actions. In 2022, 13% of doctors reported taking hard steps to do so, more than double the 5% that said the same in 2021. Hard steps include actions such as contacting a recruiter, applying for a job abroad, applying for or attending training to help them prepare for a new role.

Governments across the UK are planning major efforts to increase the numbers of medical students within UK universities, the Scottish Government intends to increase medical school places by 100 a year over five years, and have delivered 3 of those years so far. Obviously, an increase is welcome, but we must remember that it takes a long time to train a doctor, so there’s a need to focus on retention, to keep the doctors that we have. Part of that is looking at multidisciplinary team members, to ensure that doctors are properly supported.

In December this year we will be welcoming physician associates and anaesthesia associates into regulation. We are talking very small numbers in Scotland, and the Scottish Government has been clear that any increase will be gradual and evidence based. Nonetheless, here as across the UK, the increase in numbers and the introduction of regulation has provoked a lot of discussion and some strong feeling.

We’ve been clear that we will regulate doctors, physician associates and anaesthesia associates as three distinct professions, and that we recognise the importance of patients knowing who they’re receiving care from. I’m hopeful that in time more and more people who have had concerns about this will recognise that regulation will provide additional assurance about the qualifications and skills of these professionals to doctors in the workplace, as well as to patients.

We are going to need these, and other roles, as well of course as more doctors, in the future. Our rapidly ageing population is going to place additional strain on our health services, and creative thinking is going to be required from those in power to help reconfigure the infrastructure of the health service to cope as health needs change.

Add into that the impacts of climate change. The predicted global picture is grim, but there are also going to be repercussions closer to home, and older people, as well as other groups already with poorer health outcomes, may be among the most vulnerable.

It’s obviously a deeply worrying situation for everybody and many doctors are looking to the future and are dismayed about what this means.

Many doctors also feel exceptionally strongly about the impact of the healthcare system on our environment. There’s no getting away from the fact that it contributes significantly to climate change and environmental degradation through greenhouse gas emissions and clinical, chemical and plastic waste. Around 4–5% of the UK’s total carbon footprint can be attributed to healthcare.

In last year’s Realistic Medicine report, Scottish CMO, Gregor Smith, highlighted that clinicians can contribute to a culture of stewardship within NHS Scotland, where resources are safeguarded and responsibly used to provide environmentally sustainable healthcare. He pointed to successes that campaigning doctors have had here.

While power lies in the hands of politicians and policymakers at a national level, and employers at a local level, it’s not unreasonable that individual doctors want to be part of the debate, and part of a movement for change.

In the updated version of Good medical practice which came into effect in January this year, we introduced specific wording on sustainability for the first time, following an extensive consultation.

Almost as soon as we started the review, we heard from many doctors that they very much wanted us to include a new focus on sustainability. It wasn’t just individual doctors, a number of representative bodies also got in touch, asking us to focus on the impacts on public health from climate change and ecological breakdown.

It was really clear early on that this was something we needed to look at, and just how much the world had moved on since we last updated the standards in 2013 when the consultation didn’t elicit this level of response. It was one of a number of issues that we identified as ‘a gap’, alongside developments in the use of social media, clearer expectations on tackling bullying and harassment including sexual misconduct, and the advent of the use of artificial intelligence in medicine. We recognised that we needed to listen to external experts on these issues so we organised a number of single-issue roundtables.

This meant we heard in detail from doctors who wanted us to go as far as we possibly could with the standards. One of the specific questions asked of us was whether we could add a fifth domain to Good medical practice, entirely focused on sustainability.

This was one view, but naturally we needed to consider the full spectrum of perspectives expressed in responses to the consultation, including from organisations that represent doctors. Unsurprisingly perhaps, in the consultation, a counter view was made very strongly too.

While there was general agreement among respondents that the climate crisis is an urgent issue, there was a clear split between those who think it’s a public health emergency that individual medical professionals must engage with, and others who think it’s a system issue that individuals have little agency over. I don’t have any sense of a mass of doctors being climate change deniers, but rather that many were concerned about the degree to which the responsibility for tackling climate change should rest on an individual doctor’s shoulders and that this should be linked to their ongoing registration.

They made the point that it will not always be in a doctor’s gift to make a sustainable choice, highlighting that those decisions may fall to the employer and not the individual doctor. Individual examples were given of when problems may arise, for example when deciding whether a patient needs to be seen in person or remotely, balancing the best clinical interest of the patient with the sustainable choice.

More generally, many respondents (including those who, in principle, supported the inclusion of sustainability) expressed deep concern about the collective impact of the updated professional standards. When medical professionals are unable to do everything that is expected of them, this can cause stress, moral injury and undermine the credibility of the standards altogether. Many respondents argued that we appeared to be placing additional responsibilities on individuals that should, to a far greater extent, fall to service providers and employers. And a frequently expressed fear was that medical professionals will be held to account in our fitness to practise processes for matters outside their control.

So, we had to carefully balance this and, when we were finalising the content, we took advice from our external advisory forum. The wording as finalised advises doctors that they should choose sustainable solutions when they’re able to do so, provided they don’t compromise care standards. It also advises that they should consider supporting initiatives to reduce the environmental impact of healthcare.

Inevitably, many people feel this doesn’t go far enough but, listening to the views expressed, I believe this approach takes into account the strength and variance of feeling across the profession. It’s certainly not something we took lightly.

It’s very important that Good Medical Practice represents a shared, consensus view of good practice. But ultimately, it’s a set of standards that all doctors (including me!), are expected to follow. It should not offer a commentary on wider issues in medicine or society. I think sometimes the title leads to an unconscious misunderstanding on this nuanced point but it’s a very important point to make.

For me, this is clearly something doctors should be thinking about. We should all be aware and conscious of the decisions we make, and strive to improve our understanding of the environmental impact of the profession. For those who feel able to, there are opportunities to look at how to make changes, instituting local greener schemes or even looking at how to influence procurement for instance, as we know a lot of the problems occur within the supply chain.

Of course, some doctors want to take direct action and I know there has been a great deal of discussion around the recent high-profile case of a doctor receiving a five-month suspension from the Medical Practitioners Tribunal Service.

I think a clear understanding of the facts here is important. First of all, the doctor was referred to a hearing at the MPTS not for protesting about climate change, but for multiple breaches of a court order which resulted in a custodial sentence – in other words because she broke the law… and, furthermore, indicated that she intended to continue to do so. The Tribunal’s decision was based on the same.

Our fitness to practise investigations consider cases which are referred to us and where doctors have broken the law. It’s the fact of having done so, rather than the motivation for doing so that is under the microscope. And of course, it’s absolutely not the role of the regulator to determine UK law – that is a matter for Parliament…and we have to abide by it!

The Tribunal’s full determination in this case makes it clear that the sanction it has imposed isn’t intended to punish the doctor, and nor is it a response to her expression of her views or to her undertaking protest action as a matter of social conscience. The doctor concerned has every right to express her personal opinion on the issue of climate change, just as we all do. There’s nothing in our guidance to prevent me, you or any doctor from doing so. We are each perfectly entitled to lobby government and to campaign on this matter or any other, including taking part in protests. That is our right and we can each choose to exercise it. However, the courts have repeatedly made it clear that regulated professionals are held to a higher standard than the general public, and so the rights we have to protest or to express our views must not impact trust or public confidence in the profession. 

I do appreciate doctors have strong feelings about this case. I think it’s important that we communicate clearly on it, when there’s misinformation circulating it’s just another cause for alarm and potentially distress. Generally, it’s been instructive for us to see that there’s often confusion about our role and around how fitness to practise processes are deployed. Providing clarity is important.

We are also committed to engaging with stakeholders across medical education to identify where teaching can include education for sustainable healthcare. We’ve been working with representatives of the Planetary Heath Report Card - an international student advocacy group evaluating planetary health content in medical schools. There’s currently little emphasis in UK medical training on the ways in which our environment impacts our health and how the healthcare sector impacts the environment. The Education for Sustainable Healthcare curriculum – endorsed by the Medical Schools Council and included as suggested reading by the GMC – outlines learning outcomes related to the climate crisis. However, it’s unclear the level of impact it has had on what medical schools teach. 

In setting the standards and outcomes for UK medical education, we can play a vital role in ensuring that those entering the medical workforce have the necessary knowledge, skills, and experience to incorporate sustainability concepts into their clinical decision-making and we need to think about how we equip doctors to treat climate-related health conditions. Over the coming years, we’re going to be reviewing our standards and outcomes, and as part of this we will consider what needs to change – this could include a greater emphasis on climate related conditions. Our outcomes set the broad expectations that need to be achieved as part of medical training, but within this there is also the flexibility to focus more on sustainability, and we are supportive of efforts to do this.

It’s important that there’s good understanding of our role, responsibilities and potential contributions as a regulator.

It is our statutory duty to set professional standards in Good medical practice, and to maintain them with appropriate deployment of fitness to practise processes. And we certainly have a role to play in looking at climate within education and training.

Outside our statutory responsibilities, we will continue to provide high quality data that helps track workforce composition and experiences - this provides vital context to any discussions about environmental issues.

And while we do not have direct power and influence on how employers deal with matters of climate change and sustainability, but we can support services as they respond to emerging challenges. Over recent years we have significantly increased investment in our outreach services, and I imagine over time more of their energy will be dedicated to helping local services manage issues.

We also want to use our influence more broadly. We established a cross-regulator corporate social responsibility group in 2022, inviting a number of other regulators to join us at regular meetings focused on this. We now have quarterly themed meetings and group members include the General Pharmaceutical Council, the General Dental Council, and the Nursing and Midwifery Council, amongst others. We’ve recently met and shared insights on everything from responsible investment to sustainable procurement. Representatives of the Greener NHS Team joined the group in June 2023.

Our role as a regulator is tightly defined but we are also an employer, and there we have quite separate responsibilities. It’s vital that we are ethically responsible in the way we employ staff, run buildings and carry out our day-to-day activities. We want to take responsibility for our environmental impact and strive to carry out our work in a way that benefits rather than harms the environment.

In 2022 we announced our intention to become a net zero organisation by 2040, so we have the same target date as NHS Scotland. We have an ambition to be net zero for emissions we control by 2030, but it’s for emissions we can influence that we have set the 2040 target. When we released our net zero plan it was building on excellent work that had already been carried out by the Environmental Champions in our Green Group, to whom I must give credit for their work across the organisation.

Within organisations passionately motivated, and well-informed individuals can have a transformative, inspirational effect and that has certainly been the case in my experience at the GMC. As we built our net zero plan, they helped us deliver internal sessions to generate engagement and focused on data collection so that we have a robust approach to our work in this area. Since we launched it last year, they’ve been instrumental in our energy efficiency and waste management projects, have run staff awareness campaigns and have started to explore sustainable procurement. There’s a great energy and hunger for this work within the GMC, at all levels and across all functions of the organisation.

The net zero plan is hugely important, and I’m delighted that we’re making such good progress on targets, but it cannot stand in isolation. When we developed our most recent five-year strategy we were determined to make substantial strategic commitments to being environmentally-friendly, and I think anybody reading that would understand this is important to us. As a leader of the organisation I have promised myself and my colleagues that I will always challenge – is there more we can do – is there further we can go?

We have been challenged previously about our investment policy with regard to investments in fossil fuels. As a registered, not-for-profit charity, we are obligated by the Charity Commission to make sure that we protect and safeguard the value of our financial assets however we are mindful of the balance we need to strike between financial returns and having a positive impact through our investment portfolio.

We therefore use CCLA Investment Management Ltd to manage our investments and chose them because of their strong track record and high standards in ethical investing. CCLA has committed to seek to achieve net-zero emissions portfolios for all listed equity assets under management no later than 2050.

In addition, they already exclude from their investment portfolio any companies that derive more than 10% of their revenue from the extraction, production and/or refining of oil and gas. We use investment advisers and co-opted experts to sit on our investment committee, to monitor CCLA’s performance and compliance with their ethical policies.

We review our investment approach with regard to ethical investing and environmental, social and governance impact continually, with formal approval by Council on an annual basis. Council recently approved our investment approach at its meeting in April.

For me, I am committed to reducing my own carbon footprint from my role at the GMC. It’s tricky, there’s a reasonable expectation that I will be out and about meeting people, and I know how important that is. For example – travelling between Scotland and London regularly, I take the train – I do not fly. And, I’m doing my best to take a very conscious and mindful approach, to take lessons where I can from the ways of working we introduced during the pandemic, and mostly, just to keep challenging myself and colleagues.

We all need to look for inspiration and examples of best practice, and sessions like this today are particularly useful. Of course, the work of NHS Highland is a rich source of both. The achievements from the pilot of the National Green Theatres Programme, and the fact that this was the first health board in the whole of the UK to ban Desflurane, both these have been standout, influential moments.

As the regulator we must accept we cannot please all parties all the time, we operate within restrictions and limitations - we have less power and influence than some would like, and others are concerned about what they see as us overreaching. I am hopeful that with consistent communication there will be better understanding of our role and that where we can have an influence, through the setting of professional standards in Good medical practice and for medical education and training, we can do so to best effect. We remain committed to always being open to conversation and dialogue.

And as an employer I feel we can achieve a great deal. I want to signal to patients and the public, to doctors, to other employers and stakeholders that we believe this is the right thing to do. As a doctor who is conscious and concerned myself, I want to see this kind of action from organisations across the healthcare ecosystem, each building momentum and providing insights and lessons that will drive the progress we need if we are to collectively change course.

Thank you.