Review on Energy Resilience

lable at ScienceDirect

Public Health 123 (2009) 765–770

Contents lists avai

Public Health

j o u r n a l h o m e p a g e : w w w . e l s e v i e r h e a l t h . c o m / j o u r n a l s / p u b h

Original Research

Health, energy vulnerability and climate change: A retrospective thematic analysis of primary care trust policies and practices

J. Richardson a, F. Kagawa b, A. Nichols a, * a Faculty of Health and Social Work, University of Plymouth, 19 Portland Villas, Drake Circus, Plymouth PL4 8AA, UK b Centre for Sustainable Futures, University of Plymouth, Plymouth PL4 8AA, UK

a r t i c l e i n f o

Article history: Received 6 February 2009 Received in revised form 28 September 2009 Accepted 5 October 2009

Keywords: Sustainability Climate change Health care UK

* Corresponding author. E-mail address: andrew.nichols@plymouth.ac.uk (

0033-3506/$ – see front matter � 2009 The Royal So doi:10.1016/j.puhe.2009.10.006

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s u m m a r y

Objectives: To review publicly available documents produced by primary care trusts (PCTs) to assess the extent to which local activity and planning consider energy vulnerability, climate change and sustainability. Study design: Retrospective thematic content analysis of publicly available materials located on PCT websites. Methods: Thematic content analysis of publicly available materials was undertaken by two researchers over a 6-month period in 2008. These materials were obtained from the websites of 30 PCTs in England. Materials included annual reports, plans, policies and strategy documents. Results: Of the 30 PCT websites studied, four were found to have an absence of content related to climate change, energy vulnerability and sustainability. Of the remaining 26 PCT websites, consistent themes were found: strategic initiatives, joint working with other agencies, promoting sustainable communities, and targeted actions. Conclusions: Evidence of good examples in sustainable development was predominantly limited to policy statements and strategic aims; evidence of action was limited. As champions of the public health agenda, PCT action on sustainability should be integral to all aspects of organizational governance.

� 2009 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.

Introduction

Estimates of when oil production is likely to peak vary from before the middle of this century1 to as soon as 2010.2 The subse- quent decline in production will result in increased prices for goods and services that are dependent on oil for production and trans- portation. However, should fossil fuels continue to be abundant, their use will be limited because of their warming effect on the climate.3 Energy vulnerability and climate change present signifi- cant challenges to the ability of populations to maintain health and deliver services to the sick. The adverse effects will particularly impact on the poor, as energy poverty will increase and food security will be compromised, thus increasing inequalities in health.4,5

Estimates of future health effects show the main pathways by which climate change affects health, and emphasize the need for mitigation and adaptation measures.4,5,6 Significantly, authors differentiate between climate–health relationships that are easy to define (e.g. physical hazards due to heatwaves, flooding, storms, fires and infectious diseases) and those that are less easy to quantify

A. Nichols).

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(e.g. disruption to regional food supplies and fisheries, population displacement, loss of livelihoods) but are likely to have detrimental effects including risks of malnutrition and mental health problems.

In the UK, for example, an increase in mean annual temperature of 2.5–3 �C by the end of this century is likely to have a number of consequences.7 An increase in flooding will result in loss of life, injuries, water contamination and restrictions, loss of homes (temporary accommodation) and potential problems with busi- nesses/employment. Excessive rainfall is also likely to increase the bacteria in surface water due to run-off from agricultural land, and higher water temperatures will damage fish stocks. Increased heat will lead to drought and disruption to water supplies, with frequent/long heatwaves resulting in dehydration and death. Air pollution will result in respiratory problems, increased skin cancers and an increasing incidence of food-borne diseases. Malaria is unlikely to become a problem in the UK. However, vector-borne diseases such as Lyme disease may become more prevalent. The consequences will be higher demands on emergency and health services, and rising mental health problems. Add to this the chal- lenges of meeting local healthcare needs in a post peak-oil scenario, with possible limited access to some medicines, transport and energy difficulties, and we could be facing a public health disaster.1

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J. Richardson et al. / Public Health 123 (2009) 765–770766

The National Health Service (NHS) in England is responsible for emitting more than 18 million tonnes of carbon dioxide each year, representing 30% of total public sector emissions in England.8 With its large estate, purchasing power and significant number of employees (more than 1.3 million people), the UK NHS has enor- mous power to mitigate the impact of climate change by imple- menting sustainable practices and encouraging its employees to do so.9 So, what is the NHS doing about sustainability? NHS trusts have emergency plans in place to deal with disasters such as major incidents, and the Department of Health has produced a heatwave plan. However, future public health planning will need to take account of the prediction of possible climate change scenarios, and will inevitably involve multi-agency working and detailed assess- ment of local resources. Furthermore, initiatives will need to focus on both mitigation and adaptation measures.

One initiative aimed at enabling people and organizations in the NHS and wider community to engage in activities that support sustainability is the Convergence of Health and Sustainable Development.10 This is a network of health and other professionals committed to promoting sustainable development within the NHS. This network has produced a manifesto that proposes a commit- ment to promoting sustainable development in the NHS and wider community, and strengthening the position of sustainable devel- opment within the NHS workforce. Signatories to the manifesto include the Faculty of Public Health of the Royal Colleges of Physicians of the UK, the Scottish Environmental Protection Agency, the UK Public Health Association, and a number of senior public health academics and NHS managers.

It has been suggested that the responsibility of healthcare practitioners to protect and promote the health of the public should be extended to working to prevent climate change.11 In 2007, the UK Public Health Association12 outlined strategies for promoting health and sustainable development, and the UK Faculty of Public Health13 recently published a document outlining the action that can be taken at organizational and individual levels. This was closely followed by publication of the UK Department of Health guidance document on promoting sustainable communities.14 The British Medical Journal has set up a carbon council aimed at ‘har- nessing the intelligence and imagination of health professionals to expedite the transition to a low carbon world’,15 and efforts are being made to reduce the carbon footprint of attendance at medical conferences.16

The NHS Sustainable Development Commission’s good corpo- rate citizenship guidance17 describes how NHS organizations can embrace sustainable development and tackle health inequalities through their day-to-day activities. This self-assessment model helps organizations to identify and assess their contribution to good corporate citizenship, and suggests ideas for future action, providing guidance on transport, procurement, facilities, manage- ment and new buildings. Examples of action include sourcing healthy and locally produced food, and the development of park and ride schemes.

More recently, in January 2009, the NHS Sustainable Develop- ment Unit published a carbon reduction strategy.8 This strategy sets out details of where NHS carbon dioxide emissions originate, and proposes action to reduce NHS carbon emissions by 60% by 2050. However, it could be argued that genuine national leadership on actions to reduce carbon emissions within the NHS, and to address issues raised by climate change and sustainability as whole, are lacking. For example, recent English Department of Health guid- ance on planning and managing national and local healthcare priorities has introduced three tiers which indicate national priorities.18 The first two tiers indicate ‘must do’s’, which will be assessed and performance managed at a national level. The third tier is intended to allow local primary care trusts (PCTs) to make

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decisions on their local priorities, without the type of performance management applied to the first two tiers, and it is in this tier that we find reference to NHS estates’ energy and carbon efficiency.

Whilst the potential effects of climate change and energy efficiency are being considered by a number of public health agencies, little is known about current efforts to plan for these effects in a strategic and practical way at a more local level.

Given the emphasis at national level and the increasing good examples to draw upon, PCTs are well placed to provide direction on sustainability and to promote efforts to mitigate and adapt to the effects of climate change.

The aim of this study was to review publicly available docu- ments produced by PCTs to assess the extent to which local activity and planning consider energy vulnerability, climate change and sustainability.

Methods

A retrospective thematic content analysis of publicly available materials was undertaken in 2008. The websites of PCTs in England were searched for materials such as the most recent annual reports and strategic plans. These materials are available to the public under the requirements of the Freedom of Information Act (2000); consequently, ethical approval was not required for this research.

Sample

Twenty-five PCTs were selected at random using a ‘lucky draw’ method, and five PCTs were selected purposively for their potential to demonstrate good practice on the basis of participation of a senior staff member in the UK Public Health Association Climates and Climate Change Think Tank Symposium in 2007. PCT websites searched and assessment criteria used in this study are listed in Appendix 1.

Process and analysis

Website searches were carried out by two researchers. Each researcher was allocated 15 PCT websites to investigate and used a coding system for data extraction. All members of the research team contributed to and agreed upon the construction of the coding system. The coding system was constructed following an initial thematic analysis of two PCT websites and a review of policy documents outlining possible sustainability actions. This coding system consisted of three main codes addressing sustainability, energy vulnerability and climate change. Each of these main codes contained a variety of relevant subcodes. Examples of text found within PCT documents were allocated to appropriate codes within the coding system. Reliability testing was achieved by members of the research team independently reviewing and recoding a selec- tion of material previously coded by their colleagues. This enabled the authors to extract relevant details which were then used to inform a qualitative, thematic analysis from which four consistent themes were apparent.

Previous investigations of strategic health authority policy and practice with regard to energy vulnerability and climate change yielded limited data sets, and this suggested that data sets gained from the study of PCT websites could be similarly limited. Conse- quently, it was decided that quantitative analysis of the data would not be appropriate, but that a qualitative form of analysis would enable the identification and discussion of relevant, general themes emergent from the data.

Methods such as those outlined above have previously been used successfully, and have been advocated in the literature.19,20,21

For example, Yin19 argued that the analysis of evidence obtained

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J. Richardson et al. / Public Health 123 (2009) 765–770 767

from the searching of documentation can aid attention to detail, while Reason and Garcia21 found that smaller data sets comparable to that obtained during the searches of the PCT websites may well be suited to the type of qualitative content/thematic analysis described above and discussed in the following sections. Further- more, this method has been used in a similar study investigating strategic health authorities in England.22

Results

Of the 30 PCT websites searched, four were found to have an absence or lack of content related to climate change and sustain- ability. Of the remaining 26 PCT websites that did include content related to climate change and sustainability, four consistent themes were apparent from the data. These themes were:

� strategic initiatives: where evidence of relevant policies and strategies was found; � joint working: where evidence of multi-agency working at

strategic or practical level was found; e.g. working with the Environment Agency or local councils; � promoting sustainable communities: where evidence of

developing innovative models of planning, such as using inte- grated health impact assessment tools, was found; and � targeted action: for example, focusing on flooding, transport or

waste management.

Evidence related to each of these themes is presented below. PCTs discussed in this paper have been named in Appendix. However, the symbol ***** has been used to anonymise the loca- tions and names of PCTs when discussed within the results.

Strategic initiatives

Twenty-four PCTs provided examples of how they had made a clear commitment to addressing issues raised by climate change and sustainability, and adopted policies and strategies accordingly. For example, PCT 20 recognized that it ‘has a responsibility towards the environment with global warming, climate change and the production of greenhouse gases being important issues. It also has a responsibility to conserve natural resources in a manner that makes minimal demands on the environment and hence produces minimal waste in terms of the local, national and global environ- ment’. PCT 24 claimed to be ‘committed to promoting a greater awareness of the environment and sustainability throughout all of its healthcare services and related activities. Through the ways that the PCT manages its sites it seeks to influence staff, patients and contractors to recognise the opportunities they have to contribute to social progress, economic growth and environmental improve- ment. This takes place through treatment, education, research, estate management, and interactions with the wider community’.

Comparable sentiments were expressed by PCT 6 in its Public Health Annual Report in which they asserted that ‘it is about all of us working to create a culture of promoting health – through improved health services but also through improvements in the environment, crime, housing, open spaces, our schools, our trans- port system, in our communities, and through employment’.

Similarly, PCT 3 was ‘committed to reducing our carbon foot- print, both to help the environment, and the future health of the population, but also to reduce energy costs so that more resources can be concentrated on clinical and preventative services’. This PCT also recognized that implementation of this commitment and strategy would require some considerable time by acknowledging its ‘responsibility as an organisation, and as commissioners of health care, to put in place measures progressively to reduce

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greenhouse gas emissions over the coming decade (PCT 3) has prepared, with assistance from the Carbon Trust, a draft Strategy and Plan of Action to ensure this’. Likewise, PCT 4 was clear in its long-term commitment to their strategy, claiming that ‘it is not possible to predict with certainty how climate change will affect us all, but we must plan for the likely damaging effects and encourage the life style changes that will limit the impact. This strategy sets out our shared understanding of our key challenges over the next eighteen years. It provides the framework for us to work together and with regional and government agencies and our communities, in common purpose’.

Arguably, the evidence outlined above indicates that a number of PCTs accepted that not only was a long-term commitment required, but that for these strategies to be implemented success- fully, they would have to involve and be directed towards a broader community than those simply offering health care. Evidence gained from the report of the Director of Public Health of PCT 29 appears to support this argument, stating that ‘the report is directed at a wide audience, but particularly those with a direct or indirect responsi- bility for making *****shire and *****land a healthier place to live. It sits within the context of a wider programme of health needs analysis, including the multi-agency joint strategic needs assess- ment, that aim to inform and support the planning processes of the PCT and its health partners and the overall development of the sustainable community strategies for both *****shire and *****land’.

Further evidence on the development and implementation of strategies and policies was also found. For example, PCT 20 claimed that ‘The trust will participate in one of the Government approved schemes to help improve resource efficiency and environmental performance in a managed, targeted and transparent way’. In implementing the trust energy strategy, it was stated that a ‘coherent and effective programme will provide the foundation to planning a successful conservation strategy where specific targets and detailed performance requirements can be quantified’. It is also perhaps worth noting that this PCT was clear in its intent to monitor the impacts of this strategy, with targets set annually and with responsibility for the implementation of the strategy desig- nated to the head of facilities of the trust. Other good examples of implementation of policies were provided by PCTs 3, 4 and 24 which were also found to be active in putting their own strategies into effect in areas such as energy, transport, waste and procure- ment, with PCT 3 developing a local food programme which enabled it to acquire provisions in a sustainable manner. However, evidence was also found of what could be described as a policy- implementation gap. For example, a London PCT claimed to be active in taking account of sustainability issues, but no further evidence could be found regarding what this activity amounted to or how it was being implemented in practice. Further evidence of a policy-implementation gap was provided by a report from the director of public health based within another PCT who found that despite recognition of the increasing importance of climate change, little progress in addressing this had been made within the PCT.

Joint working

Evidence gained from this research appears to suggest that when PCT strategies and policies on sustainability and climate change were implemented successfully, this was often achieved in partnership and through joint working with other significant agencies. Examples of joint working towards sustainability were found on a number of PCT websites. PCT 3 was working with the Carbon Club in an attempt to establish sustainability within their daily working practices. PCT 4 was actively seeking the involvement of their local community with the aim of bringing together ‘a range of interests including key public organisations, private businesses

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J. Richardson et al. / Public Health 123 (2009) 765–770768

and voluntary and community sectors’ in partnership to ‘support sustainable development’. Evidence from the PCT 21 website indicated that ***** County Council and primary care trusts were working together, as part of their local strategy with the intention of making community ‘healthcare ‘‘greener’’ and more sustainable’. Similarly, PCT 24 acknowledged the role of partnership agencies in implementing sustainability policies and strategy. The PCT 24 Public Health Annual Report 2006–2007 was clear in stating that ‘*****shire County Council has an important role in adaptation working with partners, both via direct activities and in terms of its ability to influence the wider community. The Council has addressed adaptation actions through the sustainability principles outlined in the ‘Sustainable Community Strategy for *****shire’, the ‘Community Strategy for *****shire - Shaping Our Future Together, 2004–2007’ and its ‘Local Area Agreement’. PCT 29 was also found to be engaging in broader collaboration with the ‘***** Strategic Partnership as part of the ***** Development Agency initiative on climate change’.

In addition to these broader partnerships with other agencies, evidence was also found indicating that PCTs recognized the value of collaborating with their own staff members in implementing sustainability policies. PCT 18 was working with the Carbon Trust in pursuing sustainability initiatives and in recruiting ‘energy cham- pions’ from amongst its own staff who were tasked with the execution of these initiatives. In much the same way, PCT 28 was actively seeking to recruit ‘green champions’ that would be tasked with helping the PCT to reduce its carbon footprint. Increasing staff awareness of the use of low carbon technologies was also advo- cated by PCT 27. PCT 3 was unambiguous in its desire to involve their staff in the implementation of their policies, stating that ‘as well as looking longer-term at large scale renewable energy sour- ces, we are also working with staff so we can make a difference as individuals. With thousands of employees who can contribute at work and at home, even the simplest measures to save power and reduce waste can take us a significant way forward in reducing our carbon footprint’. PCT 20 also expressed a desire to ‘ensure employees, including contractors, are responsible for working in a manner that protects the environment. We will continue to educate our workforce by providing updated environmental awareness publications and training to reduce the impact on the environment’. This PCT also aimed to create a culture within its organization in which staff would ‘accept ownership’ of sustain- ability issues. This culture would be formed through the use of committed leadership, publicity, information and training.

Sustainable communities

Evidence appears to suggest that PCTs made some attempt to extend this culture of sustainability into the wider communities which they served. Documents found within the website of PCT 20 indicated that the trust was aware of its responsibilities to the wider community and the environment, claiming that with respect to construction and refurbishment of trust buildings, potential environmental impacts would be assessed using nationally recog- nized assessment tools with the aim of ensuring that the trust adopted a sustainable approach to construction which would ‘conserve natural resources in a way that produces minimal waste in terms of the local, national and global environment’. Further- more, this PCT asserted that its ‘holistic’ approach to construction would protect the surrounding environment, community and wildlife by taking action in areas such as waste, energy, transport management and the consumption of resources such as water. PCTs 3, 4 and 27 were clear in their desire to cultivate sustainable communities, with PCT 4 accepting the challenge to ensure that they managed change ‘within environmental limits and take

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a sustainable approach that benefits our existing communities and future generations’ with the vision of making ***** ‘a place of sustainable, inclusive, safe, healthy communities, thriving in a quality environment’. In much the same way as that intended by PCT 20, these sustainable communities would be developed through attention to areas such as construction, energy, waste, transport and tourism.

In common with PCT 4, PCT 30 also appeared to be clear in visualizing sustainable development as ‘a cornerstone’ of its community strategy, and provided details of an integrated impact assessment tool that it had constructed to promote this. This assessment tool provided clear guidance on specific topics to be addressed in tackling the challenges presented by climate change and in developing sustainable communities. These specific topics echoed many of those suggested by other PCTs; for example, with regard to the construction of buildings, minimizing waste and the prudent use of resources.

Targeted action

A number of PCTs also suggested specific topics to be addressed; for example, the reduction of air, land and water pollution; and flood prevention. Specific topics of particular interest to PCTs appeared to be those of transport and waste management. For example PCTs 4, 7 and 11 were found to be advocating the use of sustainable transport options and infrastructure. PCT 20 was seen to be encouraging the use of ‘sustainable environmentally friendly’ transport alternatives whilst advocating a reduction in the use of cars, in overall mileage travelled and in applying limitations around emission figures in keeping with its ‘Green Transport Policy’. This PCT also aimed to reduce the need for travel through the use of communication technology. ‘Green travel plans’ were also advo- cated by PCTs 7 and 11 as a means of reducing their carbon footprints.

PCT 21 was found to be working in collaboration with the local council in attempting to bring healthcare resources closer to the patients’ home, thus reducing the need for transport and promoting sustainability. PCT 22 was promoting sustainability through their initiative of enabling trust staff to buy bicycles. Similarly, PCT 27 had provided storage, changing and showering facilities for its members of staff that chose to cycle to work. PCT 24 supported the use of sustainable ‘active’ transport initiatives such as cycling as a means of improving the well-being of the local population while reducing air pollution and obesity.

In the case of waste management, PCTs such as PCT 10 were clearly mindful of environmental issues and, as a result, aimed to do their utmost to promote sustainability through actions such as the recycling of waste paper, printer cartridges and other similar consumable supplies. PCTs 7 and 9 were also explicit in their commitment to the recycling of waste. Others such as PCTs 4, 20, 25 and 30 reported that they were actively seeking to conserve resources whilst reducing the amounts of waste produced. The strategic framework produced by PCT 3 could be seen as a good example of how these PCTs encouraged organizations they worked with to reduce waste:

Providers will be expected to comply with current and anticipated future legislation, and demonstrate observance of the reduce, re- use, recycle hierarchy.

Discussion

The above evidence indicates that a number of PCTs recognize the impacts that climate change and energy vulnerability may have on the health of the populations which they serve, and have

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J. Richardson et al. / Public Health 123 (2009) 765–770 769

responded by making commitments to implement policies to promote sustainable development and other measures to combat climate change. A minority of these PCTs could be viewed as exemplary in their attempts to implement policies related to sustainability and climate change, and incorporate their principles into daily working practice. However, other PCTs (four in total) were notable for the lack of content related to climate change, energy vulnerability and sustainability found within their websites.

This evidence appears to be consistent with the diffusion theory described by Rogers23 and characterized by individuals or organi- zations that are innovators, early or later adopters, or laggards. The adoption and diffusion of innovation within health care is clearly a complex process,24 but it could be speculated that raising the profile of climate change and sustainability within the healthcare literature may help in hastening the adoption and implementation of carbon-reducing policies.

The concerns about peak oil and climate change raised in the literature present a clear rationale for implementing sustainability strategies. In assessing the implications of peak oil for public health, Frumkin et al.1 suggested that extensive health research including quantitative modelling, scenario building and epidemiological analysis is required. Furthermore, research should attempt to identify local vulnerabilities and guide adaptation strategies. The NHS, particularly policy makers, public health professionals and health service researchers, could make a significant contribution to scenario building, joint and multi-agency working, and promoting resilient and sustainable communities.22 Furthermore, the NHS makes a considerable contribution to carbon emissions, will be hugely adversely affected by climate change and peak oil, and has the potential through both its purchasing power and large number of employees to make a significant contribution to adaptation and mitigation measures. Therefore, any efforts to share best practice and lead by example are to be encouraged.

Arguably, some of the actions reported are measures which are non-controversial (such as waste management). Measures taken to mitigate against climate change should be considered in relation to actions which could be seen to further contribute to climate change. For example, commissioning new buildings that fail to meet the highest sustainable building practices, or are out of town and not easily accessed by public transport.

Clearly, there are limitations to this study. For example, it should be recognized that data obtained from the analysis of publicly available documents may well be limited, and it is unlikely that all of the action taken by PCTs with respect to sustainability will be reported on PCT websites; therefore, some examples of good practice may have been missed by the study. It should also be acknowledged that the research took place at a time when PCTs were undergoing or emerging from periods of great change and re-orga- nization, which may also have influenced the publicly available content on websites. It could be speculated that following the publication of the NHS Carbon Reduction Strategy, a repeat of the study may well reveal evidence of greater and more consistent activity in this area. In order to obtain such evidence, the authors are currently following up this study with a questionnaire/survey to be sent to PCTs/directors of public health. Finally, one could also question whether PCTs, which face a range of demands made upon their limited resources, have the means and ability to successfully address the issues raised by energy vulnerability and climate change.

Conclusions

Evidence of good examples in sustainable development was predominantly limited to policy statements and strategic aims; evidence of action was limited. As champions of the public health agenda, PCT action on sustainability should be integral to all aspects

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of organizational governance. Further research is required in order to ascertain the full extent of sustainability initiatives being undertaken by PCTs and to disseminate good practice. Issues regarding climate change, energy vulnerability and sustainability are now prominent within the healthcare literature. However, much of this literature focuses on health impacts and policy. There is limited published evidence of successful implementation of policy.

This paper provides an indication of how issues relating to climate change and sustainability may have major impacts upon PCTs. It illustrates a range of actions that are being taken by PCTs to address these issues, and highlights the need for further work and dissemination of good practice.

Acknowledgements

The authors wish to thank Lindley Owen, Consultant in Public Health for NHS Bournemouth & Poole for comments on an earlier draft of this paper.

Ethical approval

Materials used within this research were available to the public under the requirements of the Freedom of Information Act (2000); consequently, ethical approval was not required for this research.

Funding

This study was supported by a grant from the Centre For Sustainable Futures at the University of Plymouth of which Kagawa is an employee and Nichols and Richardson hold Fellowships.

Competing interests

None declared.

References

1. Frumkin H, Hess J, Vindigni S. Peak petroleum and public health. JAMA 2008;298:1688–90.

2. http://www.peakoil.net/headline-news/iea-warns-oil-supplies-are-running- out-fast [Last accessed 23/10/2009].

3. Hansen J. Global warming twenty years later: tipping points near. Goddard Institute for Space Studies, New York. NASA; 2008.

4. Haines A, Kovats RS, Campbell-Lendrum D, Corvalan C. Climate change and human health: impacts, vulnerability and public health. J R Inst Public Health 2006;120:585–96.

5. McMichael AJ, Woodruff RE, Hales S. Climate change and human health: present and future risks. Lancet 2006;367:859–69.

6. Haines A, Patz J. Health effects of climate change. JAMA 2004;291:99–103. 7. Department of Health and Health Protection Agency. Health effects of climate

change in the UK: an update of the Department of Health report 2001/2002. London: DH Publications;2007.

8. National Health Service Sustainable Development Unit. Saving carbon: improving health Cambridge: NHS Sustainable Development Unit. Available at: http://www.sdu.nhs.uk/page.php?area_id¼2. [Last accessed 23/10/2009].

9. Coote A. What health services could do about climate change. BMJ 2006;332:1343–4.

10. The Convergence of Health and Sustainable Development. A Manifesto and a Network. January 2008. http://www.healthandsustainability.net. The Convergence of Health and Sustainable Development. A Manifesto and a Network. January 2008. http://www.healthandsustainability.net. [Last accessed 23/10/2209].

11. Gill M, Godlee F, Horton R, Stott R. Doctors and climate change. BMJ 2007;335:1104–5.

12. UK Public Health Association. Available at: http://www.climateandhealth.org; 2007 [Last accessed 23/10/2009].

13. UK Faculty of Public Health. Sustaining a healthy future: taking action on climate change. London: The UK Faculty of Public Health; 2009.

14. UK Department of Health. Guidance document. The health impact of climate change: promoting sustainable communities. London: DH Publications; 2008.

15. Stott R, Godlee F. What should we do about climate change? BMJ 2006;333:983–4.

16. Roberts I, Godlee F. Reducing the carbon footprint of medical conferences. BMJ 2007;334:324–5.

ty from ClinicalKey.com by Elsevier on December 17, 2019. pyright ©2019. Elsevier Inc. All rights reserved.

East Lancashire PCT East Riding of Yorkshire PCT Eastern and coastal Kent PCT Enfield PCT Gateshead PCT Hampshire PCT Haringey PCT Hartlepool PCT Isle of Wight PCT Kirklees PCT Leicester County and Rutland PCT North Lincolnshire PCT

b) Assessment criteria:

Organization Annual Annual Associated

J. Richardson et al. / Public Health 123 (2009) 765–770770

17. NHS Sustainable Development Commission. Good corporate citizenship guid- ance. London: NHS Sustainable Development Commission. Available at: http:// www.corporatecitizen.nhs.uk [Last accessed 23/10/09].

18. English Department of Health. National planning guidance and ‘vital signs’. London: DH Publications;2008.

19. Yin RK. Case study research: design and methods. 2nd ed. London: Sage Publi- cations; 1994.

20. Watkins M, Lindsey L, Jones R. An exploratory study of the clinical content of NHS trust board meetings, in an attempt to identify good practice. London: Burdett Trust for Nursing; 2006.

21. Reason M, Garcia B. Approaches to the newspaper archive: content analysis and press coverage of Glasgow’s Year of Culture. Media Cult Soc 2007;29:304.

22. Richardson J, Kagawa F, Nichols A. Health, climate change and energy vulner- ability: a retrospective assessment of strategic health authority policy and practice in England Environ Health Insight:97–103, Available at:, http://www. la-press.com/health-climate-change-and-energy-vulnerability-a-retrospective- assessm-a1157 2008:2 [Last accessed 23/10/09].

23. Rogers EM. Diffusion of innovations. London: The Free Press; Collier Macmillan; 1983.

24. Greenhalgh T. Diffusion of innovations in health service organisations: a system- atic literature review. Oxford: Blackwell Publishing; 2005.

Appendix a) PCT websites searched:

Barnsley PCT Greenwich PCT Cornwall PCT North Somerset PCT Sandwell PCT Ashton PCT Barking and Dagenham PCT Bassetlaw PCT Berkshire East PCT Blackburn With Darwen PCT Bolton PCT Buckinghamshire PCT Bury PCT Calderdale PCT Camden PCT Central and Eastern Cheshire PCT Cumbria PCT Ealing PCT

report plan documents

Criteria Sustainability general Sustainability estates Sustainability transport Sustainability waste Sustainability planning Sustainability supplies and services Sustainability staff development Energy vulnerability general Energy vulnerability estates Energy vulnerability transport Energy vulnerability waste Energy vulnerability planning Energy vulnerability supplies and services Energy vulnerability staff development Energy vulnerability multi-agency working Climate change infectious disease Climate change flooding Climate change disaster management Climate change Air quality/pollution Climate change multi agency working, e.g. Met

Office/Environment Agency PCT links/references to relevant sustainability

documents Evidence of these being acted upon?

PCT, primary care trust.

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