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       ACKNOWLEDGEMENTS                                                                            CONTENTS
       Author: Ana-Christina Gaeta Hernández (Climate & Resources Policy Officer,                  INTRODUCTION: CLIMATE CHANGE, HEALTH, AND THE HEALTHCARE SECTOR                                           4
       HCWH Europe)
                                                                                                   BACKGROUND                                                                                                6
       Climate policy chapter author: Josh Roberts (Lawyer, ClientEarth)                              HOW CLIMATE CHANGE IMPACTS HEALTH IN EUROPE                                                            7
       Editor: Mary Taylor                                                                            CLIMATE CHANGE AND HEALTHCARE                                                                          9
                                                                                                      HEALTHCARE’S CLIMATE IMPACTS                                                                          11
       Thank you to all the hospitals, health systems and their representatives who
       collaborated with us by providing the information and images showcased in the                  EXPECTATIONS FOR THE HEALTHCARE SECTOR                                                                12
       case studies of this report: Didier Bourdon (Assistance Publique - Hôpitaux de
                                                                                                   CASE STUDIES: EUROPEAN HOSPITALS TACKLING CLIMATE CHANGE                                                 14
       Paris, France), Simon Briggs (Sustainable Development Unit, UK), Will Clark (Sus-
       sex Community NHS Foundation Trust, UK), Annegret Dickhoff (Bund für Umwelt                    FRANCE: Assistance Publique - Hôpitaux De Paris                                                       16
       und Naturschutz Deutschland e.V., Germany), Christian Dreißigacker (Klinikum                   FRANCE: Centre Hospitalier De Niort                                                                   18
       Neukölln, Germany), Kristina de Geer (Region Skåne, Sweden), Bernard Jourdain                  GERMANY: BUND “Energy Saving Hospital” Label                                                          20
       (Centre Hospitalier de Niort, France), Chris Large (Operation TLC, UK), Ahmed
                                                                                                      GERMANY: BUND KLIK Project                                                                            22
       Idhammad (Centre Hospitalier Universitaire Mohammed VI, Morocco), and Mela-
       nie Waitz (Klinikum Neukölln, Germany).                                                        GERMANY: Klinikum Neukölln                                                                            24
                                                                                                      MOROCCO: Centre Hospitalier Universitaire Mohammed VI Marrakech                                       26
       Special thanks to Grazia Cioci (Deputy Director, HCWH Europe), Anja Leetz (Ex-
       ecutive Director, HCWH Europe), and Taha Bousmaha (Volunteer, HCWH Europe),                    SWEDEN: Region Skåne                                                                                  30
       as well as Björn Fagerberg, Kristina de Geer, Hanns Moshammer, and Polyxeni                    UNITED KINGDOM: Operation TLC (Barts Health NHS Trust)                                                34
       Nicolopoulou Stamati.                                                                          UNITED KINGDOM: Sussex Community NHS Foundation Trust                                                 36
       Published: December 2016                                                                       UNITED KINGDOM: Sustainable Development Unit (SDU)                                                    38
                                                                                                   CLIMATE POLICY                                                                                           42
       Design: PrinzDesign, Marc Prinz, Maren Maiwald
                                                                                                   INTRODUCTION                                                                                             43
       Cover image: Heilig-Geist-Krankenhaus, Bingen, Germany, received the BUND
                                                                                                   OVERVIEW OF THE PARIS AGREEMENT – ESSENTIAL ELEMENTS                                                     43
       “Energy Saving Hospital” label in 2010
                                                                                                      THE EU’S 2030 CLIMATE AND ENERGY FRAMEWORK                                                            48
       Photo credits: Николай Григорьев/fotolia (P.6), Gina Sanders/fotolia (P.10),                   AN ENERGY UNION ON – OR OFF – TRACK?                                                                  48
       Manuel Hoffmann (P.14), Assistance Publique Hôpitaux de Paris (P.17), Centre
                                                                                                      POLICY RECOMMENDATIONS MOVING FORWARD                                                                 50
       Hospitalier de Niort (P.18), BUND (P.16), BUND-Anja Tech (P.20), BUND – Clinic
       Muehlacker (P.23), Vivantes Hospital Network (P.25), Health Care Without Harm               RECOMMENDATIONS FOR THE HEALTHCARE SECTOR                                                                52
       Europe (P.27/29), Region Skåne (P.31/32), Global Action Plan (GAP) (P.35), Care
       Without Carbon/Sussex Community NHS Foundation Trust (P.37), Sustainable
       Development Unit (P.39/41), Ewais/fotolia (P.52)

                                                                 air conditioning, and electric and electronic equip-
       CLIMATE CHANGE, HEALTH,                                   ment. Health systems are also major consumers of
       AND THE HEALTHCARE SECTOR                                 medical goods and equipment, which are often pro-
       Climate change is linked to an increase in the fre-       duced in carbon-intensive processes in the devel-
       quency and intensity of extreme weather events.           oping world under unsafe, toxic, and unregulated
       This means more heat waves, changing rainfall pat-        conditions. It is within the role of health systems as
       terns, rising sea levels, wildfires, drought, and in-     health stewards to make responsible decisions that
       tense cold spells. The exacerbation of these events       guarantee both human and environmental health
       can have a direct or indirect effect on human health      throughout their entire supply chain. Sustainable        METHODOLOGY
       by disrupting ecosystems, agriculture, food and           alternatives to health sector-related products and       The case studies presented in this report began with a questionnaire. The information entered into
       water quality and availability, air quality, and dam-     activities - that contribute to the mitigation of cli-    the survey by respondents was used to develop the case studies presented in this report. The sur-
       aging infrastructure.1 In turn, the disturbance of        mate change, save money, and ultimately protect            vey process was then followed up by telephone interviews with the environmental representatives
       these systems can directly affect human health by         human health - already exist. It is merely a matter         of the participating hospitals and organisations.
       causing heat-related illnesses, infectious diseases,      of structural transition and policy implementation.
       cardiovascular diseases, injuries, and respiratory                                                                     The hospitals showcased in this report were hand picked by Health Care Without Harm (HCWH)
                                                                 Climate change has been declared the greatest                 Europe for their impressive efforts in reducing their institution’s climate footprint. These case
       diseases. Climate change is already contributing to
                                                                 threat to global health of the 21st century; yet re-           studies provide examples of current best practices, yet the scope of European hospitals’
       the global burden of disease and premature deaths.
                                                                 sponding to this threat is also the greatest public             efforts to address climate change is not limited to these examples.
       Climate change induced events place great burden          health opportunity.4 This report sets out to identify
       on health systems to cope with the consequences           the threats that climate change poses to Europe-                 The report also takes a look at some useful tools and systems developed by the NHS
       of such events. These range from a hospital’s abil-       an public health, and the opportunities for action                Sustainable Development Unit in England, a behaviour change programme in UK, and
       ity to support a flood of patients after an extreme       against climate change within the healthcare sec-                  a German NGO. Their projects encourage analysis and provide ways forward in tack-
       weather event, to the potential damage to infra-          tor. The report showcases a number of initiatives,                  ling the environmental footprint of healthcare facilities. The diversity of programmes
       structure, or the ability to control infectious diseas-   including eight case studies of hospitals in Europe                   and strategies presented in this report demonstrate that reducing an institution’s
       es. The burden of responsibility that lies with health    and one in Morocco, that are already working to-                       impact on climate change requires collective input from many different sources
       systems in the face of climate change is enormous.        wards reducing the climate footprint of healthcare                      with different areas of expertise, and a recognition that responsibilities need
       For this reason, strengthening public health ser-         facilities. We hope this report can be used as a                         to be shared.
       vices must be a central component of all nations’         guide and inspire other health systems to adopt
       climate change adaptation measures and policies.          green practices, and to become leaders in the fight
                                                                 against climate change.
       According to the World Health Organization (WHO),
       health systems comprise “all the organizations,
       institutions and resources that are devoted to pro-
       ducing actions principally aimed at improving, main-
       taining or restoring health.”2 As the organisations
       that exist to be the protectors of health, the health
       sector has the moral responsibility and social ob-
       ligation to be a leader in the fight against climate
       change. This must be done by eliminating health
       systems’ own toxic emissions, and minimising their
       contribution to harming human health and the en-

       Healthcare infrastructures have a large climate
       footprint. The approximately 15,000 hospitals
       across the European Union3 (EU) have a high de-
       mand for heating and electricity and require a large
       amount of energy for transport, lighting, ventilation,

                                                                                                                                                              have significant impacts. Over 80% of Europeans
                                                                                                   HOW CLIMATE CHANGE
                                                                                                                                                              are exposed to particulate matter (PM) concentra-
                                                                                                   IMPACTS HEALTH IN EUROPE                                   tions exceeding the WHO recommended levels, al-
                                                                                                                                                              ready reducing the life expectancy of each citizen
                                                                                                   Vulnerable Europe                                          by an average of nearly nine months.12

                                                                                                   The impacts of climate change in Europe vary be-           In 2012, 403,000 premature deaths in the 28
                                                                                                   tween regions. Europe can expect to see an in-             Member States of the EU originated from long-term
                                                                                                   crease of certain weather events in the years to           exposure to air pollution;13 this is equivalent to 8%
                                                                                                   come.5,6                                                   of all deaths that year.14 Air pollution is the largest
                                                                                                                                                              contributor to the burden of disease from the envi-

                                                                                                   àà Southern and central Europe: Increased heat
                                                                                                                                                              ronment and the number one environmental cause
                                                                                                      waves, forest fires, and droughts;
                                                                                                                                                              of premature death in the EU. Heart disease and
                                                                                                   àà Mediterranean region: Expected intensifica-
                                                                                                                                                              strokes are the most common causes of premature
                                                                                                      tion of heat waves, droughts, and wildfires;
                                                                                                                                                              deaths due to air pollution, and are responsible for
                                                                                                   àà Northern Europe and The Arctic: Higher tem-
                                                                                                                                                              80% of these deaths, followed by lung diseases,
                                                                                                      peratures will cause melting of ice caps, more
                                                                                                                                                              such as cancer.15 Air pollution also has consider-
                                                                                                      intense precipitation events, and increased
                                                                                                                                                              able economic impacts: increasing medical costs,
                                                                                                      winter flooding;
                                                                                                                                                              and reducing productivity through lost working
                                                                                                   àà Urban centres: Expected intensification of
                                                                                                                                                              days. All of these figures are due to increase as
                                                                                                      heat waves, worsening of air pollution, rising
                                                                                                                                                              temperatures keep rising and air pollution is aggra-
                                                                                                      sea levels, and flooding.

                                                                                                   Heat waves                                                 Cold spells
                                                                                                   The heat wave of 2003 claimed approximately                Extreme cold spells will continue to be a public
                                                                                                   70,0007 lives in 12 countries of western and cen-          health challenge, although winter mortality is de-
                                                                                                   tral Europe. In 2010, another heat wave caused             creasing across Europe due to better social, eco-
                                                                                                   an estimated 55,000 deaths in Russia alone.8 The           nomic, and housing conditions. Nevertheless, inad-
                                                                                                   elderly are most at risk of death from heat stroke         equate indoor temperatures are a key contributor
                                                                                                   and cardiovascular, respiratory, and metabolic             to rates of cardiovascular and respiratory diseases.
                                                                                                   disorders that are caused by high temperatures.            Low-income households will continue to be the
                                                                                                   Without the implementation of adaptation meas-             most vulnerable to deaths and diseases related to
                                                                                                   ures, heat-related mortality is expected to increase       cold temperatures due to poor housing conditions
                                                                                                   across Europe, particularly in the South/Mediter-          and inability to pay for heating. In the winter of
                                                                                                   ranean regions. The European Environment Agency            2011, much of Europe was engulfed by a hostile
                                                                                                   (EEA) predicts that by 2050, heat waves will cause         cold front, and poorer populations, particularly the
                                                                                                   120,000 deaths per year in the EU alone, and this          homeless, were the ones to suffer the consequenc-
                                                                                                   will create an economic burden on public health of         es. More than 300 deaths were reported across
                                                                                                   €150 billion.9                                             Europe, and in Ukraine alone the death toll exceed-
                                                                                                                                                              ed 130, of which the majority were homeless peo-
                                                                                                   Air pollution
                                                                                                   Rising temperatures aggravate the effects of air
                                                                                                   pollutants. Recent research by the European Res-
                                                                                                   piratory Society predicts that an increase in tem-         Increased glacial melting and sea level rise lead-
                                                                                                   perature of 1°C will produce a 1-3% increase in            ing to winter flooding, as well as river and coastal
                                                                                                   mortality within the general population, but this will     flooding, are all expected to increase due to cli-
                                                                                                   result in a 6.5% increase among people with res-           mate change, threatening more than 1.6 million
                                                                                                   piratory illnesses.10 Given that asthma affects 30         people across Europe. Health effects from flooding
                                                                                                   million people in Europe,11 rising temperatures will       range from drowning, injuries, heart attacks, infec-

       tions, water-borne diseases, vector-borne diseas-         across Europe. For example, Spain is already seeing
                                                                                                                        CLIMATE CHANGE AND                                         Capacity
       es, respiratory infections, and psychological prob-       a decrease in agricultural productivity, and experts
       lems, as well as health consequences caused by            from the region fear that many of the agro-regions     HEALTHCARE                                                 The vulnerability of health professionals to climate
                                                                                                                                                                                   change events is particularly important due to the
       the disruption of services, damaged infrastructure,       will simply dry up and become fruitless deserts.
                                                                                                                                                                                   crucial role that they play in a hospital’s disaster
       and loss of food production. Flooding can lead to         In 2015, Spanish mandarin and clementine farm-         Financial burden                                           response systems. Measures must be taken to
       contamination of drinking, recreational, and irriga-      ers suffered a 25% decrease in productivity, and in
                                                                                                                        The environmental and health impacts of climate            minimise the risk to health workers, in order to
       tion water, and to the disruption of water supply         2011, maize production across Europe dropped by
                                                                                                                        change place great financial burden on health sys-         maintain high productivity for both human health
       and sanitation systems, as is already happening on        13% due to heat-stress. Galicia, in north-western
                                                                                                                        tems, and can also place substantial economic              and economic efficiency.
       a significant scale across much of the developing         Spain has experienced adverse impacts to its hy-
       world. Flooding may also lead to the vast displace-       drological system due to persistent droughts since     strain on local, national, and global economies.
                                                                                                                                                                                   The increased frequency and intensity of climate
       ment of people.17                                         2014.19                                                The health sector is a highly carbon-intensive sec-        change-induced events can lead to some social,
                                                                                                                        tor that uses a lot of energy for all of its functions     health, and emergency organisations and systems
                                                                 Droughts can also have indirect effects on human
       Drought                                                                                                          and activities. These basic activities can have an         being unfit to cope with the consequences of such
                                                                 health; they can cause dams to dry up and become
                                                                                                                        impact on the budget of hospitals and health min-          events. Having stable access to energy, clean wa-
       Prolonged rainfall shortage and high temperature          inefficient, which may lead to energy shortages
                                                                                                                        istries when their demand increases in times of            ter, food, and all other medical resources is indis-
       anomalies often lead to severe drought. This phe-         that could affect health systems. These systems
                                                                                                                        climate-related stress. An over-extended health            pensable.
       nomenon is not foreign to Europe. Countries includ-       must be prepared to cope with the adverse effects
                                                                 of periods of severe drought.                          system can have an overwhelming financial burden
       ing Belgium, The Czech Republic, France, Germany,                                                                                                                           As well as the burden that climate change places
                                                                                                                        on a nation’s economy. The WHO estimates there
       Hungary, Italy, Luxembourg, The Netherlands, and                                                                                                                            on health systems - which threatens their ability to
                                                                                                                        will be an increase of $2 to $4 billion USD in annual
       Spain have all been affected by droughts. Droughts                                                                                                                          serve their communities - other unexpected conse-
                                                                                                                        health sector costs by 2030 as a direct result of the
       are expected to increase in duration and severity                                                                                                                           quences, such as a surge in mass migration, must
                                                                                                                        adverse effects of climate change on human health
       across the Mediterranean. In 2015, (one of the hot-                                                                                                                         also be considered as a real and pressing factor
                                                                                                                        (excluding indirect costs from impacts on agricul-
       test years in recorded history), Europe was hit by                                                                                                                          that will increase the financial burden on health
                                                                                                                        ture, sanitation, etc.).20
       the worst droughts since 2003.18                                                                                                                                            systems, while impacting their ability to respond to
                                                                                                                        During extreme weather events, hospitals and               the health impacts of climate change.
       Droughts also contribute to the increased risk of
                                                                                                                        health institutions may become physically dam-
       large wild fires, which in turn increase deforesta-
                                                                                                                        aged, resulting in significant re-construction costs.
       tion. In the face of climate change, those regions
                                                                                                                        Health professionals are also at risk from the every-
       not currently vulnerable to fires may soon find
                                                                                                                        day threats of climate change, such as aggravated
       themselves affected.
                                                                                                                        air pollution and the spread of climate change-re-
       Severe droughts can result in food and water short-                                                              lated diseases in hospital settings. This reality may
       ages, malnutrition, and water and food-borne dis-                                                                result in more staff having to take sick leave, thus
       eases. Some of these effects are already being felt                                                              reducing productivity and causing economic loss.21

       Migration burden                                          they suffer from a communicable disease. Although
                                                                                                                          HEALTHCARE’S CLIMATE                                       Sustainable procurement practices (by which au-
                                                                 the provision of healthcare for all is a human right                                                                thorities, including hospitals and health systems,
       Climatic variability has long had an impact on
                                                                 that requires nations to provide care to all citizens,   IMPACTS                                                    address green and social/ethical considerations
       global migration. Throughout history people have
                                                                 legal status is the main barrier to a migrant’s ac-      It is now widely recognised that the excessive burn-       in all purchasing practices throughout their sup-
       abandoned their homes in times of deteriorating
                                                                 cess to health services.                                 ing of fossil fuels across all sectors is a major con-     ply chain)25 are becoming more commonplace in
       environmental conditions. Whether from sudden
                                                                                                                          tributor to the accelerated rate of global warming         European hospitals, and expectations for health
       natural disasters, such as floods and landslides, or      In light of the worsening adverse effects of climate
                                                                                                                          we are experiencing today, and the health sector is        systems to be held accountable for the GHG emis-
       disasters that cause more gradual environmental           change being felt all across the globe, climate in-
                                                                                                                          a major emitter of greenhouse gasses. For exam-            sions of all activities throughout their value chains
       degradation (such as droughts and sea level rise),        duced migration is bound to continue and poten-
                                                                                                                          ple, in 2012, the total carbon footprint of England’s      are growing.
       climate change undoubtedly contributes to the             tially accelerate. For the sake of public health, it
                                                                                                                          public healthcare sector was 32 million tonnes of
       mass displacement of people.                              is urgent that all citizens, including undocument-                                                                  Pharmaceuticals
                                                                                                                          carbon dioxide equivalents (MtCO2e) (CO2 equiva-
                                                                 ed migrants, receive necessary medical attention.
       Migrants are highly vulnerable to both communica-                                                                  lent refers to a combination of harmful greenhouse         Hospitals are by far the largest contributors of CO2e
                                                                 Health systems must enhance their ability to de-
       ble and non-communicable diseases during their                                                                     gases, not just carbon dioxide), accounting for 38%        emissions within the health sector. The second
                                                                 liver “migrant-sensitive” care by guaranteeing the
       journey and adaptation to a new location. They                                                                     of public sector emissions in England.23 This serves       largest polluter, providing goods for the health sec-
                                                                 ability to support a greater capacity of patients, by
       often experience socioeconomic inequalities and                                                                    to illustrate how the healthcare sector is contrib-        tor, is the pharmaceutical industry. For example,
                                                                 including cultural and interpretation services, and
       related stress that can lead to poor daily habits,                                                                 uting an enormous amount of harmful emissions,             in the case of the National Health Service (NHS)
                                                                 by pushing to remove the social, legal, and eco-
       such as unhealthy diet and physical inactivity, use                                                                which in turn undermines the health of the same            in England, the entire life cycle of pharmaceuticals
                                                                 nomic barriers that lead migrants to refrain from
       of tobacco, and harmful consumption of alcohol.                                                                    population the sector is meant to heal. The scope          accounts for 22% of the their total CO2 emissions.
                                                                 seeking medical care.22
       Many migrants avoid seeking medical attention                                                                      and size of health systems varies across all regions       The CO2-intensive activities of the pharmaceutical
       due to fear of police arrest, language barriers, ina-                                                              of Europe. Nevertheless, regardless of their size,         industry include water use, energy consumption in
       bility to pay for treatment or, ultimately, fear of de-                                                            health systems and all of their activities and servic-     buildings, manufacturing processes, and disposal
       portation. Avoiding medical attention not only puts                                                                es have an important influence on their communi-           of waste.
       migrant`s health and potentially lives at risk, it can                                                             ties and their surrounding environments.
       also become a great threat to their communities if                                                                                                                            While the majority of pharmaceutical pollution takes
                                                                                                                          In the following section, we describe some of the          place outside the hospital setting, expectations for
                                                                                                                          health sector’s most intensive greenhouse gas              health systems to take responsibility for the full
                                                                                                                          (GHG) producing activities.                                carbon footprint of their value chains is growing.
                                                                                                                                                                                     There is also growing pressure for the pharmaceu-
                                                                                                                          Procurement                                                tical industry to adopt more sustainable strategies
                                                                                                                                                                                     to reduce their carbon emissions and to clean up
                                                                                                                          The EU healthcare sector, which provides care
                                                                                                                                                                                     their production sites. Due to resource scarcities,
                                                                                                                          across the 28 Member States, is a major public
                                                                                                                                                                                     the strengthening of environmental regulations,
                                                                                                                          purchaser of goods and services. In the process of
                                                                                                                                                                                     and concerns about reputation, companies are be-
                                                                                                                          treating patients, the healthcare sector consumes
                                                                                                                                                                                     ing driven to explore solutions. The health sector
                                                                                                                          significant amounts of energy, water, building ma-
                                                                                                                                                                                     can also contribute by ensuring sound prescription
                                                                                                                          terials, food, pharmaceuticals, and medical de-
                                                                                                                                                                                     and drug management practices to minimise waste
                                                                                                                          vices, and produces vast amounts of waste. The
                                                                                                                                                                                     are in place.
                                                                                                                          processes, supply chains, and end uses involved in
                                                                                                                          this consumption create health risks and can have
                                                                                                                          serious environmental impacts.                             Energy and buildings
                                                                                                                          The majority of the healthcare sector’s CO2e emis-         A major contributor of GHG emissions within health
                                                                                                                          sions come from the procurement of goods and               systems is the high-energy consumption of build-
                                                                                                                          services.24 While hospitals might be working to            ings and medical procedures. Hospitals need to
                                                                                                                          cure diseases at home, the carbon-intensive pro-           have an uninterrupted power supply for heating,
                                                                                                                          duction of medical products and pharmaceuticals            cooling, lighting, ventilation, medical treatments
                                                                                                                          is often simultaneously polluting the air, water, and      and devices, cleaning, and much more. Health sys-
                                                                                                                          soil of developing nations across the globe, while         tems also rely heavily on the use of secondary gen-
                                                                                                                          also contributing to the health impacts of climate         eration capacity for emergency uses.

       A Health and Environment Alliance (HEAL)                  88 million tonnes of food each year.28                    ment to reduce health risks linked to climate             vices. The healthcare sector must strengthen early
       expert assessment found the health impacts                                                                          change (please see the Climate Policy chapter for         warning and disaster response systems and build
                                                                 Apart from providing care to patients, health sys-
       caused by coal power plants in the EU cost                                                                          more information about the Paris Agreement). This         climate resilient infrastructure. Health systems
                                                                 tems are also significant providers of food services.
       between €15.5 to €42.8 billion per year in                                                                          conference set a health action agenda for the im-         must also be prepared to support a greater influx of
                                                                 Hospitals offer their staff and patients at least three
       total health costs, and cause approximately                                                                         plementation of the Paris Agreement, and included         patients. It is vital that health professionals receive
                                                                 meals a day, and in some EU nations the average
       18,200 premature deaths each year.26 With                                                                           specific recommendations for the healthcare sec-          the necessary training to act as a protective force
                                                                 number of meals per day is even higher. Therefore,
       astounding numbers such as these, health systems                                                                    tor, arguing that health systems can “lead by ex-         in emergency situations.
                                                                 the food that hospitals choose to procure and the
       have the moral obligation to make a full transition                                                                 ample, advancing models of low-carbon health care
                                                                 way it is produced, processed, and transported can
       from the use of dirty energy to clean, renewable                                                                    that improve access to health care services, reduce
                                                                 have a profound effect on the environment. Also,
                                                                                                                           occupational and environmental health risks and
       energy sources that can help protect public health
                                                                 taking into account the health benefits of providing                                                                Health systems must play a strong leadership role
       from climate change. Health systems can also re-                                                                    save energy costs.”30 Similarly, the 2015 Lancet
                                                                 healthy, organic, and sustainable food, health sys-                                                                 in advocating for health, in order to encourage and
       duce their carbon footprint by reducing energy con-                                                                 Commission on Health and Climate argued that by
                                                                 tems have the opportunity to both reduce carbon                                                                     engage the support of different sectors and mem-
       sumption through a series of efficiency measures.                                                                   moving toward low-carbon health systems, health-
                                                                 emissions from food and improve human health.                                                                       bers of the government, industry, and civil society
       Combined, greater efficiency and the transition to                                                                  care can mitigate its own climate impact, become
       renewable energy can also help to improve outdoor                                                                   more resilient to the impacts of climate change,          in the implementation of effective adaptation and
       air quality, which directly benefits human health by      Waste                                                     and lead by example.31                                    mitigation policies. This influence can take many
       reducing harmful chemicals emitted from fossil fuel                                                                                                                           forms. For example, health systems and profes-
                                                                 Health facilities create significant amounts of dai-
       combustion and electricity generation.                                                                                                                                        sionals, in their role as health stewards, can pro-
                                                                 ly waste of all types of materials, ranging from          Mitigation                                                vide evidence-based information for the establish-
                                                                 recyclable materials such as paper, plastics, and
                                                                                                                           As the sector that exists to promote and maintain         ment of norms and standards for the transition
       Transportation                                            metals, to compost materials, electronics, chemi-
                                                                                                                           human health and well-being, the health sector has        from fossil fuels to clean, renewable energy, and
                                                                 cals, pharmaceuticals, and other waste considered
                                                                                                                           the challenge, opportunity, and moral obligation          the green and ethical procurement of goods and
       The burning of gasoline and diesel fuels used to          hazardous. Many of these materials must undergo
                                                                                                                           to lead by example and act on climate change by           services that can be legally enforced, locally, na-
       power motor vehicles produces large amounts of            special treatment and disposal methods, in order
                                                                                                                           reducing its own carbon footprint. The health sec-        tionally, and internationally.
       CO2 and also releases traces of methane (CH4) and         to reduce harmful impacts on humans and the en-
                                                                                                                           tor not only provides healthcare, it is also a major
       nitrous oxide (N2O), which are even more potent           vironment.                                                                                                          Health professionals have expertise, resources,
                                                                                                                           employer, landowner, purchaser of goods, and a
       and harmful greenhouse gasses. Hospitals and oth-                                                                                                                             and knowledge; they are often sought out for a
                                                                 Waste that is classified as hazardous is a minor          provider of energy-consuming services, such as 24-
       er health facilities rely on transportation systems                                                                                                                           reliable opinion regarding the health effects of cli-
                                                                 part of healthcare waste. Globally, materials that        hour hospital care and transportation. Across all of
       to transport patients, families, staff, supplies, and                                                                                                                         mate change. Therefore, their participation in ad-
                                                                 are classified as similar to domestic waste make          their activities, health systems have the opportuni-
       waste. Therefore, the careful evaluation and rede-                                                                                                                            vocacy activities adds immense value to the fight
                                                                 up between 75% to 90% of hospital waste.29 While          ty to adopt and engage in sustainable practices that
       sign of hospital transportation systems and the                                                                                                                               for adaptive and preventive action at both policy
                                                                 some of these materials get recycled, much of the         are beneficial to the environment, reduce health
       transition to less polluting vehicle fleets can have                                                                                                                          and community level. From providing public edu-
                                                                 waste is disposed by landfilling or incineration.         risks, and save money. To honour its commitment
       significant climate change mitigation benefits.27                                                                                                                             cation inside health clinics, to participating in ed-
                                                                                                                           to the Hippocratic Oath – First, do no harm – the
                                                                 Incineration of healthcare waste produces main-                                                                     ucational programmes on topics such as personal
                                                                                                                           health sector should take on the responsibility of
       Food                                                      ly gaseous emissions, including steam, carbon             moving away from fossil fuels, so that its practic-
                                                                                                                                                                                     hygiene and nutritional advice, to publicising the
                                                                 dioxide, nitrogen oxides, a range of volatile sub-                                                                  health risks of climate change for political leverage,
       Emissions from food consumption take place at                                                                       es and services, the products it consumes, and the
                                                                 stances (e.g. metals, halogenic acids, products of                                                                  health professionals have great capacity to spread
       all stages of the food supply chain: agriculture,                                                                   buildings it operates, do not harm human health
                                                                 incomplete combustion) and particulate matter,                                                                      knowledge and awareness across communities,
       manufacturing, transportation, consumption, and                                                                     and the environment.
                                                                 plus solid residues in the form of ashes.30 All of                                                                  and to influence the political momentum of climate
       disposal. It is estimated that agriculture in Europe                                                                                                                          change policies.
                                                                 these harmful gases contribute to air pollution,
       accounts for around 15% of GHG emissions from all
                                                                 increasing the burden of disease.                         Resilience
       EU food production. In agriculture, GHG emissions                                                                                                                             It is under these three pillars – mitigation, resil-
                                                                                                                           Healthcare infrastructure and services need to
       result from the cultivation of certain crops, from                                                                                                                            ience, and leadership – that we have developed
                                                                                                                           become increasingly resilient to all possible cli-
       livestock excretion, and from the use of petrole-         EXPECTATIONS FOR THE                                      mate-related conditions, such as extremes of heat,
                                                                                                                                                                                     case studies from European hospitals (including
       um-based resources such as fertilisers, pesticides,                                                                                                                           one from Morocco) that are addressing climate
       herbicides, and fuel used for farm operations, pro-
                                                                 HEALTHCARE SECTOR                                         cold, droughts, and storms. There are many differ-        change. While there is still much work to be done
                                                                                                                           ent measures that must be implemented in order
       cesses, and transportation. Food waste is a major                                                                                                                             to significantly reduce the health sector’s climate
                                                                 In July 2016, participants attending the World            to become more resilient. Vaccination programmes
       avoidable contributor to GHG emissions; when                                                                                                                                  impacts, many lessons can be learned from the
                                                                 Health Organization (WHO)’s Second Global Con-            and the monitoring of sanitation, waste, and wa-
       food is wasted, all of the resources used in it’s pro-                                                                                                                        following case studies, which provide a wide and
                                                                 ference on Health and Climate proposed key ac-            ter are necessary to build resilience to infectious
       duction and supply are also wasted. According to                                                                                                                              diverse set of strategies to reduce healthcare’s
                                                                 tions for the implementation of the Paris Agree-          diseases and strengthen environmental health ser-
       the European Commission, the EU wastes around                                                                                                                                 climate footprint.
                 FOR HEALTHCARE
                                    REDUCE CLIMATE

       WHAT EUROPEAN                                                                                FRANCE: PAGE 16
                                                                                                    Assistance Publique -
                                                                                                    Hôpitaux de Paris
                                                                                                                                         FRANCE: PAGE 18
                                                                                                                                         Centre Hospitalier de Niort

                                                                                                    GERMANY: PAGE 20                     GERMANY: PAGE 22                      GERMANY: PAGE 24
                                                                                                    Bund Label                           KLIK Project                          Klinikum Neukölln

                                                                                                    MOROCCO: PAGE 26                     SWEDEN: PAGE 30
                                                                                                    Centre Hospitalier Universitaire     Region Skåne
                                                                                                    Mohammed VI of Marrakesh

       Klinikum Neukölln, Berlin                                                                    UK: PAGE 34                           UK: PAGE 36                          UK: PAGE 38
                                                                                                    Operation TLC                         Sussex Community NHS                 Sustainable Development Unit
                                                                                                                                          Foundation Trust

                                                                        At the event, hospitals and other public services,      ing plan in each hospital of the APHP network. The
              ASSISTANCE PUBLIQUE                                -      such as the city postal service, present their pro-     aim is to promote environmentally-friendly means
              HÔPITAUX DE PARIS                                         grammes of active mobility to inspire sustainable       of transportation, and to replace each vehicle with
                                                                        travel across the city. The second annual confer-       an electric or hybrid option. APHP also encourages
                                                                        ence took place on 23rd September 2016 in Paris.        employees to reduce the use of personal vehicles
              ABOUT                                                     At the European level, APHP participates in the Eu-
                                                                                                                                through the use of Velib (a network of shared bi-
                                                                                                                                cycles)33 and Autolib (an electric car-sharing pro-
              Assistance Publique - Hôpitaux de Paris (APHP) is         ropean research project STREAMER,32 which aims
                                                                                                                                gramme),34 and has also put in place a carpooling
              the largest hospital group in Europe, delivering          to curb energy consumption and GHG emissions of
                                                                                                                                system for all its employees.
              medical care, research, and education across the          new and renovated health facilities by 50% with-
              region of Paris at its 39 hospitals. APHP has more        in 10 years. Using building information modelling
              than 22,000 beds, including 350 in intensive care         technologies, the project sets out to develop inno-     Building
              facilities. On a yearly basis, APHP medical teams         vative designs for sustainable buildings. Current-      As part of its efforts to reduce its carbon emis-
              offer advanced treatments in all medical disci-           ly, the pilot project is developing models for the      sions in its hospitals, APHP has also partnered
              plines to 7 million patients – including 5 million        Georges Pompidou Hospital in Paris.                     with the French Environment and Energy Manage-
              medical consultations and 1.5 million hospital-                                                                   ment Agency (Agence de l’Environnement et de la
                                                                        APHP is playing a key leadership role in promoting
              isations (roughly 10% of all hospitalisations in                                                                  Maîtrise de l’Énergie, ADEME). It is working to im-
                                                                        environmental policies within the Parisian health
              France). With 95,000 health professionals, includ-                                                                plement the High Quality Environmental standard
                                                                        sector. In light of the increasing awareness of the
              ing doctors, researchers, paramedics, adminis-                                                                    (a standard for green buildings in France), and re-
                                                                        impact of climate change on human health, APHP
              trative staff and workers, the APHP is the largest                                                                duce its energy consumption by 20% by 2019, com-
                                                                        acknowledges its responsibility to develop initi-
              employer in the Paris region.                                                                                     pared to its 2013 levels. ADEME provides financial
                                                                        atives that reduce GHG emissions across all of
                                                                        its activities (including those emanating from its      assistance for projects, work review services, and
                                                                        supply chain) in order to protect the health of its     recommendations for specialised consulting organ-
                                                                        patients. Through increasing its efforts to address     isations.
                                                                        climate change, APHP creates momentum through

                                                                        its relationship with the French Federation of Hos-
                                                                        pitals to influence national policies that will pave    Institut E3M: Institute of Endocrinology, Metabolic Diseases, and Internal Medicine, Paris, France
                                                                        the way for a more sustainable healthcare sector
              LEADERSHIP                                                in France.
              Given the size of their network, APHP understands
              the influence it can have in swaying public health        To this end, APHP is developing more sustaina-
              and climate change policies across the Paris region       ble policies for many of its polluting activities. In
              and is constantly working towards the implementa-         waste management, it is working towards more
              tion of them. From setting up research projects on        systematic sorting of 18 different kinds of waste,
              energy management with the City of Paris, to de-          and seeking to reduce packaging. APHP has also
              veloping new techniques on renewable energy con-          established a working group composed of medical
              sumption, APHP seeks to create awareness about            professionals to raise awareness and find ways to
              sustainable development and climate change is-            minimise carbon emissions from the procurement
              sues among health professionals and concerned             of pharmaceuticals. APHP expects to implement
              government stakeholders.                                  sustainable development policies across its many
                                                                        activities, and to develop solid programmes and
              In partnership with the Centre Hospitalier Universi-      strategies for the reduction of GHG emissions in
              taire de Bordeaux and Centre Hospitalier Universi-        years to come.
              taire de Rennes, APHP initiated the Mobility Day of
              University Hospitals in France, aimed at gathering
              professionals working on sustainable development
              in the healthcare sector to exchange and promote          APHP seeks to facilitate the use of alternative
              innovative sustainable mobility practices. This has       means of transport for its employees in order to op-
              become an important day for strengthening the             timise intra-hospital travel and to reduce its carbon
              health sector’s collaboration with the City of Paris.     footprint. It has put in place a travel and commut-

                                                                        parallel to working to meet this target, the hospi-
              CENTRE HOSPITALIER DE                                     tal seeks to solve parking problems that the staff         Positive energy buildings
              NIORT                                                     encounter. In March 2013, the hospital launched
                                                                                                                                   A significant contribution to the sustainable development programme at the Centre Hospitalier de Niort was the de-
                                                                        its travel and parking plan, aimed at reducing un-
                                                                                                                                   cision to commission a positive energy building. Positive energy buildings generate their own energy for consumption
                                                                        necessary travel and solo car journeys. It has also
                                                                                                                                   but also create surplus energy that can be used for other purposes (such as running electric vehicles or providing
              ABOUT                                                     sought to promote environmentally-friendly means
                                                                                                                                   power to the grid). Construction of such a building began in February 2014, and was completed in October 2015.
                                                                        of transportation, such as carpooling, and by grad-
              Centre Hospitalier de Niort is the largest public
                                                                        ually replacing hospital vehicles with electric or hy-     Located 30km from Niort, in the city of Parthenay, this building was built to reduce the amount of patients travelling
              health facility in the Deux-Sèvres region in West-
                                                                        brid options.                                              to Niort for consultations. The building is a day hospital and houses consultation offices, care facilities, and activity
              ern France.35 The hospital is made up of one gen-
                                                                                                                                   rooms for patients.
              eral hospital and a psychiatric unit, has 1,295
              beds, and employs more than 3,300 health pro-             Waste management                                           With the first positive energy building in the Poitou-Charentes region, the hospital succeeds in producing an amount
              fessionals.                                               Overall, the hospital produces about 1,325 tonnes          of renewable energy greater than the energy consumption of the building. In 2013, the planned hospital building won
                                                                        of waste per year (see Table 1). The hospital sep-         an award in a project launched by the region and Agence de l’Environnement et de la Maîtrise de l’Energie, ADEME,
                                                                        arates oils, paper, cardboard, green waste, toxic          in the National Research and Experimentation Programme on Energy in Buildings.
                                                                        waste from laboratories, common industrial waste,
              MITIGATION                                                scrap metal, computer waste, batteries, neon
              The hospital emits 44,165 tonnes of CO2e per year
                                                                                                                                   How is this achieved?
                                                                        bulbs, wood, and rubber. The current waste poli-
              from its collective activities. In order to reduce car-   cies encourage the sorting of waste in order to min-       Environmental concerns were considered during the project design in order to incorporate them into the construc-
              bon emissions, the hospital has implemented pol-          imise the quantities of materials going to landfill or     tion of the building. The hospital was built to maximise natural light and to reduce primary energy consumption. The
              icies in line with the United Nation’s Agenda 21,         incineration, and instead re-use or recycle them as        facade is covered by wood certified for solar protection. Safe linoleum materials were used, as well as paints without
              which is a non-binding, comprehensive plan for            much as possible.                                          any volatile organic compounds. A new boiler installed in September 2014 is fuelled with wooden pellets and gener-
              sustainable development.                                                                                             ates 3.1 MW of power. There is double-flux ventilation throughout the entire building, which helps heat and cool the
                                                                        To encourage recycling, Centre Hospitalier de Niort        building more quickly.
              Centre Hospitalier de Niort was the first public          has developed an awareness campaign for person-
              health institution in the region of Poitou-Cha-                                                                      In 2015, the hospital also installed 228 m2 of photovoltaic panels on its rooftop, producing 39,500 kWh annually

                                                                        nel in order to educate them about sorting waste.
              rentes to launch such a sustainable development           Educating the workforce is challenging, but is the         and offsetting the building’s energy consumption. These panels produce surplus electricity that is then sold to the
              approach in 2010. To this end, three committees           most important element to achieve effective imple-         general electricity grid. The total energy consumption of the building is 53,046 kWh, across a surface area of 1,596
              were established: a steering committee to devel-          mentation of waste management separation sys-              m2 (33 kWh/m2).
              op a sustainable development strategy and action          tems. The hospital has started auditing their var-
              plans, a partnership committee, and a technical           ious departments, and has established treatment
              committee to monitor the carbon footprint. More-          systems with external waste collectors for specific
              over, every employee was invited to participate in        materials, such as cardboard and plastic for recy-
              working groups to develop strategies for imple-           cling. There are over 30 sorting streams to promote      TABLE 2: CO2 EMISSIONS OF GENERAL HOSPITAL
              mentation of the sustainable development policies         the recycling of more waste and to help find ways        FOR SELECTED YEARS
              for the hospital.                                         of processing specific materials. Vegetable waste
                                                                                                                                  Year           Fuel    Emissions tCO2     % Reduction
              The hospital set a goal to reduce CO2 emissions by        is treated in industrial composting units that belong
              15% by 2020. In 2014, Centre Hospitalier de Niort         to the city of Niort.
                                                                                                                                  2010            Gas              5,475
              replaced its gas heater with a new system fuelled
              by wood. This change helped Niort to exceed its tar-                                                                2014     Gas/wood                4,204             -23%
                                                                        TABLE 1: ANNUAL WASTE PRODUCTION
              get, having reduced emissions by 25% compared to
                                                                                                                                  2015          Wood                 577             -89%
              2010 levels (see Table 2). As a result, the target was      Type of waste                Amount (in tonnes)
              reviewed in 2010 and 2014, and it will be reviewed
              again in 2018.                                              Healthcare waste                              229

                                                                          Household waste                               750
              Transportation                                              Paper & cardboard                             120
              Implementing effective travel policies is a key ob-
              jective for Niort Hospital. A 20% reduction target          Vegetable waste                                99
              in emissions from transportation has been set. In
                                                                                                                                                                                               The positive energy building at Centre Hospitalier de Niort, Parthenay

               BUND FÜR UMWELT UND                                       Today, 45 German hospitals have received the                 The “Energy Saving Hospital” Label - Case studies
                                                                         BUND label. Overall, 65,000 tonnes of CO2 emis-
               NATURSCHUTZ DEUTSCHLAND                                   sions per year have been saved. This translates              EVANGELISCHE ELISABETH KLINIK in Berlin is one of six hospitals that belong to the hospital group
                                                                                                                                      Paul Gerhardt Diakonie. It is a small hospital with 150 beds, and receives 21,400 patients each year. Based
               – THE BUND “ENERGY SAVING                                 into the reduction of 22,000 MWh electricity per
                                                                         year, and 140,000 MWh of heat per year. Through              on 2014 data, this hospital consumes about 5,600 MWh energy, and emits around 1,800 tonnes of CO2 each
               HOSPITAL” LABEL                                                                                                        year.
                                                                         the implementation of BUND label criteria, a single
                                                                         hospital could save at least €100,000. One hospital          Through the implementation of energy efficiency policies for electricity, heat, and water consumption, Elis-
               LEADERSHIP                                                in Berlin saved up to €2.1 million per year in energy        abeth Klinik has achieved a significant reduction in energy use. In 2016, the hospital paid €250,000 less in
               The “Energy Saving Hospital” label36 was estab-           costs by implementing BUND’s energy saving solu-             energy costs than in 2010.
               lished in 2001 by BUND (Bund für Umwelt und               tions. More than €20 million per year has been
               Naturschutz Berlin e.V., also known as Friends of         saved by all 45 hospitals bearing the BUND label.            Reduced CO2 emissions:
               the Earth Berlin), a German NGO active in environ-        Participating hospitals can also take advantage of
                                                                                                                                      •   2000 to 2004:
               mental policy. It is awarded to German hospitals          a growing network where they can exchange views
                                                                                                                                          CO2 reduction of approximately 30% (c. 615 tonnes per year)
               that have achieved outstanding results and en-            and experience, and learn from other success sto-
               gagement in the fields of energy saving and climate       ries to further improve their hospital’s energy effi-
                                                                                                                                      •   2004 to 2009:
               protection.                                               ciency.
                                                                                                                                          CO2 reduction of approximately 8.2% (c. 141 tonnes per year)

                                                                                                                                      •   2009 to 2015:
                                                                                                                                          CO2 reduction of approximately 7.3% (c. 142 tonnes per year)

                                                                                                                                      While the hospital made significant reductions in the first award period between 2000-2004, it becomes much
                                                                                                                                      more of a challenge to achieve further CO2 reductions in the second and third award periods on top of savings
                                                                                                                                      already achieved.

               The label is initially granted for five years to hospi-

               tals that:
                                                                                                                                      LWL LIPPSTADT is a hospital of the Regional authority of Westphalia Lippe. The hospital has 862 beds and
               a. implement an energy management plan (in-
                                                                                                                                      cares for 2,370 psychiatric patients per year. Based on data from 2015, the hospital consumes 23,470 MWh
               cluding designating an energy officer, providing for
                                                                                                                                      energy and emits 5,140 tonnes of CO2 each year.
               collection and validation of data and costs, regular
               inspection of facilities and equipment, and imple-                                                                     Through the implementation of energy efficiency policies for electricity, heat, and water consumption,
               menting a list of recommendations) and:                                                                                Lippstadt hospital has made significant reductions in their energy use.

               b. demonstrate compliance with at least two of                                                                         Reduced CO2 emissions:
               the following criteria:
                                                                                                                                      •   2000 to 2005:
               àà Reduction of CO2 emissions by more than
                                                                                                                                          CO2 reduction of approximately 40% (c. 7,400 tonnes per year)
                  25% in the last five years,
                                                                                                                                      •   2005 to 2010:
               àà Continuous reduction of energy consump-
                                                                                                                                          CO2 reduction of approximately 10.9% (c. 872 tonnes per year)
                  tion compared to the specifications of the
                  VDI-guideline 3807,37                                                                                               •   2010 to 2015:
                  or                                                                                                                      CO2 reduction of approximately 14.6% (c. 929 tonnes per year)
               àà Long term optimisation of energy consump-
                  tion in new buildings.                                                                                              Between 2010 and 2015, it has saved a total of €170,000 though energy saving strategies.

               After the initial five years, the label can only be ex-
               tended after an external audit identifies continuous
               improvements and compliance with the criteria,
               and the adoption of a further minimum target of           Top image: 2013 BUND Label ceremony for Franziskus Clinic,
               5% reduction in energy consumption over the fol-          Berlin & Havelhöhe Clinic, Berlin
               lowing five years.                                        Bottom image: Clinic Mühlacker, Germany

                                                                         Of the 51 hospitals that participated in the KLIK
               BUND’S KLIK PROJECT -                                     project, 34 were public, 14 were charities, and 3
               “DEVELOPING CLIMATE                                       three were private hospitals.

               MANAGERS IN HOSPITALS”                                    The success of the energy saving solutions of the
                                                                         KLIK project was very much determined by the
                                                                         commitment of the climate managers, and suc-
               LEADERSHIP                                                cessful implementation was reliant on strong lead-
               Following on from the success of the label project,       ership. For this reason, climate managers needed
               BUND also led a project to help hospitals to devel-       to fulfil some important criteria, such as being an-
               op climate strategies. The initiative is called KLIK38    chored in internal hospital structures. This could
               (Klimamanager für Kliniken) and exists to devel-          be an administrative role, or a technical or quality
               op and train employees in hospitals to be climate         management position, but the leader required an
               managers. Funded by the National Climate Protec-          affinity for climate protection issues, and also the
               tion Initiative (Nationale Klimaschutzinitiative), the    authority to make decisions, changing some rules
               KLIK project began in 2014, and ran until the end         or procedures if necessary.
               of 2016. The focus of the project was to increase
               energy efficiency in hospitals through low and no-        Of the hospital participants in the KLIK project, 21
               cost measures.                                            climate managers were technical leaders, 19 were
                                                                         technical qualified employees, three were adminis-
               Germany has 3,183 hospitals, which collective-            tration managers, and three held other positions.
               ly consume 12.5 million MWh of heating and 3.9
               million MWh of electricity, accounting for a to-          Within three years, all participating hospitals re-
               tal spending of approximately €1.7 billion each           duced their CO2 emissions by approximately
               year. Numerous opportunities exist to save en-            34,500 tonnes collectively. At the same time, en-
                                                                         ergy costs decreased by €9 million. Measures were

               ergy – and costs – given the diversity of energy
               use in healthcare settings. While saving money            carried out in a number of areas such as: ventila-
               is an obvious incentive, hospitals also have the          tion, cooling, heating, lighting, and consumer be-
               opportunity to be leaders in energy efficiency            haviour. The greatest reduction of CO2 emissions
               in the public sector. This is what KLIK set out to        were achieved in ventilation – approximately 3,000
               do: mobilise climate managers across the Ger-             tonnes per year.
               man health sector to guide their institutions to-         An online guidebook with tips and results is availa-
               wards more efficient and energy saving systems.           ble on the KLIK website (in German).39 From 2017,
                                                                         other (German) hospitals will be able to join the
               The specific goals of the KLIK project were to:           network40 which will continue to host seminars and
               àà maximise the energy saving potential of                workshops.
               àà train and qualify 50 climate managers in the
                  German health sector;
               àà establish an internal network of climate lead-
                  ers in every participating hospital;
               àà publish an online guidebook for hospitals;
               àà create a database with examples of best
                  practice; and
               àà reduce CO2 emissions by approximately
                  30,000 tonnes, mostly through non- and
                  low-investment measures. This meant reduc-
                  ing energy costs by approximately 6% to 10%
                  per clinic.

                                                                                                                                                                         Solar panels on the exterior of Clinic Mühlacker, Germany

               VIVANTES KLINIKUM                                         Low investment measures                                    Neukölln carries out daily checks and maintenance           of approximately 2% to 3% per year.
                                                                                                                                    of equipment consuming electrical energy. For ex-
               NEUKÖLLN                                                  Klinikum Neukölln has implemented a variety of dif-
                                                                                                                                    ample, it is critical to check that fans are running at
                                                                                                                                                                                                Since 2003, Klinikum Neukölln has prevented over
                                                                         ferent low investment measures to improve energy                                                                       100,000 tonnes of CO2e emissions, saved 400,000
                                                                                                                                    full load, and to make sure that ventilation systems
                                                                         efficiency, many of which are simple measures to                                                                       MWh of energy, and approximately €23 million in
                                                                                                                                    are clean in order to reduce power consumption.
                                                                         guide behaviour change towards more conscious                                                                          energy costs. In 2014, Neukölln consumed 60% less
               ABOUT                                                     energy use. For example, by attaching thermostat-                                                                      energy than in their baseline year of 2003.
               Klinikum Neukölln is one of the nine hospitals that       ic valves to radiators, the hospital is able to better     High investment measures
               make up the Vivantes hospital network. Located            monitor and control the temperature levels of the          Higher investments can contribute to much great-
               in central Berlin, it is an acute hospital with mul-      building. These valves have locking devices which                                                                      RESILIENCE
                                                                                                                                    er energy savings. In 2010, the Klinikum Neukölln
               tiple specialist centres, covering traumatology,          allow radiators to be set to a specific level, which       modernised its refrigeration equipment, replacing           Klinikum Neukölln has implemented particular in-
               lung cancer and thorax conditions, gastroenter-           is very important when an increase in temperature          the old steam-heated absorption refrigeration sys-          frastructure projects to support healthcare in the
               ology, and neurology, amongst others. The clinic          of 1°C means a 15% increase in heating costs. At
               has 1,288 hospital beds, and cares for 125,000            first, hospital staff were unhappy with lower tem-
               patients each year. With a large workforce of             peratures in the buildings and this resulted in valves
               400 doctors and 750 nurses, Neukölln also has             being disassembled. However, through capacity
               the largest emergency department in Berlin, with          building and awareness raising, the new system
               77,000 cases per year. In order to provide for this       was soon accepted by all.
               wide scope of specialised and emergency care, the
                                                                         The hospital also replaced all permanent lighting
               hospital has a high energy demand. Klinikum Neu-
                                                                         with more efficient fluorescent tubes. Klinikum
               kölln has taken it upon itself to become a leader in
                                                                         Neukölln has approximately 10,000 lights through-
               energy efficiency.
                                                                         out its buildings, creating great opportunity for easy
                                                                         energy saving. The costs of this measure were paid
                                                                         off in only eight months.

                                                                         Another strategy was to optimise lighting by au-
                                                                         tomatically cutting off lights after three minutes
                                                                         in areas with low transit, such as staircases, and         Aerial view of Klinikum Neukölln                            Solar panels at Klinikum Neukölln
                                                                         throughout the hospital during sleeping hours.
               MITIGATION                                                Along with signs on light switches to educate pa-          tem with three new screw compressors powered                case of emergency situations. The main parts of the
               Energy efficiency                                         tients and staff to turn off unnecessary lights, these     by electricity. This replacement required an invest-        hospital are equipped with autonomous electricity,
                                                                         ideas have proven to be valuable methods of con-           ment of approximately €4 to €5 million, but this            water, and heating supply systems. The emergen-
               In 2003, energy saving goals were set in accord-                                                                                                                                 cy generators are able to supply the hospital with
                                                                         serving energy.                                            new system has helped Neukölln reduce the costs
               ance with the BUND label for “Energy Saving Hospi-                                                                                                                               electricity for up to five days. The boilers for central
                                                                                                                                    of gas supply by €400,000 per year, and reduce an-
               tals” (see pages 20-21). In the past, energy conser-      Another energy-saving approach came from                                                                               heating are normally fuelled by city gas, but in emer-
                                                                                                                                    nual power consumption by approximately 2 million
               vation was primarily achieved by the replacement          merely adjusting the air conditioning units during                                                                     gency situations, they can be fuelled by oil reserves
               of energy-inefficient facilities and devices. Today,      low-transit hours, and shutting them down in the                                                                       kept at the hospital.
               Klinikum Neukölln is also attempting to improve           operating suites at night. Neukölln uses residual          The whole Vivantes network has switched to green
               energy conservation through construction projects.        heat from sludge and blowdown water from boil-             electricity. At Klinikum Neukölln, a photovoltaic sys-      To cope with extreme heat events, the hospital
               The hospital is currently working on a reconstruc-        ers for heating, while also making the most of re-         tem was installed on the roof. The system achieves          built its air conditioning unit with a higher capacity
               tion strategy where a key objective is the integra-       sidual heat by using recovery systems in midsum-           an output of 50.54 kilowatts peak (kWp). It produc-         than is typical. This system has sufficient reserves
               tion of energy-efficient technologies in a long-term      mer to power air conditioning.                             es 45.5 MWh of electricity and saves 30 tonnes of           to cool the hospital buildings, including medical
               strategy to reduce GHG emissions.                                                                                    CO2 per year. Excess electricity generated is fed           functional areas and intensive care units, in periods
                                                                         In order to save energy through reduced water con-                                                                     of extreme heat. The technical system is manufac-
                                                                                                                                    into the public electricity network to be used for the
               In 2003, when Klinikum Neukölln began its ener-           sumption, the clinic installed 200 waterless urinals                                                                   tured for outdoor temperatures up to 40oC.
                                                                                                                                    energy demand of Berlin. Through all of these poli-
               gy saving efforts, the hospital consumed 103,092          for staff and visitors (not for patients). Additionally,
                                                                                                                                    cies and improvements, Klinikum Neukölln has be-
               MWh of energy, and produced 31,227 t CO2 emis-            the replacement of older water circulation pumps                                                                       Taking into account possible situations of water
                                                                                                                                    come “the energy saving hospital” of the Vivantes
               sions. In 2015, after 12 years of implementing en-        with highly efficient pumps has been a significant                                                                     scarcity or contamination, Klinikum Neukölln has
                                                                                                                                    network. Considering the development of energy
               ergy efficiency solutions, the hospital consumed          contributor to the clinic’s increased water and en-                                                                    its own water tower and deep well to provide a safe
                                                                                                                                    markets and the value of energy resources, there
               52,057 MWh of energy and produced 17,927 t CO2            ergy efficiency.                                                                                                       supply of water.
                                                                                                                                    has been a saving in the hospital’s energy demand
               - a 43% reduction in emissions.
                                                                         Maintenance is crucial to maximise efficiency, and
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