lable at ScienceDirect

Public Health 123 (2009) 765–770

Contents lists avai

Public Health

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

Original Research

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

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

a r t i c l e i n f o

Article history:Received 6 February 2009Received in revised form28 September 2009Accepted 5 October 2009

Keywords:SustainabilityClimate changeHealth careUK

* Corresponding author.E-mail address: [email protected] (

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

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s u m m a r y

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

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

Introduction

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

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

A. Nichols).

ciety for Public Health. Published

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

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

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

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

One initiative aimed at enabling people and organizations in theNHS and wider community to engage in activities that supportsustainability is the Convergence of Health and SustainableDevelopment.10 This is a network of health and other professionalscommitted to promoting sustainable development within the NHS.This network has produced a manifesto that proposes a commit-ment to promoting sustainable development in the NHS and widercommunity, and strengthening the position of sustainable devel-opment within the NHS workforce. Signatories to the manifestoinclude the Faculty of Public Health of the Royal Colleges ofPhysicians of the UK, the Scottish Environmental Protection Agency,the UK Public Health Association, and a number of senior publichealth academics and NHS managers.

It has been suggested that the responsibility of healthcarepractitioners to protect and promote the health of the public shouldbe extended to working to prevent climate change.11 In 2007, theUK Public Health Association12 outlined strategies for promotinghealth and sustainable development, and the UK Faculty of PublicHealth13 recently published a document outlining the action thatcan be taken at organizational and individual levels. This wasclosely followed by publication of the UK Department of Healthguidance document on promoting sustainable communities.14 TheBritish Medical Journal has set up a carbon council aimed at ‘har-nessing the intelligence and imagination of health professionals toexpedite the transition to a low carbon world’,15 and efforts arebeing made to reduce the carbon footprint of attendance at medicalconferences.16

The NHS Sustainable Development Commission’s good corpo-rate citizenship guidance17 describes how NHS organizations canembrace sustainable development and tackle health inequalitiesthrough their day-to-day activities. This self-assessment modelhelps organizations to identify and assess their contribution togood corporate citizenship, and suggests ideas for future action,providing guidance on transport, procurement, facilities, manage-ment and new buildings. Examples of action include sourcinghealthy and locally produced food, and the development of parkand ride schemes.

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

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

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

Given the emphasis at national level and the increasing goodexamples to draw upon, PCTs are well placed to provide directionon sustainability and to promote efforts to mitigate and adapt to theeffects of climate change.

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

Methods

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

Sample

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

Process and analysis

Website searches were carried out by two researchers. Eachresearcher was allocated 15 PCT websites to investigate and useda coding system for data extraction. All members of the researchteam contributed to and agreed upon the construction of thecoding system. The coding system was constructed following aninitial thematic analysis of two PCT websites and a review of policydocuments outlining possible sustainability actions. This codingsystem consisted of three main codes addressing sustainability,energy vulnerability and climate change. Each of these main codescontained a variety of relevant subcodes. Examples of text foundwithin PCT documents were allocated to appropriate codes withinthe coding system. Reliability testing was achieved by members ofthe research team independently reviewing and recoding a selec-tion of material previously coded by their colleagues. This enabledthe authors to extract relevant details which were then used toinform a qualitative, thematic analysis from which four consistentthemes were apparent.

Previous investigations of strategic health authority policy andpractice with regard to energy vulnerability and climate changeyielded limited data sets, and this suggested that data sets gainedfrom the study of PCT websites could be similarly limited. Conse-quently, it was decided that quantitative analysis of the data wouldnot be appropriate, but that a qualitative form of analysis wouldenable the identification and discussion of relevant, general themesemergent from the data.

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

For example, Yin19 argued that the analysis of evidence obtained

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

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

Results

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

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

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

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

waste management.

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

Strategic initiatives

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

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

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

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greenhouse gas emissions over the coming decade (PCT 3) hasprepared, with assistance from the Carbon Trust, a draft Strategyand Plan of Action to ensure this’. Likewise, PCT 4 was clear in itslong-term commitment to their strategy, claiming that ‘it is notpossible to predict with certainty how climate change will affect usall, but we must plan for the likely damaging effects and encouragethe life style changes that will limit the impact. This strategy setsout our shared understanding of our key challenges over the nexteighteen years. It provides the framework for us to work togetherand with regional and government agencies and our communities,in common purpose’.

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

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

Joint working

Evidence gained from this research appears to suggest thatwhen PCT strategies and policies on sustainability and climatechange were implemented successfully, this was often achieved inpartnership and through joint working with other significantagencies. Examples of joint working towards sustainability werefound on a number of PCT websites. PCT 3 was working with theCarbon Club in an attempt to establish sustainability within theirdaily working practices. PCT 4 was actively seeking the involvementof their local community with the aim of bringing together ‘a rangeof interests including key public organisations, private businesses

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

and voluntary and community sectors’ in partnership to ‘supportsustainable development’. Evidence from the PCT 21 websiteindicated that ***** County Council and primary care trusts wereworking together, as part of their local strategy with the intentionof making community ‘healthcare ‘‘greener’’ and more sustainable’.Similarly, PCT 24 acknowledged the role of partnership agencies inimplementing sustainability policies and strategy. The PCT 24Public Health Annual Report 2006–2007 was clear in stating that‘*****shire County Council has an important role in adaptationworking with partners, both via direct activities and in terms of itsability to influence the wider community. The Council hasaddressed adaptation actions through the sustainability principlesoutlined in the ‘Sustainable Community Strategy for *****shire’, the‘Community Strategy for *****shire – Shaping Our Future Together,2004–2007’ and its ‘Local Area Agreement’. PCT 29 was also foundto be engaging in broader collaboration with the ‘***** StrategicPartnership as part of the ***** Development Agency initiative onclimate change’.

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

Sustainable communities

Evidence appears to suggest that PCTs made some attempt toextend this culture of sustainability into the wider communitieswhich they served. Documents found within the website of PCT 20indicated that the trust was aware of its responsibilities to thewider community and the environment, claiming that with respectto construction and refurbishment of trust buildings, potentialenvironmental impacts would be assessed using nationally recog-nized assessment tools with the aim of ensuring that the trustadopted a sustainable approach to construction which would‘conserve natural resources in a way that produces minimal wastein terms of the local, national and global environment’. Further-more, this PCT asserted that its ‘holistic’ approach to constructionwould protect the surrounding environment, community andwildlife by taking action in areas such as waste, energy, transportmanagement and the consumption of resources such as water. PCTs3, 4 and 27 were clear in their desire to cultivate sustainablecommunities, with PCT 4 accepting the challenge to ensure thatthey managed change ‘within environmental limits and take

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

In common with PCT 4, PCT 30 also appeared to be clear invisualizing sustainable development as ‘a cornerstone’ of itscommunity strategy, and provided details of an integrated impactassessment tool that it had constructed to promote this. Thisassessment tool provided clear guidance on specific topics to beaddressed in tackling the challenges presented by climate changeand in developing sustainable communities. These specific topicsechoed many of those suggested by other PCTs; for example, withregard to the construction of buildings, minimizing waste and theprudent use of resources.

Targeted action

A number of PCTs also suggested specific topics to be addressed;for example, the reduction of air, land and water pollution; andflood prevention. Specific topics of particular interest to PCTsappeared to be those of transport and waste management. Forexample PCTs 4, 7 and 11 were found to be advocating the use ofsustainable transport options and infrastructure. PCT 20 was seento be encouraging the use of ‘sustainable environmentally friendly’transport alternatives whilst advocating a reduction in the use ofcars, in overall mileage travelled and in applying limitations aroundemission figures in keeping with its ‘Green Transport Policy’. ThisPCT also aimed to reduce the need for travel through the use ofcommunication technology. ‘Green travel plans’ were also advo-cated by PCTs 7 and 11 as a means of reducing their carbonfootprints.

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

In the case of waste management, PCTs such as PCT 10 wereclearly mindful of environmental issues and, as a result, aimed to dotheir utmost to promote sustainability through actions such as therecycling of waste paper, printer cartridges and other similarconsumable supplies. PCTs 7 and 9 were also explicit in theircommitment to the recycling of waste. Others such as PCTs 4, 20, 25and 30 reported that they were actively seeking to conserveresources whilst reducing the amounts of waste produced. Thestrategic framework produced by PCT 3 could be seen as a goodexample of how these PCTs encouraged organizations they workedwith to reduce waste:

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

Discussion

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

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

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

This evidence appears to be consistent with the diffusion theorydescribed by Rogers23 and characterized by individuals or organi-zations that are innovators, early or later adopters, or laggards. Theadoption and diffusion of innovation within health care is clearlya complex process,24 but it could be speculated that raising theprofile of climate change and sustainability within the healthcareliterature may help in hastening the adoption and implementationof carbon-reducing policies.

The concerns about peak oil and climate change raised in theliterature present a clear rationale for implementing sustainabilitystrategies. In assessing the implications of peak oil for public health,Frumkin et al.1 suggested that extensive health research includingquantitative modelling, scenario building and epidemiologicalanalysis is required. Furthermore, research should attempt toidentify local vulnerabilities and guide adaptation strategies. TheNHS, particularly policy makers, public health professionals andhealth service researchers, could make a significant contribution toscenario building, joint and multi-agency working, and promotingresilient and sustainable communities.22 Furthermore, the NHSmakes a considerable contribution to carbon emissions, will behugely adversely affected by climate change and peak oil, and hasthe potential through both its purchasing power and large numberof employees to make a significant contribution to adaptation andmitigation measures. Therefore, any efforts to share best practiceand lead by example are to be encouraged.

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

Clearly, there are limitations to this study. For example, it shouldbe recognized that data obtained from the analysis of publiclyavailable documents may well be limited, and it is unlikely that all ofthe action taken by PCTs with respect to sustainability will bereported on PCT websites; therefore, some examples of goodpractice may have been missed by the study. It should also beacknowledged that the research took place at a time when PCTs wereundergoing or emerging from periods of great change and re-orga-nization, which may also have influenced the publicly availablecontent on websites. It could be speculated that following thepublication of the NHS Carbon Reduction Strategy, a repeat of thestudy may well reveal evidence of greater and more consistentactivity in this area. In order to obtain such evidence, the authors arecurrently following up this study with a questionnaire/survey to besent to PCTs/directors of public health. Finally, one could alsoquestion whether PCTs, which face a range of demands made upontheir limited resources, have the means and ability to successfullyaddress the issues raised by energy vulnerability and climate change.

Conclusions

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

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of organizational governance. Further research is required in orderto ascertain the full extent of sustainability initiatives beingundertaken by PCTs and to disseminate good practice. Issuesregarding climate change, energy vulnerability and sustainabilityare now prominent within the healthcare literature. However, muchof this literature focuses on health impacts and policy. There islimited published evidence of successful implementation of policy.

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

Acknowledgements

The authors wish to thank Lindley Owen, Consultant in PublicHealth for NHS Bournemouth & Poole for comments on an earlierdraft of this paper.

Ethical approval

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

Funding

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

Competing interests

None declared.

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East Lancashire PCTEast Riding of Yorkshire PCTEastern and coastal Kent PCTEnfield PCTGateshead PCTHampshire PCTHaringey PCTHartlepool PCTIsle of Wight PCTKirklees PCTLeicester County and Rutland PCTNorth Lincolnshire PCT

b) Assessment criteria:

Organization Annual Annual Associated

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Appendixa) PCT websites searched:

Barnsley PCTGreenwich PCTCornwall PCTNorth Somerset PCTSandwell PCTAshton PCTBarking and Dagenham PCTBassetlaw PCTBerkshire East PCTBlackburn With Darwen PCTBolton PCTBuckinghamshire PCTBury PCTCalderdale PCTCamden PCTCentral and Eastern Cheshire PCTCumbria PCTEaling PCT

report plan documents

CriteriaSustainability generalSustainability estatesSustainability transportSustainability wasteSustainability planningSustainability supplies and servicesSustainability staff developmentEnergy vulnerability generalEnergy vulnerability estatesEnergy vulnerability transportEnergy vulnerability wasteEnergy vulnerability planningEnergy vulnerability supplies and servicesEnergy vulnerability staff developmentEnergy vulnerability multi-agency workingClimate change infectious diseaseClimate change floodingClimate change disaster managementClimate change Air quality/pollutionClimate change multi agency working, e.g. Met

Office/Environment AgencyPCT links/references to relevant sustainability

documentsEvidence of these being acted upon?

PCT, primary care trust.

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