There is mounting evidence to suggest that exposure to air pollution has a wide range of ill effects on people's overall health. Airborne pollutants such as nitrogen oxides and particulate matter can become especially dense in highly populated areas with increased use of fuel for heat and transport. Particulate matter is made up of a mixture of organic and inorganic particles, such as dust, pollen, soot, smoke, and liquid droplets, which are suspended in the air. The World Health Organization (WHO) sees particulate matter as the most damaging pollutant, and considers outdoor air pollution as a major environmental health problem, estimated to cause 4.2 million premature deaths worldwide each year (WHO, 2018).
Long-term exposure to air pollution in the UK contributes to between 28 000 and 36 000 deaths each year, according to the Committee on the Medical Effects of Air Pollutants (COMEAP) (2018) report. The report describes the many studies of the ways that exposure to air pollution can result in cardiovascular ill health, including raised blood pressure, increased coagulation of the blood, the progression of atherosclerosis, increased risk of arrhythmias, and systemic inflammation. Children under the age of 15 and adults over 64 are most prone to the effects of air pollution, which also include respiratory damage and chronic diseases such as asthma (Policy Connect, 2018).
The COMEAP (2018) report recommends that converting strict air quality guidelines into UK law will help reduce the risk for people living with cardiovascular disease. The UK government launched a Clean Air Strategy in January 2019, with a pledge to reduce harm from air pollution, by halving the population living in areas with concentrations of particulate matter above WHO guideline levels by 2025 (WHO, 2005; GOV.UK, 2019).
Quality standards set out the priority areas for quality improvement in health and social care, particularly where there is variation in care. Each standard provides a set of statements to help improve quality with information on how progress can be measured. Quality standards identify gaps and areas for improvement, show how quality care has been provided, and commission high quality services.
The National Institute for Health and Care Excellence (NICE) published the Quality Standard QS181 in February of this year (NICE, 2019). This Quality Standard focuses on the impact of outdoor air quality and road-traffic-related air pollution on health, and states that periods of poor air quality are linked with adverse health effects, including asthma attacks, reduced lung function, and increased mortality and admission to hospital.
Four quality statements cover local authority strategic plans, planning applications, reducing emissions, and advice for people with chronic respiratory or cardiovascular conditions. Achieving these goals is the collective responsibility of individuals, the community, public services and, in particular, health services.
In this issue of the Journal of Paramedic Practice, Sheldon and Hill's (2019) literature review (p. 305) suggests that ambulance services are a major contributor to emissions from greenhouse gases. Sheldon and Hill recommend ways in which ambulance staff can reduce emissions, by reducing idling time, using vehicle data monitoring systems, and converting their vehicles to an electric or hybrid fleet.
Recently, the NHS published a report reviewing the performance within England's ambulance trust and found significant variations in the national ambulance fleet in terms of vehicle specification (NHS Improvement, 2018). Since then, NHS England Improvement Services have worked with managers and ambulance staff to develop the first standard ambulance vehicle specification, with a lighter frame, black box technology, CCTV, 4G Wi-Fi, and temperature-controlled drug storage, which aims to deliver a more efficient and environmentally friendly service to benefit health professionals, patients and the public (NHS Improvement, 2019).
The NICE Quality Standard provides four main quality statements which are set out below:
Statement 1: ‘Local authorities identify in the Local Plan, local transport plan and other key strategies how they will address air pollution, including enabling zero- and low-emission travel and developing buildings and spaces to reduce exposure to air pollution.’
Quality measures include recording:
Local organisations should work together to ensure that the Local Plan (the strategic plan for the local area), local transport plan, and other strategies, identify ways to address air pollution, including encouraging zero- and low-emission travel and developing buildings and spaces to reduce exposure to air pollution.
Statement 2: ‘Local planning authorities assess proposals to minimise and mitigate road-traffic-related air pollution in planning applications for major developments’.
Buildings affect the way air pollutants are dispersed, through street design and its effect on air flow. Addressing air pollution at the planning stage for major developments may lessen the need for more expensive corrective action later. It can also help to maintain the public's health and wellbeing during and after construction. Planners need to show that applications for major developments include proposals to minimise road-traffic-related air pollution, with good walking and cycling facilities, and a clear framework to lessen traffic-related air pollution in planning applications for major developments.
Quality measures include recording:
Local planning authorities need to ensure that any applications for major developments aim to lessen road-traffic-related air pollution, both during and after construction and that these applications are modified if necessary.
Statement 3: ‘Public sector organisations reduce emissions from their vehicle fleets to address air pollution’.
The public sector vehicle fleets include various types of vehicle, some of which are very polluting. Reducing emissions from these vehicles will help reduce road-traffic-related air pollution.
Public sector organisations can extend their impact by only commissioning fleet services from organisations that reduce emissions to address air pollution. This action should spur on other organisations to do the same. Organisations should present evidence that they are reducing emissions from their vehicle fleets, and show that they also commission transport services that reduce emissions from their vehicle fleets to address air pollution. Quality measures include:
This quality statement should encourage local services to make sure that drivers are trained to change their driving style; that vehicles are shared; and that congestion is minimised with different delivery schedules.
Statement 4: ‘Children, young people and adults with chronic respiratory or cardiovascular conditions are given advice at routine health appointments on what to do when outdoor air quality is poor’.
Periods of poor air quality are associated with adverse health effects, including asthma attacks, reduced lung function, increased mortality and admission to hospital. Public services need to show that health professionals provide advice to children, young people and adults with chronic respiratory or cardiovascular conditions at their routine health appointments to improve their awareness of how to protect themselves when outdoor air quality is poor and prevent their condition from escalating.
Quality measures involve:
This should impact their awareness about air quality, and the rate of hospital admissions for respiratory or cardiovascular illnesses. Health services must ensure that health professionals are fully informed about air quality, what advice to give and how to find out when outdoor air quality is expected to be poor. The Daily Air Quality Index is compiled by the Department for Environment, Food and Rural Affairs (DEFRA) (2019) and shows air pollution on a colour-coded map, with 10 bands ranging from low to very high.
The advice for people with respiratory or cardiovascular conditions should be to:
Conclusion
This quality standard reinforces the importance of tackling air pollution, especially given its negative impact on children, the elderly and those living with a lung disease. The standard demands a heightened awareness among planners, industry, transport services, health services, and the general public. By working closely together, and meeting the demands of the quality statements, these services will have a positive impact on public health and wellbeing.
The recent plan to upgrade England's ambulance fleet with a new single specification, with which all ambulances must comply by Autumn this year, is a huge step in making the health service environmentally friendly. However, the NHS must ensure that adequate funding is available to be able to set this in motion without compromising access to an adequate number of trained paramedics. Demand for ambulance services is growing—increased from 7.9 million calls in 2009–2010 to 10.7 million calls in 2015–2016 (National Audit Office, 2017). This increase in demand could be a result of the increasing elderly population, demand on primary care services in the community, and increased alcohol-related calls (Gilkes, 2019). Furthermore, ambulance trusts are facing problems with funding, recruiting and retaining the staff they need, with an added strain on existing paramedics, and resourcing the ambulance service as a whole (National Audit Office, 2017).
These challenges should not deter transport companies from working towards the goal of a greener health service in the UK, and this Quality Standard will drive companies to reduce emissions and improve the health of our population.