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Objective: The climate crisis necessitates urgent decarbonisation. The health sector must address its large carbon footprint. In the present study, we sought healthcare thought leaders' views about a future environmentally sustainable health system. Methods: The present study was a qualitative exploratory study consisting of semistructured, in-depth interviews with 15 healthcare thought leaders from Australia, the UK, the US and New Zealand. Audio recordings of the interviews were transcribed and analysed by matrix display and thematic analysis. Results: Overall, healthcare thought leaders believe that to reduce the carbon footprint of healthcare we need to look beyond traditional 'green' initiatives towards a more fundamental and longer-term redesign. Five main themes and one 'key enabler' (information communication technology) were identified. In this paper we draw on other relevant findings, but chiefly focus on the fifth theme about reshaping the role of healthcare within society and using the size and influence of the health sector to leverage wider health, environmental and societal benefits. Conclusions: These ideas represent potentially low-carbon models of care. The next step would be to pilot and measure the outcomes (health, environmental, financial) of these models. What is known about the topic?: The health sector needs to reduce its large carbon footprint. Traditional 'green' initiatives, such as recycling and improving energy efficiency, are insufficient to achieve the scale of decarbonisation required. What does this paper add?: Healthcare thought leaders surveyed in the present study suggested that we also consider other, non-traditional ways to achieve environmental sustainability. In this paper we discuss their ideas about adopting an anticipatory approach to healthcare using predictive analytics, and using the size and influence of the health sector to effect wider health and environmental benefits. What are the implications for practitioners?: Achieving an environmentally sustainable healthcare system is likely to require broad and fundamental (i.e. transformational) change to the current service model. Health practitioners throughout the sector must be closely engaged in this process. [ABSTRACT FROM AUTHOR]

Objective: Despite needs, people with advanced non-malignant respiratory disease are infrequently referred to palliative care services. Integrated models of palliative care and respiratory service delivery have been advocated to address this inequity of access. This study mapped current ambulatory palliative care service provision for patients with advanced non-malignant respiratory disease in Australia and New Zealand. Methods: An online survey was distributed to the palliative care physician membership of the Australian and New Zealand Society of Palliative Medicine. Information was sought regarding access to specific breathlessness and integrated respiratory and palliative care services, and their operation. Data were described using descriptive statistics. Results: In all, 133 respondents (93 from Australia, 40 from New Zealand; representing 55 Australian and 26 New Zealand discrete sites) with complete data were available for analysis. More than half the respondents reported seeing patients with advanced non-malignant respiratory disease frequently (56/97; 58%), and 18 of 81 services (22%) reported having breathlessness or integrated respiratory and palliative care services caring for this patient group. Such services were mostly staffed by respiratory and palliative care doctors and nurses and based in the clinic environment, with limited support available outside this setting. Of the 63 respondents without existing breathlessness or integrated services, 49 (78%) expressed interest in their establishment, with limited resources cited as the most common barrier. Conclusions: There is limited availability of integrated respiratory and palliative care or specialised breathlessness services in Australia and New Zealand despite widespread support by palliative care physicians. This study provides a snapshot to inform strategic service development. What is known about the topic?: People with advanced respiratory disease have very significant morbidity with complex needs equivalent to, and in many cases more intense than, people with end-stage lung cancer; they also have significant mortality. Yet, these people frequently do not access palliative care services. The establishment of integrated respiratory and palliative care services has been advocated as an effective means to overcome the barriers to palliative care access. Such services have demonstrated improved patient and family-reported outcomes, as well as service-level improvements. What does this paper add?: This paper maps the availability of integrated respiratory palliative care services in Australia and New Zealand. We reveal that although most palliative care physicians report seeing patients with advanced respiratory disease in practice, just one-fifth of services report having an integrated service approach. There was high interest and enthusiasm for such services (78%), but resources limited their establishment. What are the implications for practitioners?: Palliative care services recognise the needs of patients with advanced respiratory disease and the benefits of integrated respiratory and palliative care services to address these needs, but scarcity of resources limits the ability to respond accordingly. This study provides a snapshot of current service level to inform strategic development. [ABSTRACT FROM AUTHOR]

Pelvic exenteration (PE) is a potentially curative, ultra-radical surgical procedure for the treatment of advanced pelvic tumours, which involves surgical resection of multiple pelvic organs. Delivering such a complex low-volume, high-cost surgical program presents a number of unique health management challenges, and requires an organisation-wide approach involving both clinical and administrative teams. In contrast to the United Kingdom and France, where PE services have been historically decentralised, a centralised approach was developed early on in Australia and New Zealand (ANZ) with referral of these complex patients to a small number of quaternary centres. The PE program at the authors’ institution was established in 1994 and has since evolved into the highest volume PE centre in the ANZ region and the largest single institution experience globally. These achievements have required navigation of specific funding and management issues, supported from inception by a proactive and collaborative relationship with hospital administration and management. The comprehensive statewide quaternary referral model that has been developed has subsequently been successfully applied to other complex surgical services at the authors’ institution, as well as by more recently established PE centres in Australia. This article aims to summarise the authors’ experience with establishing and expanding this service and the lessons learned from a health management perspective. [ABSTRACT FROM AUTHOR]

Of the total intensive care unit (ICU) admissions in Australia and New Zealand, 36.6% occur following an elective surgical procedure. How best to use ICU services in this setting is not clear, despite this being an expensive and resource-intensive method of care delivery. The literature relating to this area has not demonstrated a clear association between improved outcomes and routine ICU utilisation. It has, however, demonstrated that methods of care delivery in this setting vary at the local, national and international level. There is now an increased interest in how we can offer safe, efficient care to patients who need ICU-level support after elective surgery, as well as where and when that care can be offered. We had previously performed a literature review relating to ICU utilisation in the elective surgical post-operative setting. This perspective piece arises from this literature review as well as extensive clinical experience from the authors. We discuss the need for a move towards an evidence-based indication for ICU admission and how this may be achieved. We then move on to the various alternative models of care that could be offered, briefly discussing their positives and potential drawbacks. We finish by outlining the research priorities and how these might be implemented in clinical practice. Getting the balance right between ICU admission and higher acuity ward-level care for post-operative elective surgical patients is difficult. However, this is an important challenge that we as a healthcare community must be working to answer. [ABSTRACT FROM AUTHOR]