Aarti Bansal and Grant Blashki: Six steps to both greener and better primary care

Most primary care clinicians are well aware that the climate crisis is a health crisis and of the immediate and significant health co-benefits of climate action, such as through reduced air pollution. However, when it comes to taking action, in our experience many clinicians do not make the link with clinical practice. This is perhaps a result of extrapolating from actions to reduce one’s personal carbon footprint in areas like energy, waste, and transport. Yet, the majority of general practice’s carbon footprint results from clinical activity. In this article we focus on clinical practice and outline six practical steps that primary care can take towards sustainable healthcare that align with evidence-informed and person-centred practice. 

  1. Prudent Prescribing 

Approximately two-thirds of general practice’s carbon footprint comes from prescribing. Reducing unnecessary prescribing is an obvious first place to start and has flow on benefits for patients such as in reducing problematic polypharmacy. The open prescribing website gives UK general practices easy access to their prescribing data to help support safe and efficient prescribing.

Prescribing low-carbon alternatives, such as dry-powder inhalers (DPIs) instead of metered-dose inhalers (MDIs), also has enormous potential to reduce general practice’s carbon footprint. MDIs contain powerful greenhouse gases in their propellants that are 1000-3000 times more powerful than carbon dioxide and constitute a quarter of general practice’s prescribing footprint! Overuse of short-acting beta-agonist (SABA) MDI inhalers is associated with sub-optimal control and poorer health outcomes in asthma patients. A focus on reducing SABA overuse in asthma patients is likely to improve asthma care and reduce environmental impacts. Switching to DPIs for prevention may also present an opportunity to support self-management and reduce greenhouse gas emissions. Most patients are able to use a DPI for prevention and some may prefer them as they do not require spacer devices and contain dose counters to aid correct use. The National Institute for Clinical Excellence has produced a patient-decision aid to support switching to low-carbon inhalers on an individual basis where clinically appropriate.

  1. Responsible Referrals 

As gatekeepers in many health systems, primary care clinicians hold the keys to allied and specialist services, radiology, pathology and other investigations. According to the NHS Sustainable Development Unit, commissioned services make up at least 63% of the carbon footprint in primary care. For clinicians, reducing unnecessary investigations and referrals is part of good clinical practice and consistent with the worldwide Choosing Wisely movement that seeks to reduce the harm from unnecessary interventions through evidence-informed shared decision making.

  1. Connecting communities

Most health determinants lie outside of healthcare and there is a growing appreciation of the vital role that communities have in health creation. Co-creating the conditions of health with communities can develop resources and assets specific to that community’s needs. Peer volunteers and champions can work alongside trained link-workers to help patients access community-based resources. Activities such as community food growing, green gyms and social cafes can improve health and wellbeing through social connectedness, sustainable healthy diets, increased physical activity and access to biodiverse green spaces in local environments. 

  1. Identifying inequalities

The climate crisis disproportionately affects poorer sections of society, and there is increasing recognition of the need to address health inequalities on the road to a green and fair recovery. One specific area for action is support for people living in cold homes who are at increased risk of many health conditions leading to excess winter deaths. Initiatives where general practices have identified patients who are unable to afford a warm home and directed them to support around energy efficiency, have demonstrated significant reductions in GP appointments, hospital admissions and fossil fuel use. Innovative award-winning projects such as “Saving lives with solar” have combined reducing the NHS carbon footprint with raising funds for fuel poverty schemes. 

  1. Empowering patients

Around the world the burden of long-term conditions is increasing and there is growing evidence that a person-centred approach to practice, where care is tailored to individual needs and wishes, and patients are empowered to self-manage their conditions, can lead to health and wellbeing gains as well as reduced healthcare use. In addition, the appropriate use of telehealth may support good outcomes through improved follow-up and self-management as well as reducing carbon from unnecessary patient travel. 

  1. Respected Role-models/Role-modelling

In the world of fake news and obsession with social media, GPs and nurses remain trusted sources of health information and guidance. Through advertising their participation in green initiatives, general practices send a public health message to their patients about the importance and urgency of action on environmental sustainability. By choosing to walk or cycle to work and home visits, clinicians can model the benefits of active transport on individual health through exercise and promote the gains to population health through lower air pollution. Clinicians are ideally situated to advocate for urgent action for a healthy recovery from Covid-19 through national and international networks. 

We hope that these six steps help to make the connection between greener general practice and good, thoughtful clinical practice.  There are a number of resources (e.g. the Greener Practice website) and tools (e.g. Green Impact Audit for Health) available for general practices to start their journey towards more sustainable clinical practice. The important thing is to pick an area that resonates and to make a start. 

Aarti Bansal is a GP in Sheffield, an NIHR research fellow at Hull York Medical School and the founder of the Greener Practice initiative which aims to support general practices to take action for the health of patients and planet. 

Competing interests: none 

Grant Blashki is an Australian GP, Associate Professor of Global Health at the University of Melbourne, Australia. He is a cofounder of Doctors for the Environment Australia, and Former Chair of the Environmental Working Group of WONCA 

Competing interests: none