The multiple challenges to primary care are well rehearsed; an excessive workload, a need to achieve health equity, achieving genuine patient centredness, providing better care and preventing more illnesses. Simple, right?
But wait, there’s more. All of this needs to be done whilst addressing the financial costs, the environmental costs and the impacts on the communities that primary care exists within. At the same time the demands on primary care are changing not least because of the impact of the climate and ecological emergency which change the health demands on our populations and increases health inequality.
It can feel like this is a perfect storm for clinicians and healthcare leaders but are there ways to approach the challenges which through positive feedback loops will begin to address them all?
Planetary health – concerning the health of the natural living world – is a relatively new discipline. It examines the impact on the health of us all from the changes that mankind has caused to the planet. Direct effects of weather extremes include deaths from flooding, cold and from heat waves; indirect effects include increased waterborne infection rates and crop failures; air pollution contributes to IHD, and diabetes as well as respiratory illnesses. It also looks in the other direction – at the impact that delivery of healthcare has on our planetary boundaries. Healthcare represents 4-5% of the carbon footprint of most Western countries and about 23% of this is from primary care in the UK, as well as contributing pharmaceuticals to our rivers and oceans, and generating significant air pollution.
Improving planetary health through delivery of environmentally sustainable healthcare will depend on leadership at individual, local, national and political levels. You don’t need a title or a fancy office though – all healthcare staff can demonstrate leadership – whether individually through role modelling… (e.g. by adopting more active travel, shifting the emphasis of their diet towards plant-based foods or reducing their energy use through either behaviour changes or increased insulation), and changes in their practice.
Followership is also important. If someone is seen as doing good work, taking impactful actions, or greening their role, followership is a proactive process or act to demonstrate support, providing praise and encouragement and empowering them to lead further. Which leaders would you follow?
At a practice level, leadership in environmentally sustainable primary care starts with the interventions which the team are keenest to support rather than being based on more conceptual frameworks. A team which successfully and jointly takes and completes an action which makes a difference is much more likely to continue to other or more impactful steps. Two critical elements determine the likelihood of success: degree of control and desire to be involved. Staff with a high level of control in their work life AND a high degree of desire are unstoppable! Frameworks like the Centre for Sustainable Healthcare’s four principles are helpful though to remind us that developing environmentally sustainable care depends on prioritising prevention, patient empowerment, lean service delivery and then low carbon alternatives.
Prevention of illness involves developing allies to enable people including some with limited finances to move to more plant led diets, to find routes into active transport, to address fuel poverty and to increase access to nature. The evidence for these is large, the potential health gains enormous and the longer-term benefits on workload significant too. Not everybody has the same power or privilege in society, and it is crucial to understand how to enable those with less privilege or power to take these steps too. Prevention can be achieved with many allies – from the health insurance industry to the local council planning department – taking actions within their power to create and enable the healthiest options to be the default, easiest options. Collaboration is key.
Patient self- care or empowerment is a route to better health outcomes as well as happier patients and productive consultations. As clinicians and leaders, we have a responsibility to help patients help themselves. We know that many prescriptions are never used because patients do not believe that they will gain enough from them or are scared of potential side effects. We know too that doctors are better at adding new treatments than stopping treatments. There is health gain available from better conversations offering choice and highlighting the risks as well as the hoped for benefits of treatments in language that empowers patients to choose.
Lean pathways depend on a clear diagnosis, which may be harder to achieve in primary care with multiple diseases and overlapping medical and social factors to be teased out. The evidence for pathways in primary care is worse than in other areas with NICE guidelines relevant to primary care so often not based on primary care populations. Over diagnosis, over investigation and over prescribing are all important quality of care issues, issues which have significant financial costs, cause greater workload and have a very significant carbon and planetary health impact. To paraphrase Abraham Maslow, if the only tools we have are investigations, prescriptions and diagnoses then we will see every problem as needing one of these. Whilst NICE guidance is generally useful to improve care for each individual disease, it is important to adapt this to a holistic patient centred approach to enable the life led by each person respecting their multi-morbidity, culture, and desires.
Clinical leadership can be demonstrated at individual patient level too – for example when changing medication for one individual. At practice or organisation level, leadership is needed to achieve a more widespread outcome. For example, some low carbon alternatives can be pharmacy switches, but most will need patient engagement e.g. inhaler technique is different between high carbon metered dose inhalers and low carbon dry powder devices, or teaching kids to swallow tablets (e.g. using Kidzmed ) rather than taking high carbon liquid preparations. Some low carbon options like green or social prescribing or Cognitive Behavioural Therapy for anxiety or depression as alternatives to anti-depressants come back to patient empowerment and information sharing. System leadership is also needed to ensure that the services have the capacity to deliver.
Sixty percent of primary care’s carbon footprint is from clinical sources. Addressing this through clinical leadership offers possibilities of improved care outcomes and improved patient and staff satisfaction. The work needed around energy use, buildings, travel and organisational change is important and can be challenging to achieve in multiple separate organisations. Organisations like Greener Practice have enabled significant progress in areas like Cornwall, Frome and Gloucester who are leading the way on both clinical and organisational change, with positive visions of health creation rather than simply illness prevention.
In order to meet this mammoth task, leadership across sustainable primary care needs support from voices leading in planetary health. Thankfully, there are an increasing number of leaders showing us the way. A compilation of their ideas, thoughts and research is now available through a multi-author book , which we had the privilege of editing. It offers clinical scenarios and practical advice to help leaders achieve better care, at a better price which is also fairer and more environmentally sustainable for patients, practices and planet.
Authors
Dr. Matt Sawyer
Dr. Matt Sawyer worked as a GP for nearly two decades in the North East of England. Now, he runs an environmental sustainability consultancy – SEE Sustainability – working to improve human and planetary health. He covers sustainability issues facing healthcare including understanding their carbon emissions footprint and helping to produce roadmaps and action plans to meet the NHS net zero ambition.
Declaration of interests
I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: My declaration is as an advocate of good planetary health and averting the climate and ecological breakdown, I work (paid and unpaid) with people and organisations who have a similar goal. My full bio and my declaration of interests for 2023 and 2034 is here. It includes the paid work or consultancy for a number of health bodies (ICS/PCNs).
Dr. Mike Tomson
Dr Mike Tomson is a clinically retired GP, medical educator and coach. He was a GP and Trainer in Sheffield and an Associate Postgraduate Dean. He was coauthor of the RCGP’s curriculum statement on population and planetary health. He supported the development of Greener Practice as a founding director. He is a trustee for the Centre for Sustainable Healthcare. He continues to teach and develop educational courses and materials.
Declaration of interests
I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: I am a trustee for Centre for Sustainable Healthcare and Greener Practice (though no longer a director). I do occasional ad hoc non contracted work as an educator.