Environmentally Sustainable Primary Care

Our health, wellbeing and livelihoods are dependent on nature, and yet nature is more under threat than ever [1]. The repeated warnings from IPCC and others on the causes and impacts of the climate crisis are seen, but possibly not felt, and that emergency action is needed to reduce planetary harm. 

Are the emissions and impacts associated with providing high quality primary care significant, and if so, are they within the role and responsibility of primary care to manage? Are there harmful impacts on our patients, the populations we serve and the staff we work with that could be reduced through approaching primary care with a greener planetary health lens?

Healthcare delivery is contributing to environmental harm [2] with climate and ecological crises affecting human health negatively [3], leading to a vicious circle of increasing patient ill-health and health-care demand. The safe space for humankind to exist - which ensures no one is left falling short on life’s essentials and we’re within an ecological ceiling that ensures humanity does not overshoot planetary boundaries - is increasingly being eroded [4]. Primary care, through its influence and with 800,000 [5,6] or so daily patient contacts is in a prime position to be at the forefront of positive change.

In High Income Countries, the delivery of healthcare accounts for 4-5% of a country’s total carbon footprint [7]. Primary care is responsible for about 25% [8] of that through medication and prescribing, energy use, transport of staff and patients, procurement and services. Primary care has impacts on air quality and ocean health, microplastics and waste, water pollution and nature loss.

A paradox is that the manner in which healthcare has been - and still is - delivered is contributing to the climate, ecological and health crisis of today. This is an added ethical onus to decarbonise and reduce our overall environmental impact. First, do no harm.

What can be done? 

The largest gains, as described by the UK Centre for Sustainable Healthcare, are in prevention [9].

The NHS’s net zero targets demonstrate that healthcare can advance beyond ‘business as normal’, and can achieve not just better planetary health, but healthier patients and populations. A Lancet study [10] showed the UK could reduce premature deaths by 20% by implementing its current climate commitments. Chronic disease could be reduced – for example a study [11] showed a 19% reduction in diabetes, 12% reduction in cardiovascular disease through moving to a plant-based diet as well as 81% reduction in greenhouse gas emissions. Better for patients, population and planet.

One of the many challenges for primary care in the current political and social climate is not knowing what else is going on, what actions are being taken and by who, and what actions can be undertaken by the individual or practice.

The book shows through practice case studies the breadth of actions underway across primary care and the range of people leading them. It demonstrates the international reach of UKHACC, national organisations – such as RCGP – who have declared a climate emergency - and groups such as Greener Practice who provide practical and emotional support to staff and practices. The book has input from Canada, Australia and Ireland as well as England, Scotland, Wales and NI.

The book – Environmentally Sustainable Primary Care - offers inputs, tips and guidance on achieving behaviour change as individuals, within practices and at wider scale. Actions taken by individuals have a role to inspire and empower others, whilst actions at a large scale working across borders and boundaries, and with a host of interconnected organisations can lead to whole system change. 

Addressing environmental sustainability in our healthcare systems must include challenges like addressing social deprivation and social inequalities, and the need for an honest conversation about sustainable plant-based diets, safe public transport, physical activity and industry-free conversations about our relationship with consumption.

The content of primary care has been changed by mankind’s impact on our world. The clinical vignettes included throughout the book remind us that planetary health changes the epidemiology, the application of pharmacology and the consultations occurring every day. Useful for seasoned healthcare practitioners through to staff in training via teaching sessions, the cases highlight the cause and solutions for patients.

Clinical emissions from primary care account for 60% of total primary care emissions. Reducing inappropriate prescribing – where the patient is harmed or receives no health gain– benefits patients, practice and planet. Less prescribing means less time reviewing or issuing medication, fewer drug interactions for patients, and less financial cost to the health system.

Another part of the solution is shifting from NICE’s ‘what works best for this disease’ approach to a lifestyle ‘what works best for this patient’ approach. This is echoed in the 2023 Chief Medical Officers Annual report [12] ‘It is essential that all patients, but especially those in later old age, are able to have realistic discussions with their doctors about whether more treatment will improve quality of remaining life. Some treatments may extend life but at the expense of reducing its remaining quality and independence; the decision about how to balance these should be the patient’s.’

The majority of chronic diseases are caused by environmental and lifestyle factors [5], with a minority caused by genetics. In addition to increasing lifespan (length of life), lifestyle medicine can also increase healthspan (i.e. length of healthy life). While no single set of principles lie behind lifestyle medicine, the British Society for Lifestyle Medicines (BSLM) six principles: healthy eating, physical activity, healthy relationships, sleep, minimising harmful substances, and mental well-being also tend to be less environmentally harmful. The book addresses the impact of an individual’s rank and power, cultural forces and deprivation on the ability to take on lifestyle medicine’s suggestions. 

The impact primary care has on land, water and air is highlighted with a chapter on each. The converse - the impact on human health from polluted air and water or degraded land is highlighted with key actions for staff and practices through to organisation level including, in the UK, PCNs and ICSs.

Pro-environmental behaviour change is more likely if ‘greener’ actions are easy, default, sexier, take less time, better for patient health, practice and staff wealth and improve morale and wellbeing. Using a Sustainable Quality Improvement model helps with a framework of the practicalities for successful action [13].

Taking action

The best time to have acted on the climate was last year.. or a decade ago.. or a century ago. The second best time is today. 

This book - Environmentally Sustainable Primary Care - aims to guide staff and practices to the actions they can take, the ‘greener swaps’ that cumulatively have significant impacts and maintain hope for a cleaner, greener, more equitable world. 

Prioritising action to ‘urgent’ is difficult when there are additional competing demands for staff time, energy and headspace. Action needs to be active, with no more reliance on ‘thoughts and prayers’ that things will magically change for the better or waiting for ‘jam tomorrow’ tech solutions. 

The voice of primary care should be clear and unequivocal that environmental issues are health issues, that the environmental impact from delivering primary care is the responsibility of primary care, and that actions taken can be better from patients, populations, practices, personnel and planet simultaneously. 

This book helps all involved in primary care to recognise their role and responsibilities, and the hope that is delivered from taking such positive actions. 

The Editors:

Dr Matt Sawyer is a former GP, current Director of SEE Sustainability and a Carbon Literacy trainer, UK.

Dr Mike Tomson is a former GP (clinically retired), a medical educator, coach and a Trustee for Centre for Sustainable Healthcare, previously Director of Greener Practice CIC, UK.

The book is available at https://www.routledge.com/Environmentally-Sustainable-Primary-Care-Good-for-the-planet-good-for-practices-good-for-patients/Sawyer-Tomson/p/book/9781032793573

References

1. Final Report – The Economics of Biodiversity: The Dasgupta Review https://www.gov.uk/government/publications/final-report-the-economics-of-biodiversity-the-dasgupta-review 

2. Environmental sustainability https://www.nice.org.uk/about/who-we-are/sustainability

3. Human Health Impacts of Climate Change https://www.niehs.nih.gov/research/programs/climatechange/health_impacts 

4. Kate Raworth, Doughnut Economics - https://www.kateraworth.com/doughnut/

5. Primary care services in a nutshell https://www.kingsfund.org.uk/insight-and-analysis/data-and-charts/NHS-activity-nutshell 

6. https://digital.nhs.uk/services/podac/pharmacy

7. Pencheon D, Wight J. Making healthcare and health systems net zero. BMJ 2020;368:m970. Available at: https://www.bmj.com/content/368/bmj.m970

8. Health care's response to climate change: a carbon footprint assessment of the NHS in England. https://www.thelancet.com/journals/lanplh/article/PIIS2542-5196(20)30271-0/fulltext

9. Centre for Sustainable Healthcare - https://sustainablehealthcare.org.uk/ 

10. The public health implications of the Paris Agreement: a modelling study. The Lancet. https://www.thelancet.com/journals/lanplh/article/PIIS2542-5196(20)30249-7/fulltext 

11. Genetic Factors Are Not the Major Causes of Chronic Diseases. PLoS One.  https://pubmed.ncbi.nlm.nih.gov/27105432/ 

12. Chief Medical Officer’s Annual [MS33] report 2023 https://assets.publishing.service.gov.uk/media/6674096b64e554df3bd0dbc6/chief-medical-officers-annual-report-2023-web-accessible.pdf 

13. Sustainability in Quality Improvement susqi.org