The Rise of the Green General Practice

Jessica Powell meets the doctors and their staff who are practising what they preach when it comes to environmental initiatives to protect the planet—and their patients.
If you think of a climate crusader you might picture someone chained to a tree or touting a placard. But there’s a new activist in town: the local GP. With the NHS having committed to reaching a net zero carbon footprint by 2040,¹ many general practices around the UK are already using their position at the heart of communities, and their huge reach, to lead the charge.
Last year the Royal College of General Practitioners (RCGP) declared a climate emergency and highlighted “the catastrophic effect on human health of not acting decisively and urgently on climate change.”² Terry Kemple, RCGP representative for sustainability, climate change, and green issues, says, “We’re not talking about if there will be climate change—we’re talking about how bad it’s going to be. If we’re concerned with the health of our patients, it’s not something any rational person can ignore.”
And a growing number of GPs don’t need convincing. Well before the RCGP declaration, general practices throughout the UK were working to decarbonise. In 2014 the Green Impact for Health Toolkit was launched by Kemple and colleagues,³ giving GPs practical steps for going greener, and over 750 practices have signed up so far. Then in 2017 Aarti Bansal, a Sheffield based GP, founded the Greener Practice group: a network of GPs, medical students, and others aiming to help general practices take action to benefit people and the planet.⁴ (See box: Three ways to grow a greener practice.)
For GPs engaged in the green mission, the health effects of an unhealthy planet are obvious: an increase in heatwaves (which killed nearly 900 people in England alone last year) and greater spread of infectious diseases, to name just a couple.⁵
“In the UK, 40 000 people are dying from air pollution each year,”⁶ says Matthew Sawyer, a GP and director of SEE Sustainability (seesustainability.co.uk), which offers carbon footprinting of general practices and “carbon literacy” training. “We’ve had about 40 000 deaths from covid-19 so far [at the time of interview].⁷ We had that from air pollution last year, but did we have a lockdown? Did we have billions of pounds being spent?⁸ No, we just accepted it—and to me that’s criminal.”

Impact on practices

But what have environmental issues got to do with GPs, beyond them tackling the health fallout? You may think it’s down to governments and industry to clean up the climate mess. Honey Smith, GP and chair of Greener Practice, notes that it can be hard for GPs to make the connection between the climate and ecological crisis and their clinical work. She says, “They may see that climate change is going to have a massive impact on health but question, ‘How does that change my practice?’”
That’s where groups such as Greener Practice come in—to show GPs how they contribute to, or could help to combat, the climate catastrophe.
Take, for example, medicines. NHS England’s Delivering a “Net Zero” National Health Service report has found that they account for 25% of emissions within the NHS and are the greatest contributor within primary care.⁵ As such, groups including Greener Practice advocate deprescribing where clinically appropriate: reviewing whether patients’ prescriptions are appropriate, determining whether they actually take them, and exploring low carbon alternatives.
Smith explains, “If we have patients with, say, borderline raised blood pressure, we can either reach for our prescription pad or we can look at things other than medicines such as using social prescribing,⁹ health trainers,¹⁰ and ‘green prescribing’¹¹ – prescribing nature based activities, as nature is known to have additional benefits for mental and physical wellbeing.
“Reducing problematic polypharmacy and medicines wastage is also a major strand of this work.”

Breathe easy

Crucially, Delivering a “Net Zero” National Health Service notes that a small number of medicines account for a large portion of emissions—one such group being inhalers.⁵ As such, there’s a drive by climate conscious GPs
to move away from prescribing metered dose inhalers (MDIs), where clinically appropriate, towards dry powder inhalers (DPIs), which have a smaller carbon footprint.^{5, 1, 2}
Vasumathy Sivarajasingam, GP partner at Hillview Surgery in London, was shocked by the impact of inhalers. She says, “I read that the amount of emissions from a particular MDI inhaler we use in practice could be equivalent to driving 175 miles, say from London to Sheffield.”^{1, 3, 1, 4}
Smith adds, “All of the patients I’ve spoken to about the carbon footprint of their inhaler said they’d be delighted to change. After all, air pollution causes enormous problems for asthma patients, so they understand the importance of looking after the environment.”
And that’s the thing: it’s not about weighing up planet versus patients. “Reducing prescribing, for example, is good for patients, as it reduces the risks of side effects and it’s good for the planet. So, it’s win-win,” says Smith.
Where MDIs are still needed, many practices are working on establishing “green disposal” schemes for patients to recycle them in an environmentally friendly way.

Practise what you preach

Another major contributor to a general practice’s carbon footprint is travel. Sawyer explains, “From the work I’ve done I know that, if you add up the distance travelled by patients and staff in a large practice, it’s about 100 000 miles a year. And in [carbon footprint expert] Mike Berners-Lee’s latest book, How Bad are Bananas? The Carbon Footprint of Everything, there’s a chart which shows that 3.5 minutes of life is lost by a surrounding urban community per mile you drive through it in a petrol car. So, for that large practice, it works out as nearly 250 days of life being lost.”

“Realising that the healthcare you’re providing causes harm is galling,” says Munro Stewart, a GP and representative for the RCGP on climate change and health in Tayside. But it can galvanise change.
The tactics GP surgeries are employing to tackle the impact of travel include installing charging points for electric vehicles, bike racks, and promoting active travel—be it cycling, walking, or running. Sawyer, who cycles to home visits, says, “It’s about being a good role model.”
The fact that GPs are seen as pillars of the community is one reason why many consider themselves well placed to lead the climate charge. “Patients believe in us,” argues Sivarajasingam. “As GPs we are educators. Every day we’re educating about exercise, or blood pressure, or depression. So, we’re in a perfect place to educate about climate change too.”
Indeed, in a recent survey doctors were considered to be the most trustworthy professionals,¹⁵ so if they talk about the connection between the environment and health, people are likely to listen. The beauty of the mission is that it becomes a whole team effort: Sivarajasingam says, “It brings everyone in the practice—clinical staff, admin staff, receptionists—together.”

Pandemic opportunities

For all the devastation covid has brought, Stewart believes that the pandemic could provide a golden opportunity. “I feel there’s a real window here while systems are changing,” he explains. “There have been some positives, like getting GPs rapidly skilled at telephone and video consultations.” These, he believes, could be built on where appropriate, to shrink practices’ carbon footprints.
Of course, time and money are two inevitable barriers for practices, and organisations such as Greener Practice are calling for funding to support their work and that of individual practices. In the long run it will pay off, says Kemple. “The whole point of sustainability is that you use less, you waste less, and actually that saves you money,” he says.
Karen Creffield is practice manager at Frome Medical Practice in Somerset, which is held up as a shining example of what can be done, having taken 85 green actions listed on its website.¹⁶ She notes that the practice saved £10 000 (€11 090; $13 610) in one year just from reducing its photocopying and printing.
And it’s not about having to do everything at once, says Sawyer. He recommends that practices work out their
carbon footprint and then chip away at it with, say, a 10 year plan. This can also help you dodge red herrings, he says—recycling being a common one. “When I’ve assessed the carbon footprint of practices, only about 0.1% of the footprint is waste,” he explains. “We cannot recycle our way out of the climate crisis.”

Once you get started, “virtuous circles” often develop, says Maria Read, a GP at Dovercourt Surgery in Sheffield. She set up an allotment at the practice to provide her patients, in a deprived area, with fresh fruit and veg. But she’s seen numerous other benefits for patient volunteers. She says, “Being out in the open, being productive, has meant that people in a community who feel disempowered begin to feel good about themselves. And they see the value in the natural world, as something important to save.”

Do no harm

Some nervousness exists about this responsibility being dumped on GPs’ shoulders, but Smith believes that it’s about staging a multipronged attack. She says, “If enough health professionals commit to decarbonising, and to making their voices heard about the climate and ecological crisis as an urgent health issue, it may become more and more difficult for governments not to listen.” She encourages GPs to get involved with their clinical commissioning groups, local medical committees, and RCGP faculties—anywhere that they can lobby for
change.

“Doctors sign up to a Hippocratic principle of doing no harm,” she notes, adding, “We also sign up to GMC [General Medical Council] duties to protect and promote the public health—and if we’re not taking that seriously, what kind of doctors are we?”

Three ways to grow a greener practice

Check out the Green Impact for Health Toolkit (greenimpact.org.uk/GIforHealth).³ It lists actions that general practices can take, from using a renewable energy supplier to fitting valves on taps to save water—all with the opportunity to be awarded for your work.
Visit openprescribing.net to see how your practice’s prescription data compare with others, to help assess opportunities to deprescribe or make lower carbon medicine swaps.
Head to greenerpractice.co.uk and sign up to the mailing list to join this community of green GPs. The site can also connect you with like minded practices in your area.

References

1. NHS England. NHS becomes the world’s first national health system to commit to become “carbon net zero”, backed by clear deliverables and milestones. 1 Oct 2020. https://www.england.nhs.uk/2020/10/nhs-becomes-the-worlds-national-health-system-to-commit-to-become-carbon-net-zero-backed-by-clear-deliverables-and-milestones/.
2. Royal College of General Practitioners. Sustainable development, climate change and green issues. https://www.rcgp.org.uk/policy/rcgp-policy-areas/climate-change-sustainable-development-and-health.aspx.
3. National Union of Students, Royal College of General Practitioners. Green Impact for Health. 2014. https://www.greenimpact.org.uk/GIforHealth.
4. Greener Practice. Healthy planet, healthy people. https://www.greenerpractice.co.uk/.
5. NHS England. Delivering a “net zero” National Health Service. Oct 2020. https://www.england.nhs.uk/greenernhs/wp-content/uploads/sites/51/2020/10/delivering-a-net-zero-national-health-service.pdf.
6. NHS. Air pollution “kills 40 000 a year” in the UK, says report. 23 Feb 2016. https://www.nhs.uk/news/heart-and-lungs/air-pollution-kills-40000-a-year-in-the-uk-says-report/.
7. Official UK government website for data and insights on coronavirus (covid-19). UK summary. 2020. https://coronavirus.data.gov.uk/.
8. National Audit Office. Covid-19 cost tracker. 2020. https://www.nao.org.uk/covid-19/cost-tracker/.
9. NHS England. Social prescribing. https://www.england.nhs.uk/personalisedcare/social-prescribing/.
10. NHS. Health trainer. https://www.healthcareers.nhs.uk/explore-roles/public-health/roles-public-health/health-trainer.
11. NHS England. Green social prescribing. 2020. https://www.england.nhs.uk/personalisedcare/social-prescribing/green-social-prescribing/.
12. Greener Practice. Inhaler switch. https://www.greenerpractice.co.uk/inhaler-switch.
13. Siva V. Hillview going greener—how we got our team on board? 14 Dec 2020. https://www.greenerpractice.co.uk/blog.
14. Green Inhaler. https://greeninhaler.org/.
15. Revealed: the 10 least and most trusted professions in the UK. HR News 2019 Aug 5. http://hrnews.co.uk/revealed-the-10-least-and-most-trusted-professions-in-the-uk/.
16. Frome Medical Practice. Sustainability—what we are doing. https://www.fromemedicalpractice.co.uk/sustainability-what-we-are-doing.