On July 10th Thornfields will hold its first Sustainability webinar led by expert and GP Dr Matthew Sawyer. A helpful overview of some of the issues we will cover was published by Victoria Vaughan in Healthcare Leader earlier this year.

Q. In October 2020, NHS England launched its Greener NHS programme and all ICBs have green plans. But do you think more is needed? 

MS: I’m not employed or accountable to Greener NHS, but I do keep saying ‘ primary care’ to them because I think they are missing a trick. ICBs have a green plan because all were mandated to have one. However, almost all of them are secondary care focused. There are very few with even a mention of primary care and, if they do, they really only talk about general practice.

The problem, I think, was that it was a bit of a rush job. They were told to get a green plan by the end of tomorrow and they’re like, ‘Oh, what are we going to do? I know, we’ll talk to the hospitals because they already have green plans and departments and people’. And so primary care got missed out.

Q. If primary care has been overlooked, what opportunities have been lost?

MS: I’m a GP by background – I was a GP partner then a salaried locum before I went back to university to do environmental science and environmental sustainability.

A decade or so ago, I realised that being a GP meant spending my time ‘fishing people out of the river’, rescuing them after they’d become ill.

Primary care does the bulk of patient contacts a year across GPs, pharmacies, dentists and so on. And so, I do think that we have a great opportunity in primary care to help structure some of the changes needed which in turn will help with the prevention agenda so that people don’t ‘fall in the river’.

Q. Are there examples of ICBs getting it right with primary care sustainability? And, if so, what are they doing?

MS: Some ICBs and PCNs are incentivising practices to do environmentally sustainable actions. For example, Gloucestershire ICB set 15 different environmental actions and they had an incentive scheme where practices chose three of them and there was some money that went with it to help them to do those actions. There were some around energy and estates, travel, medicines and inhalers. But there’s a lot of ICBs where primary care and environmental sustainability are not even on the agenda. 

Q. What can primary care do to be more sustainable? 

MS: The first is reducing activity. So, when it comes to prescribing, don’t prescribe if it’s not needed. From a sustainability perspective, the best thing is to prevent people from getting illnesses.

Second is the environmental impact of primary care. When it comes to the carbon footprint, there is clinical and non-clinical. There is a carbon footprint of the medicines that are prescribed and there are non-clinical carbon emissions, which are from running the practice – the energy, the gas, the electric, and the travel from patients and staff. And it’s not just carbon. There’s plastic, pharmaceutical pollution into waterways and all sorts of other environmental impacts, which can be quite hard to measure.

Then there are goods and services. For example, if you buy a minor surgery kit, how much of it is just going straight in the bin? So, we then need to be working with the suppliers to say, ‘Can you stop? We don’t use them so why are you putting them in a pack for us to buy? That doesn’t make any sense’.

And then there is how we can use our medical and health knowledge to influence things like how many fast-food chains there are. We may be able to use our knowledge and our experience to influence others to make decisions that are best for the community in the long run.

Q. Some of that is at a system level, then?

MS: A GP practice will not and cannot do these things on their own. That’s really where the system needs to change. It’s where the ICS, ICB, PCN and local authorities all come together and we need to get the staff, the patients, and the practices to be able to feed this back up to the ICS.

For example, creating low traffic neighbourhoods is better for social cohesion, there is less air pollution and it’s far better for kids getting into school. If you do it in towns, people are more likely to visit shops because they’re out walking rather than driving down the high street. And then we get other benefits such as money in the pockets of local businesses.

So, from a sustainability point of view, we can make the argument that if we improve travel and traffic options, we get lots of benefits. We’re not just doing it because it’s environmentally good to get people out of cars, but because the knock-on effects are even greater.

Q. What can individual practices do to be more sustainable?

MS: In general practice, we don’t always recognise that the way we do things might be environmentally harmful, or that it might be affecting our patients. And if a GP practice doesn’t recognise where the harm is coming from, they’re not going to make any changes.

So for example, I did a travel survey with a practice and asked staff how they got to work – how far they travelled and what mode of transport?  

Prof Mike Berners Lee has estimated how much time is lost from a human life by one mile travelled by different vehicle types. And in that one practice, we could calculate that the patients and staff who are travelling to either deliver or receive healthcare services took away about eight years of life from the community.

Then there are things like decarbonising the heating of a practice. If your boiler has got another 10 years of life left in it, use it for 10 years – then once you can’t use it anymore, go for the alternative. Using air source heat pumps and running it on electricity, rather than gas, makes a big difference to the carbon footprint.

Q. Primary care medicines account for most of the carbon footprint in primary care. How can practices help in addressing that problem?  

Rough figures are 48% of the carbon footprint of primary care – that is, general practice – is medicines and four areas – inhalers, energy, travel, and goods and services – are all 13%.

Yet everyone focuses on inhalers. If we’re putting a lot of effort into inhalers, we should be putting the same energy into reducing our carbon footprint in travel and goods and services.

We’ve known about the carbon footprint of inhalers because of the prepared gases, but we’ve not known it for medicines. Now we do because of an app that was launched about a month ago. Anybody can go online and have a look at the carbon footprint of an aerosol, a fibrate, a statin, antibiotic or whatever. You can see whether it’s low, medium, or high in terms of carbon footprint. 

Until now, we’ve only had clinical and financial data. So, this is just another piece of research that gives a bit more information. It means that we can start to say that if we have got something which is good for patients and it’s cheap – realistically, that’s the way that some of the NHS decisions are made – and it’s less harmful for the environment, then that medication is going to get three green ticks.

Q. Do you think that practices should be making prescribing decisions around this?

At the moment, the medicines management committee in an ICB are making decisions based on two bits of information – the NICE clinical guidelines and the financial indication. This is just a third piece. So that when it comes to the local guidance or regional guidance, it will be incorporated into that process of producing that formulary in the same way as we have now: this is your first choice, your second and this is your third choice on the formulary.

Q. The NHS set quite ambitious Net Zero targets. Do you think they will be met?

I think that if we continue to provide services in the way that we do at the moment, I don’t know that we will meet the targets.

However, if there’s a change of focus to say that this is not about disease, but about preventing people from getting the illness in the first place then that’s the most sustainable thing we can do and we have a very powerful opportunity to provide great outcomes for the whole population as well as individual patients.

And we can do it within the financial budget that the NHS is always constrained by, and without causing anywhere near as much harm to the natural living world as we are at the moment. So, I am optimistic.