Prescribing, travel, infrastructure and equipment all key contributors to environmental impact of primary care services, says new report
The British Medical Association has laid out a plan to ensure GP services can become carbon neutral by the Government’s 2030 target.
The measures are outlined in a new report published this month, entitled Sustainable and environmentally-friendly general practice, which states that reducing the carbon footprint of GP services will not only help to mitigate climate change, but could ‘potentially improve patient health, reduce workload and save money’.
Key to this reduction, the publication states, is improving pharmaceutical prescribing, which, it is estimated, is associated with between 65%-95% of the total carbon footprint of GP surgeries.
The next most-carbon-intensive area is patient and staff travel (see below).
But the premises from which GPs practise is also coming under the spotlight, with widespread improvements needed to outdated buildings across the country.
The report states: “With added pressures on the health service and the ever-increasing carbon footprint on the planet, it is imperative that general practice evolves into a more-environmentally-friendly and sustainable service.”
The report lays out six priorities. They are:
This free toolkit supports practices to make environmentally-responsible changes.
Those which sign up are provided with an extensive list of actions that can be taken to make improvements.
There is also a ‘continuing improvement process’ for practice teams where points are collected, and awards made each year to recognise a practice’s positive achievements.
The report states: “Small and simple changes that a practice may not have considered can lead to significant carbon footprint reductions, and developing a checklist is an easy way to start making improvements.
“The next version of the toolkit will include a plan to help practices reduce the carbon footprint of the business side of their general practice by 50% by 2030, which is in line with the NHS commitment.
“Currently there are about 700 practices that are engaged with the programme and this has been achieved with limited promotion.”
The report calls on the pharmaceutical industry to take a range of measures to help reduce the impact their activity has on the overall carbon footprint of GP services.
Primarily these actions focus on labelling and inhalers.
With labelling, it says that GPs and other prescribers must be provided with information about the relative carbon footprint of the drugs that they prescribe.
With added pressures on the health service and the ever-increasing carbon footprint on the planet, it is imperative that general practice evolves into a more-environmentally-friendly and sustainable service
And, where more than one suitable option is available for a patient, prescribers require clear and helpful guidance on which of the options will be less damaging to the environment.
It adds: “A consistent methodology to assess the total environmental impact of all drugs is required and it would also be necessary to work with IT providers to ensure this is incorporated into all GP systems.”
The 2020/21 update to the GMS contract includes a goal for practices to reduce Metered Dose Inhaler (MDI) prescriptions as a percentage of all inhaler prescriptions.
Where it is clinically appropriate, says the document, ‘practices should be offering their patients the opportunity to make the switch to Dry Powder Inhalers (DPIs), which are considerably better for the environment’.
The BMA estimates that a 50% cut in the carbon footprint of inhalers would save 0.425MtCO2e, which amounts to 4% of the total carbon saving needed for the NHS to meet its 2030 carbon reduction target.
To support this aim, NICE has produced a patient decision aid and there is work being undertaken by the RCGP climate advisory group to develop quality improvement case studies and FAQs to help clinicians consider this switch with patients.
Overprescribing and waste is also being highlighted as an area for consideration.
The report states: “Pharmaceutical wastage is a financial burden on the NHS and has a negative environmental impact.
”Discouraging stockpiling and regularly reviewing repeat prescriptions can help to reduce waste and benefit patients by potentially reducing the number of medicines they take.
”Currently, any medicines that have left a pharmacy cannot be given to another patient even if they are unopened.
“The COVID-19 crisis has seen some relaxation of similar rules in secondary care and care homes and therefore DHSC should build on these emergency changes and review the current regulations concerning use of returned medication in unused packaging.”
And it guides medics towards online tools such as Medstopper, which could play a pivotal role if incorporated into GP practice IT systems.
The tool helps clinicians and patients make decisions about reducing or stopping medications.
By entering the list of medications a patient is receiving, it sequences the drugs from ‘more likely to stop’ to ‘less likely to stop’ based on three key criteria: the potential of the drug to improve symptoms, its potential to reduce the risk of future illness, and its likelihood of causing harm.
Suggestions for how to taper the medication are also provided.
Effective use of social prescribing has the potential to improve patients’ health and wellbeing while also reducing practice attendances and wider NHS use, says the report.
“For some patients, social prescribing may take the form of nature-based health interventions (green prescribing) which can be used to supplement orthodox medical treatments,” the report states.
Small and simple changes that a practice may not have considered can lead to significant carbon footprint reductions, and developing a checklist is an easy way to start making improvements
“Nature-based activities may lead patients into better health as well as into more pro-environmental behaviours and a general sense of environmental stewardship.
“Through social prescribing, GPs have the potential to lead patients into more environmentally-aware lifestyles.” <.p>
Social prescribing has been part of the GMS contract since 2019, with 100% of funding for access to social prescribers being paid for through the PCN DES.
However, to ensure that it is used to its full potential, social prescribing needs to be added as a default option to all GP IT systems, says the BMA.
Practices may also benefit from educational resources on the evidence for physical, psychological and social benefits of nature-based activities.
For most patients and clinicians, disposable medical instruments became the norm as a result of concerns about diseases such as Creutzfeldt-Jacob.
However, medical equipment and instruments are the leading contributor to the NHS’s carbon footprint and while their contribution is not as high in primary care, there is still room for improvement.
One way to address this part of the carbon footprint would be to return to the use of re-usable instruments, either sterilised onsite or by an external service in order to benefit from economies of scale.
This change would require significant work, however, not least in light of the current COVID-19 pandemic, to overcome resistance from the CQC, to establish environmentally and economically sound sterilisation processes, and to bring patients and clinicians along with the change.
The COVID-19 pandemic has encouraged practices and patients into finding alternatives to face-to-face consultations.
And, as both practitioners and patients become more familiar with the use of telephone and video consultations, many will want to continue to use both remote working and remote consultations beyond the lockdown.
Remote consulting can be appropriate for certain kinds of consultation and its use would reduce the need for potentially-environmentally-damaging patient travel.
A consistent methodology to assess the total environmental impact of all drugs is required and it would also be necessary to work with IT providers to ensure this is incorporated into all GP systems
“The pandemic has also shown that GPs and practice staff themselves do not always have to travel into work to carry out consultations, providing they have access to the suitable technology to work from home,” says the report.
”This not only has potential benefits in terms of carbon reduction but also promotes more-flexible ways of working.
According to the report, many practice premises will need improvements to make them fit for the future in terms of the service they provide to patients and the working conditions for clinicians.
In the BMA’s 2018 premises survey, only half of practices considered their premises to be fit for present needs and only 20% of practices felt their premises were fit for the future.
The report says: “The process for making these improvements should also consider those which would lead to a reduction in the practice’s carbon footprint (e.g. installing solar panels).
“The carbon emissions impact of these improvements needs to be properly assessed and appropriate funding provided.”
The report ends with a call to action, with GPC England asking the Government and NHSE/I to take immediate steps to support the implementation of a 10-pint plan ‘in order to ensure the impact of the provision of health services on climate change is reversed’.
The COVID-19 pandemic has also shown that GPs and practice staff themselves do not always have to travel into work to carry out consultations, providing they have access to the suitable technology to work from home
The 10 stages are:
1. Support the development of the Green Impact programme to ensure it covers all the clinical domains of sustainability change and that it is easily available to all GP practices
2. Develop and encourage uptake of carbon literacy training modules that support clinicians and other practice staff to make an action plan for carbon footprint reduction
3. The pharmaceutical industry must develop an independently-validated methodology to assess the total environmental impact of all medications
4. All medications must clearly display their carbon footprint. This should operate on the familiar red, amber, green (RAG) rating system and must be incorporated into the GP IT systems
5. A nationwide medication (including inhalers and devices) returns and recycling scheme to be introduced that is easily available for the public to use to reduce prescribing waste and the impact of inhaler propellants
6. IT system providers to incorporate validated deprescribing tools into the general practice operating system
7. Social prescribing to be considered a default option for management plans and for these to be incorporated fully into GP IT systems
8. Support and resource GP practices to return to re-usable medical equipment safely to reduce the carbon impact of disposable equipment
9. Promote and support more remote working for staff to decrease the carbon impact of travel
10. Invest in infrastructure and premises to make the general practice estate carbon neutral by no later than 1st of January 2030