10-step plan to greener primary care

Breaking the silence on the subject of the climate and ecological crisis, the risks to health, and the co-benefits of taking action is an important step. Making a decision as a practice, and declaring this, demonstrates your joint determination to address this emergency.

a. Create a statement to post on your website, feature in your newsletter, and share on social media.

• i. Climate emergency declaration guide available from SEE Sustainability

• ii. Sample wording for the declaration available from SEE Sustainability

b. Embed sustainability as a core organisation value. View all existing and new projects and changes through the lens of environmental impact and choose environmentally friendly options wherever possible.

c. Communicate your declaration to your landlord and begin a conversation about ways to work on sustainability together.

d. Communicate your declaration to your organisation links, like PCN, locality board and commissioning team to encourage others, work together and identify support.

e. Join other networks like Greater Manchester Greener Practice group as a support.

We are all in the climate and ecological emergency together. Sharing and engaging with all staff members can add energy and prompt some wonderful creative thinking.

a. Have a whole organisation event to highlight the issue. This Lancet Countdown video may be useful.

b. Listen to everyone’s ideas, start small and build on that to co-create a team green plan (see point 3 about including any patient group you may have).

c. Review the plan as a standing agenda item at all meetings. Maybe post your green plan on your website.

d. Appoint a green champion to link with other local organisations and attend events to inform the team.

e. Increase the knowledge of your team by offering this 30-minute e-learning programme on ‘Building a net Zero NHS’ as a starter for everyone. It could even become part of mandatory training. Discuss at annual appraisals whether someone would like to go deeper.

The RCGP has some further training and the Centre for Sustainable Healthcare offers great courses as well. CPD Match can be a great way of finding other suitable courses. 

Share your declaration of climate and ecological emergency with your patients and involve them in co-creating your practice green plan. This demonstrates to patients that your organisation takes their health and future seriously.

a. Discuss your Climate Emergency Declaration with any patient group you may have and consider ways of working together. 

b. Discuss projects you might be working on like, prescribing changes, or promoting social prescribing and work together to promote this (see point 6 about social prescribing).

c. Involve you patient group in doing a travel survey with other patients, and how to encourage the use of active transport (see point 8 about travel).

d. Co-create a resource of local exercise options. For example, Ramblers Walking for Health have many local routes and social groups for patients and staff of all mobility levels.

e. Signpost patients to Salford City Council’s Improve energy efficiency in the home for information if they are experiencing issues with energy costs.

Pressurised meter dose inhalers make up four per cent of the NHS’s total carbon footprint due to the propellant gases used in them. Changing prescribing to more environmentally friendly inhalers is arguably the biggest and quickest way primary care can reduce its impact on climate change. Asthma care can also be improved at the same time by reducing over reliance on SABA relievers.

Greater Manchester primary care and community pharmacy teams can access new resources. Other primary care teams like dentists and opticians may be able to help patients understand that reducing the use of pressurised inhalers and moving to dry powder inhalers can reduce the greenhouse gas effect of the propellant gases.

Nearly half of primary care’s total carbon footprint is due to medicines prescribing on top of the inhaler prescribing. Clearly, anything that can be done to optimise prescribing and reduce inappropriate prescribing and waste will have a big impact on this.

1. Ensure non-pharmaceutical medical interventions such as social prescribing and physical activity are embedded in the organisation.
   a. Sign up to become an Active Practice.
   b. Green social prescribing is growing in Greater Manchester. Contact Sophie Glinka sophie.glinka@nhs.net to see what is going on in your area.
   c. Try to ensure dietary advice is in line with Lancet EAT advice.
2. Focus on preventative care wherever possible, as opposed to reactive care, such as treating pre-diabetes through lifestyle changes to prevent diabetes, or good dental hygiene to reduce caries.
3. For general practice and pharmacies – engage with the polypharmacy reviews and deprescribing where appropriate, including signposting and collaborative working with community pharmacy.
   a. Follow Royal Pharmaceutical Society medicines optimisation guidance.
   b. Engage in a low waste prescribing approach:
   i. Deprescribe where appropriate
   ii. Stop unnecessary third party ordering
   iii. Encourage patient-led ordering using the NHS App
   iv. Raise awareness of, and encourage, recycling options
   v. Avoid unnecessary waste for care home residents and people living independently
   iv. Align script ordering to minimise journeys to collect/deliver medicines

Calculating your carbon footprint can be a really helpful way for you to understand where your practice’s carbon hotspots are, and so help you to identify areas to focus on.

1. A free carbon calculator tool available from See Sustainability focuses specifically on the business operations of GP practices (this does not include carbon calculations for drugs, treatments or procedures).
   
2. Review your plan to target and reduce each hotspot identified

The SHAPE tool can be used to assist with data gathering on the patient population.

1. Reduce use: look for simple easy wins, for example:
   a. ensuring appropriate settings on the boiler
   b. ensuring good insulation
   c. changing to LED light bulbs
   d. switching off or unplugging electrical items that have standby mode at the end of the day
   e. install motion detectors for lights in toilets and corridors
   f. consider heating system upgrades, including using air or ground source heat pumps
   g. For ideas on retrofitting your building, GMCA has some information
   h. Learn top energy saving tips from the NHS GM Salford General Practice Energy Reduction Project
2. Generate energy locally: Consider options for producing energy on site. For example, solar panels and battery storage, or if your site has the space, consider installing a small wind turbine. Greater Manchester Community Renewables can help install capital-free solar power. Find out more about installing solar power in our NHS Guide to Installing Solar Power
3. Buy sustainably: Change to a green energy supplier. Big Clean Switch is a renewable energy comparison site. Currently, the three greenest renewable energy suppliers are Ecotricity, Good Energy and Octopus.

It is estimated that about a third of the carbon footprint of primary care in Greater Manchester is due to travel. More active travel can also have big health co-benefits, like increasing exercise, reducing air pollution and increasing social interaction.

1. Conduct a travel survey with patients and staff and discuss the findings with the practice team and patient group, and create a plan to promote the positive impacts of active travel. A Healthier Greener Travel toolkit to support this is coming soon!
2. Consider offering a cycle to work scheme to encourage and support staff to cycle more. To find out more check out our Short Guide to Cycle to Work Schemes for Primary Care.

Where we spend our money and how we use our resources can have a big impact on our carbon footprint. This quick starter video, and some suggestions:

1. Strongly consider switching your business banking provider to a green bank. Greening your money is the single most effective thing you can do to reduce your personal or business impact on the climate crisis. And do tell your bank why you have done it.
   • Many banks directly invest in the fossil fuel industry and may have other unethical practices. Find out more about green and ethical banking:
     • www.moneyexpert.com/current-account/ethical-banking
     • www.moralfibres.co.uk/best-ethical-banks
     • www.ethicalconsumer.org/money-finance/shopping-guide/current-accounts
   • This can also apply to private pensions (although this does not apply to NHS pensions). To find out more, visit: www.makemymoneymatter.co.uk
   • To learn more about the importance of money and invested funds on the climate, watch this COP26 talk and film (about two hours in total).
     
2. Use a local stationery supplier to reduce transport costs, aim for 100 per cent recycled paper products, including hand towels and bed rolls (recycled paper has half the carbon footprint of virgin wood based paper), have no-print rules, consider re-usable equipment rather than disposable etc.
   
3. Swapping to an environmentally friendly stationery company. Organisations can choose to sign up to access the NHS Supply Chain to access their frameworks.
   
4. Ask suppliers and support services (eg accountants) if they have a green plan, and if not, why not.
   
5. Embed the ‘three Rs’ into practice culture – Reduce, Reuse, Recycle:
   • Reduce – consider alternative options rather than buying new items. This can also apply to consumption of energy and other resources.
     • Use scrap paper and paperclips instead of post-it notes.
     • Reduce the number of investigation request forms you print – save time and paper waste by saving forms electronically and only printing when the patient requests the form for collection or attends for their test.
     • This can also apply to office snacks – try opting for naturally wrapped treats such as satsumas, or snacks with compostable or recyclable packaging.
   • Reuse – consider how existing or second-hand items can be utilised.
     • www.revolution-zero.co.uk reusable IIR masks have been successfully trialled and adopted across the country.
     • NB: National free PPE suppliers have been contacted, and reusable options are currently being considered.
   • Recycle – discuss with your waste contractor to review your in-house recycling. Maybe that can be done off-site for you. Consider how to recycle hard-to-recycle items, such as:
     • Lotion tubes or pumps (Boots and Superdrug offer recycling schemes).
     • Printer toners using existing schemes such as:
       www.brother.co.uk/recycling (for genuine Brother parts, high quality items can be refilled and directly reused)
       www.zerowasterecycling.co.uk
       www.cartridges4charity.co.uk
       www.everycartridge.com
       www.officexpress.co.uk (requires purchase of toner through Office Xpress to become a customer)

Absolutely key, as we all know, is not only to start implementing a plan, but also to revisit it to monitor how you are getting on. The PDSA cycle can be a helpful way of looking at this.

More ideas for going further

1. Green Impact for Health Toolkit.
   • This super resource is laid out in a way that practices can review progress, and attain various levels of award. It is free to use.
   • There are many useful large and small ideas to follow and can be used as best fits the practice – many of which are included in this plan so you will be off to a good start in achieving an award.
   • The toolkit can be completed by volunteers; either formal volunteers, PPG members, or willing friends or family (know any bored students during school/university holidays?).
2. Keep your eye on the sustainability section of this site for local resources.
3. Talk to other primary care teams, hear what they are doing, encourage each other.
4. When thinking of commissioning or organising health services, consider using the framework of the 4 pillars of sustainable healthcare:
   • Prevention
   • Patient empowerment and self-care
   • Lean care systems
   • Low carbon alternatives
5. Once you have got going, you might want to revisit your plan, keeping your eye on the destination… getting to net zero by 2038 – the Greater Manchester Net Zero Goal.