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Technical Case Study from Public Health Wales

Approach:

  • As healthcare accounts for an estimated 5% of global carbon emissions and the majority of healthcare is delivered in primary care, there is a need to engage the primary healthcare workforce in low carbon sustainability.  
  • The aim is to improve the health of local communities through primary care interventions that improve health and address climate change.
  • The Greener Primary Care Wales Framework and Award Scheme provides an approach  to enable primary care to take action against climate change by engaging the workforce, supporting, and rewarding primary healthcare workers to take action. Primary care is this context is described as the four contractor professions; general practice, community pharmacy, community optometry and primary care dental practice.
  • The Scheme includes a framework consisting of a series of environmentally sustainable and low carbon actions which can be adopted by primary care professionals. The framework is accessible on a digital platform where practice teams can identify actions and report implementation through uploading of evidence. The platform is hosted by SOS-UK which is commissioned by Public Health Wales.
  • Depending on the number of actions reported, the practice can achieve a level of award.
  • The Scheme supports adoption and spread of best practice through case study generation.

Why take action?

Conference photo
Members of the Greener Primary Care Wales team at the NHS Welsh Sustainability Conference and Awards 2024. From left to right: Martin Naughton, Angharad Wooldridge, Rebecca Williams Howells, Sian Evans. © Greener Primary Care Wales team: Photo by: Sian Evans

This case study highlights how a workforce engagement intervention has been developed and implemented to support low carbon healthcare in Wales.  Engaging and motivating the health care workforce in adopting low carbon practices is critical to progress towards health system decarbonization.

Healthcare demand continues to increase, fueled in part by the impact of the COVID-19 pandemic. Primary care is at the forefront of healthcare - it delivers the largest proportion of health and care in Wales and internationally, while facing critical workforce pressures. Therefore, engaging primary care staff in delivering low carbon care is crucial for the success of national decarbonization efforts.

The Greener Primary Care Wales Framework and Award Scheme offers practical steps that can be adopted by primary care practices to reduce the emissions in their workplace. It was developed to engage the primary care workforce to become more environmentally sustainable. By acting together, primary care practitioners can contribute significantly to the reduction of carbon emissions and improve the health of their local population. 

The intervention was designed to make it as easy as possible for the workforce to take action, based on the four EAST principles of behaviour change - easy, attractive, social and timely. Award schemes that offer recognition for specific actions are generally known to enhance workers’ engagement and motivation.  Examples from across Wales and the UK show how award schemes can be successful in engaging businesses, clinical and non-clinical staff in adopting and sustaining practice changes. Examples of other successful award schemes operating in the UK include Healthy Working Wales and a variety of SOS-UK led green impact award schemes. 

Key messages

  • The healthcare workforce, including primary care staff, have a significant role in taking action towards low carbon sustainable healthcare, and leading by example.
  • Engagement of the workforce involves increasing knowledge about climate change and its impacts on health, identifying and creating opportunities for action and harnessing motivation. This will bring about long-term sustainable behaviour change and practice.
  • A climate aware workforce can lead to climate conscious patients which will bring about co-benefits for health and the planet.
  • National schemes that promote and reward action are an effective intervention to engage and motivate the workforce in adopting environmentally sustainable and low carbon health care practices. Ultimately, this can help to:
    • Reduce carbon and other greenhouse gas emissions from healthcare.
    • Improve the quality of patient care.
    • Improve collaboration in health care teams.
    • Improve health care workers’ occupational well-being.
    • Reduce costs in health care facility operations.

How to get started

Public Health Wales identified climate change as an emerging threat to health in 2017.  The Health and its determinants in Wales report (2018) describes how the projected changes will have implications for health.  In 2019, the Welsh Government declared a climate emergency for Wales to increase focus on the challenges presented by the climate crisis and drive action. Wales has a legally binding target to deliver net-zero emissions by 2050, alongside an ambition for the public sector in Wales to be collectively net zero carbon by 2030. Decarbonizing the NHS in Wales is a critical component of this journey and a huge challenge.

In 2021 the NHS in Wales published its first Decarbonisation Strategic Delivery Plan, setting out a plan for reducing the environmental impact of the NHS and addressing climate change. A Health Impact Assessment on the health and wellbeing impacts of climate change across Wales, published by Public Health Wales in 2023, further reinforced the health argument for climate action. The link between climate change and health has been a useful lever to engage the workforce to take action and realize carbon saving potentials as well of health co-benefits.

The general process of developing the Greener Primary Care Wales Framework and Award Scheme is outlined here, and key learnings are summarized below.

About the Greener Primary Care Wales Framework and Award Scheme

The Greener Primary Care Wales Framework and Award Scheme was developed by Public Health Wales and launched in June 2022. It is designed to support general practices, community pharmacies, dental surgeries, and optometry practices to take environmentally sustainable actions, including climate change mitigation measures.

The Scheme consists of a suite of clinical and non-clinical actions, agreed by an Expert Group and accessible via a digital platform hosted by SOS-UK. The Expert Group consists of a wide range of over 30 stakeholders including Welsh Government, professional bodies representing general practice, community pharmacy, optometry and dental practices in Wales and users i.e., practices. Each action is accompanied by further information and resources to help with implementation. Practices self-select which actions to complete and one point is achieved per completed action, measured by an audit at the end of the year. As the number of actions completed increases, so does the level of award achieved (from bronze, to silver and gold). Many actions are climate change mitigation measures, in line with the NHS Wales Decarbonisation Strategic Delivery Plan. They also include action for adaptation and planning for access to primary healthcare services in the event of service failure due to adverse events, such as extreme weather. 

The following categories of actions are included in the Framework:

  • Adaptation: The practice has a system in place to inform and alert patients about access to the practice and/or information about self-care in the event of extreme weather or disaster affecting the practice.
  • Buildings and estate: The practice adopts, wherever possible, the use of energy efficient lighting options.
  • Carbon management: The practice has a Green/Environmental Sustainability policy in place, has put it into practice and communicates this to its practice staff and wider multidisciplinary primary care teams.
  • Healthy behaviours: The practice promotes physical exercise and active travel to patients, staff and the wider MDT and promotes a culture of physical activity and role modelling through a range of everyday activities.
  • Procurement: The practice preferentially buys sustainable stationery and office consumables.
  • Transport & smart working: The practice carries out an annual staff travel audit for members of the practice team.
  • Waste: The practice preferentially buys rechargeable batteries as opposed to single use batteries to minimise its waste. Where this is not possible, single use batteries are recycled appropriately.
  • Professional specific: The practice reviews and takes action to increase the proportion of dry powder inhalers (DPIs) and soft-mist inhalers (SMIs) prescribed compared to metered dose inhalers (MDIs), where clinically appropriate.

The scheme has been developed in partnership with the charity Students Organising for Sustainability UK (SOS-UK) who will manage its use and train Welsh University students to become auditors of the evidence submitted by practices.  

A short animation provides a helpful overview of the Scheme:

Key learning: Engaging stakeholders

  • The scheme is the first of its kind in Wales and is delivered in partnership with SOS-UK Green Impact. A stakeholder mapping exercise was helpful in identifying the stakeholders to engage with and to what extent. The Expert Group was established from the outset and was one of the main methods for stakeholder engagement.  The Expert Group have also been invaluable in cascading information to their networks. As a result of engagement, the Scheme has been endorsed by several professional bodies. Obtaining endorsement from professional organisations and other key stakeholders in Wales has been instrumental in shaping the Framework, promoting the Scheme to their workforce, and leveraging partnerships for delivery.

  • In Wales, primary care contractors operate as independent businesses contracted via health boards (often regarded as outside of the NHS). The need to focus the scheme on primary care was reinforced by the NHS Wales Decarbonisation Strategic Delivery Plan which calculates the carbon footprint of NHS Wales based on data from hospitals only, without considering the impact of primary care. Engagement with Welsh Government has meant that primary care will now feature it the review and update of the NHS Wales Decarbonisation Strategic Delivery Plan expected during 2026.
  • Opportunities to promote the Scheme to engage stakeholders ranged from written newsletters (internal and in other organizational newsletters), presentations to small local groups and national conferences, use of press releases around the time of the annual relaunches and editorials in peer review journals.
  • Having three Welsh Government Ministerial endorsements for the Scheme helped with national stakeholder buy in. These endorsements can be viewed on Primary Care One. 

Key learning: Sharing best practices to scale and spread

  • Practices have approached implementation of the actions in the Framework in different ways.  Collecting case studies from participating practices was helpful in providing practice advice about where to start, what could be achieved and sharing the learning.  These were presented as a report (Yearbook) and a series of video case studies.
  • The Greener Primary Care Wales 2022 Yearbook was developed to share examples of practice and celebrate the successes of practices involved in the Scheme during the first year. It contains a collection of practical case studies to inspire others to register and take action. This publication is used widely to promote the Scheme and features in all presentations delivered. The Yearbook is available on the public facing Primary Care One webpage.
  • A series of short video case studies, one for community pharmacy, dental, optometry and general practice provide further examples of best practice. They feature a walk through each different practice highlighting the actions implemented by the workforce showing the viewer what could also be achieved in their practice.
  • Applying to be a part of the Bevan Commission Exemplar programme at the same time as developing the Scheme provided an opportunity to sharing of ideas and suggestions of how to spread and scale the intervention.

Key learning: Tailoring engagement to diverse practice settings

Public Health Wales investigated what was being implemented elsewhere across the UK and found the RCGP Green Impact Toolkit. Through collaboration with RCGP, it was decided that the RCGP Green Impact Toolkit would require significant modification to go beyond general practitioner (GP) practices in England, aiming to include all primary care contractors regardless of setting and to stimulate local cross-professional collaboration. As a result, the bespoke Greener Primary Care Wales Framework and Award Scheme was developed.

The steps taken to develop the tailored Scheme for Wales included:

  • Partnership arrangement with SOS-UK to collaborate to develop and host the digital framework. This has involved a small cost to SOS-UK for their support and hosting of the framework as part of their UNESCO award-winning Green Impact programme designed to support environmentally and socially sustainable practice within organizations.
  • Review of the RCGP Green Impact Toolkit and identification of relevant GP practice actions which could be adopted with their permission for inclusion in the framework.
  • Establishment of the Expert Group, to review and inform the proposed actions.
  • Alignment to Welsh Government policy for climate change and health and care.  
  • Access to funding through the Welsh Governments’ Health and Social Care Climate Emergency national programme to support a range of activities and products to support the promotion and implementation of the Scheme.

 

Greenspace
Team members from Talbot Road Dental practice enjoying the newly created ‘green space’ for staff to enjoy time outside during their breaks. ©Talbot Road Dental Practice colleagues: Photo by: Janette Harrison.

Key learning: Aligning actions with existing policies

  • Many of the actions in the Scheme support local implementation of national and international policy, strategy and legislation. Aligning the actions to national drivers, including the Well-being of Future Generations Act (2015), A Healthier Wales, Prudent Healthcare Principles and the UN Sustainable Development Goals , provided a policy context for the inclusion of these actions in the Framework.
  • The Scheme supports the Just Transition to Net Zero Wales commitment.
  • Existing targets helped mobilize health care workers in the Scheme: the NHS Wales Decarbonization plan requires a reduction in emissions of 16% by 2025 and 34% by 2030 in the health and social care sector. These targets helped with engagement and motivated practices to get involved.

Key learning: Enhancing visibility through high-level endorsement

Multiple high-level endorsements enhanced the Scheme’s visibility among the health care workforce and added legitimacy to the environmental sustainability and low carbon work in health care. It also unlocked the availability of resources and funding. Endorsements included:

Key learning: Accessing funding streams

  • The initial framework and Award Scheme were developed with existing/minimal resources in Public Health Wales.

  • A grant of approximately £12,500 was provided to SOS-UK to support the development of the Framework and initial annual operational costs which includes the audit element of the Scheme. This was provided by Public Health Wales. There is a recurring annual cost of approximately £12,000 for ongoing support provided by SOS-UK.  
  • Approximately 1.2 WTE/FTE staff capacity was identified at the start (provided across several team members at different grades and skills) to support the development, launch and annual operation of the Scheme. Although this has reduced slightly as the Scheme is now developed, staff capacity in the region of 1 WTE is still required to support the Scheme.
  • Accessing additional funding from the Welsh Governments’ Health and Social Care Climate Emergency National Programme in 2022 and 2023 allowed Public Health Wales to develop and test methods to facilitate the scale and spread of the Award Scheme.
  • Public Health Wales received £5000 funding in 2022 to develop the Yearbook and animation and a further £140,000 funding in 2023/2024 to invest in several initiatives. Through this funding the following was made possible:
    • The testing of a six-month local health board sited Champion pilot (7 across Wales) to promote the Scheme locally;
    • The development of collateral to support the Champions;
    •  Gathering behavioral insight exploring enablers and barriers to participating in the Scheme;
    • The development of a bespoke carbon calculator tool to perform modelling and calculations of carbon and financial savings associated with the actions in the Framework.

This has enabled further development of the Scheme to be responsive to the needs of the Scheme’s audience and facilitate climate change action in practice.

 

Awards
Members of the Greener Primary Care Wales team at the NHS Welsh Sustainability Conference and Awards 2024. From left to right: Sian Evans, Angharad Wooldridge, Rebecca Williams Howells. © Greener Primary Care Wales team: Photo by: Rebecca Williams Howells.

Tracking progress

The first two years of the Greener Primary Care Wales Scheme (2022/23) and 2023/24) were reviewed and reported to inform subsequent years.  The review was based on quantitative data about raising awareness, education and implementation of the intervention and formed part of the participation in the Bevan Exemplar programme.  Qualitative data harvested opportunistically was also used to inform the review.  A case study and poster was published as part of the Scheme’s involvement with the Bevan Commission exemplar programme, which highlighted the following outcomes from the first year:

  • The objective of 5% of professional contractors across Wales registering with the framework was achieved ahead of schedule by early August 2022.
  • General Practices were by far the most engaged contractor type, with over 14% across Wales registering.
  • Around a third of registered practices recorded progress against actions via the digital platform.

The review of the second year was based on a framework of awareness raising, advocacy and action and the report is available upon request. At the time, data on results of GHG emissions reductions of all the actions in the Framework were not available.  SOS-UK however reported that practices participating in the first year of the Scheme saved an estimated 44,088 CO2 this year, as a result of the actions SOS-UK could assign carbon savings values to. The actual savings are estimated to be far greater.  An exercise has been implemented to assign carbon calculation savings to all relevant actions in the Scheme. This information will be available via Primary Care One in the summer 2024. 

In practice

The Greener Primary Care Wales Scheme is conducted on an annual basis. It is launched early each calendar year and primary care practices submit their progress in the Autumn, which is then audited, and awards granted. Year 2 and 3 saw many practices returning to increase their award level, as well as new ones enrolling in the Scheme for the first time. Participation in the Scheme is currently voluntary, but we are working to influence a mandate for participation through national contract reform negotiations. Public Health Wales are working with health boards and healthcare provider groups in Wales to embed this practice in their delivery of 3-year plans.

At the end of its first year, over 100 teams across Wales and all four contractor settings consisting of 162 individuals had registered with the Scheme. A similar uprate was reported for year 2 including collaboration with a large multiple community pharmacy chain who rolled it out to all 99 community pharmacies in Wales. Over 2300 actions were reported to have been implemented during the first two years of the Scheme. The early adopters have helped raise awareness of the Scheme and communicated the co-benefits for health of the planet and for their business. 

Public Health Wales is looking at a range of opportunities to embed low carbon practice where possible. For example, the primary care contracts via the annual contract negotiations, inclusion of specific clinical actions as national prescribing indicators and implementing these locally via incentive schemes, testing a model of a local primary care green champion and discussing how this agenda can be incorporated into the national NHS Planning Frameworks. 

The Scheme continues to attract a lot of attention. Public Health Wales continually seek feedback from the primary care workforce in Wales about how to spread and scale the uptake of the Scheme. This has involved identifying drivers on a national level for local practices to engage and gaining a better understanding of the enablers and barriers to engagement. This was via a survey launched in winter 2023 and a series of uni-professional engagement events planned for 2024. The findings are expected during the summer 2024 and will inform how primary care practice engagement is taken forward.

team award
The team from Nantgarw Road Surgery who recently received the Public Health Wales Greener Primary Care Wales Gold Award in 2023. Left to right: Dr Royal, David Rogers, Dr Bounds, Dr Rogers, Jan Ryzy, Liz Whitney, Anne Thomas. © Dr Gemma Rogers. Photo by: Staff at Nantgarw Road Surgery.

Key resources

 

More information

For more information, please contact greenerprimarycare@wales.nhs.uk

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