Toolkit to Engage Primary Care Workers in Low Carbon Sustainable Care

Key learning: Sharing best practices to scale and spread

In the UK, General Practices operate as independent businesses managed via the NHS regional health boards. The GIFH toolkit is a way to reach these practices, allowing to promote and support their uptake of actions for low carbon sustainable care. Practices implement actions from the toolkit in various ways. Some use the toolkit's content as a checklist without registering, some register but don't record their actions, some register and record actions but don't submit for an award. Overall, about 10% of registered practices record their actions and submit for an award each year. NHS regions support raising awareness and implementation through various schemes, such as having a local green champion who promotes the scheme to local practices.

Key learning: Promoting co-benefits

The toolkit is a SusQI project (Sustainable Quality Improvement). Actions from the toolkit help GPs achieve multiple co-benefits, making the toolkit relevant to integrate into routine practice:

• Clinical care benefits

20% of the criteria are clinical and for the direct benefit of patients. Important clinical achievements include improved asthma care of patients, with reduction in the carbon footprint of their inhalers.

• Financial benefits

There are direct financial benefits for practices. Examples include reduction in utility costs. By auditing utility use, practices can expect to make 10-20% recurring annual savings on utility bills. General Practices in Cornwall reviewed their utility bills and on average saved £2,500 each per annum. If every practice in the UK saved only £1,000 each on average, that would amount to about £10m in recurring savings every year.

There are also financial benefits to the NHS, through the promotion of low carbon alternatives to medication. Examples include Green and Blue Prescribing, as well as tackling over prescribing, both of which help enhance patient outcomes and address causes of increasing prescribing budgets.

• Public health benefits

The toolkit promotes active travel for both staff and patients. Actions aim to both increase the physical activity of all whilst reducing the use of patient and staff car travel, which is a significant contributor to both carbon emissions and air pollution. The toolkit further raises awareness specifically within the practice and with patients around the issues of air quality.

Winning action example 1

In the Travel and Exercise category there are 4 criteria. One of them is:

WHAT? The practice carries out a staff travel audit consisting of home postcode, method of travel, distance from the practice, number of days worked. Total travel distance can be calculated. The practice discusses any barriers to active transport, shared transport or low carbon alternatives.

With the following further information for practices:

WHY? Staff travel is an important contribution to a practices carbon footprint. Understanding the travel patterns of staff can raise awareness about the benefits of active transport and help reduce their carbon footprint.

HOW? See SEESustainability's template for an audit of staff travel, PowerPoint on low carbon footprint travel and a staff travel survey and report of 400 staff from across primary care.

• Service delivery benefits

Since the toolkit is a SusQI project, most of the promoted actions have service delivery benefits.

Winning action example 2

In the Quality Improvement category there are 11 criteria. One of them is:

WHAT? The practice has reviewed the 'choosing wisely' recommendations to help reduce unnecessary tests and procedures. Clinicians incorporate the recommendations shared decision making into management with patients.

With the following further information for practices:

WHY? Choosing Wisely encourages clinicians and patients to discuss treatments to avoid unnecessary tests and procedures.

HOW? The Academy of Royal Medical Colleges host the international Choosing Wisely campaign. For example, PSA sampling is an expensive test where there is the risk that it might not be helpful to or wanted by the patient see  Gov.uk patient leaflet which is a patient information leaflet for Prostate Cancer Screening. By incorporating shared decision making into patient care, we may be able to reduce the number of over diagnosed procedures. Other useful resources are https://labtestsonline.org.uk/

What else? The GP Evidence website has been developed to make the scientific evidence underpinning guideline-recommended treatments easier to access and understand for practising GPs.

• Environmental sustainability benefits

There are over 120 actions in the toolkit that practices can and do take to improve their sustainability and reduce their carbon footprints.

For example, the propellants in inhalers are often 2-3000 times more potent greenhouse gases than carbon dioxide and account for 13% of the carbon footprint of general practices. More sustainable asthma care and disposal of used inhalers dramatically reduces the carbon footprint of practices and improves the clinical care of patients.

• Reducing health inequities benefits

Social deprivation is associated with poorer health. While the toolkit promotes better health care for all, one of the themes for action is ‘vulnerable patients’. This includes specifically taking steps to reduce barriers for migrants in accessing healthcare and making plans for those in fuel poverty and cold homes.

Winning action example 3

In the Governance category there are 2 criteria, one of which is:

WHAT? The practice has declared itself a Safe Surgery

With the following further information for practices:

WHY? Becoming a safe surgery is an example of a way a practice can demonstrate that they are striving to reduce health inequity. It means a practice is allowing people to register with a GP practice even if they do not have ID or proof of address. This means that their immigration status, housing status and language are not barriers to patient registration. Climate change impacts more on vulnerable individuals. Those least responsible for climate change bear the costs. In addition, ensuring people have access to primary care can give them the preventive care, family planning, antenatal care and better care that will save lives and reduce the costs to the NHS and the carbon footprint of poor care. The carbon footprint of disorganised, poor healthcare resulting in emergency hospital admissions cannot be ignored. How? Register to become a Safe Surgery with Doctors of the World UK and receive their information pack.

What else?  The direct and indirect impacts of climate change will widen existing health inequalities in the UK. Safe Surgeries recognise the barriers to healthcare access that exist and believe that small changes in practice can make a difference. They are willing to lead by example and work to ensure that nobody in their community is excluded.

• Workforce/staff benefits

The toolkit has positive impacts on the physical and mental well-being of healthcare staff, including increased team working (helped by the design of the web platform), increased morale (through positive feedback, the awards scheme and group activities prompted by the toolkit), and reduced car travel but more active travel (through the actions in the toolkit).

Winning action example 4

In the Learning category, there are 11 criteria. One criterion is:

WHAT? Staff are encouraged and supported in the habits that promote better health e.g. to stop smoking.

With the following further information for practices:

WHY? The NHS is an anchor institution and employs many staff from our local communities. Supporting the health and wellbeing amongst staff has never been more important. There is also an opportunity to create a shared sense of purpose amongst staff to become role models and work towards better health for all.

HOW? Some regions may already have schemes that support this such as the Better Health at Work awards, but there are specific or smaller steps that staff can work towards. Examples include becoming a Park Run Practice, and becoming RCGP active charter practice or smoking cessation - October is the perfect month to start this actions thanks to the NHS's 'Stoptober' campaign.

Key learning: Accessing funding

• The initial framework, Award Scheme, and evaluation were developed with minimal resources from RCGP (£500).
• RCGP provided a grant of about £10,000 per year to SOS-UK to cover annual operational costs, including the audit part of the toolkit.
• Currently, there is no funding for the volunteers who manage and update the toolkit content. If funding became available, one full-time employee (1 WTE) would be needed to support the toolkit.
• Some Regional NHS Health Boards and other organizations provide local funding to support their Green Plans for general practice and use the toolkit to raise awareness and implement environmental actions.