Dr Emma Radcliffe on how general practice can be used to green the NHS
I have devoted a large part of the past 20 years of my life endeavouring to provide high quality health care to the community I work in: Tower Hamlets in East London.
However, my mind and working life has been increasingly dominated by two fights: one to protect general practice; and the other to protect the world in which we live. Many might see these two agendas as incompatible. The existential threat from which general practice is currently suffering obviously pales in comparison to the peril faced by the planet due to the climate and nature crisis. There are daily reminders of how urgent the situation is even if recording-breaking heat waves don’t top the UK news agenda.
However, if healthcare were a country, it would be the fifth largest emitter of carbon in the world. Therefore, as healthcare workers, we must take rapid and significant steps to reduce our carbon footprint and impact on the environment. I believe that general practice is key to this.
General practice as low environmental impact healthcare
As someone involved with the NHS’s net zero commitment (now embedded into law), I understand how the two agendas are aligned. Greening the NHS certainly involves innovation in clinical care, enormous changes to the estates, and a radical overhaul of the supply chain. However, we will only reach our net zero targets if we use resources wisely. Achieving the best outcomes for our patients and the planet, while reducing health inequalities, is at the heart of the general practice model and core to what we do. The majority of daily NHS activity happens within general practice and the community; yet primary care accounts for only 23% of the carbon emissions of the NHS. This means that general practice is one of the greenest parts of the NHS.
General practice is rooted in local communities. I know my patients well and this provides me with a great deal of job satisfaction. However, there is an abundance of evidence which shows how effective continuity of care is. Patients who receive continuity of care are: more likely to follow medical advice; more likely to take up offers of personal preventative medicine; less likely to need to go to A&E; less likely to need hospital admissions; have more cost effective healthcare and higher quality of management of long-term conditions; and have reduced number of prescriptions and tests. All these parameters are important for patient health outcomes and increase the efficiency of the health care system. But continuity also reduces the environmental impact of health care. It is therefore distressing to note that continuity is falling, with policies that focus on access at the expense of continuity contributing to this.
A report by the King’s Fund notes that: ‘The failure to grow and invest in primary and community health and care services ranks as one of the most significant and long-running failures of policy and implementation in the NHS and social care for more than 30 years. If this shift in focus does not happen, more expensive hospitals will need to be built to manage people with acute needs that could have been prevented or better managed.’
The environmental impact of the failure to invest in primary care and in particular, general practice, will be enormous as the shift will be to high cost, high carbon and highly environmentally damaging hospital care and this will widen health inequalities for our most vulnerable communities.
Promoting health and reducing demand
General practice delivers key health messages to communities. If we are able to invest time in talking to patients about healthier diets and being more active this could reap massive rewards both in terms of health benefits and financial costs but also environmental impact. As an example, diet related ill health costs the NHS and wider UK society £5.1billion a year. However, healthier diets also have considerably reduced carbon impact. General practice is well placed to advocate for benefit both human and planetary health.
One of the major principles of constructing an environmentally sustainable health service is to reduce demand. General practice is key to this by providing immunisation, contraception, screening programmes and disease management. Countries that do not invest adequately in primary care such as the US have extremely expensive and inequitable healthcare. The lack of access to primary care has contributed to inadequate prevention and management of chronic disease, delayed diagnosis and wasteful overuse of drugs and technologies.
Wasteful current systems
GPs are burnt out. We know the number of GPs is falling, and GPs are working fewer hours and leaving the profession. Each GP costs approx. £430,000 to train (and a further huge personal cost)… But every pound spent by the individual GP or the wider system also has an environmental impact. A system which is unable to make the most of a highly trained professional is wasteful. The benefits of continuity of care over many years aren’t fully maximised and the system has to invest more resources to replace those who might otherwise have worked longer.
The carbon footprint of general practice is dominated by medicines and prescribing. We know that polypharmacy causes huge problems and that there is an enormous waste of medicines – estimated to be around £300 million. It is therefore of paramount importance that a healthcare system looking to use its financial resources wisely and reduce its environmental impact should prioritise medicines. There are effective interventions that general practice can make, but in a system under pressure it is difficult to prioritise routine review of medication over other equally pressing concerns.
Reaching net zero
The NHS has committed to become a net zero health service. It has tackled some of the easier ‘high carbon’ targets first e.g. anaesthetic gases. However, if it is to succeed overall, I believe we must address some of the fundamental issues of how and where care is delivered.
I do not have to choose between fighting for the planet and fighting to save general practice. General practice is one of the greenest parts of the NHS, and it has the potential to help the UK healthcare system reach its net zero targets. The current systematic destruction of general practice is leading to a more financially and environmentally resource intensive health care system – that is bad for patients and bad for the planet. I am advocating for saving and enhancing general practice because of my commitment to planetary health, not in spite of it.
Dr Emma Radcliffe is a GP Partner in London. She is also a Net Zero Clinical Lead for NHS North East London. You can find her on X (formerly Twitter) @emmrad
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“GPs ideally placed to save planet and take blame for climate change”. A spokesperson for the RCGP said that although they felt GPs were not solely responsible for the demise of the planet, they should have done more to avoid it.
“Net Zero Clinical Lead”. That there is even such a job title is unutterably depressing.