10 point green plan for practices

In October 2020, the NHS published the Delivering a Net Zero National Health Service report which set ambitions on reaching net zero for emissions controlled directly by the NHS by 2040, and for emissions influenced by the NHS by 2045.

This 10-point plan has been developed by the Lancashire and South Cumbria ICB alongside primary care colleagues, to help guide practices to reduce their environmental impact in line with the NHS’ net zero ambitions. For feedback and/or suggestions, please contact allison.sathiyanathan@nhs.net.

The plan is outlined below. Actions can be delivered in any order, so please customise to best suit your practice.

Whilst the idea of reducing your environmental impact may seem daunting, every positive change you make, however small, will bring benefits to you, your practice, your patients, and our planet, both now and for generations to come

This will demonstrate to both staff and patients that the practice takes their health and future seriously.

  • Create a statement to put on your website, feature in your newsletter, and share on social medi

  • Keep the climate crisis as a standing agenda item which features on every practice meeting.

  • Join your local Greener Practice group – (Lancashire & South Cumbria Group to be established).

  • Embed sustainability in your practice culture – view all existing and new projects/changes through the lens of environmental impact and choose environmentally friendly options wherever possible.

  • Attend your local Sustainability Network.

Metered Dose Inhalers (MDIs) make up a significant proportion of the greenhouse gas emissions from primary care, and so optimising asthma care and inhaler use, in addition to switching inhalers to lower emission equivalents, is a national priority.

  • Previously there were four Investment and Impact Fund (IIF) 2022/23 Indicators aimed at improving asthma care and reducing the environmental impact:
    • RESP-01 – Increase preventer inhaler use. Preventer inhalers are often low-emission Dry Powder Inhalers (DPIs) and improve overall asthma care.
    • RESP-02 – Reduce high usage of reliever inhalers (6+ prescriptions annually). In addition to the health risks associated with reliever over-use, reliever inhalers tend to be high emission MDIs.
    • ES-01 – Reduce the percentage of non-Salbutamol inhalers prescribed as MDIs.
    • ES-02 – Optimise prescribing to prioritise lower emission Salbutamol inhalers. i.e. consider a dry-powder option such as an Easyhaler or if an MDI is still needed, prescribe specific lower emission MDIs such as Salamol Easi-Breathe.

These indicators are still important markers for improving asthma management and reducing our carbon footprint.

  • Utilise the L&SC ICB resource pack, available at: LSC Respiratory Resources - Lancashire and South Cumbria Medicines Management Group (lancsmmg.nhs.uk) and the Greener Practice’s online High Quality and Low Carbon Asthma Care Toolkit, containing step-by-step Quality Improvement projects that correspond with the former IIF Indicators, with numerous helpful resources.
  • The ICB Resource pack and the Greener Practice both have a guide setting out key priorities and principles for low carbon asthma care, and include a handy crib sheet for easy reference and comparison of inhaler carbon footprints.
  • The ICB Respiratory Programme Medicines Optimistion Workstream now issue a Place-specific dashboard to help identify patients suitable for review who are prescribed particularly high carbon MDI inhalers (i.e. Flutiform MDI, Symbicort MDI, Ventolin Evohaler MDI).
  • Consider implementing Maintenance & Reliever Therapy (MART), as per the updated ICB Asthma Guidelines for Adults aged 17 yrs and over:
  • Asthma Treatment Guideline for Adults (lancsmmg.nhs.uk). By using a dual component inhaler, instead of single-components, this will reduce the number of inhalers needed by the patient and hence reduce the carbon emissions.
  • Consider environmental impact at each respiratory review.​​​​​​​
  • Encourage patients to return old or unwanted inhalers to community pharmacies for environmentally safe disposal, through reminders and posters available for promotion of the service.
  • At every opportunity, check inhaler technique e.g., using placebo devices. and promoting the Rightbreathe app and website.
  • Utilise Greener Practice resources as an educational tool for both patients and staff, including two informative videos.

By doing this, you can identify hotspots of non-clinical carbon emissions for reduction.

  • Free carbon calculator tool available from See Sustainability (option for low detail input available – please note this does not include carbon calculations for treatments or procedures).
  • Create a plan to target and reduce each hotspot identified, such as:
    • Swapping to an environmentally friendly stationery company. Practices can choose to sign up to access the NHS Supply Chain to access their frameworks.
    • Use yellow and black striped waste bags (known as tiger bags) for non-infectious clinical waste to reduce unecessary waste. NHS Property Services have a number of resources to support making sure all waste is disposed of correctly.
    • Reduce electricity costs from constantly boiling kettles by installing a boiling water tap and turning this off outside of working hours.
    • Save on water by labelling the appropriate flush to use with dual-flush toilets. For single flush toilets, Hippo Bags can be installed to save water with each flush.
    • Have a robust system for reporting facilities problems, i.e. leaky taps, such as having screensaver reminders for the process.
  • The SHAPE tool can be used to assist with data gathering on the patient population.
     

This will help to save money as well as reduce environmental impact.

  • Promote energy saving guides and pointers for staff and patients on saving energy both in practice and at home, such as the Energy Saving Trust or Get Energy Savvy.
  • Review your practice’s EPC/DEC for recommendations to improve energy efficiency, including projected payback periods.
  • Take steps to improve insulation such as using radiator backing and refreshing ceiling insulation.
  • Consider switching to a 100% renewable electricity provider.
    • NB: C&M ICB are currently working to get a cost-saving mass tariff arranged through NHS Property Services; however, this will take time so if you wish to please make the switch in the meantime.
  • Undertake an energy audit to find hotspots for energy use, for example:
    • Changing lightbulbs to LED.
    • Turning off monitors when not in use to reduce electricity consumption. This can be done automatically or on a timer (i.e. to turn off at 7pm)
    • Install PIR (aka magic eye or dawn and dusk sensors) for corridors and outdoor lights.
    • Turn off equipment such as air conditioners, heaters, when not in use.
    • Install heating timers.
    • Switching to one central printer instead of multiple smaller printers in one room.
  • When electricity use has been reduced as much as possible, consider installing solar panels or sources of renewable energy. This can be considered as part of estates contract renewals with the building landlord/s.

Greening your money is the single most effective thing you can do to reduce your personal or business impact on the climate crisis.

Approximately 48% of general practice’s carbon footprint comes from prescribing pharmaceuticals.

  • Consider non-pharmaceutical medical interventions such as green social prescribing or an increase in physical activity, bearing accessibility in mind.
  • Engage with the PCN DES Structured Medication Reviews (SMRs) , including signposting and collaborative working with community pharmacy. Polypharmacy: Getting our medicines right (rpharms.com
  • Identify options for preventative care wherever possible such as treating pre-diabetes through lifestyle changes to prevent diabetes.
  • Utilise the place-specific data to monitor the former IIF indicators to track progress, or sign up for bulletins on your practice prescribing trends at https://openprescribing.net/.
  • Share Healthcare Without Harm Europe’s Safer Pharma video with prescribers and patients.
  • Engage in a low waste prescribing approach:
    • Avoid overprescribing by reading the ‘Good for you, good for us, good for everybody’ plan from the Department of Health & Social Care.
    • Deprescribe where appropriate, following Royal Pharmaceutical Society medicines optimisation guidance.
    • Stop unnnecessary third party ordering.
    • Encourage patient-led ordering using the NHS App.
    • Raise awareness of, and encourage, recycling options such as:
      • Returning inhalers to pharmacies for safe disposal
    • Use Proxy Ordering for Care Homes to avoid unnecessary waste for care home residents.
    • For repeat medication, only issue 28 days supply or implement Electronic Repeat Dispensing. Ensure other prescription durations are appropriate for the course of medication required.
    • Check for medicine stockpiling where appropriate as part of home visits, see Dr Deb Gompertz’s talk for more information.
    • Encourage patients to check the bag whilst in the pharmacy when collecting their prescriptions to ensure they only have the items they ordered, to reduce medicine waste.
  • Continue remote consultations where appropriate.
    • Encourage care home staff to use iPads and RESTORE2 for remote care home consultations.
       

By increasing awareness and empowering patients, smaller actions can have a bigger impact. Keen patients may also be able to support implementing green actions at the practice and spread messages wider.

  • Discuss the climate crisis with your Patient Participation Group (PPG) and get them involved in practice actions as identified through discussion and carbon foot printing.
    • Encourage PPGs to take an activist approach to supporting with green actions, such as examples from this Plan or the Green Impact for Health Toolkit
    • Use PPGs to link with local climate or environment groups
    • Get in contact with your ICB for support, and to share successes widely
  • Share the series of 7 short videos on waiting room screens and social media to help promote patient awareness on the link between planet and health. YouTube links are also available for the videos.
  • Engage with your Social Prescribing Link Worker on green social prescribing schemes and discussing climate and health initiatives in your local care community group, including schemes run by your local Hospital Trust.
    • Set up green care community/PCN meetings to include social prescribers and other ARRS staff
    • Encourage balanced plant-based diets and activity for maintaining a healthy weight and reducing car use and improved physical and mental health. Free resources available from Plant Based Health Professionals UK.
    • Engage with and promote green community schemes such as community gardens, tree planting, gardening, and caring for wildflower areas. Contact your local borough Council for more information and support – ICB colleagues will have best contact details.
    • There are a range of organisations which have volunteer schemes running locally,
    • RSPB & NHS Scotland ran a Nature Prescription pilot and have shared their results (video also available) for evidence and testimonials about green social prescribing.
    • Nature on Prescription Handbook – European Centre for Environment and Human Health | ECEHH 
  • Include environmental rationale when prescribing treatment such as increased exercise, linking with active travel.
    • Ramblers Walking for Health have many local routes and social groups for patients and staff of all mobility levels.​​​​​​​
  • Promote self-care practices and education using ICB resources, to help improve overall personal and planetary health through healthy living.
  • For group education sessions, consider combining these with walking routes. A list of local walking routes/groups is available on the Ramblers website.

Active transport, also known as active travel, is any type of transport method which involves physical activity. For example, walking, wheeling or cycling.

  • Sign up to a Bicycle Lease scheme for staff and install bike lockers/secure shelters and changing facilities if required.
  • Encourage staff to walk or cycle to work where possible.
    • Testimonial from a Chester GP: About 2 years ago I gave up my car for work and got on my bike. The main reason was concern about the environmental and health impact of driving lots of short distances in a car and to see if cycle commuting and visits were a viable option. Since then, I’ve cycled to work every day and done home visits by bike or on foot. My GP bag clips on my bike rack, but a colleague uses a small backpack instead. The rainfall radar App on my phone helps me time showers if it's raining. After visits I come back to the surgery refreshed and energised. The look on patient’s faces when I turn up on my bike is always worthwhile and it means that I can truly preach what I practice. As well as keeping me fit I hope it inspires others to look at what is possible.
  • Be aware of local Council information on transport schemes available for residents.
  • Encourage patients to attend appointments using active transport as opposed to driving; explain the cardiovascular and respiratory benefits of this and encourage the adoption of active transport into daily life.
  • Consider installing Electric Vehicle charging points for cars and bikes at the practic
  • Get involved with the CHAMPS All Together Active strategy
  • Get involved with Active Lancashire with resources for both patients and staff.
  • Sign up to the RCGP Active Practice Charter – assistance may be available from Active Lancashire & MSP for eligible practices.
  • Review how well mapped your practice is on Google Maps – is the pin in the correct location, and are all cycle paths and pedestrian routes shown? If not, request for them to be added.

The ‘3 Rs’ is a simple mindset to adopt to help prevent waste.

1 – reduce the need to buy something new.

2 – if you can’t remove the need for the item, reuse or repurpose what you already have.

3 – at the end of the items life cycle, recycle it, and choose to buy easily recyclable items, or items made from recycled materials.

  • Reduce – consider alternative options rather than buying new items. This can also apply to consumption of energy and other resources.
    • Use scrap paper and paper clips instead of post it notes.
    • Reduce the number of blood forms which are printed – 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. i.e., use an old projector stand as a standing desk.
    • Revolution Zero reusable IIR masks were successfully trialled and adopted across the country
    • Warp It offer a way to find, loan or give away office equipment and other resources
    • Promote return and reuse of community equipment through local scheme, i.e. Trust schemes
  • Recycle – sort your recycling in house or sign up to a company who can sort off-site for you.

Developed by the RCGP using the NUS/SOS Green Impact web platform, the toolkit answers the question ‘What can I do in my practice?’ It gives the reason for the suggested actions and tips about how to make the change.

  • The toolkit is free to use at https://toolkit.sos-uk.org/greenimpact/giforhealth/login. You don’t have to complete everything at once (unless you want to) – you can dip in and out, and use the toolkits for useful examples and ideas for projects.
  • It contains 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! You may be surprised by how many things you are already doing.
  • An example of a quick change from the toolkit is switching your default search engine (i.e. Google) to Ecosia, which uses ad profits to plant trees.
  • The toolkit can be completed by volunteers; either formal volunteers, PPG members, or willing friends or family.
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