Updated 4 May 2022
‘Going green’ is a common phrase these days but what does it mean for GP practices?
Improving environmental sustainability is being promoted across society, from individuals, businesses to whole nations. It covers topics including climate change, greenhouse gas emissions (GHGs), impact on plants and animals and wider wildlife, water use, plastic waste and many others. How healthcare is delivered affects the living natural world around us.
GHGs from the activities of mankind are well recognised to be driving climate change. They include carbon dioxide, methane, nitrous oxide and fluorinated gases. GHGs are often rolled into a single figure – the carbon dioxide equivalent or CO2e – for convenience and to compare different activities.
Legislation in the UK (Climate Change Act (2008)) sets a goal of net zero carbon emissions by 2050, with a Climate Change Committee reporting on progress.
Importantly for GP practices, an NHS England report published in 2020, ‘Delivering a “Net Zero” National Health Service’ declared the NHS as the first health service in the world with Net Zero ambitions.
The undoubted health impacts of the climate emergency are going to severely test healthcare as poor environmental health contributes to many major diseases. However, healthcare itself affects the natural world – the NHS is responsible for around 4% of total UK greenhouse gas emissions.
We can instigate change in our practices to improve the care of our patients, and reduce the environmental impact – but what are the financial costs? While some measures will require investment up front, there are payoffs in the medium and long-term for both your practice and the wider health economy.
Here are some cost effective steps you can take to improve your practice’s green credentials:
Every time we see patients, use energy, procure kit and equipment and so forth, greenhouse gases are emitted from their manufacture, distribution, use and disposal. Generally, using ‘stuff’ generates GHGs and costs money. If we can successfully decarbonise while improving patient care, we make a positive impact on the environment and even save money at the same time.
For me, this is about investing in the future of the practice. Any savings should be put into a greener investment fund for the next sustainable purchase, which in turn saves more money for a bigger investment fund.
In November 2021, a carbon footprint calculator was launched for practices to measure their own nonclinical emissions. The calculator covers the main hotspots – energy use, travel (staff and patients), and the use of goods and services – and is specific to a GP practice. The results provide a baseline for implementing a practice decarbonisation plan. The calculator is quick and free to use, and the exercise can be repeated, so you can see the impact of actions the practice takes.
UK Government figures suggest that the average small business could reduce its energy bill by 18-25% by installing energy efficiency measures, with an average payback time of under 1.5 years.
The savings from simple behaviour changes can be significant. And this can be achieved by investing in your staff and enabling pro-environmental behaviours.
Setting up a ‘green team’ to turn off unused equipment when the surgery is closed is a great way to start. Leaving a single machine on standby overnight may only cost about £10-20 per year, but if the practice has 20 computers, 20 printers and a photocopier, the potential savings from switching everything off at night soon add up. Turning equipment off also extends the lifetime of the item, meaning less frequent replacement costs.
Overall, Barts Health NHS Trust’s change project, Operation TLC, saved £100,000 and 800 tonnes of CO2e in one year. GP practices are much smaller operations and vary considerably in terms of size and building age, but in general the more wasteful, the bigger the savings from behaviour change. The Carbon Trust estimates that investing 1-2% of energy spend in staff awareness can result in a 10% reduction in energy bills.
Anecdotally, one practice recently calculated it was spending about £20 per year for each socket used with equipment left on standby. It used an electric usage monitoring socket that can be bought cheaply online and are simple to operate. The practice had 50 sockets left on, so is now looking at saving around £1,000 per year by switching equipment off out of office hours.
Another practice recently reported it saved £2,500 last year on annual fuel bills through ‘intelligent building management’ – basically, controllingheating more carefully and installing glazing that reduced overheating in summer. This resulted in a 38% reduction in its gas bill and 6% reduction in its electricity bill, along with staff behaviour changes that led to a 10% overall reduction in energy costs. These savings were achieved despite a 10% increase in unit energy prices. Recent energy price rises help reinforce the adage that, ‘the lowest cost kWh of electricity is the one that isn’t used’.
Investing in technology can reduce energy use and save both money and emissions.
Heating of space and water is both expensive and carbon intensive. Decarbonising this is vital to achieve ambitions of Net Zero. The Government has committed to phasing out installation of natural gas boilers in all newbuilds over the next few years and switching to much more efficient air (or ground) source heat pumps. If run from renewable electricity sources these can also be carbon neutral.
Heat pumps are relatively expensive to install. The Government’s Non-domestic Renewable Heat Incentive programme is now closed. If the practice is part of NHS Estates, then there is Salix funding available for public sector decarbonisation. Additionally, for energy reduction projects, there are different projects in different parts of the country. For example, in County Durham there is BEEP. It depends where the practice is located as to what may be available. There are other funding sources for different aspects of environmental sustainability. Zero Carbon Business provides a comprehensive list. However, not all funding is available in all places.
The NHS report, Estates ‘Net Zero’ Carbon Delivery Plan, published in August 2021 has four key steps that practices can follow:
The Energy Saving Trust provides lots of tips on installing efficient lighting and heating technology, as well as appliances. For example, installing light or motion sensor light switches and phasing out old light bulbs will soon pay for itself through extended life of the equipment and lower energy bills.
It has become harder to switch to a renewable energy source supplier such as Good Energy, Octopus or Ecotricity since the energy crisis in 2021 and 2022, but when available, they may give you a competitive tariff leading to savings.
Expert on carbon footprinting Mike Berners-Lee calculated that for each mile travelled across a town or city, between 3.5 and 12 minutes of life is lost in the surrounding community, depending on type of fuel used. This is primarily due to particulate matter and nitrogen dioxide emissions.
A simple but effective way to tackle this is to promote active travel – it costs the practice almost nothing, improves the health of the individual and reduces damage to the community.
For staff, it can help build team relationships as well as save them money on fuel,which is a huge benefit considering the recent fuel cost crisis and concerns this is part of a long-term trend.
Simply highlighting that nationally 83% of journeys of under a mile are taken by foot can encourage both patients and staff to do the same since it helps normalise walking as the best mode of transport.
Identifying real and perceived barriers to active transport is a useful exercise. Practices can help overcome these barrier by offering salary sacrifice schemes for buying bikes, as well as installing a cycle rack or store for both staff and patients. A spin-off co-benefit is that practices that act in an environmentally responsible manner tend to be more attractive to new recruits, which in turn improves the calibre of talent they bring in and staff and morale.
Patients are also increasingly aware of their GP practice’s environmental impact, in terms of resource use and treatments such as inhalers.
Studies have shown that electric vehicles should produce lower emissions than fossil fuel vehicles over their lifetime, if charged from renewable energy sources. Promotion of e-bikes to staff can make cycling a more viable option for many people especially in hilly locations. They are the most energy efficient mode of transport – even better than walking!
For inner-city practices, switching to electric vehicles for home visits will avoid city congestion charges. In addition, practices can currently benefit from reduced tax and National Insurance contributions on electric cars. The workplace charging scheme also provides financial support to install electric car charging stations on premises.
Cutting down on paper use is an easy way to make savings. Less paper means less printing – saving printer cartridges and electricity – and less waste. Reusing a laser toner cartridge through a return and refill scheme saves 2kg CO2e per cartridge and up to 90% on the costs of printing.
Switching to recycled paper will cost the same as using virgin paper, but will more than halve your CO2e burden, as it uses 50% of the resources and energy to produce and cuts the amount of used paper going for incineration by 20%.
Paper-free options have increased in practices during Covid-19 with electronic prescribing, emailing of sick notes and more digital sharing of information. Practices should aim to make this standard practice where possible.
Reducing waste starts with examining what is bought in the first place. Practices that adopt the ‘waste hierarchy’ approach – aiming to first reduce, then reuse, recycle, recover or lastly dispose of waste – and put in place proper waste segregation will reduce overall waste disposal costs, largely through buying wisely in the first place. For example, using reusable masks, changing hand towels to electric dryers, and avoiding single-use disposable medical equipment all reduces waste.
Since the Covid-19 pandemic, some practices have reportedly stopped using couch roll, because infection control measures now require chairs and couches are wiped down in between patients.
One practice is exploring a contract with its local hospital Sterile Services Department to autoclave reusable pieces of medical equipment such as speculums. Depending on the volumes of equipment used, this can be more cost effective for the practice than purchasing and disposal of single use equipment.
Increasing demand for sustainable procurement will also influence change at supplier level, resulting in a greater choice of sustainable products and services at a more cost effective price. Buying reusable, long lasting products with minimal packaging can reduce purchasing volumes and waste production.
Cutting down or changing how we prescribe can reduce our carbon impact without costing the practice anything, while leading to savings for the local health system.
Respiratory treatments in particular contribute to the NHS carbon footprint. The network, Greener Practice, has launched a High quality and Low Carbon Asthma Care toolkit with step-by-step projects and sustainable QI work. Organisations including NICE and the Primary Care Respiratory Society, and websites such as greeninhaler.org, offer advice on how to support patients to choose the most environmentally friendly inhaler possible.
Deprescribing in general is a vital skill for clinicians, as is referring for ‘green’ social prescribing initiatives where available. Green social prescribing involves linking people to nature-based interventions and activities. These may include exercise, such as local Walking for Health schemes and dementia walks, active travel (such as walking or cycling), local ParkRuns, care farming, community gardening and food growing projects, as well as conservation volunteering, green gyms, and arts and cultural activities that take place outdoors. These initiatives are available through local link workers who can give people time and focus on what matters to the person.
PCNs have an ideal opportunity to take a lead by framing the sustainability agenda for general practice, incentivising practices to use the online non-clinical GP carbon calculator and helping them to develop and implement practice-level green action plans. South East London ICS has produced a Green Plan for sustainable primary care, which has plenty of great ideas for improving patient, practice and planetary health.
It is very difficult to predict average investment costs and the payback period because each practice is unique. The size and age of the building,dedication of the staff, geographical location and availability of transport options, motivation of patients and many other factors play a part. Having a bespoke assessment of options for a practice would be an ideal first step.
There is a fear that going green is expensive – but it doesn’t need to be that way. It depends on the practice view of spending money. Is getting more efficient equipment an expense or an investment? If you think it’s the latter, then the purchases can, quite rightly, be justified in terms of future savings.
Dr Matt Sawyer is a part-time GP partner in the North East of England. He runs the consultancy SEE Sustainability, running an online carbon literacy course for NHS staff, works with a variety of partners to help general practice reach the net zero ambition.
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