Sustainability for planetary health: A seventh domain of quality in primary care
Article Category: Invited editorial
Published Online: Sep 28, 2022
Page range: 198 - 200
Received: Sep 09, 2022
Accepted: Sep 12, 2022
DOI: https://doi.org/10.2478/sjph-2022-0026
Keywords
© 2022 National Institute of Public Health, Slovenia, published by Sciendo
This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 3.0 License.
Climate change is one of the biggest threats to public health, and has already begun to cause a health crisis. “Public health policy is set in a world of complexity, ambiguity and politics, in which evidence is important, but insufficient“ (1). The health sector has the responsibility to take immediate and decisive action to achieve sustainable health care. Sustainability is characterized by protecting finite resources and the environment by using resources wisely while taking into account the needs of our planet’s inhabitants in the future (2). There are an increasing number of initiatives supporting the inclusion of sustainability as an additional domain of quality in health care (3). Indeed, a more sustainable health care service can improve patient outcomes, and improve capacity for health care workers to engage in quality improvement (4) and thereby improve the quality of care (3).
Primary care has huge potential to significantly influence the sustainability of health care and mitigate the effects of climate change. High quality primary care leads to decreased health care costs and better health outcomes (5). Primary care workers are in the frontline within patients’ own communities, which enables them to advocate for actions to reduce the effects of climate change, increase public participation and promote activities to protect people from the effects of climate change (6).
The health care sector is a significant carbon emitter, and if health care were a country it would be the fifth largest global emitter on the planet (7). Primary care has a high carbon footprint, in particular from prescribing medication, which accounts for up to 60% of this (8, 9). If we exclude the latter, the greatest source is transport by patients and staff to health care sites (9). Other sources are heating systems, medical consumables, non-medical equipment, waste, laboratory analysis, non-medical consumables, medical equipment, and electricity (2, 8) The average primary care consultation can produce up to 66 CO2eq kg of carbon (8).
We can see from the literature (2, 8, 9) that the main areas for improvement are on the micro and meso levels. That is a very promising finding, as such changes can be made quickly and with minimum effort.
An infographic was created by six family doctors to succinctly illustrate some of the small but effective actions that can be initiated in general practice at the micro and meso levels. The infographic was endorsed by the Irish College of General Practitioners in 2021 (10).
Primary care practices should aim at reducing the environmental impact of prescribing and drug use. Currently, a major problem is polypharmacy and overprescribing (11), and other examples such as overuse of antibiotics and hypnotics. Tapering off medication can help improve the quality of life for patients (12) ,and better uptake of lifestyle interventions and social prescribing (13) can also be beneficial to patient outcomes.
More sustainable primary care is harder to achieve if the health care workers are not educated on the benefits of action, if they are not supported by the health systems in which they work or the professional organizations they belong to, and if work time constraints, which is the most frequently reported barrier, are not managed (6).
We suggest several steps that could help to achieve more sustainable and greener primary care.
There is a lack of studies on this topic, so it is difficult to suggest evidence-based interventions. We need international data to understand the scope of the problem (i.e. the carbon footprint in primary care in different countries and health care systems). We need qualitative studies among health care workers and patients to assess their understanding, barriers, and readiness for improvement. Sustainability research should thus be declared one of the main target areas in primary care research in the coming years.
Sustainability and planetary health topics should become an obligatory part of the curriculum at the undergraduate, postgraduate and continuous medical education levels. Public campaigns should be initiated and continuously implemented. Primary care workers have high levels of public trust, and can be strong advocates for planetary health. They are influential role models for their patients with regard to the adoption of green behaviours and lifestyles.
An integrative approach to managing patients in primary care can reduce the burden on individual health workers, increase the quality of care and foster patient satisfaction (14). Improving health literacy among patients is a critical factor in the prevention and management of non-communicable diseases (15). Empowering patients through education and self-management support results in the more rational use of health services. Digitalization has great potential to reduce the burden when used appropriately, and remote care should be used when possible and safe for the patient.
Each primary care practice should engage in a structured approach to improving sustainability in their practice. A sustainability in quality improvement (SusQI) framework and educator’s toolkit (3) could serve as a starting point in identifying the possibilities and developing interventions. Quality indicators on sustainability in primary care should be developed as part of the promotion of sustainability as a quality improvement domain. Interventions should be developed, tested and monitored.
Academic, administrative and clinical leaders in primary care need to work closely with researchers and health policy makers, with each other and in partnership with patients. Medical organizations can lead the way in keeping patients informed of the benefits of including the concepts of sustainability and planetary health as part of routine medical care.
Regulators, indemnity insurers and legal professionals have a role to play in managing the increase in legal complaints against doctors (16), so that it becomes more acceptable to practice sustainably than to practice defensively.
Primary care manages the majority of health problems in the population, and it is responsible for a proportion of the health care sector’s carbon footprint. Small adjustments could significantly decrease the carbon footprint of primary care practices over time, whilst also fostering better quality of care and patient outcomes. Each individual primary care practice has the potential to be a leader and a role model for sustainable health care, which is a domain of quality improvement. A structured approach is needed at the practice level, and in transitions of care with other service providers to identify possible interventions. The best way to start these changes is by adopting a bottom-up approach by clinicians in partnership with patients.