<abstract xmlns="http://www.w3.org/1999/xhtml"><p>Climate change is one of the biggest threats to public health. Sustainability is characterized by using resources wisely in a way that protects finite resources and the environment, and takes into account the needs of our planets’ inhabitants in the future. Sustainability in health care should be considered as a seventh domain of quality, as it can lead to improvement of patient outcomes, and more capacity for health care workers to engage in quality improvement and thereby improve the quality of care.</p>
<p>The carbon footprint of primary care is high, mainly due to prescribing medication, but also due to the transport of patients to hospitals and primary care services for interventions requested by family medicine. Other causes are the transport of staff and supplies, consumables and staff involved in laboratory analysis and radiation, medical and non-medical equipment, clinical and non-clinical waste, heating and cooling systems and other activities. Small adjustments in these areas could significantly decrease the carbon footprint of primary care practices. The suggested steps for primary care to achieve a more sustainable practice are fostering research, raising awareness, reducing the burden on primary care, engaging in quality improvement, and leadership and advocacy.</p>
<p>Each individual primary care practice has the potential to be a leader and role model for sustainable health care. With the implementation of interventions to reduce carbon footprints, primary care could set an example within the health sector and for patients. This could significantly raise the awareness of the public about the need to take actions for a greener health system.</p></abstract>

Climate change is one of the biggest threats to public health. Sustainability is characterized by using resources wisely in a way that protects finite resources and the environment, and takes into account the needs of our planets’ inhabitants in the future. Sustainability in health care should be considered as a seventh domain of quality, as it can lead to improvement of patient outcomes, and more capacity for health care workers to engage in quality improvement and thereby improve the quality of care.
The carbon footprint of primary care is high, mainly due to prescribing medication, but also due to the transport of patients to hospitals and primary care services for interventions requested by family medicine. Other causes are the transport of staff and supplies, consumables and staff involved in laboratory analysis and radiation, medical and non-medical equipment, clinical and non-clinical waste, heating and cooling systems and other activities. Small adjustments in these areas could significantly decrease the carbon footprint of primary care practices. The suggested steps for primary care to achieve a more sustainable practice are fostering research, raising awareness, reducing the burden on primary care, engaging in quality improvement, and leadership and advocacy.
Each individual primary care practice has the potential to be a leader and role model for sustainable health care. With the implementation of interventions to reduce carbon footprints, primary care could set an example within the health sector and for patients. This could significantly raise the awareness of the public about the need to take actions for a greener health system.

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<sec id="j_sjph-2022-0026_s_001"><label>1</label><div>Introduction</div>
<p>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“ (<a ref-type="bibr" href="#j_sjph-2022-0026_ref_001">1</a>). 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 (<a ref-type="bibr" href="#j_sjph-2022-0026_ref_002">2</a>). There are an increasing number of initiatives supporting the inclusion of sustainability as an additional domain of quality in health care (<a ref-type="bibr" href="#j_sjph-2022-0026_ref_003">3</a>). Indeed, a more sustainable health care service can improve patient outcomes, and improve capacity for health care workers to engage in quality improvement (<a ref-type="bibr" href="#j_sjph-2022-0026_ref_004">4</a>) and thereby improve the quality of care (<a ref-type="bibr" href="#j_sjph-2022-0026_ref_003">3</a>).</p>
<p>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 (<a ref-type="bibr" href="#j_sjph-2022-0026_ref_005">5</a>). 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 (<a ref-type="bibr" href="#j_sjph-2022-0026_ref_006">6</a>).</p>
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<sec id="j_sjph-2022-0026_s_002"><label>2</label><div>Carbon footprint in primary care</div>
<p>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 (<a ref-type="bibr" href="#j_sjph-2022-0026_ref_007">7</a>). Primary care has a high carbon footprint, in particular from prescribing medication, which accounts for up to 60% of this (<a ref-type="bibr" href="#j_sjph-2022-0026_ref_008">8</a>, <a ref-type="bibr" href="#j_sjph-2022-0026_ref_009">9</a>). If we exclude the latter, the greatest source is transport by patients and staff to health care sites (<a ref-type="bibr" href="#j_sjph-2022-0026_ref_009">9</a>). Other sources are heating systems, medical consumables, non-medical equipment, waste, laboratory analysis, non-medical consumables, medical equipment, and electricity (<a ref-type="bibr" href="#j_sjph-2022-0026_ref_002">2</a>, <a ref-type="bibr" href="#j_sjph-2022-0026_ref_008">8</a>) The average primary care consultation can produce up to 66 CO<sub>2eq</sub> kg of carbon (<a ref-type="bibr" href="#j_sjph-2022-0026_ref_008">8</a>).</p>
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<sec id="j_sjph-2022-0026_s_003"><label>3</label><div>What can be improved in primary care?</div>
<p>We can see from the literature (<a ref-type="bibr" href="#j_sjph-2022-0026_ref_002">2</a>, <a ref-type="bibr" href="#j_sjph-2022-0026_ref_008">8</a>, <a ref-type="bibr" href="#j_sjph-2022-0026_ref_009">9</a>) 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.</p>
<p>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 (<a ref-type="bibr" href="#j_sjph-2022-0026_ref_010">10</a>).</p>
<p>Primary care practices should aim at reducing the environmental impact of prescribing and drug use. Currently, a major problem is polypharmacy and overprescribing (<a ref-type="bibr" href="#j_sjph-2022-0026_ref_011">11</a>), and other examples such as overuse of antibiotics and hypnotics. Tapering off medication can help improve the quality of life for patients (<a ref-type="bibr" href="#j_sjph-2022-0026_ref_012">12</a>) ,and better uptake of lifestyle interventions and social prescribing (<a ref-type="bibr" href="#j_sjph-2022-0026_ref_013">13</a>) can also be beneficial to patient outcomes.</p>
<p>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 (<a ref-type="bibr" href="#j_sjph-2022-0026_ref_006">6</a>).</p>
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<sec id="j_sjph-2022-0026_s_004"><label>4</label><div>Steps towards more sustainable primary care</div>
<p>We suggest several steps that could help to achieve more sustainable and greener primary care.</p>
<sec id="j_sjph-2022-0026_s_004_s_001"><label>4.1</label><div>Foster research</div>
<p>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.</p>
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<sec id="j_sjph-2022-0026_s_004_s_002"><label>4.2</label><div>Raising awareness of health care workers and patients</div>
<p>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.</p>
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<sec id="j_sjph-2022-0026_s_004_s_003"><label>4.3</label><div>Reducing the burden on primary health care</div>
<p>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 (<a ref-type="bibr" href="#j_sjph-2022-0026_ref_014">14</a>). Improving health literacy among patients is a critical factor in the prevention and management of non-communicable diseases (<a ref-type="bibr" href="#j_sjph-2022-0026_ref_015">15</a>). 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.</p>
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<sec id="j_sjph-2022-0026_s_004_s_004"><label>4.4</label><div>Engaging in quality improvement</div>
<p>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 (<a ref-type="bibr" href="#j_sjph-2022-0026_ref_003">3</a>) 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.</p>
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<sec id="j_sjph-2022-0026_s_004_s_005"><label>4.5</label><div>Leadership and advocacy</div>
<p>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.</p>
<p>Regulators, indemnity insurers and legal professionals have a role to play in managing the increase in legal complaints against doctors (<a ref-type="bibr" href="#j_sjph-2022-0026_ref_016">16</a>), so that it becomes more acceptable to practice sustainably than to practice defensively.</p>
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<sec id="j_sjph-2022-0026_s_005"><label>5</label><div>Conclusion</div>
<p>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.</p>
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Sustainability for planetary health: A seventh domain of quality in primary care

Slovenian Journal of Public Health

This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 3.0 License.

Trajnost za planetarno zdravje: sedma domena kakovosti na primarni ravni

Climate change is one of the biggest threats to public health. Sustainability is characterized by using resources wisely in a way that protects finite...

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
primary care, sustainability, carbon footprint, quality

© 2022 National Institute of Public Health, Slovenia, published by Sciendo

This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 3.0 License.

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

Keywordsprimary care, sustainability, carbon footprint, quality

© 2022 National Institute of Public Health, Slovenia, published by Sciendo

This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 3.0 License.

Keywords
primary care, sustainability, carbon footprint, quality