Greening the NHS: Where do I Start?

A high volume pressurized metered dose inhaler (MDI) unit, such as Ventolin Evohaler™, the most commonly prescribed salbutamol inhaler in the UK⁷, is responsible for the carbon dioxide equivalent of driving from London to Sheffield (175 miles) due to the harmful hydrofluorocarbon (HFC) propellant gases contained, compared with around 4 miles for a dry powder inhaler (DPI) (see figure right from greeninhaler.org ref ⁷). Many patients need to continue using MDIs, particularly those needing a spacer device or with poor respiratory effort, so there is an option to change to low volume MDIs, which more than halve the carbon footprint. It was news to me that MDIs leak HFC gases even if just sitting in a cupboard; they continue to do so in landfill sites unless taken back to the chemist for incineration which destroys the gases. There are small-scale pilot recycling schemes underway (for example Teva Inhaler Recycling Service⁸), but if not available locally, teaching patients when to know the inhaler is empty and encouraging them to return their inhalers to the chemist is an excellent way to reduce their carbon footprint. Undoubtedly the most important factor when considering inhaler alternatives is patient-centred decision-making, prioritising patient preference and ease of use (9), to ensure safe control of symptoms and the avoidance of respiratory admissions, which not only impact adversely on patients’ lives but far exceed the carbon footprint of an MDI inhaler.

So where do we start if we want to know more? The Royal College of GPs has a Green Impact for Health toolkit¹ which can be accessed for a test run by anybody using the login gifh [at] greenimpact [dot] org [dot] uk and password testtoolkit. The site is broken down into 13 areas such as prescribing, social prescribing, quality improvement and vulnerable groups. Within each there are graded levels of actions contributing towards bronze, silver, gold and carbon awards. Social prescribing is becoming a fundamental part of general practice¹⁰. Green (in nature) or blue (water based) social prescribing encourages patients to take part in activities outdoors which are low in carbon, low in cost and potentially reduce use of medication, in addition to many well-documented  physical, psychological and social benefits¹¹.

A wonderfully uplifting example comes from the video testimony of a patient from Frome Medical Practice near Bristol¹². In her late 50s, she had hypertension, peripheral neuropathy, osteoarthritis and walked with a stick. Having been helped initially with strength and balance exercises, dance and yoga, aged 68 she agreed to join a couch to 5k running group which started from the surgery. She was reassured due to the presence of the GP in the group. Over time, her weight and blood pressure improved so she stopped her BP and pain medications, including tramadol and gabapentin; the neuropathic pain was better whilst exercising and her well-being improved. She is now approaching 70 and runs 15 kms a week. The GP got fitter, the patient’s family got fitter and other patients became run leaders themselves to continue the cycle.

These are exciting times. We have the power to improve patient care whilst improving the health of our planet, so that in future our young people will enjoy a “dose of nature” with their own families. If more of us do what we can imperfectly, rather than a few doing it perfectly, we will look back and know we did our best to help the NHS achieve net zero carbon by 2040. Let’s see where we can start today.