15 Action Areas

The first step in reducing your practice’s carbon footprint is knowing where the carbon hotspots are.  There is a really easy and free way to find this out. It doesn’t measure the impact of pharmaceuticals but it does show carbon impact in terms of energy use, building use, travel and all non-clinical activities.
Have a look at the free toolkit developed by Dr Matt Sawyer, another member of the Greener Practice network.

Join more than 1300 practices throughout the UK using the Green Impact for Health toolkit. This is a free toolkit with guidance on specific practical actions that GP practices can take to make their practices more environmentally sustainable. Each action cites the reasons needed for the action, references the available evidence, and has practical tips to make each task easier. The toolkit has 5 levels of achievement and each can attract an award: Pioneer, Bronze, Silver, Gold and Carbon. Using it can be a great way to get the entire practice team involved in sustainability.

Metered dose inhalers (MDIs) are one of the biggest contributors to the NHS total carbon footprint

4% of the total NHS footprint comes from one small medication group! (i) This is because the propellants used are powerful greenhouse gases (hydrofluorocarbons). The UK prescribes a much higher proportion of MDI inhalers than most other countries in Europe but has some of the worst asthma death rates on the continent (ii)&(iii).

There are clinically safe ways to reduce MDI prescribing and many patients prefer soft mist and dry powder inhalers (DPIs)(iv).  Check out the Greener Practice guide.  Remember that DPIs and MDIs are joint first line options on the Tayside formulary for both asthma and COPD. This means that you can prescribe the right inhaler for each patient.  New asthma guidelines will be released in the next few months and this page will be updated accordingly.

In the meantime, have a look at our recent education session on Greener and Better Asthma Care and the excellent Greener Practice Asthma toolkit.  This includes step-by-step quality improvement projects.

(i) House of Commons Environmental Audit Committee. UK progress on reducing F-gas emissions. April 18, 2018. Accessed November 19, 2024. 
(ii) British Thoracic Society. 2020. Position Statement: The Environment and Lung Health 2020. 
(iii) Asthma and Lung UK. 2022. Lung conditions kill more people in the UK than anywhere in Western Europe.
(iv) Schreiber at al. 2020. Inhaler devices in asthma and COPD patients – a prospective cross-sectional study on inhaler preferences and error rates. BMC Pulmonary Medicine. 20(222). 

Medicines and chemicals make up 25% of the total NHS carbon footprint, and we prescribe 79% of this in primary care (i). Many of these medications improve our patients’ health and wellbeing, but not always. It is estimated that 11% of unplanned hospital admissions are attributable to harm from medications, and over 70% of these are elderly patients on multiple medications (ii). We can help to prevent this through deprescribing – reducing the burden of medications that are no longer useful, or on balance harmful.

We also know that up to 50% of medications are not taken as intended (iii), and every year in the UK to £300 million of medications are unused and discarded (iv). Many medications are discarded into landfill or down sinks and toilets. Even when medication is taken as intended, 30 to 90% is excreted as an active substance in the urine and sewage treatment plants are only able to remove 80% of this (v). All this means that a lot of medications and active metabolites are passing into wastewater and into our environment. There is a lot of evidence that these are affecting plants and animals. Fish populations have been adversely affected by synthetic oestrogens in the water, and fish behaviours have been altered by fluoxetine, sertraline, and their biometabolites (v). Medication and metabolites have been found in rivers worldwide, including throughout Scotland (vi). By deprescribing, we can help to reduce unnecessary medication ending up in our environment.

Many practices are already reviewing medications and deprescribing where appropriate. It can be helpful to focus on deprescribing in elderly patients with a high anticholinergic burden. Anticholinergics increase the risk of falls, dementia and early death, and patients’ risk can be assessed easily using an anticholinergic burden calculator.

A small project from the Family Medical Group, Douglas, Dundee, reviewed 187 elderly patients taking 10 or more medications. They stopped 330 medications overall – an average of 2 per patient. This reduced the cost to the health board by £8560.27 over a one year period, decreased the carbon footprint by 1327kg/CO2, and patients were happier to be on fewer medications.

The National Therapeutic Indicators can be a useful way to see how your practice prescribing compares to others in your cluster and health board, and guide where to focus deprescribing efforts.  Realistic Medicine and the ScotGov Polypharmacy team have produced a comprehensive guide on polypharmacy and how to reduce this.

Medstopper and the Stopp Start tool can help to support rational prescribing in patients.

(i). NHS England and NHS Improvement. Delivering a Net Zero National Health Service. 2020.
(ii). Scottish Government Polypharmacy Model of Care Group. 2018. Polypharmacy Guidance, Realistic Prescribing 3rd Edition. Scottish Government.
(iii). World Health Organisation. 2003. The World Health Report 2003: Shaping the Future. 
(iv). NHS England 2015. Pharmaceutical waste reduction.
(v). Healthcare Without Harm Europe 2014. How doctors can help reduce pharmaceutical pollution.
(vi). Pharmaceuticals in the water environment. 2022. 

Social prescribing can result in multiple benefits for patients including:

- Increasing physical activity levels and improving quality of life for over 12 months
- Therapeutic effects on hypertension
- Reducing patients’ experience of pain
- Reducing ADHD symptoms in children

In Edinburgh, five GP practices worked with RSPB Scotland to deliver Nature Prescriptions. This included a leaflet and a monthly calendar of nature activities and ideas. The feedback from patients was very positive, and the majority of prescribers also reported that their awareness of nature in the local area had increased.

Practices throughout Tayside can refer patients for social prescribing – either through a link worker or Sources of Support (Dundee). However, there are many ways that practices can support social prescribing without onward referral. These include:

• Updating your practice website to include information about being healthy without needing medication. This can include sections on moving more and getting outside. Have a look at Douglas Medical Centre for some patient information ideas.
• Support patients to consider nature based activities. This Nature Prescription document includes some ideas for Dundee. This patient information section on the Greener Practice page contains some good ideas about how to word your website
• Become a Park Run practice. The Links Health Centre in Montrose regularly does a Park Run takeover at their local Montrose Park Run
  
• Direct patients to therapeutic gardening opportunities through Trellis Scotland
• Although the Dundee Green Health Partnership has sadly come to an end, their website is still operational with information about activities throughout the city 

Encouraging our patients to incorporate physical activity into their daily lives  is a great example of something with health and climate co-benefits. The patient’s own health will improve directly and if they travel actively (rather than using a motorised vehicle) they can reduce air pollution levels for those in their local community.

There are some excellent resources to support patients to move more.

The Moving Medicine page is a brilliant resource which supports clinicians to integrate movement conversations into routine clinical care. It encourages tailored advice about activity for different illnesses e.g. supporting patients with cancer to be more active and improve their health outcomes in a one minute discussion.

The RCGP Active Practice Charter includes many simple and creative ideas to encourage staff and patients to be more active.

The Family Medical Group, Dundee updated their page to include more information about physical activity and they regularly text the link through to patients. They have noticed that patients are more receptive to discussions about anything which might reduce their risk of dementia.

Supporting patients to have a diet low in red meat and high in fresh fruit and vegetables is good for their health and the planet.
The infographic from the EAT-Lancet Commission gives an indication of the different carbon footprints of different diets.

This doesn’t mean that we should be encouraging everyone to eat only vegetarian or vegan food but it does show that reducing meat consumption can have a big impact.
The EAT-Lancet Commission has developed the planetary health diet – good for patients and planet.

This might look very different to what our patients are currently eating or can afford to eat.

The Family Medical Group have developed some patient information on their website to support a healthier diet through small achievable steps. Our next Greener Practice meeting in January 2025 will cover ways to support patients to eat healthy, sustainable, affordable food. To find out more email tay.fifegreenerpractice@nhs.scot.

The One Blue Dot Sustainable Diet Project by the British Dietetic Association includes ideas for sustainable diet swaps like the one below:

Increasing evidence shows that our patients care about the sustainability of the NHS. A recent study by Health Improvement Scotland found that 76% of patients would consider switching their medication to something more environmentally sustainable (with no negative effect on treatment) and 68% would support a more environmentally friendly medicine even if less convenient than a regular medicine (1). Those who discuss sustainability with patients are finding that they are shocked by the size of the carbon footprint of certain medications. We may be doing our patients a disservice by not discussing sustainability as part of shared decision making.

Very few clinicians receive any training about speaking to patients about sustainability. This is changing with teaching at an undergraduate and postgraduate level. The following Health Improvement Scotland document contains some excellent tips about speaking to patients and colleagues about this.

In our own experience, we have found it helpful to focus on actions which have clear health and climate co-benefits – such as deprescribing, active travel and more sustainable food. Many of us have made changes in our lives to make them more sustainable but it can be harder to know where to begin when it comes to health. Your patients may just be waiting for an opportunity to be more sustainable in this area – by starting a conversation about this, you can help them.

It’s much easier to make and sustain changes when your team is on board. Many of your colleagues may have made changes in their personal lives to become more sustainable, but it often seems like this disappears when we step over the threshold at work. It can be much harder to know where to start in healthcare. Your colleagues may be waiting for someone to start a conversation about this, even during a chat over a cup of tea.

Everyone has different priorities. In a UK wide study looking at why people engaged with sustainability, the top three reasons were protecting the planet for future generations, creating a healthier society, and preserving the beauty of the countryside. Framing sustainable healthcare in these ways can help people to understand that it aligns with their priorities.

In our own experience with colleagues, we have found it helpful to focus on actions which have clear health and climate co-benefits – such as deprescribing, active travel, and more sustainable food. This focus also leads to actions that colleagues can take in their consultations, which in turn protects against the powerlessness people can feel in the face of the climate crisis. If you find that your colleagues (or you) feel overwhelmed by the problem then be assured that this is a common problem. Have a look at the section on eco-distress for advice and support.

We hope that the ideas we have shared provide some inspiration for making changes in your workplace. However, we know it can be overwhelming to think about all the things that could be done. It can be helpful to take small actions with clear results to get started, or keep you ticking over when things are really busy. See the 5 minute actions section for some ideas.

There are so many overlaps between Realistic Medicine and sustainable healthcare. All of the recent CMO annual reports on Realistic Medicine include a focus on sustainability and the Sustainability team in Tayside continues to work with the Realistic Medicine team to highlight these overlaps.

Reducing over investigation and over diagnosis is good for our patients, and good for the planet. This graph shows how primary care investigations have increased dramatically in recent years, particularly laboratory tests.


Some of this is due to increased test availability and multi-morbidity. However, at times there is unnecessary duplication of tests by primary and secondary care and sometimes investigations are requested even when they will not alter management. We all have our part to play in ensuring investigations are done for the right reasons at the right time for our patients.

Energy use is the biggest non-clinical contributor to the carbon footprint of general practice.


Choosing a green energy provider can be a good start. Updated rankings for the most ethical and green energy suppliers are available from Ethical Consumer. You may wish to subscribe to Ethical Consumer, which allows up to 40 people online access to help the practice and its staff make ethical decisions on various services and products. Ensuring that your practice building is well insulated reduces energy bills and carbon emissions. Low carbon energy generation, such as solar panels and air source heat pumps, are also worth considering.

Zero Waste Scotland have many resources to help. They visited the Family Medical Group in Dundee and advised on changes to insulation and heating systems. The practice removed the old night storage heaters and installed air source heat pumps, as well as improving their insulation. Which? have developed a guide for air source heat pumps.

The Energy Saving Trust and Business Energy Scotland have information about grants and loans that may be available to support any changes in the practice.  

Energy inefficient homes contribute to fuel poverty, wasted energy and bad health. Many of our patients are spending a large proportion of their income on heating homes which are poorly insulated and therefore remain cold.  Cold weather has a direct effect on the incidence of hypothermia, respiratory disease, heart attacks, stroke, respiratory disease, flu, falls and injuries. The indirect effects of cold weather include mental health problems, and the risk of carbon monoxide poisoning by poorly maintained or ventilated appliances (1).

Home Energy Scotland is funded by the Scottish Government and run by the Energy Saving Trust. It has lots of information for patients about how to address fuel poverty including where to access funding. Some practices in Tayside send texts or emails to all patients in autumn with a link to Home Energy Scotland.

1. NICE. 2015. Excess winter deaths and illness and the health risks associated with cold homes.

Reduce, Reuse, Recycle is the mantra which underlies sustainable usage. Reducing waste can reduce harm to patients and financial costs.

The Great Ormond Street Hospital ‘Gloves Off’ campaign was very successful in encouraging healthcare professionals to reduce their use of non-sterile gloves and instead wash their hands more regularly.

Many patients order prescriptions every month for medications which should be taken as required. This needs to be addressed, for patient safety and to reduce the carbon footprint and financial cost to the NHS. For more information see the Deprescribing section above.

Patients can recycle some pre-filled insulin pens at their local pharmacies. Have a look at PenCycle for more information.
Blister pack recycling is available through Superdrug pharmacies for individuals. Some practices share this information with patients via their website.

Appropriate inhaler disposal is an important part of sustainable inhaler prescribing. Particularly with MDIs, it is difficult to tell when they are empty. This leads to many patients disposing of inhalers with medication still in them. If thrown into landfill, the MDIs will still release the hydrofluorocarbon propellants (powerful greenhouse gases). Patients should be encouraged to return all inhalers to their pharmacy for safe disposal. Unfortunately there are no active inhaler recycling schemes operating in Scotland at this time but all pharmacies will accept inhalers for safe disposal. If you become aware of any issues in this regard please contact tay.fifegreenerpractice@nhs.scot.

Most of us are used to recycling at home but sometimes staff find it difficult to do this at work. Ensuring that appropriate recycling bins are available in different practice areas can be a simple way to make recycling easier.

Coming Soon ! Watch this space for updates! 

For most businesses, the biggest source of carbon emissions comes from where they keep their money. This is because of where the bank is lending money (1).

UK banks are contributing to the climate crisis by channelling billions of pounds into projects which harm the climate. In 2023 alone, five big UK high street banks (Barclays, HSBC, Standard Chartered, Lloyds and NatWest) provided nearly £39 billion of support to fossil fuel companies (2).

As Dr Matt Sawyer (GP who runs SEE Sustainability) puts it: ‘Healthcare professionals decided a long time ago that it is no longer ethically viable to financially associate with the tobacco industry while it continues to drive lung disease and premature death.’ (3) So why would we do the same for banking organisations actively contributing to climate change?

The easiest way to check what your bank is doing with your money is by looking on Bank Green. You might be surprised!
Make Your Money Matter is an initiative to move money away from investing in what harms us and into what keeps us well.  The Family Medical Group are currently looking into changing their practice bank for exactly these reasons.

1. My Mother Tree, 2024.
2. Banking on Climate Chaos 2024.
3. Sawyer, M. 2024. Banking and Greener Practice.