What sustainability means for primary care: primary care leads to better overall resource use and higher quality outcomes

EFFECT OF THE ECOSYSTEM ON HEALTH

The concept of sustainability in its broadest context is an easy one. It is about using resources wisely in a way that not only protects the environment in which we live here and now, but also takes account of the needs of our planet’s inhabitants in the future. I choose my words carefully; as humans we are only one species in this ecosystem and our future wellbeing is inextricably linked with the rest of the biosphere. Climate change presents a major threat to the biosphere and there is overwhelming evidence that the activities of mankind are contributing to this phenomenon. The stress that the wider ecosystem is being put under is likely to impact on health in many ways and as GPs, health is our core business. Margaret Chan, the Director General of the World Health Organization, described climate change as the biggest threat to health in the 21st century. In part she is right but the implications for health will run for far longer than this century alone.

Since the Industrial Revolution the ever-growing world population has been consuming planetary resources at an ever-increasing pace. This is true of many types of resource, however burning the locked stores of hydrocarbon in the form of coal, gas, and oil has led to a rise in CO₂ levels in the atmosphere, resulting in climate change. If we continue as we are then climate modelling predicts a 2–5 °C increase in ambient temperature by 2050; the projected impact of the higher range is devastating. The report of the UCL/Lancet commission on climate change and health1 gives an authoritative account of the likely health impacts of global warming. Our healthy existence is made possible by a self-regulating environment staying within quite narrow habitable confines, much like the homeostatic processes that keep us functioning as human beings. Our biosphere is showing signs of great stress, with species extinctions at a rate not seen in millions of years. We rely on the biosphere in ways we understand and in ways that we don’t. Sustainable Healthcare2 has recently been published and I thoroughly recommend it for its easy reading and accessible style. Excessive consumption is also directly affecting health and wellbeing with rising levels of obesity and the consequent rise in associated long-term conditions.

The delivery of health services in the western world is in itself part of the problem. The carbon footprint of the NHS is estimated to be 21 million tonnes of CO₂, 25% of the total public sector in England.3 We are developing an understanding that delivering health care the way we have done comes at a price. Antibiotic overuse has led to the development of super-resistant organisms and we understand the clear and direct effect that this has on health. The contribution to our overall greenhouse gas emissions and other pollutants attributable to the health sector also has direct effects on the health of our population. The causation and exacerbation of respiratory conditions especially in urban areas being just one example. The Climate Change Act 2008 has set enormous legally binding challenges for carbon reduction and the healthcare sector is not immune from these. It seems clear that to continue with a ‘business as usual’ attitude in the face of these challenges is not an option. We are seeing the resource pressure already starting to bite with the first manifestations being the financial squeeze combined with a shift in demography and patterns of illness. I suspect that this is a landscape that is here to stay.

WHAT DOES THIS MEAN FOR PRIMARY CARE?

What does all of this mean for the healthcare system and in particular for GPs and primary care? General practice and primary care are important elements of the solution and need to be seen and valued as such. The evidence is clear that high quality primary care leads to decreased overall costs and better health outcomes. The penny dropped with me at the RCGP Annual Conference in Harrogate last year, that the best way of future proofing the healthcare system in the UK is to invest in the education and skills of GPs and their teams, in short, helping them to deliver high quality generalist personalised care. At the heart of this is the skill to deliver bespoke patient care and manage risk without resorting to over-medicalisation and consequent high resource use. The old maxim that prevention is better than cure resonates well with the sustainability agenda but employing GPs to tackle issues like obesity uses expensive skills to close a door once the horse has bolted. There is of course an important role for high quality general practice to manage the problems associated with long-term conditions in order to decrease high resource emergency admissions to hospital.

On a parochial level there are simple things that we can do within our practices and primary healthcare teams, including prudent energy and water use, use of consumables of all types, and recycling when we can. One-stop services lead to faster care and decision making, increased patient satisfaction, and fewer patient journeys.4 There is clear evidence that better continuity of care leads to fewer hospital admissions. Ipsos MORI consistently rank GPs as the most trusted professionals in the UK and we must not underestimate the influence that we have; demonstrating engagement with the sustainability agenda in our surgeries is not likely to go unnoticed.

CCGs AND THE FUTURE

The advent of clinical commissioning groups and the influence that they will have on the provision of services is potentially the biggest game in town. Integrating care around the needs of patients, and in doing this working with small groups of trusted providers of care rather than duplicating services and operating with multiple companies, is likely to improve patient care and minimise the total resource cost. Historically, commissioning has been about securing volumes of activity aimed at providing a population with its wants and needs, often by professionals working in ways and places that have changed little for decades. This has led to the structure of care being delivered in much the same way as it was at the inception of the NHS in 1948 with a persistent primary and secondary care divide. There is an urgent need for clinical commissioners to think holistically about the care pathways that they develop. If they and hospital trusts were responsible for the overall societal costs of care provision then service delivery would look very different indeed.

In the face of the evidence that primary care leads to better overall resource use and higher quality outcomes, the recent Nuffield Health Report5 showed that in 2011–2012 spending on hospital care grew by 1.2% compared with a 1.2% reduction in spending on GP services. In England the spending on primary care services was £400 million lower in 2011–2012 than it was in 2009–2010. At its most basic, for general practice itself to be sustainable it needs to continue to be an attractive career choice for the next generation of medical students and doctors in training. There is evidence that the working pattern in general practice runs the risk of becoming unbearable over the next 3–5 years.6 The RCGP needs to work collaboratively with the Academy of Medical Royal Colleges and the BMA to call on the NHS England and the equivalent bodies in the devolved countries to improve the share of general practice funding from within the NHS funding allocation. A small redistribution in favour of primary care would bring with it the potential to decrease the overall environmental footprint of the NHS.

Finally, perhaps the time has come for a radical review of what we want our NHS to be and do. Maybe only a Royal Commission on the future of the NHS would help us with this.