Farah Bede is a North East London Net Zero Primary Care Clinical Lead, and health inequalities researcher at London School of Economics. She is on Twitter: @drbede
Emma Radcliffe is a North East London Primary Care Net Zero Clinical Lead, and GP at The Aberfeldy Practice. She is on Twitter: @emmrad
The role of promoting environmental sustainability must be linked with reducing health inequalities. We believe that placing the principles of sustainable and equitable health care at the heart of what we do will build an NHS that is healthier for our patients, the people we work with, and our planet.
The COVID-19 pandemic has shone a spotlight on health inequalities, which have been exacerbated in the UK following austerity measures from the global recession over a decade ago. Black and Asian minority ethnic groups and those living in the most deprived areas have experienced higher mortality rates and lower vaccine uptake.1
The pandemic has demonstrated how interconnected we are regionally and globally, and how collaboration and concerted efforts are the only way to address the challenges of our time. The same is true of the climate crisis.
… those at greatest risk of the climate crisis lack resources and are least resilient to it due to pre-existing societal inequality …
The ‘catastrophic’ threat to health that the climate crisis poses is widely recognised.2 Likewise, the fact that the consequences of the climate crisis will affect the most vulnerable communities more profoundly has been extensively highlighted.3 It is also recognised that those affected most by the crisis have contributed least to its cause.4
Julian Tudor Hart’s inverse care law outlined that availability of good medical or social care varies inversely with need.5 We describe an ‘inverse climate law’, where those at greatest risk of the climate crisis lack resources and are least resilient to it due to pre-existing societal inequality as a whole.
As GPs working in North East London, we know that the communities we serve are some of the most deprived in London with significant health inequalities; there are higher than average rates of diabetes, mental health problems, and obesity.6 Air pollution, which shares many of the same causes of climate change, is linked to a huge number of health conditions and this disproportionately affects our population. Children in Tower Hamlets have up to 5% less lung capacity than the national average and this is never regained.7
Simple suggestions for primary care on becoming more environmentally sustainable include:8,9
• preventing ill-health (for example, promoting active travel, community health creation, and social prescribing);
• reducing harm and waste (for example, avoiding harmful polypharmacy and using collaborative plans to prevent unplanned admissions);
• empowering patients in their self-management;
• low carbon prescribing (prescribing dominates primary care’s carbon footprint10); and
• providing optimal health care while avoiding unnecessary staff or patient travel.
Tackling our emissions and reducing health inequalities go hand-in-hand …
The Core20Plus initiative11 identifies the most deprived 20% of the population with other groups who may benefit from tailored health care, and has highlighted five areas of health inequality to work on: maternity, severe mental illness, chronic respiratory disease, cancer, and hypertension. We are struck that action on both environmental sustainability and actions that may reduce health inequalities as outlined by the Core20Plus initiative produce co-benefits. Tackling our emissions and reducing health inequalities go hand-in-hand and form the basis of care many of us would strive to provide in general practice.
We are under no illusion of the pace and scale of change that is required to tackle the climate emergency but rather than feeling overwhelmed by the problem and the potential inadequacies of solutions, we believe that confronting the inequalities is part of the solution and green plans across the UK need to include this work.
Primary care has a substantial opportunity to help deliver a net zero NHS as 90% of patient contact occurs there,12 and patients would be in a better position to adopt greener actions if narrowing health inequalities was a central aim. This requires active input from key stakeholders like local and national governments to address the social determinants of health, such as poor housing, poverty, and air pollution. The NHS and primary care in particular need to deliver low carbon, high-quality, and fairer health care by moving towards a sustainable and equitable healthcare model that always values health, wellbeing, and nature for all.
References
1. Curtis HJ, Inglesby P, Morton CE, et al. Trends and clinical characteristics of COVID-19 vaccine recipients: a federated analysis of 57.9 million patients’ primary care records in situ using OpenSAFELY. Br J Gen Pract 2022; DOI: https://doi.org/10.3399/BJGP.2021.0376.
2. Wise J. Climate crisis: over 200 health journals urge world leaders to tackle “catastrophic harm”. BMJ 2021; 374: n2177.
3. Atwoli L, Baqui AH, Benfield T, et al. Call for emergency action to limit global temperature increases, restore biodiversity and protect health. BMJ Open 2021; 11(9): e056565.
4. Timperley J. Who is really to blame for climate change? BBC Future 2020; 19 Jun: https://www.bbc.com/future/article/20200618-climate-change-who-is-to-blame-and-why-does-it-matter (accessed 5 Apr 2022).
5. University of Glasgow. The Scottish Deep End Project. Deep End Conference 2021: 50 years of the inverse care law (May 2021). 2021. https://www.gla.ac.uk/researchinstitutes/healthwellbeing/research/generalpractice/deepend/events/conference2021 (accessed 5 Apr 2022).
6. North East London Health & Care Partnership. About us. https://www.eastlondonhcp.nhs.uk/aboutus (accessed 5 Apr 2022).
7. Tower Hamlets Council. What we are monitoring and why. https://www.towerhamlets.gov.uk/lgnl/environment_and_waste/environmental_health/pollution/air_quality/Advanced_information_on_air_quality/What_we_are_monitoring_and_why.aspx (accessed 5 Apr 2022).
8. Royal College of General Practitioners. Sustainable development, climate change and green issues. https://www.rcgp.org.uk/policy/rcgp-policy-areas/climate-change-sustainable-development-and-health.aspx (accessed 5 Apr 2022).
9. Bansal A, Blashki G. Aarti Bansal and Grant Blashki: six steps to both greener and better primary care. BMJ Opinion 2020; 15 Dec: https://blogs.bmj.com/bmj/2020/12/15/aarti-bansal-and-grant-blashki-six-steps-to-both-greener-and-better-primary-care (accessed 5 Apr 2022).
10. British Medical Association. Sustainable and environmentally friendly general practice: GPC England policy document. https://www.bma.org.uk/media/2570/bma-sustainable-and-environmentally-friendly-general-practice-report-june-2020.pdf (accessed 5 Apr 2022).
11. NHS Race & Health Observatory. NHS Race & Health Observatory consultation response — Core20PLUS5. 2022. https://www.nhsrho.org/publications/nhs-race-health-observatory-consultation-response-core20plus5 (accessed 5 Apr 2022).
12. Hodes S, Hussain S, Jha N, et al. If general practice fails, the NHS fails. BMJ Opinion 2021; 14 May: https://blogs.bmj.com/bmj/2021/05/14/if-general-practice-fails-the-nhs-fails (accessed 5 Apr 2022).
Featured photo by Markus Spiske on Unsplash.
