In this study, the average primary care consultation generated 4.8 CO2eq kg. The average practice produced 30.5 CO2eq tons overall annually. Transport of staff and patients produced almost half of the total emissions. The heating system was the second emission domain, whereas medical consumables or in-house laboratory had a small impact. Emergency analyses requiring on-call couriers caused 5.7% of the total. Overall, most of the footprint involved domains not directly linked to medical activity. A hypothetical practice conceived by the most efficient characteristics of the ten practices, would produce ten times less CO2eq than a hypothetical practice with the least efficient characteristics.

A recent UK study found that the average primary care consultation produces 66 CO2eq kg [12], which is ten times that of our results. The main difference between the studies is that the UK study took into account drug prescription (pharmaceuticals supply chain and metered dose inhalers), which represented 60% (3517 out of 5770 CO2eq kilotons) of the measured total footprint. Moreover, Swiss and British GP practice organization differ highly, for example in their average consultation times (UK: 9 min., CH: 16 min) [27] and the daily number of consultations, therefore daily patient transport. In addition, in this UK study, patients commuted an average of 13.3 km (8.3 miles) compared to 5.5 km (3.4 miles) in our study, which increases the UK practice footprint. Of note, the localisation of the practice greatly influences its carbon footprint in our study, in that an increase in transport distance from 5.5 to 15 km (distance representative of rural areas) raises the footprint of an average consultation by 56%. Outside of these three aspects, (prescription, consultation times and distance to practices), our results are comparable. This illustrates the importance of reporting variables for each context so that comparisons address the specificities of each setting, for example, mobility habits, average consultation times. It is becoming necessary to standardise measures for primary care variables so that the increasing numbers of studies can be effectively compared.

We chose not to take drug prescription into account, although studies have suggested that this domain accounts for 10 to 22% of the health system footprint [13, 28, 29], and even more in primary care practice as published recently [12]. Primarily, in the Swiss context physicians do not handle prescription alone but alongside other specialists. It would not have been possible, within our design and without access to individual prescription data, to specifically quantify the part of the prescription attributable to primary care. However, physicians can have a direct influence on aspects like choosing lower impact emission supply (for example dry powder inhaler vs metered dose inhalers) or prescribing from manufacturers that seek to improve emissions [30]. Thus, prescription strategy should be set at a higher level. For example, The Nordic organization Sykehusinnkjøp, the NHS and the European Union have developed joint pharmaceutical procurement strategies that include sustainability criteria [16, 31, 32]. These plans aim to push industry to mitigate their carbon footprints. Finally, on a methodological level, as prescriptions were not recorded electronically in some participating practices, estimation of the prescription patterns would have been imprecise. Further, using these individual data would have required ethical clearance, which we did not have. For similar reasons, we did not analyse referrals to secondary care and other emissions than CO2eq, such as micro pollutants.

Overall, we found that domains not directly linked to medical activities had the biggest footprints. We could therefore achieve acceptable mitigation without affecting the quality of patient care.

As we found that more than half of the practice emissions come from staff, patient or courier transport, it means that mitigation of a practice’s carbon footprint is grounded primarily in transport organization. While this domain is not directly under the practice’s control, it could ultimately have an impact on the patient’s health. Specifically, directly, in that a long journey means poorer access to primary care, or indirectly, as pollution causes many diseases. Primary care practices could act as a role model for the patient and the community as regards carbon footprints, as they did for tobacco consumption when they demanded smoke-free facilities. Indeed, a dense and local network of primary care practices could decrease the length of the journey a patient needs to make to see his or her doctor and encourage her or him to come by foot. In addition, an effective network of public transportation could prompt staff to commute to work rather than use their car. Finally, the ability to perform urgent laboratory tests within the practice would significantly reduce their carbon footprint, by less usage of the on-call courier.

Among domains not directly linked to medical activities, improving heating systems and optimizing a practice’s occupancy could be high priorities. We noticed that some practices improve significantly their carbon footprints by providing many consultations at the same time. Indeed, a room seldom used but heated weighs significantly on a practice’s footprint. However, even if a well-insulated practice uses less energy and eventually has less expenses, initial investment is very high and can be out of reach of young doctors opening new practices.

In addition, telehealth could be investigated as a carbon mitigation option, to cut down on transportation (patient and staff), which are the top emitters in this study. Indeed, online consultation does not require any travelling. In the other hand, online consultations could raise emissions through increased electronic usage and data storage equipment. Further, patient could still need to travel to do some test or examination. Furthermore, although the current COVID-19 pandemic has shown that primary care can be delivered online in special and emergency times [33], it is unclear if and how habits will change in the near future. In addition, telehealth can only partly replace the multifaceted aspects of a clinical encounter. For example, continuity of care has several dimensions, continuity of information, continuity of management and interpersonal continuity. The latter, probably the most important in primary care, may never be achieved through telehealth. In this respect, in 2014, only 12% of the Swiss population chose an insurance model that implied first consultations delivered online. Moreover, 80.1% lived less than 20 min away from their primary care practice (independent of mean of travel and area) [16].

Medical consumables, often suspected as having a large impact, had, in fact, a small footprint, mainly from bandages and gauze pads. In this respect, questions about the packaging, compounds, and necessity for systematic sterilisation could be raised.

The study has limitations including the fact that only 10 practices were included; however, they were relatively representative of the variety of practices that can be found in Switzerland [22]. Furthermore, the high difference between the best- and worst-case practice emissions indicates that we probably captured a large spectrum of practices.

It was outside the scope of this study to estimate the respective contributions of primary care and other parts of the health system to the overall carbon footprint. Additionally, we could have speculated on the Beneficial effect on emissions of reinforcing prevention, for example favouring active mobility or healthier nutritional habits, important aspects of primary care, but not possible to examine in our calculation.

Finally, this study focused on direct and indirect carbon emission activities in ten primary care practices in Switzerland, allowing a first glance into their carbon footprints in a truly bottom-up approach. The method could be extended to other settings to produce comparable results. Also, due to its importance, drug prescription should be evaluated in future work. Nevertheless, our results already provide important leads on sources of carbon emission in practices, which can be translated into recommendations for primary care physicians and policy makers.

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