Intended for healthcare professionals

Views And Reviews Taking Stock

Rammya Mathew: Climate action will require radical reform of how we practise medicine

BMJ 2021; 375 doi: (Published 05 October 2021) Cite this as: BMJ 2021;375:n2416

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  1. Rammya Mathew, GP
  1. London
  1. rammya.mathew{at}
    Follow Rammya on Twitter: @RammyaMathew

In 2020 the NHS adopted a multi-year plan to become the world’s first carbon net zero national health system.1 Simon Stevens, then chief of NHS England, said that “it’s not enough for the NHS to treat the problems caused by air pollution and climate change—we need to play our part in tackling them at source.”

Since then, remote consulting has brought us a long way down the road to a greener NHS. In hospitals and in primary care the ability to conduct remote reviews will have significantly reduced vehicle emissions associated with travel to and from the 400 million healthcare appointments each year across the NHS. Laudable work is also under way at many NHS trusts to reduce the environmental impact of volatile anaesthetics, which alone are reported to account for over 2% of all NHS emissions. And in primary care there’s now a drive to review the management of asthma and an attempt to reduce the carbon footprint from the use and overuse of metered dose inhalers.

It’s clear that policy is already in action, but I’m still left wondering whether we’re focusing on the real carbon hotspots or just placating ourselves by targeting a few low hanging fruits. What about our growing dependence on pharmaceuticals—isn’t this the tide that needs turning? I recently learnt that the management of raised lipids in people at high risk of cardiovascular disease can now extend to using three different lipid lowering medications. Isn’t our over-reliance on medicines, and our underinvestment in public health, the elephant in the room? As long as healthcare fuels the pharmaceutical industry in this way, can we ever truly claim to be carbon net zero?

The pressure to diagnose cancers earlier and earlier is another major contributor to modern medicine’s carbon footprint. Over successive years we’ve been told to continually lower our threshold for suspecting cancer, and we’re encouraged to investigate sooner and more extensively. In primary care, most patients with mildly elevated or even high normal platelet counts now undergo a barrage of investigations in case thrombocytosis is an early indicator of underlying cancer. What does the yield of these tests have to be to make this an acceptable approach? And shouldn’t we be considering the environmental impact of putting so many patients on a conveyor belt of investigations, as part of cost-benefit calculations?

When many other industries are simply paying lip service to the sustainability agenda, it’s encouraging to see change already happening in the NHS. However, the most impactful changes won’t be limited to single specialties or standalone diseases—they will require us to radically reform how we practise medicine. The NHS will need to challenge the “more is better” mentality that modern medicine has insidiously embraced and take a much broader view on what constitutes waste in healthcare.


  • Competing interests: I am in receipt of a grant from the Health Foundation to support high quality low carbon asthma care in general practice.

  • Provenance and peer review: Commissioned; not externally peer reviewed.