How green is our health service? The NHS is the biggest organisation in Europe, with huge energy consumption and vast spending power .The annual environment report of Health Facilities Scotland, a division of NHS Scotland, provides data on energy and water consumption, waste water and trade effluent, and both clinical and non-clinical waste.

Last year's report showed that the overall reduction in CO2 emissions since 1989-90 stands at 42.5% and, over the same 17-year period, absolute energy usage reduced by 36.5%. But the targets set by the Scottish Government are to reduce national emissions by 80% by 2011. Is the health service on track to achieve them?

Doctors are becoming more aware that what is good health advice for individual patients is also good for the health of the planet. Advocating cycling, eating less fat and controlling fertility benefits people's health as well as reducing their carbon footprint. At a recent conference at the Royal College of Physicians in London on climate change and its impact on health, doctors were encouraged to use their skills to advocate, innovate and network about carbon reduction.

Dr Richard Horton, editor of the medical journal The Lancet, says: "Climate change is about social and environmental justice, and doctors need to be advocates for their patients and their countries and create a social movement across the health sector."

Fiona Godlee, editor of the British Medical Journal, quotes the General Medical Council guidelines. One of the two duties of a doctor laid down by them is "to protect and promote the health of the public". "Gone are the days when doctors care only for the health of individual patients," she said. "Climate change should be on the agenda of every health meeting".

But are these just fine words? How do they translate into organisational action? The Royal College of Physicians and the Royal College of Paediatrics and Child Health (RCPCH) have adopted policies, dealing with heating, food, travel, use of green energy and improved use of technology, to become carbon neutral. Increasingly, large international conferences at exotic, carbon-expensive locations are being spurned in favour of video-conferencing and the RCPCH has appointed a champion for carbon footprint reduction.

Health boards are also moving towards carbon reduction policies that make both good environmental and economic sense. In a foreword to NHS Fife's environmental policy statement, the chair, Professor Jim McGoldrick, said: "We have a duty to our patients and a direct benefit of saving energy is more money is available for patient care". The policy outlines measures for recycling, reduced consumption, sustainable travel, purchase of environmentally friendly products and training.

Last November, NHS Grampian won the Energy and Environment Award from Health Facilities Scotland, for its carbon management plan to make substantial CO2 savings. "It is a tremendous endorsement of our commitment to becoming a greener organisation," says NHS Grampian Estates Manager Gary Mortimer.

"Our submission showed the wide-ranging projects which we have already carried out, such as £170,000 of improvements to boiler plant, and a similar sum on the steam system, which supports heating, ventilation, hot water, catering, laundry and sterile services provision at Aberdeen Royal Infirmary.

"It also showed those projects we have planned, such as a combined heat and power (CHP) plant on the Foresterhill site, partly fuelled by biomass a renewable energy source, such as wood pellets, which will make a major contribution to CO2 savings."

NHS Grampian has assessed its carbon footprint, with the support of the Carbon Trust, and staff are making their contribution as Carbon Champions who encourage efficient energy use where they are working.

The NHS has set up a Sustainable Development Commission which has produced a Good Corporate Citizenship toolkit, and Greater Glasgow and Clyde Health Board is adopting similar principles in developing its approach to sustainability. The World Wildlife Fund has calculated the ecological footprint of all major UK cities. Glasgow's footprint is currently at just under the "three planet living" level - in other words, if the whole world followed Glasgow's example, it would require the resources of three planets rather than just one.

Phil Hanlon, Professor of Public Health at the University of Glasgow, says: "Economic growth associated with rising consumerism and individualism seems to be damaging our sense of wellbeing and the cohesion of our society."

The board's discussion paper draws on the work of the International Futures Forum and the three horizons model to examine the roles of employers, investors and community partners in the areas of facilities, transport, new buildings, procurement, employment and skills development. Hanlon and his colleagues believe that sustainable policies will improve, not only environmental and physical, but also mental and even spiritual health. In primary care, with general practices operating as small businesses, the challenges, and opportunities, are different. The IT revolution and emergence of paper-light practices, with computer records replacing paper notes, has made a substantial contribution to sustainability. Many e-mail systems carry the message, "Please consider the environment before printing this e-mail".

Environmental campaigning can never intrude into the individual consultation but GPs can work with their primary health care teams to reduce their practices' carbon footprints.

Dr Joe Wilton is one of the co-ordinators of a Borders-wide primary care CPD programme, Borders Time (Time for Medical Education), and, through it, Borders health board plans to offer a green practice prize. Welcoming the initiative, Wilton says: "Practices will be encouraged to submit schemes which result in carbon emission reduction, be it limiting car use, reducing heating bills or improving recycling."

GPs in rural areas tend, however, to be car-dependent. Breaking the stranglehold of the car is easier in the city. Dr Irene Paterson, GP at Dalkeith Road Practice in Edinburgh, says: "I've cycled the three miles across the city to my work as a GP for years. None of the doctors have cars at work. The practice supports the doctors to cycle by having a contract with a local taxi firm that any of us can use, if required, for urgent or distant visits.

"In fact, we don't often use it as we all do most of our visits by bike. The whole issue of making transport around the city environmentally friendly has to be tackled by large-scale planning and made available and beneficial to all."

At the forefront of greening primary care is Dr Mark Thompson, a GP in Powys. He says: "It's nice for primary care to put these issues in the mainstream and promote carbon reduction as part of health promotion."

At their travel clinics, patients planning air travel are encouraged to offset. The practice also has an environmental policy addressing recycling, minimising patient visits to the practice for tests, and energy use. It is an example Thompson hopes others will follow.

He is pleased that the road map produced by the Royal College of GPs for their vision for the future of primary care included a reference to carbon emissions. But the most potentially powerful initiative is submitting to the Quality and Outcomes Framework Committee (the group which sets the criteria by which practice performance is measured and GPs are paid) a proposal that QOF points should be awarded for carbon emission reduction.

"General practices could switch from being carbon emitters to looking for carbon solutions." Thompson is speaking at a conference in June on carbon reduction and health, a guide to reducing the footprint of the health sector, being organized by the BMJ, RCPCH and the Faculty of Public Health.

Professor Antony Seaton, from Edinburgh and a world authority on respiratory disease, became interested in carbon dioxide and its effect on health when he chaired a government expert panel on air quality standards. He draws a parallel with the campaign against smoking where doctors' concern over a health issue grew to such an extent that politicians finally had to act and legislate. "Every individual counts. We all need to take action."