1 Towards a Cycling Culture in Primary Care
2 I started riding a bicycle as a student in London. Cycling as a GP in North Bristol is a lot less scary. It took me a while to take the plunge, put off my colleagues assertions that it was dangerous and impractical. Once in the saddle though, I was hooked. People assume that my motivations are virtuous lowering my carbon footprint and keeping fit. These, however, are secondary to the sheer joy of cycling. I m privileged to ride to work through ancient wooded parkland but even during less rewarding urban cycling, something good seems to happen to my brain. I m convinced that cycling makes me a more creative and cheerful doctor so what s the downside? I ve been bitten by a bulldog, mistaken for the postman (red panniers) and castigated by the practice nurse for shaking up the emergency drugs box I m wondering how many years my knees will cope with the hills, but an enthusiast tells me an electric bike could be the next step. 1 Dr Marion Steiner, a Bristol General Practitioner, paints the world of cycling in vibrant splashes of positivity in her personal account above. If cycling to work is as pleasant an experience as Dr Steiner beguiles to us, then why is it that most of us fail to make the most of it? Why is there a relatively insignificant cycling culture amongst primary care staff? Can something be done to change this? These are the questions that this article aims to answer to help inform how we should promote a cycling culture amongst primary care workers. But firstly, let s consider the significance of cycling: why does it matter? Cycling boasts a wonderful array of benefits, from health-related perks to environmental blessings: we can no longer be in denial that more cycling and less vehicle transport is better for the environment by lowering carbon footprint 2. It thus seems commonsensical to include the promotion of cycling amongst staff members under the Travel criteria of the Green Impact toolkit (GIT). Cycling policymaking in the health sector is already strongly recommended and endorsed by the European Cyclists Federation 3. Asking a General Practice (GP) to promote cycling amongst its staff members should be a major focus here as it is something simple, practical, and thusly feasible for GPs to implement. To investigate what the barriers to a cycling culture are and how
3 these barriers can be overcome, firstly GPs were contacted directly in order to discuss these matters with the practice manager. The practice managers were asked a series of questions and their responses recorded (see appendix 1). The qualitative data collected was then used to identify their perceived benefits of cycling to work, what they believe the barriers are to cycling to work and how they felt cycling could be promoted in order to overcome these barriers (see appendix 2). The problems that they identified were then presented to and discussed with Sustrans, a Bristol-based leading charity which promotes cycling, in order to brainstorm ways in which these can be practically and simply overcome. These suggestions were then collated with further research where possible, despite there being very limited academic discourse and literature on the quintessential matter. Here, the findings are presented and proposals offered as to how a cycling culture can be promoted amongst primary care staff in order to inform the Green Impact toolkit. Let s start with the most common, recurring theme footnoted by the GPs: safety. Unequivocally, the most formidable threat to cyclists is their petrol-loaded counterparts: cars! All of the 8 GPs contacted fretted over the safety aspect, but Sustrans says the solutions are quick and easy, effortlessly implemented by the concerned practice manager. Firstly, address visibility: how easily are your staff members seen? Consider allocating budget for supplying staff members with safety equipment including lights and helmets. These do not need to be á la vogue: their only prerequisite is that they do the job! Additionally, consider educating staff members about cycling as this can surge confident levels. For example, educate them on cycling in different weather conditions and that braking on wet surface will take longer than breaking on dry surfaces and so forth. Educate them on appropriate cyclist behaviour: when cycling, one needs to ride positively and decisively. Alternatively, organise for staff members to be sent on cycle training courses delivered by the National Standard for Cycle Training. These are all reasonable measures a practice can implement without difficulty to ensure staff safety to the highest degree, and are measures which would thusly be appropriate for inclusion in the GIT. But people like evidence
4 because evidence is convincing. So what s the evidence that taking these measures will improve safety for staff members? Well, an observational study conducted by McGuire and Smith (2000) 4 on 392 Oxford cyclists set out to investigate how effective safety measures are in preventing cycling injuries. The researchers observed cyclists passing through a busy, central two-way road serving both university and business areas in the city from 17:30 (when most motor vehicles had lights on) until 18:30 (when no daylight remained). Street lighting time was at 18:00. Cyclist visibility was therefore reduced throughout the period of study. The measures taken by these cyclists included wearing helmets, high visibility clothing, and the employment of lights. The study concluded that cyclists taking measures to prevent injury in the event of collision are more likely to also take measures to appear more visible and thus avoid such collisions in busy city roads. Whilst the study flags up that current measures by cyclists in a major cycling centre may not be enough to completely prevent collisions, this study goes to show that cycling can be safe if appropriate and sufficient measures are taken. Furthermore, studies of injured cyclists have recorded helmet use rates of 14% in South Wales 5 and 11% in Cambridge 6. So wherever there is an incidence of cycle injury there tends to be a low incidence of the use of safety measures. The take-home message is surely to take safety measures if you want to be safe. In fact, there is an inverse relationship between the number of cyclists and the number of cyclist casualties: research suggests that a doubling of cycling activity would lead to a reduction in the risks of cycling by around a third, i.e. the increase in cycle use is far higher than the increase in cycle causalities. There are plenty of examples to show that steep increases in cycling can go with reductions in cycle causalities. In the UK for example, London has seen a 91% increase in cycling since 2000 and a 33% fall in cycle causalities since This means that cycling in the city is 2.9 times safer than it was previously 7. Even if cycling a particular path is safe, what if the time it takes one to cycle there is dauntingly protracted? This cycles us away from the grand piece that is safety and puts under the microscope another big barrier to cycling highlighted by our
5 GPs: distance. Several of our GP managers pondered not just how long it may take staff members to cycle into work but also specifically how long it would take doctors and nurses to carry out home visits. This is of course dependent on the location of the practice in relation to where its staff members live and the location of the practice in relation to where the patients live. Discourse with Sustrans offered some valuable suggestions to work around these. They say that cycling to work can save time and be quicker than travelling by car, especially for some of the Bristol practices considered in this study as access to these practices by car would involve enduring a monotonous standstill jaunt through a miserably congested city! Transport for Greater Manchester agrees with this 8, as does common sense. For those staff members who live out of the city and thusly have a considerably greater distance to travel to and from work, consider promoting combined travel: Sustrans have found that cycling and using train can save money (a great incentive for staff members), and these journeys can be scheduled and timed so as to arrive in work on time and get home at a reasonable hour! With regards to home visits, we propose setting a certain radius within which doctors and nurses can cycle to, for example any patient residence that s within a 1.5-mile radius from the practice. Any residence required to visit beyond this distance can be travelled to by car in the interest of time: we must accept that doctors and nurses are busy people! So, primary care staff can travel safely in a shorter amount of time. Still unconvinced, I hear you say? Another trepidation is that provoked by cost. 50% of the practices included in this study reported cost as a barrier to promoting cycling amongst its staff members. The practice managers thought that purchasing bikes for staff members would be too much of a cost to its staff members as bikes aren t exactly cheap. However, there are schemes which make cycle purchase cheaper. For example, King s College Hospital Trust 9 uses the Cyclescheme cycle to work scheme, which helps people to get a tax-free bike and save about 40% of the usual cost. You can apply to take part and hire a bike plus safety equipment up to the value of 1,000. Once you have hired the bike for a certain length of time and all the payments have been made, the bike is yours. By means of another example, the Nottingham University Hospitals Trust have
6 partnered with Halfords to offer staff the Cycle2work scheme. Through this scheme, you can hire a new bike and accessories by making monthly payments from your salary. You will not pay tax or national insurance on these payments. After 12 months, you will have the option to buy the bike for a small sum. You can spend as little as 100 on a new bike (and accessories) and up to 1, Thusly, through these price reduction themes, options vary from being lofty in price to being affordable to most. It is at least encouraging to see that 2 of the practices included in this study are already using such schemes, including the NHS cycle to work scheme, namely Pembroke Road Surgery and The Family Practice. However, on the downside, Southville Surgery regarded cycle to work schemes as financial disincentives for a General Practice as they involve the practice having to initially bear the cost of the bikes and the employee pays the practice back in monthly installments. This monetary barrier is one which could be worked around with current schemes by arranging for the staff member to purchase from the scheme directly, bypassing the cost to the practice. Furthermore, 3 practice managers were concerned with the additional costs incurred from having to provide bike storage, install showers, and install changing rooms. Whilst most will agree that bike safety is paramount, these financial dissuasions necessitate further investigation: maybe a survey for primary care staff workers could be conducted to see whether they deem showers and changing rooms necessary or whether they think they can suffice without them. Perhaps further research should be conducted on this before finalising the GIT. So this study of 8 GPs offers a brief insight into their concerns and potential solutions to them. We have seen that it is possible to cycle safely, in a shorter amount of time and have it be affordable to primary care staff. Indeed, Daly and Rissel explicate that there is a need to improve the public acceptability of cycling and change public norms so it is seen as an everyday activity that can be undertaken by almost anyone, without the need for special clothing, expensive equipment or limited to purpose built facilities 11. Different GPs had different
7 outlooks and attitudes towards a cycling culture amongst its staff but ultimately most were interested to find out more about and engage with the Green Impact toolkit and it thus has capacity to bring about great change. We cannot save the white rhino and we cannot stop the destructive life-taking floods of Asia, but we can start making the difference here, and in doing so become one step closer to seeing ourselves as visitors rather than owners of this world and make a longlasting environmental impact. Let s send an earthquake through the way in which travel is perceived and conducted in General Practice.
8 References 1. Schroeder K, Thompson T, Frith K, Pencheon D. Sustainable Healthcare. UK: Wiley-Blackwell; Climate Focus. Bikes to reduce emissions. Amsterdam: Climate Focus; [Accessed 30 th November 2014]. Available from: climate_finance _briefing.pdf 3. European Cyclists Federation, Economic Benefits of Cycling, [Accessed 29 th November 2014]. Available from: 4. McGuire L, Smith N. Cycling safety: injury prevention in Oxford cyclists, Injury Prevention. 2000; 6: [Accessed 3 rd December 2014]. Available from: 5. Harrison MG, Shepherd JP. The circumstances and scope for prevention of maxillofacial injuries in cyclists. J R Coll Surg Edinb 1999;44:82 6 [Accessed 3 rd December 2014]. Available from: 6. Maimaris C, Summers CL, Browning C, et al. Injury patterns in cyclists attending an accident and emergency department: a comparison of helmet wearers and non-wearers. BMJ 1994;308: [Accessed 3 rd December 2014]. Available from: 94c8b97f c9143e0cb8e52&keytype2=tf_ipsecsha 7. CTC. Safety in Numbers. Surrey: CTC [Accessed 3 rd December 2014]. Available from: pdf 8. Transport for Greater Manchester. Commuting by bike. [Accessed 4 th December 2014]. Available from:
9 9. Kind s College Hospital NHS Foundation Trust. Cycle to work scheme. [Accessed 4 th December 2014]. Available from: https://careers.kch.nhs.uk/offering/benefits/cycle-to-work-scheme 10. Nottingham University Hospitals NHS Trust. Cycle2work scheme. [Accessed 4 th December 2014]. Available from: 11. Daley M, Rissel C. Perspectives and images of cycling as a barrier or facilitator of cycling, Transport Policy, 2011; 18: [Accessed 7 th December 2014]. Available from:
10 Appendix 1 GP Question List On Cycling 1. Is it ok with you if I include anything you say in the present study? 2. What is your name? 3. What is the practice s attitude towards cycling? 4. Do any of the staff members cycle? If so, how many and how often? 5. Do you think you would consider promoting cycling in the practice more? 6. If so, how would you do this? 7. What do you consider to be the advantages and barriers/disadvantages of cycling to work as a GP (or any other general practice staff member) and cycling to carry out work duties (such as home visits)? 8. Would the practice be interested in finding out more about the Green Impact toolkit and in participating in the pilot study?
11 Appendix 2 Pembroke Road Surgery 2. Heather Carrigan 3. The practice encourages cycling and has a positive attitude towards cycling 4. 3 out of 8 of the GPs cycle to work all of the time, 1 GP cycles occasionally. No other staff members cycles 5. Yes 6. The practice already promotes the NHS cycle to work scheme, offers bike stands, and is currently converting a spare room into a staff changing room. The practice would also consider installing showers (however this is cost-dependant) 7. Advantages: saves the practice money as they do not have to reimburse doctor mileage; Disadvantages: safety element; cost to the staff members; the transportation of doctor equipment to patients home 8. Yes The Malago Surgery 2. John Gibson 3. The practice has a very positive attitude towards cycling 4. 5 staff members always cycle, and 1 other occasionally. This includes 3 GPs, 1 pharmacist, and the practice manager. 5. The cycle promotes the cycling to work scheme: 2 staff members at the practice had purchased through this scheme. They would have used the NHS cycle to work scheme however the local bike shop they wanted to use does not run it. Therefore, maybe we should consider tackling bike shops also with regards to implementing NHS schemes more widely. 6. Not much to say 7. Advantages: health etc. Disadvantages: don t have shower facilities; dangerous cycling routes; cost; safety element; distance to home visits is too far; the arrogance of cyclists 8. Yes. St. Augustine s Medical Practice 2. John Moon
12 3. The practice isn t particularly cycle active but may consider promoting cycling more 4. Only one of the staff members currently cycle 5. Yes, the practice is interested in promoting cycling further. 6. Security; offering staff discounts (schemes) 7. Advantages: Disadvantages: slow (time-wasting); distance; potential bulky load in home visits; safety element 8. Yes The Southville Surgery 2. Andrew Bale 3. The practice does not actively promote cycling or see it as a priority 4. None of the staff members cycle, however some walk and most drive 5. Potentially because the practice does not have much parking availability for patients. 6. Cycle to work scheme. However this is a financial disincentive because this often involves the employer (the practice) having to fund the purchase of the bicycles and the practice doesn t have the budget for this 7. Advantages: none Disadvantages: Safety element; staff aren t confident; mention of imposing a legal liability upon the practice if something were to happen to staff members 8. Yes The Family Practice 2. Keith Minty 3. The practice has a very positive attitude towards cycling staff members always cycle: 10 doctors cycle and 20 non-medical staff members, including pharmacists and cleaners 5. Yes 6. The practice promotes the NHS cycle to work scheme; installing more bicycle wracks (for staff and for patients); changing rooms 7. Advantages: health benefits; Disadvantages: location is a problem being at the top of St. Michaels Hill! However, this hasn t dissuaded many staff members; distance to work and home visits; safety 8. Yes Stroud Valleys Family Practice 2. Hilary French
13 3. The practice encourages cycling where possible but cycling to and from the practice is not very easy staff members cycle occasionally 5. Potentially 6. Cycling wracks and additional safety measures; discount schemes; notices; also posters in waiting rooms to encourage patient cycling 7. Advantages: health benefits; better for the environment Disadvantages: safety element; distance; cost to the staff members and the cost of having to install extra facilities such as showers and changing rooms 8. Yes Park Lane Practice 2. Sarah Francome 3. The practice does not actively promote cycling. 4. None of the staff members currently cycle 5. The practice may consider promoting cycling further in the future 6. Install safety features; hygiene features 7. Advantages: healthier; Disadvantages: Additional costs; safety; bad/cold/snowy weather 8. Yes Dalkeith Road Medical Practice 2. Kevin Lawrie 3. The practice did not particularly have a positive attitude towards cycling 4. 3 doctors cycle to work 5. Not necessarily; it is not seen as much of a priority 6. Offering appropriate wear (depending on the cost this incurs on the practice); 7. Advantages: health benefits; lower CO2 footprint Disadvantages: weather (particularly in winter); cost; with regards to home visits = time; safety aspects; legal aspects: what if we promote cycling and something happens to them? 8. Yes
14 Appendix 3 Suggested possible criteria for the GIT that have emerged from this project: 1. Has the practice allocated a budget for safety equipment or has it promoted the use of safety equipment? 2. Does the practice offer cycle training courses to its staff members? 3. Does the practice promote combined travel? 4. Does the practice set a radius in within which home visits may be conducted? 5. Does the practice promote cycle-to-work schemes to make cycling more affordable to its staff members?