Embedding Sustainability in Practice Through Undergraduate Medical Education: The ScotGEM Agents of Change Approach

Health systems face dual imperatives: delivering high-quality, person-centred care while responding to the climate crisis. In the UK, the National Health Service (NHS) contributes substantially to greenhouse gas emissions, driving commitments to Net Zero and sustainable practice. Medical education has a role in preparing graduates to consider environmental sustainability in clinical decision-making, including prescribing. This study aimed to classify and describe the topics represented in undergraduate primary care quality improvement (QI) projects and examine their alignment with sustainability, prescribing, and person-centred care priorities within the NHS. We analysed 500 primary care QI project titles from the Agents of Change (AoC) curriculum using a rule-based, multi-label classification framework comprising four categories: sustainability, prescribing, patient monitoring, safety and care processes, and regulations and audit. Descriptive statistics summarised the distribution of topics, while descriptive content analysis was used to examine titles that did not map to the predefined categories. Of the 500 titles, 46 were classified as relating to sustainability, 260 to prescribing, 404 to patient monitoring, safety and care processes, and 202 to regulations and audit; 27 titles could not be mapped to the predefined categories. As titles could be assigned to more than one category, these counts represent overlapping topic classifications. Analysis of unmapped titles identified themes relating to workflow optimisation, patient engagement, clinical communication, social prescribing, and access to care. These findings describe the range of topics represented in ScotGEM primary care QI projects, including those relevant to sustainability, prescribing, and person-centred care. The Agents of Change curriculum provides opportunities for students to develop systems thinking, quality improvement skills, and leadership through engagement with real-world healthcare challenges. However, as this study analysed project titles rather than full project reports or outcome data, it cannot determine whether the projects resulted in measurable changes in clinical practice, patient outcomes, or environmental impact. Further evaluation using project reports and outcome data would help assess these effects.