Sustainability Policies

^{First Published: 21 October 2021}

1. Improving prescribing and medicines use

Sustainable Prescribing

Prescribing guidance and formularies

Information for prescribers and patients

Inhaler choice

Anaesthetic gases

Optimising medicines use

Sustainable prescribing

Around 25% of NHS carbon emissions are from medicines.¹ The majority of these emissions result from the manufacture, procurement, transport and use of medicines (20%), with the remaining 5% specifically from inhalers (3%) and anaesthetic gases (2%).

Evidence shows that the number of items dispensed by primary care providers has doubled in recent years, from an average of 10 per person in 1996 to around 20 per person by 2020. 

A recent report estimated that at least 10% of prescriptions in primary care need not have been issued.² Adverse effects of medicines account for 6.5% of hospital admissions.³

Every hospital admission and unnecessary prescription adds to the carbon footprint of the NHS, so we must work hard to prevent patient harm from medicines and associated waste in the system. The most environmentally friendly medicine is the one that is not required and not prescribed.

Repeat prescriptions make up an estimated 75% of all prescription items. Repeat prescription arrangements must ensure that patients’ requirements for medicines are checked at every issue. Medicines' waste occurs when every item on a repeat prescription list is automatically ordered but not all are needed. Patients should be encouraged to only order what they need.

Pharmacists and pharmacy technicians in all sectors are responsible for medication reviews. These are an ideal opportunity to work with patients to reduce medicines waste by addressing concerns, improving compliance and de-prescribing medicines the patient no longer takes or are not appropriate.

Prescribing guidance and formularies

Most prescribers are not aware of the environmental impact of medicines. To support environmentally sustainable decision-making, prescribing guidelines should be produced and reviewed to consider the environmental impact of medicines. Where medicines have equivalent clinical efficacy, the medicine with the lowest environmental impact should be first choice.

To enable pharmacists to produce informed, evidence-based guidance on sustainable prescribing, more research is needed to inform prescribing guidance.  Environmental risk assessments (ERAs) should be readily accessible for all new medicines and the pharmaceutical industry should carry out ERAs on the most commonly prescribed medicines on the market as well as new products to enable prescribing guidance and formularies to better guide greener prescribing decisions.

Information for prescribers and patients

Ensuring prescribers and patients can make informed choices about the environmental impact of prescribed medication is essential. Pharmacists can encourage and empower patients to be part of the decision-making process by giving them the tools and information to do so.

Being involved in this process can result in increased compliance which can lead to reduced medicines waste.  Pharmacists can also make a difference by discussing environmental impact with prescribers to encourage ‘greener’ prescribing.

Inhaler choice

Some medicines have more of a negative environmental impact than others, for example, inhalers. It’s reported that nine out of 10 people are already breathing polluted air every day, which kills seven million people every year⁴, the ever-increasing levels of air pollution must be addressed. 

RPS supports FIP’s calls to action in mobilising pharmacists to help mitigate the impact of air pollution on health⁵, which will subsequently reduce the current trend of increasing numbers of people needing inhalers.

Metered dose inhalers (MDI) contribute an estimated 3% of the carbon footprint of the NHS in the UK.⁶ In Scotland, 2.5 million salbutamol inhalers were prescribed in the last year: if they were all MDIs, the carbon footprint would be equivalent to 1.125 billion miles driven in a car. This is set against a background of an increase in prescribing of salbutamol inhalers of 7.4% on the previous year.^{7, 8}

It is clear there is a significant opportunity to optimise medicines and reduce emissions associated with inhalers.  Pharmacists can review a patient’s diagnosis, inhaler technique,⁹ frequency of inhaler use and, if appropriate, switch to a lower carbon inhaler.¹⁰

Research has shown that recycling of used inhalers, switching to inhalers with lower propellant levels and encouraging patients to keep track of doses to avoid disposing of half used inhalers and reducing waste can have a positive environmental and cost benefit.¹¹

Anaesthetic gases

Across the NHS, inhalational anaesthetic agents (IAAs) are commonly used as a part of everyday surgeries. Following their use, they are expelled into the atmosphere and contribute to climate change. These gases alone, are responsible for over 2% of all NHS emissions.¹²

The most damaging inhalational agent is Desflurane.¹³ It has 60 times the environmental impact of other less harmful greenhouse gases such as Sevoflurane and using a bottle has the same global warming effect as burning 440 kg of coal.¹⁴

Nitrous Oxide, a potent greenhouse gas, has less global warming potential than the inhalation anaesthetic agents, nevertheless it does still have nearly 300 times greater Global Warming Potential than that of carbon dioxide and much greater atmospheric longevity than IAAs taking an average of 114 years to disintegrate.

Within the UK, anaesthetic nitrous oxide emissions are comparable to 320,000 flights from London to New York, and it constitutes over 80% of the total anaesthetic gas carbon footprint.

Pharmacists in anaesthetics departments can raise awareness of more sustainable anaesthesia and work to reduce the carbon footprint of all medical gases.

Optimising medicines use

An important role of all pharmacists is to optimise the health outcomes for patients taking medicines. This starts by ensuring that a medicine is necessary and appropriate. 

There is a significant environmental cost from medicines that are prescribed but not taken, through both waste of the medicine itself and the wasted resource to produce and supply the medicine. 

Asking people what really matters¹⁵ to them within the wider context of their life is important; we know that when patients are engaged with their healthcare decisions it can greatly improve their outcomes. Prescribers should therefore take a shared decision-making approach to actively involve patients in understanding just what matters to them and then deciding the best treatment option.

Where a medicine is required, pharmacists should ensure that the relevant information is available and provided to a prescriber to help make an appropriate choice and that the correct dose is selected. The medication should be reviewed regularly to ensure the correct dose is prescribed, there is a continued need for the medicine and that the patient is not suffering from adverse effects. 

NICE has suggested that implementing the best practice outlined in its medicine’s optimisation guideline in England would save 202 tonnes of greenhouse emissions, 0.3 million m³ of fresh water and 24 tonnes of waste.¹⁶ To calculate this, NICE looked at reducing non-elective admissions for adverse drug reactions.

New technologies can play a role in reducing the impact of medicines on the environment. The developments of personalised medicines recognise that ‘one size fits all’ is not appropriate for some treatments and conditions, as there may be variation in the effectiveness of treatments.¹⁷   

By knowing genomic and diagnostic characterisation, the treatment can be tailored to the patient’s specific genetic profile resulting in more effective treatment, reduced side effects and reduced pharmaceutical waste. 

Personalised medicines are already being utilised in cancer and HIV. In some countries pharmacists lead on pharmacogenomics.¹⁸ For example, genetic diagnostic tests are available within the community pharmacy for patients who report the treatment is ineffective or who have experienced adverse drug reactions.

See also:

• Case Study #3 - Green Theatre Groups
• Case Study #4 - Reducing Use of Nitrous Oxide
• Case Study #5 - Anaesthetic Gases: Banning Desflurane
• Case Study #6 - Sustainable Prescription Ordering

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2. Tackling medicines waste

Increasing public awareness on the prudent use and disposal of medicines

Research into the re-use of medicines

A circular economy approach to the use of medicines

Reducing single use plastic

Reducing antimicrobial resistance due to pollution by pharmaceutical waste

Increasing public awareness on the prudent use and disposal of medicines

Each year, it has been estimated that more than £300 million is wasted on unused or partially used medicines in the UK.¹⁹

As well as carbon emissions, medicines have other adverse environmental impacts. Pharmaceutical residues have been found in the environment resulting from production and formulation, patient use, use in food production and improper disposal.

When a medicine is taken, between 30-100% of it is excreted by the human body and enters the sewage system,²⁰ and skin products can be washed off into waste water. 

Not all medicine traces are removed by water treatment plants which can result in water pollution. Even tiny amounts can impact marine life, for example pollution of waters with female hormones can result in male fish becoming feminised. Other effects on reproduction, behaviour and physiological changes have also been cited in the literature. 

Finally, medicines packaging can be difficult to recycle, so instead it contributes to landfill waste and inappropriate kerbside recycling which may lead to a load of mixed recycling being rejected.

Pharmacists are ideally placed to advise patients on the appropriate handling and disposal of medicines, reminding them never to flush them down a toilet or drain and always return them to the community pharmacy for safe disposal. When advising patients to return medicines, pharmacists should ask them to return only the medicine and blister packs and recycle the cardboard and paper leaflets in their usual paper recycling.

Research into the re-use of medicines

Currently, when full or part-packs of medicines are returned to pharmacies, they cannot be returned to stock because it cannot be guaranteed the medicines have been stored appropriately and not tampered with. This leads to significant waste as well as a negative environmental impact. 

Studies, including one published as recently as 2020, have investigated public attitudes towards medicines waste and medicines reuse. It was found the public showed a high acceptance for the reuse of prescription medicines which have been returned unused by patients.  This acceptance can be encouraged with education around the positive environmental impact of re-use as well as the introduction of measures to illustrate the safety and quality assurance of the reissued medicines.^{21, 22}

As the economics of behaviour and the need to take immediate action on climate become apparent, we need to examine whether the current legislation and waste management processes are fit for purpose and may be impeding efforts to reduce carbon emissions.

A circular economy approach to the use of medicines

A circular economy approach aims to reduce waste, maximise the value of a product and enable sustainability within the supply chain. There is a need to move from a linear economy, where a product is manufactured, used and discarded to a circular one where the product or its component parts can be repurposed.  This is particularly important for inhalers and anaesthetic gases which together contribute 5% of the total carbon footprint of the NHS. 

More than 26 million MDIs were prescribed in England alone in 2016/17. Landfill disposal of inhalers is harmful to the environment both in materials lost, and greenhouse gases released into the atmosphere as even when the inhaler is spent significant amounts of gas can remain in the canister. MDI use in England alone is responsible for nearly 1 million tonnes of CO2 equivalent per year.²³

A circular economy approach to inhaler recycling should be investigated to consider a national separate waste stream in community pharmacies for inhalers so that the gases can be extracted, cleaned and reused, the precision metal components and plastic would also be recycled and reused.

Reducing single use plastic

Single use plastic is ubiquitous in healthcare and even more so due to the COVID pandemic. Environmentally friendly alternatives should be identified in order to cut down the use of medicine syringes, spoons, cups and compliance aids. 

Ongoing work is required to ensure that compliance aids are only used when necessary. RPS has long advocated for the better use of multi-compartment compliance aids (MCA). With the use of decision aids and a review of the stability data for medication being considered for an MCA, we can ensure these aids are used only when appropriate, safe and necessary.²⁴

Reducing antimicrobial resistance due to pollution by pharmaceutical waste

Between 30-100% of a medicine is excreted by the human body into our wastewater systems²⁰, which cannot remove all traces, resulting in traces of pharmaceuticals entering the environment.  This can lead to the conditions being created which results in the development of antimicrobial resistance (AMR).^{25, 26}

AMR is a significant public health concern and has the potential to nullify over 100 years of modern medicine. AMR caused more than 90,000 hospital admissions in England in 2019/20 – an increase of nearly 4 per cent on the previous year. It’s estimated that by 2050, antimicrobial resistant infections may become the leading cause of death, killing 10 million people every year worldwide and costing the worldwide economy $100 trillion.²⁷

Professor Dame Sally Davies, Co-convenor of the United Nations Inter-Agency Co-ordination Group on AMR and past Chief Medical Officer for NHS England has said that “AMR is an escalating and highly complex problem — ultimately, we are in an arms race against microbes, which are expert at evolving resistance rapidly, so we have to respond quickly and in a multifaceted way”.²⁸

Every part of the health system depends on antibiotics. It is thanks to antibiotics that, in the UK, common but previously life-threatening illnesses such as pneumonia, meningitis and TB are now treatable. They also enable routine operations and even cancer chemotherapy to be carried out safely and effectively. 

Drug-resistant infections pose the biggest threat to modern medicine. Chemotherapy would not be possible and even common surgeries, such as hip operations and caesarean sections, could be become life-threatening procedures with prolonged hospital stays.

All pharmacy professionals across all sectors can significantly contribute to AMS through several activities, such as providing clinical advice, developing guidelines and delivering education and training to other healthcare professionals and the public. 

Embedding local and national guidelines is crucial to ensure narrow spectrum antibiotics that cause less collateral damage to the environment are used where possible and that course length is not extended to reduce total use of antibiotics. 

Education of patients and the public about self-care of common infections and appropriate use of antibiotics is a key activity for pharmacists.

To find solutions that prevent AMR and drive appropriate antimicrobial (including antibiotic) use, a One Health Approach is required bringing together action and researchers from across science, human, animal, agriculture and environmental fields, as well as in data science, human behaviour and even anthropology.²⁹

All stakeholders across the One Health arena need to be aware of the threat of antimicrobial resistance and apply best practice in agriculture, aquaculture and pharmaceutical manufacturing in order to mitigate antibiotic resistance development.

See also:

• Case Study #1 - Recycling Blister Packets
• Case Study #2 - Inhaler Recycling
• Case Study #8 - Reducing Water Pollution from Medicines

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3. Preventing ill health

Supporting the public to stay well, reducing need for medicines

Social prescribing

To achieve sustainability goals, it is vital that steps are taken to improve the health and wellbeing of the population to help reduce demand for health services and clinical interventions.

Pharmacy teams can play a key role in supporting the public to stay well. Current schemes such as the Pharmacy First service in Scotland³⁰, Stay Well pharmacy campaign in England³¹ and Choose Pharmacy in Wales, are designed to improve access to care for patients who could be treated successfully and quickly in the community.

Supporting the public to stay well, reducing need for medicines

Pharmacy has a crucial role in public health: to encourage and support people to take an active role in managing their health and wellbeing to prevent the onset of health conditions and reduce the need for medication.

Making every contact count (MECC) is an evidence-based approach to improving people’s health and wellbeing and helping them to change their behaviour.^{32, 33} Every day the NHS has contact with more than a million people at moments which bring home the personal impact of their ill health. Such moments provide an opportunity to engage people in conversations about improving their health by addressing risk factors such as alcohol, diet, smoking, physical activity and mental well-being.

Community pharmacy teams are uniquely placed to deliver public health services and make every contact count due to their accessibility and expert knowledge with 95% of the population living within 20 minutes of a community pharmacy.³⁴   

During the pandemic, pharmacies have increasingly become the first point of contact with the NHS. The pandemic has also provided a reset button for many people on the importance of self-care, so there is an opportunity to capitalise on this sea change in people’s attitudes and educate the public and address their health concerns. 

The pandemic has also raised awareness about infection prevention such as the importance of hand hygiene and cough etiquette. Pharmacy teams should continue to promote these behaviours.

In hospitals and GP practices, pharmacists can also deliver key public health messages at the point of prescribing and care. Ensuring consistent messages across pharmacy sectors would strengthen the impact and embed these conversations in everyday practice.

By supporting and empowering people with their health and wellbeing, pharmacy teams can have a huge impact on population health and sustainability. For example, providing dietary advice to reduce processed food and increase intake of seasonal and locally sourced produce³⁵ can help decrease carbon emissions and prevent the development of obesity related illnesses.³⁶

Social prescribing

There is an increasing recognition that people’s health is affected by social, economic and environmental factors. As a result, there has been increased interest in social prescribing: where healthcare professionals refer patients to non-clinical services, for example, arts activities, gardening and sports.³⁷   

The evidence suggests that social prescribing can positively affect the physical and emotional wellbeing of people, improving their quality of life, levels of depression and anxiety and combatting loneliness. It may also reduce demand for NHS services and medicines, resulting in an intervention with a lower environmental impact.³⁸

Pharmacy represents an opportunity to suggest social prescribing interventions and signpost people to them. Current evidence suggests that community pharmacy involvement is limited, but there is potential for more meaningful contact.³⁹

RPS calls for research around social prescribing to be conducted to investigate how pharmacists can provide evidence based public health interventions with maximum impact, potential pathways and funding streams with a view to embedding social prescribing in the community pharmacy contract.

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4. Infrastructure and ways of working

Digital innovation to access care from or close to home

Procurement

Transport

Education

In all government strategies for sustainability, much emphasis is placed on the infrastructure of the NHS.^{6, 40, 41, 42} Considerations include the buildings themselves, transport and procurement, as well as ways of working. 

The Royal College of General Practitioners, with the National Union of Students has developed a Green Impact for Health toolkit for GP practices. Over 900 GP practices have used the toolkit, which has over a hundred actions that can help the GP practice improve sustainability and potentially save money. 

The actions are grouped into a number of areas including prescribing, water, food, travel, energy and waste. A similar toolkit should be developed for pharmacy.

Road travel to the NHS by patients, staff, visitors and suppliers is an important contributing factor to environmental damage. 

It accounts for around 14% of NHS England emissions,¹ divided into: 

• Patient travel 5%
• Visitor travel 1%
• Staff travel 4% 
• and Business and fleet transport 4%. 

Approximately 3.5% (9.5 billion miles) of all road travel in England relates to patients, visitors, staff and suppliers to the NHS.⁶ Digital innovation to provide care at or close to home is a vital way of reducing travel and the subsequent environmental and human health harms.

Digital innovation to access care from or close to home

Digital innovation has been expanded recently, particularly in response to the COVID-19 pandemic, with a significant growth in virtual consultations across health and care services. More staff worked from home providing telephone and video consultations, which reduced both staff and patient travel. Joint multidisciplinary team consultations by video also reduced unnecessary journeys for patients and clinicians.

A public consultation and evaluation⁴³ showed video consulting was viewed positively, in particular for improving accessibility of services, reducing travel and improving convenience. 

The public also noted the environmental benefits in this consultation. The scale up of the Near Me video consulting service across NHS Scotland to 20,000 consultations per week is estimated to be saving 28 million patient travel miles per annum.⁴³  

Not only does digital care secure environmental benefits, but it also builds into the system adaptive capacity and resilience which is important for managing the increased demand in the NHS.

Further work and investment are now needed across all sectors of pharmacy to ensure virtual consultations are used whenever it is clinically appropriate, and appropriate for the individual patients, and that services do not revert to the pre-COVID default way of working.

To support the increase in digital working, improved digital infrastructure is required across the NHS. Equipment for digital services is required in all NHS settings, including community pharmacies.  Education and training are required across all sectors to maximise use of digital consultations.

To facilitate improved access for patients and remote working, pharmacists need access to a single shared patient record and electronic prescribing must be introduced in all sectors.

Some community pharmacies could be set up as hubs where patients could access digital health and care services, particularly in rural and deprived areas where access to the internet may be a barrier to care.

Procurement

Procurement of pharmaceuticals in the NHS contributes approximately one fifth of the total NHS carbon footprint.^{6, 40, 42} Ways to reduce carbon emissions include more efficient use of medicines, low-carbon substitutions (e.g. inhaler choice), product innovation and by working with suppliers, who themselves have a responsibility to consider environmental impact of what they do.

Pharmacies should consider how often they order products and receive deliveries, as well as ensuring appropriate stock control to reduce any wastage. Wholesalers and manufacturers should improve their delivery arrangements to reduce unnecessary journeys.

We support recommendations highlighted in the Carter report⁴⁴ centred on transformation of hospital services and improving efficiency. It is interesting that one of the recommendations was for better medicines' stockholding, modernising the supply chain and rationalising deliveries to less than five per day. These recommendations were made to help workflow and workload; however, they will also have an environmental impact.

Use of medicines with low carbon emissions should be promoted. However, it is important that any changes in guidelines that will result in a large change in practice are communicated to those in procurement. This will ensure that appropriate stock can be obtained and that the supply chain is robust. It is also important that there is no negative impact on patients or their ability to access medication in a timely manner.

Government strategies for sustainability in the NHS state that the suppliers will need to support their net-zero goal. It is important that a consistent approach to evaluate the carbon impact of pharmaceutical suppliers is developed across the UK.

Transport

Greener travel and transport include a range of interventions to reduce carbon emissions such as zero emission vehicles, reducing unnecessary journeys, active travel such as walking or cycling.

Transport vehicles are used throughout the medicines supply chain, including transporting medicines to pharmacies and between sites, and for the delivery of medicines to patients and patients and the public themselves will also incur “care miles” in accessing pharmacy services.

Medicine deliveries should consider electric vehicles or vehicles with low or ultra-low emissions wherever possible. In addition to the type of vehicle used, logistical improvements are needed to reduce the number of deliveries or journeys required.

Pharmacy staff should consider using active travel methods to get to work and encourage the public to use active travel where possible to both improve their physical and mental health while helping mitigate climate change.

Education

An increased awareness of environmentally sustainable healthcare practice is needed^{45, 46} both at an undergraduate and post graduate level. Healthcare education should acknowledge the effect climate change is having on health and the healthcare system. 

Areas to be considered include:

• How the environment and healthcare interact at different levels
• The health effects of climate change
• Sustainable healthcare practice
• Low carbon staff and patient behaviours 
• Ways in which pharmaceutical waste and harm can be minimised.

Sustainable healthcare has already been embedded into some healthcare graduate outcomes as directed by their regulatory bodies, for example the General Medical Council.⁴⁷ It is not currently included as part of the General Pharmaceutical Council’s Standards for the Initial Education and Training of Pharmacists. 

The RPS Prescribing Competency Framework⁴⁸ does acknowledge that a key competence for all prescribers is to ‘Consider the impact of prescribing on sustainability, as well as methods of reducing the carbon footprint and environmental impact of any medicine.’

To maximise pharmacy’s input in achieving the net-zero goal, it is imperative that appropriate education in this area is available for all relevant staff. This extends to clinical practitioners in all sectors, as well as procurement leads, and other pharmacists where increasingly it will be expected to report not only pharmaceutical data analysis but also carbon footprint metrics too. 

Higher education institutions should also encourage MSc and PhD students to consider the sustainability agenda when completing their projects.

See also:

• Case Study #7 - Sustainability in the Workplace

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