4. Infrastructure and ways of working
Digital innovation to access care from or close to home
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 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.
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.
An increased awareness of environmentally sustainable healthcare practice is needed45, 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.
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