Anna Edwards, innovation project manager at Health Innovation West Midlands, discusses how we can reduce the environmental impacts of medicines and the challenges being faced to achieve this.
Healthcare contributes significantly to the UK’s carbon footprint, with medicines in particular having a profound effect on the environment. Around 4-5 per cent of the UK’s carbon footprint is attributed to healthcare, with medicines accounting for 25 per cent of emissions within the NHS.
Action is needed from both the healthcare industry and patients to reduce the impacts of medicines on the environment and ensure that they protect both patients and the planet.
Pharmaceutical pollution
One way medicines negatively impact the environment is through spread into waterways. A study by the Global Monitoring of Pharmaceuticals has shown how some rivers in the UK have significant amounts of antimicrobials, hormones and anti-depressants within them.
This is because the human body can only break down a proportion of the medicines it is exposed to, and whatever it doesn’t break down leaves the body and enters the sewage network. Although sewage facilities in the UK are mostly effective in providing a barrier against larger materials, they cannot completely remove pharmaceuticals.
This is especially relevant in the wake of the Environment Agency’s findings that, in 2022, water companies discharged raw sewage into rivers and waterways 301,000 times, over 1.75m hours.
As a result, there is evidence of this polluted water threatening food and water supplies, increasing the risk of antimicrobial resistance and causing species decline.
However, waterways pollution is not the only environmental problem caused by medicines. Medicines containing greenhouse gases also contribute to the carbon footprint of the NHS and there are two particularly big offenders – inhalers and anaesthetic gases.
Inhalers contribute to 3 per cent of the entire NHS carbon footprint, especially metered dose inhalers which use greenhouse gases as propellants. Salbutamol metered dose inhalers, a type of inhaler that is often referred to as a reliever or rescue inhaler, are responsible for the largest carbon emissions of all NHS prescribing.
The second major contributor, anaesthetic gases, are responsible for 2 per cent of all NHS emissions. The NHS Long Term Plan aims to reduce this figure by 40 per cent by using alternative practices, particularly by moving away from the use of desflurane, but also looking into alternative anaesthetic processes, like Total Intravenous Anaesthesia. Addressing wastage from nitrous oxide and mixed nitrous oxide is another key area which has been audited for their use and wastage, putting into place alternative systems to address this and improving their overall environmental impact.
What can be done within the NHS?
Studies show that a large proportion of health professionals have a good understanding of the global warming potential of medications, particularly the carbon intensive inhalers and anaesthetic gases.
However, conflicting priorities, such as time and patient perception, can influence their willingness to get involved with taking action to reduce these impacts.
There is also evidence suggesting NHS staff would like further knowledge and training in environmental sustainability. Health Innovation West Midlands undertook a study of over 70 anaesthetic staff in November 2022 and found that, although the majority believed they had reasonable sustainability knowledge, there is a desire to build their knowledge around the environmental impact of theatres and anaesthetics.
With this in mind, there are a number of things healthcare professionals can do to reduce the impact of medicines on the environment. First of all, we all must take responsibility to become informed and undertake training about the climate crisis and how it impacts healthcare and our working practices.
It is also useful to connect with other likeminded professional groups – for example, the West Midlands Pharmacy Environmental Sustainability Network – which provide insight sharing and collaborative approaches for change.
When it comes to making a direct positive impact, healthcare professionals can also use sustainable principles in their own use of medicines.
For example, stopping the use of unnecessary overprescribing of medications by implementing evidence-based prescribing and medicines optimisation, using antimicrobials wisely, including using appropriate course lengths for patients, and disposing of leftover medicines responsibly.
The healthcare industry is slowly making progress towards greater sustainability with action already taking place through organisations readying themselves to start the journey to more sustainable healthcare.
For example, Greener NHS sets guidance for healthcare organisations, and The Royal Pharmaceutical Society is in the process of developing guidance specifically for pharmacists. As we develop our response to climate change, it is likely regulators will start to include environmental sustainability requirements in their new guidance for healthcare.
What can be done by patients?
For patients, perhaps the most important element in reducing the environmental impact of medicines is prevention. Taking steps to ensure a healthy lifestyle will reduce the risk of needing to take medication or being hospitalised in the first place.
For those patients who do take medications, there is the option to ask about lower carbon alternatives – for example, using a dry powder inhaler that doesn’t use greenhouse gases as propellants.
Patients can also discuss with their pharmacists, prescribers and doctors whether they are on the right medications to reduce over-prescribing and they should also make sure they are returning all unused or unwanted medication to a pharmacy for appropriate and safe disposal.
Looking to the future
There are a number of targets the NHS is working towards as part of its sustainability journey. These targets are embedded into NHS legislation and include commitments to becoming net zero by 2040 for the emissions it controls and by 2045 for its carbon footprint.
The NHS has also developed a net zero supplier roadmap, which provides guidance on how to reduce emissions when it comes to contracting goods and services to the NHS. There are also tools in place which allow suppliers to demonstrate their sustainability and steps taken on their net zero journeys.
Looking to the next 10 years, innovation is going to be key. We need to use new technologies to achieve a gold standard of patient care, while reducing our climate impact. This will naturally include a wider roll-out of digital solutions like remote monitoring and smart inhalers that give real-time data on patient disease state and medication effect.
There also needs to be the widespread implementation of technologies which reduce the risks of medications to patients and healthcare professionals, such as anaesthetic gas and inhaler propellant recapture.
Finally, we need to address the issue of waste from medicines. This can be done by implementing biodegradable packaging to reduce the use of plastics and also introducing tamper proof and temperature sensitive packaging, to reduce the amount of medication being thrown away.
We initially think of the planet when we hear the words ‘sustainable medicine’ but we need to realise that, as well as benefitting the environment, it also needs to result in good patient care – protecting patients both now and in the future.
