Climate change is a ‘health’ issue, described by the World Health Organisation as the greatest threat to human health we will ever face. However, tackling it offers the single greatest opportunity to improve human health we will ever have.

Medicines use accounts for 25% of the NHS’s carbon footprint, which is itself responsible for approximately 5% of the UK’s carbon footprint, and so optimising medicine protects the environment and simultaneously protects our patients, our colleagues and every single member of our community.

There are 4 principles of Sustainable Healthcare, ranked in order of importance.

  1. Prevention of ill-health/Promotion of good health
  2. Patient Empowerment to Self-Care
  3. Lean Service Delivery
  4. Low Carbon Alternatives

We are incredibly proud of our progress, however we are always delighted to champion new projects, sharing success across the region. If you want to know more or have any other questions, please get in touch via medicine.question@nhsdorset.nhs.uk

Respiratory Medicines

High carbon inhalers account for a large part of the carbon footprint of the health service, especially in general practice. The aim of this section is to promote key carbon reducing interventions and help clinicians find the practical guidance they need to help provide our patients in Dorset with “Great Green Respiratory Care”.

New Dorset asthma guidance is available to help optimise asthma treatment and promote modern evidence-based prescribing decisions. The guideline recommends low carbon Dry Powder Devices (DPI) as the first-line device to offer to all patients.

A comprehensive ‘Green Inhaler Support Pack’ gives full details about steps to take to reduce the carbon footprint of inhaler prescribing – including inhaler device & dose conversation tables. A ‘quick reference’ summary of this guidance is also available.

  • The clinical and environmental harm of poor disease control outweighs any benefits from the choice of any inhaler devices. Full advice on how to optimise asthma control can be found on page two of the Dorset Asthma Guidance.
  • Offer a Dry Powder Inhalers: DPIs must be the first-choice device wherever clinically appropriate
  • Prescribe the lowest carbon salbutamol pMDI: Where a DPI is not clinically appropriate prescribe the brand and dose regimen with the lowest carbon footprint. Dorset supports prescribing branded Salamol® as the first choice Beta-2 agonist pMDI.
  • Return used or unwanted inhalers to their community pharmacy. Educate patients that disposal by domestic waste or recycling is bad for the environment (greenhouse gases leaks from landfill – only incineration with other pharmaceutical waste destroys them)

Good evidence exists that shows that that raising the environmental impact of inhalers during conversations between patients and healthcare professionals results in most patients being open to consider changes to help the environment. Conversations drive positive change, so good patient education is vital. Practices/ Primary Care Networks could engage with any respiratory patients – but possible good starting places include patients with:

  • Signs of poor disease control such as excess reliance on relievers (e.g. more than 3-6 salbutamol devices per year)  
  • Poor inhaler technique with their current devices (especially if struggling to use a pMDI)
  • Patients that would benefit from a device with a dose counter
  • Patients already being prescribed mixed devices so can already manage a DPI (e.g. pMDI and DPI on the same prescription) 
  • Prescribed separate inhalers where a combination device exists (especially a combination DPI) 
  • Patients prescribed the recognised “highest” carbon devices these are: Branded Ventolin [as a pMDI], Symbicort [as a pMDI] and all Flutiform devices 
  • Any patient newly diagnosed with a respiratory condition and being prescribed an inhaler for the first time 

  • pMDIs account for 70% of all UK inhaler prescriptions. The proportion in most other European countries is less than 50% 

  • 3.5% of the NHS’s total carbon footprint comes from pMDIs 

  • pMDIs have a carbon footprint approximately 18 times that of DPIs 

  • If every patient currently prescribed a pMDI was switched to a DPI (where appropriate), this move alone would reduce carbon emissions in the NHS in England by 4%  

  • Five doses from a pMDI is equivalent to a nine-mile trip in a typical car 

This intervention is vital – remember: “The greenist inhaler is the one the patient can use”.

It is critical to match the right device to the right patient to optimise control and compliance with treatment (NICE decision aid). If a patient can only manage a pMDI but they are using it in an optimised way, this is still appropriate green prescribing (especially if a patient is regularly using inhaled corticosteroids as preventer treatments).  

If a patient can inhale “hard and deep” then their inspiratory flow rate should allow them to use a dry powder inhaler, which are the lowest carbon option. Allowing patients to try different devices can help ensure they use the minimum dose needed to control symptoms and avoid side effects. Instructional videos can be sent via SMS software such as ‘AccuRx’ to patients.

Various support videos are available: 

Right Breath 

Asthma & Lung UK

Our Dorset 

A variety of DPIs are available such as Ellipta, Breezhaler, Nexthaler, Genuair and Turbohaler devices. Refer to guidelines for best choice. Most patients can be consdiered for DPI, those who may not be suitable (e.g. cannot manage ‘hard and deep’) are generally younger children, the very elderly or patients with very severe asthma.

Remember, dry powder inhalers offer a lower-carbon clinical alternative to pMDIs. For most patients, pMDIs do not confer any additional clinical advantages over DPIs

This means using a combination inhaled steroid/formoterol device as a reliever only (no preventer doses – so different to standard MART regimens). This approach is suitable for patients with mild asthma and is currently an off-label indication. It is backed by a strong evidence-base.

Formoterol is a long-acting beta –2 agonist and has an onset of action equal to salbutamol so suitable for rapid relief of breathlessness. The GINA approach has been shown to reduce the rate of severe exacerbations (vs. patients using SABA alone). The green implications of the GINA approach are 1) better disease control at an earlier stage (due to earlier uptake of inhaled corticosteroids vs. traditional approaches) 2) reduced reliance on SABA relievers (particularly pMDIs) 3) Offer options to patients whose asthma is well controlled by a regular inhaled steroid/minimal use of SABA.

GINA Full Report Details (2024)

Greener Practice: what is asthma and how to treat it?

Greener Practice: inhaler device types for asthma

Resources

Recycling

Blister pack recycling – this is currently available in selected Boots and Superdrug pharmacies.

PenCycling – PenCycle is a recycling scheme run by the pharma company NovoNordisk for their diabetes, weight management and growth hormone pens.  Community Pharmacies can set themselves up as a recycling hub, or patients can recycle their own pens directly.  Full information here.

(But remember!  Medicines that aren’t needed, don’t need to be recycled.  Always think “Health Optimisation” as a first step!)

KidzMed Pill School

Liquid medications are less sustainable and have more ecological impacts than tablets/capsules (they weight more and so more energy is needed when transporting and disposing of them. Conversely, tablets or capsules tend to contain less sugar than liquid medicines, are easier to source, transport and store, and are associated with less waste, so are good for patients, carers and pharmacies as well as the environment).

­In 2018, charity Pharmacy Research UK and the Evelina London Children’s Hospital undertook a project to teach young patients how to swallow tablets. This led to the launch of the award-winning KidzMed Pill School at the Great North Children’s Hospital, Newcastle.

Poole Hospital’s paediatric department now runs ‘Pill School’ classes which are accessible to any child in Dorset. Email paediatricpharmacists@uhd.nhs.uk for information on class times and availability.

Pharmaceutical Waste Management

Pharmaceuticals in the environment is a growing problem, but one that we can tackle. Drugs taken by humans and animals find their way into rivers, lakes and even drinking water, and can have devastating effects on the environment and human health.

There are three main ways that pharmaceuticals make their way into the environment:

  • The biggest contribution comes from drugs taken by people or animals that are then excreted in urine or faeces –  up to 90% of the active ingredient and the metabolites of many drugs can remain active in the environment after being excreted
  • Improper disposal of drugs also makes a contribution — all pharmaceuticals should be returned to a pharmacy for proper disposal. When people throw the leftover drugs in the sink, down the toilet or into general rubbish, drugs end up in sewage treatment plants and wastewater. Commonly found contaminants include anti-inflammatories, sex hormones and antibiotics
  • Some drug manufacturing facilities have also been shown to release active ingredients into nearby waterways, creating localised hotspots of pharmaceutical pollution

The most effective solutions are to prevent the need for medication waste through health promotion and medicines optimisation efforts (which will also reduce the volume of plastic waste produced), as well as educating patients about returning all unwanted drug doses to their pharmacy. Health care professionals can also ensure that drug disposal bins are used, regardless of sector. University Hospitals Dorset NHS Trust have produced a flow-chart guidance document explaining best practice, based on NHS England HTM recommendations for disposal of healthcare waste. A logo-less version for local adaptation can be obtained – please email tracy.lyons@nhsdorset.nhs.uk

Education

Knowledge is power!  We want all Dorset healthcare professionals to be able to make the best decisions in terms of our patients and our planet. There is a world of information available to staff keen to know more about environmental sustainability and health, but to get you started, we’ve listed information on 4 brilliant free resources to start your journey today.

Environmentally Sustainable Healthcare module

Environmentally Sustainable Healthcare – elearning for healthcare

The Environmentally Sustainable Healthcare (ESH) programme was developed with the Centre for Sustainable Healthcare and the HEE Northeast Faculty of Sustainable Healthcare to provide the healthcare workforce with the knowledge and skills to deliver healthcare for financial, social and environmental sustainability. There are 3 sessions in the Environmentally Sustainable Healthcare programme. Sessions 1 (Building a Net Zero NHS) and 2 (Environmental Sustainability in Quality Improvement) are suitable for all in the NHS healthcare workforce. Session 3 has been designed for the dentistry profession (Environmental Sustainability in Dentistry).

Greener NHS

The Greener NHS programme is spear-heading the NHS England road to Net Zero. This page outlines the national ambition, how to take action and showcases examples of system progress.

Climate and Health

From the UK Government office of Health Improvement, this resource helps health and care professionals prevent ill health and promote wellbeing as part of their everyday practice. It is designed to help frontline health and care professionals use their trusted relationships with patients, families and communities to reduce the contribution of the health and care system to the climate crisis.

Centre for Sustainable Healthcare

Since 2008 the Centre for Sustainable Healthcare has engaged healthcare professionals, patients and the wider community to understand the connections between health and environment and reduce healthcare’s resource footprint. The CSH offers (paid) education & training, free resources (including Sustainability in Quality Improvement) and free Sustainable Healthcare Networks for different professions/sectors.

Their work is guided by the principles of sustainable healthcare.