Royal Pharmaceutical Society has optimistic prognosis for Scotland despite testing times

Good healthcare is at the centre of any civilised society, and the benefits it brings in terms of enriching and saving human life are immeasurable. But there is a surprising downside: it can also damage the planet.

In the world’s largest economies, healthcare services are estimated to account for five per cent of carbon emissions. In most countries, this is only exceeded by energy, transport and construction.

Now a leading organisation in the sector is proactively working to change things for the better. The Royal Pharmaceutical Society (RPS) has just published a declaration making commitments to play its own part in tackling the climate and ecological emergency.

The document includes developing policy statements on how pharmacy can contribute to environmental sustainability and decarbonisation; mitigating the risks; championing and promoting best practice and sharing this digitally; and applying environmental, social and corporate governance to the organisation’s investment and procurement policy.

Clare Morrison, the RPS’s Scotland Director, explains why the declaration was published. “We absolutely believe that the climate crisis is the biggest threat we face and we feel it’s vital that we take some action. The climate emergency will affect our daily lives, not just as an environmental issue but as a public health crisis as well. The consequences will include things like extreme heat, adverse weather and rising sea levels.

“That will result in problems such as an increased incidence of malnutrition and respiratory and infectious disease. The consequences are being felt right around the world now.”

It is eye-opening to hear that a quarter of the NHS’s total carbon emissions come from the manufacture, procurement, transport and use of medicines. Inhalers alone account for three per cent.

“Most of these are from the propellant in metered dose inhalers”, Ms Morrison says.

“Actions could include changing to different inhaler types such as dry powder inhalers, and recycling inhalers.” She points out that there are also concerns around anaesthetic gases. These account for two per cent of total emissions within the NHS. 
Nitrous oxide, still used in healthcare across Scotland, persists in the environment for more than 120 years and is 250 times more polluting than carbon dioxide.

Antimicrobial resistance is also a growing problem. Antibiotics used by humans can be excreted into waste water, creating the conditions in which new antimicrobial resistant genes are created. 

Concerns over this problem cannot be overstated. It is estimated that by 2050, infections resulting from it may become the leading cause of death, killing 10 million people worldwide every year.

Yet another issue is the fact that the pharmaceutical residues found in fresh water globally can result in a toxic impact on wildlife. “This happens when medicines are excreted in human waste and when they are incorrectly disposed of. 

“Examples include oral contraceptives causing feminisation of fish, psychiatric drugs altering their behaviour, and antimicrobial resistance.”

The answer to this, Ms Morrison believes, is that health professionals should consider the environmental impact of medicines in prescribing decisions. 

Greener drugs should also be designed, more information needs to be made available and there should be closer monitoring of the effects and presence of pharmaceuticals.

“There also needs to be more awareness when it comes to prescribing decisions. We’re currently developing policies on this to allow pharmacists to play their part in choices made at health board level.”

Other actions that can be taken by professionals in the pharmacy sector include developing a realistic approach to prescribing to reduce unnecessary use, promoting medicine return for safe disposal or recycling, checking requirements for repeat prescriptions and addressing the risk of over-ordering and taking a net zero approach to consultations.

The public can also help by steps such as recycling packaging wherever possible, using video or telephone consultations to avoid travel and always completing a full course of antibiotics.

One example of positive action currently being taken involves the Superdrug pharmacy chain, which has become the first in the UK to enable the public to recycle empty medicine packs in store. 

“Empty prescription or over the counter blister packs can’t normally be accepted for recycling because they are made of mixed materials. 

“But they can now be returned to be recycled and converted into reusable raw materials. This prevents them going to landfill.”

The potential impact of this is huge: research has shown that no less than 65 per cent of UK adults use medicines in these packs on at least a weekly basis, with 29 per cent of people wrongly dropping them into household recycling bins.

This move by Superdrug is clearly laudable, but the healthcare sector can be notoriously conservative. Does Ms Morrison foresee challenges in getting these vital messages across?

She believes that the culture has now changed for the better. “There is a groundswell of opinion that we need to tackle the environmental impacts of all of our industries, and now is the time to ask those questions of the health service. I think changes will happen.

“For instance, the Chief Medical Officer’s report in Scotland published earlier this year has a whole large section about environmental issues. It’s up to professional bodies like ours to make things happen.”

Scotland, Ms Morrison believes, can be a leader in this area. “I’d like to see action worldwide, but we all have to start at home and work on an individual level. 

“Because we are a smaller country, it sometimes makes change easier for us to achieve.  We can be bold and try to lead on this action. It’s something that is needed.”
www.rpharms.com/scotland

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CASE STUDY: Consultant Sharon Pfleger 

NHS Highland activists raise awareness of a new wave of water pollution issues

CLEAN and safe water is a vital part of environmental sustainability. It’s something which has been a long-time passion for Sharon Pfleger, a Consultant in Pharmaceutical Public Health with NHS Highland.

Her work on medicines pollution in this area has led to the Caithness General Hospital in Wick becoming the first public sector agency in the world to achieve Alliance for Water Stewardship certification in recognition of its environmentally responsible use.

The effects of medicines on the water ecosystem can be highly damaging. Between 30 and 100 per cent of a pharmaceutical is excreted by the human body and after being flushed down the toilet it enters the sewage system.

Skin creams and lotions can also cause a problem as they may be washed off in the shower or bath. 

Water treatment plants do not remove all of this, meaning small amounts can enter rivers and oceans.

Even these tiny amounts can have detrimental effects on fish, with males becoming feminised – something which threatens the entire fish population. 

Another problem is that antibiotics used by humans can also be excreted into waste water, creating conditions that can result in the development of new antimicrobial resistant genes. 

To research this, Ms Pfleger and colleagues from the One Health Breakthrough Partnership tested the hospital’s waste water and effluent for eight commonly used medicines and found seven of them in the supply. 

They then looked at how to address the problem right across the NHS Highland region.

One action they took was looking at how to make the formulary – the NHS list of preferred medicines – greener. 

This is normally all assessed on the basis of efficacy, safety and cost effectiveness, but they added in environmental impact. 

They also encouraged patients to take a so-called realistic medicine approach. This involves ensuring that they are involved in decisions about whether to take a medicine or clinical procedure and consider if green options such as lifestyle changes might be better.

Another move was to provide information to the public on antimicrobial resistance and on improving understanding of antibiotics. 

A video was created that produced a dramatic 56 per cent increase in understanding of the environmental issues surrounding antibiotic pollution.

In addition, the team are looking at the use of nanotechnology to take medicines out of the waste water before it enters the sewage system. 

Ms Pfleger says: “When you visit your healthcare professional, always have a think about what matters most to you and explain what it is you need help with. The best option may not be a medicine.”

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CASE STUDY: Pharmacist Alifia Chakera

Medics urged to take stock of harmful gas

NITROUS oxide is still used as an anaesthetic in Scotland, but it is a toxic greenhouse gas that causes much more damage than carbon dioxide. 

It persists in the environment for more than a century.

Climate activist Alifia Chakera, lead pharmacist for anaesthetics at NHS Lothian, is the national lead on an initiative, the Nitrous Oxide Project, launched at the beginning of this year.

She analysed the use of this gas, discovering that its use in hospital theatres was actually low. 

The main problem was wastage in the supply chain through poor stock management, theft or even leaks.

Ms Chakera realised that by tackling these issues, the carbon footprint could be cut significantly from its current output – it accounts for 80 per cent of the carbon footprint of all anaesthetic gases used –without any impact on patient care. 

A multi-disciplinary team was established to collect and review data. 

A broad range of people and organisations including porters, anaesthetics and theatre staff, the medical gases committee and the sustainability network were included.

The team identified and resolved the sources of waste along with some stock management issues. 

Removing it from the three main sites resulted in a dramatic saving of more than 1000 tonnes in carbon equivalent savings every year – that’s the real-world equivalent of more than 400 flights to Australia every year.

The work is still progressing. The group is continuing to look at new ways to remove waste and to encourage environmentally favourable practices.  
In addition, novel technologies are being explored with the aim of achieving zero emissions of nitrous oxide within the next five years.