Intro Earth Day is a global celebration of the natural world around us involving more than 1 billion people each year.  Created by an American politician in the 1960s after he witnessed the ravages of an oil spill on the Californian coast, it’s now widely regarded as the birth of the modern environmental movement. It gives us a chance to appreciate the wonders of the natural world, and hopefully, inspires everyone to protect ‘the most precious thing we have’ (Sir David Attenborough).

So if the next question that springs to mind is something akin to ‘What’s pharmacy’s role in this?’  Our answer is ‘Crucial.’  We’re in the perfect position to deliver the most sustainable use of medicines within healthcare as well champion activities which support healthy, clean environments, reducing the need for health interventions.

With that in mind, we’ve collated inspiring examples from pharmacy teams around the country.  Dip in and out, come and go as you have time and most importantly, let us know where Earth Day 2022 takes you.

Develop an understanding of ‘Planetary Health’ – possibly the most important climate-health concept you’ve never heard of.  The premise of planetary health is that human survival is dependent on and intricately interwoven into the well-being of the earth.  To thrive, humans need a flourishing environment around them to provide a suite of facilities such as clean air and water, a safe, stable climate and prospering ecosystems.  With these in place we’re provided with food, water, protection from illness and security from unpredictable, extreme weather events. Conversely, when those support systems are moved beyond safe boundaries the human health gains we’ve achieved over the last hundred years are threatened.

Every single action we take, both professional and personal will result in carbon emissions, with the potential to harm the world around us.  For health professionals, once we’ve imbibed this concept, it’ll mean changing the way we view both the causes of ill-health and health service delivery for ever.  As emissions rise, the worse the health outcomes will be, with a resultant need for greater health services.  The beauty of this cycle however is that it can be reversed and as emissions are lowered, patients, communities and the environment they’re sited in prosper together.

Support Greener NHS pathways

Greener Respiratory Care:  The NHS has identified use of metered dose inhalers (MDIs) as a significant cause of carbon emissions.  Whilst the propellant gases are safe they have significant global warming potential, and are responsible for approximately 3% of the NHS’s total carbon footprint.  Reducing MDI use (where clinically appropriate & in agreement with patients.) is one of the simplest ways pharmacy professionals can reduce healthcare emissions and formularies around the country are being updated to include lower carbon alternatives, dry-powder and soft-mist inhalers.

Ravijyot Saggu, Chair of the UKCPA Respiratory committee shares advice for the transition greener respiratory care.

• Well controlled lungs have the lowest carbon emissions. Whilst there is a drive to reduce MDI use, not all patients can manage the alternative inhalers proposed. Patients should be empowered to understand and be involved in decisions about their care. 
• Invest time reviewing patients, especially those who are less well controlled.  Someone requiring frequent SABA therapy (3 or more times a week) would  benefit from therapy review (non-adherence to preventer maintenance therapy, poor inhaler technique and anxiety are some factors contributing to SABA overuse) however some patients may have more severe asthma (undiagnosed) which warrants further referral and specialist input. Review would be the ideal time to counsel/optimise inhaler technique and potentially look at switching to a non-MDI device. 
• Does a patient use inhaler devices with different delivery methods (i.e. not using one consistent type like DPI)?  Research has shown that patients have better respiratory control when they only have one inhaler technique to remember.
• Consider prescription dose directions: Can a patient have a single puff of higher dose MDI rather than 2 (or more) puffs of a lower dose inhaler?  The inhaler will last longer and fewer repeat prescriptions are needed, however, ensure patients are aware to avoid accidental overuse.
• Would patients with asthma benefit from MART therapy?  If a patient is likely to favour a particular inhaler device, changing to one which delivers inhaled corticosteroids combined with longer acting bronchodilator (used regularly and ‘when required’) can improve asthma control and reduce exacerbations.
• Make sure your patients know that inhalers don’t go in household waste – return to pharmacies for disposal/recycling. 
• Sign post to resources -to help patients learn more/make a decision about inhaler devices that they feel are right for them See https://www.rightbreathe.com and https://www.asthma.org.uk/advice/inhalers-medicines-treatments for asthma care while https://greeninhaler.org/the-problem-with-inhalers/ can help explain environmental concerns.

Greener Anaesthesia

The NHS Long Term plan commits to “transforming anaesthetic practices”, reducing the carbon impacts from use, or atmospheric release, of environmentally damaging gases such as nitrous oxide and fluorinated gas anaesthetic agents.  

#DitchTheDesflurane Of the 3 commonly available inhaled volatile anaesthetics desflurane is the most environmentally harmful. Theatre teams around the country have developed a number of strategies to encourage use of alternative surgical anaesthesia, in particularly a switch to the lower carbon alternative sevoflurane.  Staff at University Hospitals Bristol and Weston NHS Foundation Trust developed several engagement tools to raise awareness and provide information, including coloured prompt cards placed on anaesthetic machines with facts about the impact linked to everyday activities such as driving a car and QR codes on machines directing clinicians to website resources for more information.  The success of programmes so far mean that the target set out in the NHS Standard Contract (reducing the proportion of desflurane to sevoflurane used in surgery to less than 10% by volume) has now been lowered further to 5% by volume. This is being tracked in English acute Trusts via the Greener NHS Dashboard.

NixTheNitrous  In 2019/20 nitrous oxide accounted for at least 80% of the NHS England’s anaesthetic gas carbon footprint, however a pharmacist led project has shown how this impact can be reduced dramatically.   Investigation by Pharmacist Alifia Chakera (National Lead Pharmacist for the Green Theatre Programme, Scottish Government) highlighted that a significant portion of nitrous oxide emissions are due to waste from manifolds and the associated piped infrastructure. The Nitrous Oxide Mitigation Project was developed as a way to centralise this work, using lean  methodology to identify system waste and improve medical gas management at acute sites.  The project emphasises a multi-disciplinary team (MDT) approach, including portering staff to clinical leads, to taking into account clinical use, product supply and total product turnover.  

Alifia has estimated that if all NHS England sites implemented the project methodologies that carbon savings would be equivalent to approximately 112,000 tonnes carbon dioxide equivalents from piped waste alone – equivalent to 45,000 flights from London to Perth. Alifia’s message for pharmacy is that our representation is essential to the success of these projects “When pharmacy staff engage with medical gas management it results in leaner and more resilient system.”

Medicines Optimisation – Creating new medicines sustainability channels?

At the moment precise carbon footprinting data are only available for a few distinct groups of medications, but the overall carbon burden from medication use within the NHS is huge and importantly, reducible.  The National Over Prescribing Review, led by Keith Ridge as Chief Pharmaceutical Officer set out a plan to improve patient care, and simultaneously, reduce carbon emissions.  The report estimated that millions of packets of medicine are wasted each year, consuming energy, plastics and other resources from manufacturing, distribution, storage and disposal. Beyond the footprint of the drugs themselves, it’s estimated that nearly 375,000 hospital admissions per year result from adverse medicine events, 75% of which may be avoidable. This translates to approximately 3 million hospital bed days and over 700,000 patient journeys. If we were able to mitigate these we could:

· Avoid 110,910 tonnes of greenhouse gas emissions

· Avoid the use of 179,133 million litres of fresh water (includes direct water use and indirect water use, for example water used in the supply chain or the generation of electricity).

· Prevent the creation of 13,300 tonnes of waste

It’s time for clinical pharmacy staff to review the entire medicines use pathway and identify points of medicine mismanagement as an environmental target.   Sunderland CCG have successfully helped over 1000 patients stop taking unnecessary antidepressant therapy following the introduction of deprescribing guidelines.  The guidelines supported prescribers to identify and engage patients in the review process which can be tailored to allow for more gradual reduction plans as per patient need. They also include prompts for referral to social prescribers.  The CCG is now committed to ensuring that each new or reviewed guideline contains deprescribing direction in order to ‘normalise’ the process.

Poole Hospital (University Hospitals Dorset NHS Trust) has targeted the other end of the medicines use pathway and created pharmaceutical waste guidance that has increased correct medication disposal by 500kg per month.  Aside from reducing reputational and financial risk this limits the possibility of environmental contamination by pharmaceuticals which can seep into the surrounding freshwater systems and eventually into the oceans, lakes, streams, and rivers.

Our message is that all medicines optimisation processes (clinical medicines review, patient counselling, therapeutic drug monitoring, disposal etc) deliver sustainability gains. Any single process which helps patients to enhance their therapy, regain their health and prevent readmission has distinct environmental benefits.

Beyond Medicines – Plastic reduction

Plastic is everywhere. Microplastics have pervaded every corner of the natural environment, found in every continent and the deepest reach of the oceans. Microplastics are also now in us.  They have been found in food, bottled water and as a result in adult and infant faeces.  As yet, the impact on health is unclear but in vivo experiments have shown that they can travel around bodily systems and damage human cells.  Despite this, plastic use within health care is pervasive and 2% of global plastic production is due to healthcare use, a figure which is growing by nearly 7% annually. The NHS itself disposes 133,000 tonnes of plastic each year with only about 5% currently recovered.

Changes can be implemented however. Sam Coombes, Pharmacy Technician at East Kent Hospitals NHS Foundation Trust worked with staff at his 2 trust sites to remove nearly 300,000 single use plastic bags from dispensaries annually by increasing awareness of the problem, as well as innovating with reusable bag replacements.  Sam believes that the widespread use of plastic in healthcare is often because of perceived infection control benefits but found that the evidence for use in the situations studied was lacking.   ‘To meet the infection control requirements identified we sought out alternative technologies such as reusable canvas bags coated with plastic and impregnated with antimicrobials, or cardboard boxes would otherwise have been recycled (and then still can be).  We can end pointless use of this toxic material and support a more circular economy within healthcare.’   

Lauren Redwood, rotational pharmacist at University Hospitals Dorset has taken the plastic pollution message out into the local community, where she established ‘Poseidon Pickers’ a beach cleaning group ‘On a mission to keep our coastline clean of plastic & rubbish to protect our ocean and sea life’.  The team which started with Lauren and her flatmates is now so successful and popular it has been supported by the council and meets regularly over the summer months.

Beyond the Pharmacy?

Active Travel

Fossil fuel air pollution is known to cause cardiovascular and respiratory disease, but studies have demonstrated a ‘top to toe’ effect on body systems.  It is associated with depression, dementia, diabetes, as well has premature birth and miscarriage.  Each time we are able to reduce community exposure to fossil fuels the risk of these presentations diminishes along with the need to treat them.

Active travel, which includes even small levels of exercise like walking to a bus stop or train station, can lead to health benefits for the person actually exercising as well as everyone around them. The individual gains the direct physical and psychological value of exercise but the act of taking an internal combustion engine off the road is positive for the wider community as well.  Fewer vehicles mean a reduction in noise and the wider toxic effect of polluted air.

Additionally, physical activity can replace the need for pharmacotherapy.  It has been shown to have similar effects or greater effect than antidepressants in treatment of mild depression, whilst studies from Purdue University have shown that regular cycling has the potential to reduce one’s risk of heart disease by an astounding 50%.

Peter Morgan, Associate Director of the NHSEI Medicines Sustainability team and active travel champion.  

Using your professional platform

If climate change is the single biggest health threat modern humans have ever faced, tackling it, in whichever form you choose, then becomes our single greatest opportunity to positively change the world in which we live.  Climate action needs pharmacy leaders, regardless of field or position, to step forward & champion what needs to be done. As UKCPA members we were extremely proud of its stance, becoming the first UK pharmacy organisation to declare a climate emergency and defining for our profession the extent of what lies before us. UKCPA membership represents the clinical expertise across the spectrum and each of us needs to use our position to innovate ways of reducing environmental harm. We recognise that since our professional and personal activities both contribute to and are affected by climate & ecological crisis, every action is crucial to success.

“You can’t go back and change the beginning, but you can start where you are and change the ending.” CS Lewis.

• Tracy Lyons, Medicines Optimisation & Sustainability Pharmacist, University Hospitals Dorset. UKCPA Environment & Sustainability Advisor

• Lauren Redwood, Rotational Pharmacist, University Hospitals Dorset.