Polypharmacy prescribing guidance - draft: consultation

7. The environmental impact of polypharmacy

NHS Scotland has set a target of becoming a net zero health service by 2040 and the plans for this are outlined in the NHS Scotland climate emergency and sustainability strategy: 2022-2026. This commitment was made in response to the recognition that climate change is currently the greatest global health threat of this century.

The professional leadership bodies in Scotland recognise the scale and the importance of the climate and ecological crisis, and the catastrophic effect on human health of not acting urgently and decisively. Therefore, in June 2022, the Royal College of General Practitioners Scotland published a joint statement with the Royal Pharmaceutical Society and the Scottish Academy of Medical Royal Colleges and Faculties to show commitment to reducing the environmental impact of prescribing and medicines.

Medication is by far the most common form of medical intervention for many acute and chronic conditions with around 280,000 items prescribed every day in Scotland. Approximately 25% of NHS carbon emissions is accounted for by the use of medicines and this can be reduced by:

• improving prescribing and medicine use, taking a value-based approach
• tackling medicines waste including medication reviews
• preventing ill health, and considering non-pharmacological approaches
• improving infrastructure and ways of working ^[147]

Approximately 10% of medicines are thought to be inappropriately prescribed and the Department of Health and Social Care’s National overprescribing review report outlines the importance of review, ensuring appropriate prescribing, to improve patient care, support the NHS, and reduce carbon emissions.^[148] The Royal Pharmaceutical Society quotes studies finding that only 16% of people who are prescribed a new medicine take it as intended, experience no problems and feel adequately informed.147 Ten days after starting a medicine, a third of people are not taking them correctly. Research estimates between 30 to 50% of medications prescribed for long-term conditions are not taken as intended.[149] Medicine taken incorrectly, or not taken at all, is a potential risk to patients and leads to medicine wastage and contributes to the financial and carbon burden of the NHS. There are multiple factors that can potentially hinder patient adherence to treatment, and a recent paper You need to be healthy to be sick’: exploring older people’s experiences with medication packaging at home found that the design of medication packaging poses challenges for older people.[150] It is therefore important that what matters to the person is taken into consideration, alongside a shared decision-making approach which takes into account their needs, preferences and values, to aid adherence. To ensure outcomes from medication are optimised, and prescribing is appropriate and safe, the 7-Steps medication review process provides a clear structure for both the initiation of new and the review of existing treatments and places an emphasis on ‘what matters to the individual’.

In Scotland every 10 days a 10-tonne truck of medicines waste (from community and hospital pharmacies) is transported for incineration. There are multiple associated costs with incineration of medicines waste including the transport costs, incineration costs, the environmental impacts and the direct costs of the unused medicines. In addition, one in six unplanned hospital admissions are due to harm from medicines. Environmental impact from hospital admissions includes patient and visitor travel, medicines and use of goods and services whilst in hospital.^[151] (see Figure 6 below). Ensuring appropriate prescribing and initiation of medicines and undertaking regular person-centred medication reviews can reduce waste and reduce harms associated with medicines use. This can benefit the individual by ensuring the effective use of medicines whilst reducing the NHS carbon footprint.

Reducing waste from medicines has a double carbon benefit by minimising:

• upstream emissions e.g. in distribution
• downstream emissions, with fewer medicines for disposal

Some medicines have a larger negative impact on the environment than others, and one area which has been particularly recognised as having a high environmental impact is the use of pressurised metered dose inhalers (pMDI). The carbon footprint from pMDI accounts for approximately 3% of the entire NHS carbon footprint in the UK. The NHS Scotland climate emergency and sustainability strategy: 2022-2026 has set a target of a 70% reduction of CO2 emissions from inhalers by the end of 2028. The environmental impact of inhalers section in the updated Respiratory conditions - quality prescribing strategy: improvement guide 2024 to 2027 includes new National Therapeutic Indicators which relate to reducing CO2 emissions from inhalers. These focus on promoting improved respiratory care, reducing over-reliance on short-acting beta₂ agonist (SABA) reliever therapy, prescribing inhalers with lower global warming potential where appropriate, and promoting the safe disposal of inhalers.

Pharmaceuticals in wastewater

The One Health Breakthrough Partnership highlights that medicines not only have a significant carbon footprint but can also lead to water pollution and loss of biodiversity. Every oral dose of a medicine is converted to a metabolite or excreted unchanged and 30-100% enters our wastewater system which cannot effectively remove all traces. The occurrence of pharmaceuticals in the environment is of global concern and the extent of their risks and impacts on human health and biota is growing. There is already evidence that they can affect aquatic wildlife, increase microbial resistance and enter the human food chain.

Pharmaceutical residues have been found in the environment as a result of production and formulation, patient use, use in agriculture and food production, and from improper disposal of medicines. Everyone should be encouraged to avoid flushing medication down the toilet or drain, and to return medicines to community pharmacies for safe disposal.

NHS health boards are responsible for providing a service whereby patients can return unwanted and out of date medicines to community pharmacies. Through local contractual arrangements, funded by the local board, pharmacy contractors are required to accept returned waste medicine from patients. Each pharmacy is allocated a specific number of waste bins and receives regular uplifts of these bins. Once collected, the health board is responsible for ensuring its disposal by incineration.

This guidance supports reducing inappropriate prescribing by recommending:

• person-centred decision-making
• providing guidance and support
• more alternatives to medicines, such as physical and social activities and lifestyle change
• regular 7-Steps medication review