Pharmacy medicines optimisation and sustainability checklist for green plans

Background

Climate change poses a major threat to our health as well as our planet. The environment is changing, that change is accelerating, and this has direct and immediate consequences for our patients, the public and the NHS.

In October 2020, the NHS became the world’s first National Health Service to commit to reaching ‘Net Zero’. The “Delivering a Net Zero Health Service” report sets out the NHS’s clear ambition and the Greener NHS programme is working with pharmacy staff across ICSs to ensure this most important of sectors is at the forefront of healthcare. It builds on exemplar work already evident across the country and promotes sharing of best practice to reduce the environmental impact of healthcare delivery, whilst simultaneously making economic efficiencies and improving patient outcomes. A Greener NHS is emerging, however, together, we can achieve even more.

Purpose

Pharmacy sustainability workstreams rightly centre on the output of the Greener NHS and NHS England Medicines Net Zero teams, however there are multiple ‘sustainability supporting’ programmes which deliver on one of the four principles of sustainable healthcare: prevention of ill-health, patient empowerment, waste reduction/lean care delivery and low-carbon technologies. It is important that these are acknowledged and optimised as part of pharmacy green plans.

Use of this Checklist

  • In collaboration with colleagues across the interface and representing diverse specialities, we present a tableau of options for delivery of sustainability within pharmacy green plans. They should be use alongside NHS England Medicines Net Zero guidance and medicines optimisation strategies.
  • This is not a compulsory check list of targets, rather, we hope that this enables ICS teams re-evaluate the potential of pharmacy services to reduce carbon emissions and hence, promote wider community health and acknowledge the latent power of multi-sector working.
  • It is envisioned that over time Green Plans will adapt according to local need and workforce capacity, as well as the growing proficiency within our profession to deliver planetary health.
  • We wholeheartedly encourage idea sharing between teams and would be delighted to receive feedback for further development.

Aileen O’Hare, Chief Pharmaceutical Officer’s Clinical Fellow 21/22 / GPhC Specialist Inspector aileen.ohare@pharmacyregulation.org

Tracy Lyons UK Clinical Pharmacy Association Environment & Sustainability Advisor, Co-founder Pharmacy Declares tracy.lyons@uhd.nhs or pharmacy.declares@gmail.com

Leadership

  1. Nominate an ICS pharmacy and medicines optimisation sustainability lead pharmacist to develop and co-ordinate key individuals/teams across the ICS.
  2. Develop a multi-sector, multi-year ICS pharmacy and medicines optimisation green plan that includes actionable targets.
  3. Include ICS pharmacy green plans as a standing agenda item at all ICS pharmacy and medicines optimisation committees.
  4. Utilise data and analytics to track green plan progress and delivery. Benchmark green plan metrics across and between systems using available data sources.
  5. Include population health tools and progress with health inequality metrics such as Core20PLUS5 in ICS pharmacy and medicines optimisation green plans, to demonstrate action targeting ill-health prevention, a cornerstone of sustainable healthcare.
  6. Recognise/incorporate the sustainability benefits of work streams throughout the NHS Long Term Plan such as digital integration and new models of care across health and social care networks.
  7. Build sustainability and net zero targets into all ICS pharmacy commissioning contracts.
  8. Incorporate sustainability and net zero objectives into all pharmacy job descriptions.
  9. ICS leadership should support/promote wider NHS sustainability programmes which in turn will reduce the need for healthcare utilisation and medicines use, such as Active Travel and estate decarbonisation.

Respiratory

  1. Support the recommendations held within greener practice guide ‘How to Reduce the Carbon Footprint of Inhaler Prescribing’ (endorsed by the NHS England and NHS Improvement Inhaler Working Group, Asthma UK and the British Lung Foundation)
  2. Develop updated adult and paediatric (where applicable) respiratory care guidance allowing for non-MDI use at each stage of care.
  3. Update drug formularies to reflect new models of care, migrating towards a regional formulary as per local respiratory networks to standardise choice and availability whilst incorporating carbon footprint information.
  4. Utilise/create a cross-sector patient and staff communications package explicitly on the topic of principles of greener respiratory care.
  5. Support PCN users of the Network Contract Direct Enhanced Service Investment and Impact Fund to deliver on respiratory indicators
  6. Support primary care pharmacy teams to support training and delivery of Respiratory elements of the Pharmacy Quality Scheme 21/22.

Anaesthesia

  1. Desflurane reduction - as per NHS standard contract, ensure desflurane use in acute Trusts is no greater than 5% of total volume inhaled anaesthetic use.
  2. Nitrous oxide mitigation – as per the greener NHS nitrous oxide toolkit, ensure that users of piped nitrous oxide review functionality of systems to reduce waste.
  3. As per the Association of Anaesthetists: action guidance for addressing pollution from inhalational anaesthetics, investigate protocols for use of inhaled anaesthetics and alternatives to minimise waste, improve sustainability and research evidence base for ‘cracking’ technologies.
  4. Support reduction in use of ethyl chloride spray where ‘cold sticks’ present a suitable alternative to check spinal and epidural anaesthesia blocks.

Procurement

  1. Work with suppliers to ensure that they meet or exceed the NHS commitment on net zero emissions as laid out in the NHS net zero supplier roadmap.
  2. Ensure that lead ICS pharmacy procurement staff are educated in/aware of core requirements of NHSEI guidance ‘Applying net zero and social value in the procurement of NHS goods and services’.

Pharmaceutical pollution and medicines waste

  1. Establish clear guidance across the health system for pharmaceutical waste disposal on healthcare sites as per (HTM 07-01) management and disposal of healthcare waste.
  2. Develop patient communication packages regarding pharma waste disposal as per Recommendation 7 of the OECD report: Management of Pharmaceutical Household Waste: Limiting Environmental Impacts of Unused or Expired Medicine.
  3. Acute sites to develop a strategy for achievement of the Alliance for Water Stewardship standard certification, as demonstrated by NHS Highland
  4. ICS leadership should use their professional voice to call for medicines recycling schemes and adopt where available, whilst ensuring that staff/patients are aware of the benefits of medicines optimisation as a primary principle of waste reduction.

Formulary/overprescribing

  1. The drug formulary assessment process and application proforma should be updated to include requests for carbon footprint and ecotoxicology data for individual agents. Accepting that information may be limited at present, formulary teams should use this as an opportunity to educate clinicians on ideal answer sets and request such information from pharmaceutical industry partners.
  2. Implement locally, applicable actions from the recommendations of the National Overprescribing Report (DHSC, 2021).
  3. Ensure all formulary applications, shared care guidance and medication policies include guidance on reviewing and discontinuation of medicines.
  4. Improve the delivery of structured medication review (SMR) to target groups most at risk of overprescribing.
  5. Monitor the effectiveness of targeting at-risk groups receiving SMRs in PCNs and rates of linking with social prescribers after an SMR.
  6. Work with NHS Digital to link anonymised NHSBSA data into population health management applications to identify links between overprescribing and inequalities.
  7. Promote the use of the NHSBSA medicines optimisation-polypharmacy dashboard
  8. Encourage engagement by prescribers with polypharmacy action learning sets commissioned via Academic Health and Science Networks (AHSN) to improve prescribing culture and improve confidence in stopping inappropriate medicines.
  9. Champion delivery of the KidzMed programme, enabling children to swallow tablets rather than liquid medications (supports reduced carbon emissions from transport and disposal of primary packaging materials).

Antimicrobial Stewardship

  1. Promote adherence to the principles of Start Smart, then focus guidance from the Department of Health and Social Care, to optimise the appropriate use of antibiotics and to promote the UK 5-year AMR National Action Plan.
  2. Collaborate with NHS England regional AMS leads and local AHSNs to ensure a co-ordinated approach to understanding variation in practice of antimicrobial prescribing and addressing unwarranted variation.
  3. Support Antimicrobial Stewardship (AMS) utilising local expertise to co-ordinate an approach to reducing overprescribing (and hence environmental burden) of antimicrobials.
  4. Promote shorter antibiotic prescription course length where this is safe and appropriate, to selection pressure for resistance and reduce waste/overconsumption.
  5. Promote timely IV-to-oral switch as a means of reducing carbon footprint of primary packaging materials, plastic waste and potentially allowing for earlier hospital discharge.
  6. Antibiotic Amnesty - develop a plan for area-wide support of Antibiotic Amnesty campaigns (during World Antimicrobial Awareness Week)
  7. Optimise access to outpatient parenteral antimicrobial treatment (OPAT) to support low carbon care pathways for patients with infections.

Medicines safety

  1. Support system partners to deliver the NHSEI Medicine Safety Improvement Programme (MedSIP) as part of the National Patient Safety Strategy, to reduce severe avoidable medication related harm by 50% by 2024. Medication related harm is associated with high healthcare need (hospital admission and prolonged stay) with resultant carbon emissions. A focus on building quality and safety improvements should be incorporated into sustainability targets: e.g. reduction in inappropriate opiate use for non-cancer pain, anticoagulation and valproate safety.
  2. Optimise referrals to the discharge medicines service to support patients on discharge from hospital to improve outcomes, prevent harm and reduce readmissions.
  3. Conduct pharmacy quality scheme patient safety audits such as anticoagulant audits to improve outcomes, prevent harm and reduce readmissions.

Plastic reduction

  1. In support of the NHS Plastic Pledge, develop plans to eliminate the use of unnecessary single use plastics such as spoons, bags, syringes, and packaging within pharmacy service delivery.

Education

  1. Support all staff to undertake the eLfH module ‘Environmentally Sustainable Healthcare’.
  2. Incorporate ‘sustainability’ into quality improvement programmes across the ICS partnership.
  3. Promote and support the RPS Climate change charter, identifying specialist foci for medicines sustainability.
  4. Support staff in demonstration of sustainability elements of the RPS credentialing frameworks.
  5. ICS pharmacy system leaders to engage with undergraduate and post graduate Higher Education Institutions to develop sustainability resources and training.

Acknowledgements


With special thanks to:

  • Vanessa Burgess, Chief Pharmacist, South East London Integrated Care Board
  • Dr Kieran Hand, AMR: National Pharmacy and Prescribing Clinical Lead, NHS England and NHS Improvement
  • Dr Conor Jamieson, Regional Antimicrobial Stewardship Lead Midlands Region, NHS England and NHS Improvement
  • Ewan Maule, Head of Medicines Optimisation at Sunderland CCG and Interim Integrated Care System Lead Pharmacist for the North East and North Cumbria.
  • Mike Pollard, Senior Buyer, Berkshire Healthcare NHS Foundation Trust
  • Samantha Ruston, Antimicrobial Pharmacist, University Hospitals Dorset NHS Trust
  • Belinda Rycroft, Lead Pharmacy Technician for Medicines Procurement, University Hospitals Dorset NHS Trust
  • Ravijyot Saggu, Chief Pharmaceutical Officer’s Clinical Fellow, NHS England and Improvement, and UKCPA Committee Chair - Respiratory group
  • Costas Vasilou, Senior Medicines Optimisation Pharmacist, Bradford District and Craven Health and Care Partnership
  • Laura Whitney, Regional Antimicrobial Stewardship Lead London, NHS England and NHS Improvement
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