This Podcast is brought to you by the GOSH Learning Academy.
[00:00:04] SA: Welcome to the third season of GOSHpods Goes Green. In this season, we're going to be focusing on medicine sustainability. In 2021, Great Ormond Street Hospital was the first UK children's hospital to declare a climate and health emergency. The NHS as an employer is responsible for 4 percent of the UK's total carbon emissions.
And medicines are responsible for 25 percent of that. We're going to explore this topic further, taking a journey through the life cycle of a medicine, covering everything from production and procurement, use of medicines in hospitals and homes, all the way through to medicines disposal, to properly explore how we can change the impact that medicines have on the environment.
[00:00:46] Steve: Hi everyone. I'm Steve Tomlin. I'm the director of the Children's Medicines Research and Innovation Centre at Great Ormond Street, but I also have the hat of being the Lead for Medicine Sustainability, both at Great Ormond Street and for our ICB. And we have got a podcast series, this is the first one, but it's part of series three of our podcasts, and this is totally on medicine sustainability. It is my joy and my privilege to. Welcome Minna Eii from South Tyneside and Sunderland, NHS Foundation Trust. She's an advanced pharmacy practitioner, but what we hear is that she's been doing lots and lots of work in the field of medicine sustainability, so we would love to have a chat with her and just have a delve into the overarching issues of medicine sustainability.
Hi Mina, would you like to just introduce yourself from your side? Tell us a bit about yourself and why, and how you've got into medicine sustainability.
[00:02:01] Minna: Hi Steve. Thank you so much for having me on the podcast today. So a bit of a background. So, I've been a pharmacist, for over a decade now I've been in community, I've worked in hospital.
I currently also work for the English, NHS 111 Service with the Ambulance Trust. So, a variety of experience kind of shaped my career and seeing, how much, operational, efficiencies, could be had if we do things, differently. So, for those who are not familiar, we talk about in sustainability world the low carbon pathways.
So how can we work more efficiently? kind of saving money, also improve, staff morale, staff time at the workplace. So, sustainability is something I only came across maybe five or six years ago when, where I co-founded the organisation Pharmacy Declares, which is a group of, UK pharmacy, team members who want to just do something and talk about medicine sustainability professionally.
Because these are some of the people who are already doing something in their personal life. But how do you translate that professionally in your career? So that's how it all started, Steve.
[00:03:07] Steve: Wonderful. It sounds as if we're speaking to exactly the right person to start our podcast series, so thank you very much for that.
But I suppose I'm gonna take you on. So why are we focusing on medicines, as a focus for having an effect on the carbon emissions. I don’t know. If you just want to take us through the real background of medicine sustainability, and why, particularly for the NHS, but across the world, why are medicines such a big issue?
[00:03:38] Minna: So, if you are, probably in the field and sustainability, you would've heard this figure thrown around kind of 25% NHS of, carbon footprint is related to medicines, which includes anaesthetic, gases, inhalers. However, it actually is the same, when people kind of audited across Europe. In France, I believe it's something like 60% of their, health systems footprint is medicines and, in the same, can be seen in Canada when they did theirs.
Just medicines as pharmacy professionals, I feel like where medicines are involved, we should be involved as well. And, as I mentioned previously, the past decade of work, frontline, speaking to patients, medicine's weight is a huge issue. There's also statistics being thrown around up to eight or nine figures
million pound savings could be had if we speak to our patients that kind of shared decision making, to promote patient's health and also promote a low carbon, pharmacy pathway as well. So, there's a lot of, kind of co-benefits if you like, if we tackle, sustainability and medicine's use and pharmacy operations, that we can actually see, people living a healthier life and improve, operation efficiencies if you like, to promote this kind of net zero agenda as well as our health agenda in the NHS.
[00:05:01] Steve: Thank you. Now you are an advanced pharmacy practitioner and obviously therefore involved with medicines through and through, and it's easy to say that medicines are sort of the largest therapeutic intervention of healthcare. You know, more than anything else, we use medicines to treat things. So how much of this is important just to pharmacists and how much is important to the rest of the healthcare team and to the public?
[00:05:30] Minna: So, I would think it might be good to give some tangible examples of what I see frontline rather than kind of arbitrarily, saying some sort of policies and quoting statistics round. So, one common example I always use in presentations is when I reviewed, a patient, Doris, obviously that's not the real name.
Doris is, taking adcal d three chewable tablets, when I did a medication history on the ward, I know as Doris has dentures on her bedside and got me thinking holistically at this patient. Doris cannot chew tablets properly because she's got dentures. So, conversation goes, and this happened,
I can't count the numerous times; it happened already in my career. So, I delve into how do you manage to chew this? Doris says, no, I can't chew them. I've been them the last three, four months. So, Doris is not getting her treatment for osteoporosis and at risk of getting, fractures in the future, which decreases her quality of life in the future.
So, these are kind of the things we talk about medicine, sustainability of avoiding medicines going to waste, but we're also promoting, thinking about the patient's health as well. And there's a lot of, fighting fire situation as you know, Steven, NHS at the, and they we're kind of, are a response service.
So, I would like us to, look at more a kind of prevention agenda. So, the best people placed in this is our community pharmacy colleagues, actually, the kind of in the neighbourhoods, they provide vaccination services. They provide a kind of health and wellbeing and, weight loss management services, which all in all decreases your long-term and chronic diseases risk, and it reduces kind of exacerbations of illness that results in hospital admissions, which is tagged with a huge carbon emission footprint, in the long run. So, that kind of longer thinking of planning aware to put, your money, your efforts, your energy in medicine, sustainability, in economical scale that in the whole healthcare system.
So, when I talk about medicine sustainability, with people who hasn't been familiar with a subject, the first thing people go to is waste. Oh my god. Medicine's, packaging, the plastic, the boxes. But actually, when you talk about medicines packaging, etc, waste is about one to 2% maybe of the NHSs carbon emissions overall,
because it's so visible, that's naturally the thing that people go to first. But actually it's more than about waste and the recycling, when we talk about medicine, sustainability.
[00:07:55] Steve: Okay, so, should we just pick up on that just a little bit more? As you say, everyone talks about waste, but you're saying that the waste is not the primary issue.
[00:08:05] Steve: So if waste isn't the primary issue, where does our big carbon footprint from medicines really come from?
[00:08:13] Minna: I'll again use, examples from personal working experiences. in, GOSH for example, I know you have an initiative, of looking at, pill.
Pill versus liquid medications. Liquid medications often they need to be kept in the fridge, the cold chain and the energy use to store these medicines, to transport these medicines. And also, you can only get a tiny few doses per bottle of liquid medications as opposed to 28, pill box of, tablets.
So, when you look at the comparison as such, one of the efforts, that in medicine, sustainability, our pharmacy professionals, teaching, our patients how to swallow tablets as opposed to relying on liquid medications. So that's one way of reducing your carbon footprint overall, the long term.
And the other one is medicines, operations, which I've mentioned a few times now. So, this is something as part of the Royal Pharmaceutical Society toolkit that I've written, with a lot of colleagues, that we are trying to reduce, a necessary duplication of work, use of staff time.
So, the review of Nomad Trace, for example, so many people are put on these dosette boxes unnecessarily and that's plastic waste. It doesn't get reviewed, and patients are kind of de-skilled in knowing what the medications they've been taking. And this is evident in when I do a medication history.
They just know it's five white tablets. They don't know what they're for. They don't know the sick day rules, which one of them to take out. And subsequently end up in hospital being unwell. And again, that's a big carbon footprint, a hospital stay. So, by better conversations, you know, with healthcare professionals, with our patients on how they use their medicines, that's another way to reduce your big, carbon emissions down the line.
There's higher up level, if you like, of procurement decision as well, a good example would be inhalers, formulation that people seem to have the conversations about. So dry powder inhaler promotion versus your propellants that has the high, hydrofluorocarbon gas. Which, in the pipeline, our pharmaceutical industry colleagues are working hard to reduce the emissions of the propellant.
But currently, we're giving the patient choice, and having that, discussion on using, low carbon inhaler and also, I've never seen that much of an inhaler review by non-respiratory colleagues since the sustainability agenda came out, as a priority. So there is interested, colleagues who are, like I say, not in a respiratory field, suddenly are experts in inhalers just because they want to do something in terms of medicine, sustainability. It's upskilling people's knowledge on, how to treat the common conditions like asthma which, is, associated with high mortality rates in the UK compared to the rest of Europe. so yeah, multiple benefits there, Steve, on how we could, tackle medicine sustainability up the chain.
[00:11:06] Steve: Wonderful. There were so many things that you've said there that I want to come back on.
We could talk for hours, I'm sure, but just on that last bit, I'll take it slightly broader than the inhalers. There's a choice to be made as to which products we use now, based on a slightly different criteria to what we used to use. Slightly cynically, a lot of it was based on money before, obviously clinical outcome, but money was a big part of it.
But now sustainability is another big thing. You know, we're going to end up with meter dose inhalers, some with gases in which are fine for the environment and others, which gases, which are almost some of the worst medicine, sort of outputs in terms of the environment.
How do you think formularies need to think about this moving forward? I'll take that as my first question, then I'll come back with a few others. But, have we got to start looking at formularies in a different way?
[00:12:01] Minna: Yeah, I think the one that comes to mind, instantly is the recent, change in nice guidance on how we treat asthma in November, 2024.
The update says we no longer use, salbutamol Blue Inhalers for your short-term reliever, we're promoting an anti-inflammatory reliever therapy, which is a combination inhaler with steroids in, that in theory will, get patients better asthma controlled. It's reviewed by, multiple peer review journals to say that patients are better off with a combination inhaler when required and up, titrate to your BD your twice daily regime, with one required doses in between. However, many commissioners are, struggling to promote this new guideline because the combination inhalers are more expensive than your short-term relievers, which cost you pennies, but you've got to look at it in a bigger picture. So, I have patient, in fact I have a trainee pharmacist who did an audit for me last, year.
He has found some patients they've been dispensed up to 30 blue inhalers per year from our hospital, but due to recurrent admissions on top of the inhalers issued by his GP, how did that happen? So, in theory, if we tackle this earlier down the line, so we might be, able to get his asthma better control with steroids, containing inhalers, which might or might have reduced his asthma exacerbation, rather than using, these short term relievers, which it's what it says on a tin, short term. But it's really hard convince commissioners of the long-term economic benefits of it all, the cost of hospital admission versus, better control of your asthma, when it comes to your Excel spreadsheet, money saving, as you said.
And I suppose in terms of the liquid versus tablet one, that's a very good, savings measure. So, liquid medications tend to be unlicensed. They tend to be more expensive and cold chain especially. And you need multiple bottles to make up a week's dose as opposed to, half a strip in a box.
So, the cost savings, for, liquid versus tablet is a straightforward one to see. Whereas something like inhalers, combination versus short-term relievers times 30, it's difficult to scale until you really look into it.
[00:14:16] Steve: So, I mean, if I'm hearing this right and I'm sure I am, it's essential that we start putting sort of sustainability into our thoughts about what we're using.
It sounds as if what we are seeing is clinicians already starting to think about that, or some are. Maybe we need to start thinking about it at governance levels, formulary levels, and, it needs to be embedded the same as finance, the same as clinical efficacy in everything, in all of our decisions.
At sort of all levels of decision making, probably into our EPMA systems, our electronic prescribing systems, embedding, which are the right ones to choose first. So, it sounds, if we've all got a lot to do to do that, it's sometimes hard to work out what the carbon footprint of individual devices and medicines are.
But we do need to have a thought, when we're making these decisions about it. I just mentioned, working out the carbon footprint of drugs, generically there's been a look at carbon footprint of medicine, sort of based on the price of medicines for the NHS. Now, obviously that's fundamentally wrong for an individual drug.
Just because it's an expensive drug, it doesn't mean it's got a high carbon footprint. Do you just want to mention that and how do you think about that? And have you got a secret process in place, that we should all know about?
[00:15:47] Minna: So, I think what you've mentioned there is the top down spend method, and that's how the sustainable development unit back in the days has calculated the NHS carbon footprint and attributed, 25%, isn't it,
for, carbon footprint, two medicines based on your costs. majority of them, but luckily, due to, work with Greener NHS and collaborate is worldwide, with the pharmaceutical companies who are buying into the agenda as well, because they see the greater good, as part of their social value, for companies, doing ESGs.
So, the evergreen suppliers framework in NHS England is a framework that, works with loads of suppliers in the NHS to, go on and, accredit themself, if you like, on how sustainable, they are. So, have they got a carbon reduction plan? There is this mandate for a scope three emission product level data to be made available in the coming years, if they would like to continue to trade with the NHS. So it's up to companies, to look into the lifecycle assessment of the products and to reduce their carbon emissions from, manufacture, to do that, accurately, I would say. But there's also this, question mark of, these are companies selling products, doing their own assessment and promoting the data they're publishing.
So how accurate is it? Is there an assessment tool globally that we can use to be honest, Steve, this is way beyond me. I wouldn't like to say I'm an expert in pharmaceutical industry, carbon calculating. There are data analysts who are really, really good at that.
I always get currently asked by our pharmacy colleagues up and down the country of how do I accurately calculate, I've done this QI project, I've calculated how much savings in time and money, but I don't know how to do the carbon, but I think, if you use not really accurate method, of a top down money spend method to do the carbon, it is just a figure.
But the overall is you have made that savings and you've proven the co benefit of it. So, I don't think, you need to be top notch, accurate, down to the digit, for these numbers. It is just a figure. but we know that the process works if you're trying to save carbon, through various different processes.
[00:17:58] Steve: Thank you. And it's really good to see that one the NHS is, I'm going to say, encouraging industry, via their processes to work green. But I think, from certainly the industries that I've spoken to and the ABPI, part of their regulation. They all seem to be on board with achieving this almost more potentially than the NHS is it does feel that most of, certainly big pharma, that they actually want to make a difference and they are looking seriously at what they're doing.
So that's all positive. I think we've got a long, long way to go, but, it is all very positive. Generally, we've been talking about, I'm gonna use the term net zero and carbon footprints, and that's what we've been talking about. But, in terms of sustainability and the effect on the environment, medicines have got a lot more than just a carbon footprint.
Do you just want to talk us through that and anything that you've been engaged with along those lines?
[00:18:59] Minna: Yeah. So, I'm part of, a group currently, called Pharma Pollution Hub. So, they're looking at your medicines in the environment, if you like. So how medicines reach our water aways, so to damage our, marine environment.
So, one of the things pharmacies has been doing actively, is telling people not to pour your leftover antibiotics or any liquid medicines down the sink. And there's been several peer review published journals that says people do that still. They put the liquid medicines in landfill. And when that gets leaked out in landfill, it gets to our environment that way.
And when it goes to our water sewage system, some of these metabolites, are not, filtered off by the chemicals in our water sewage system and it eventually reaches our environment. And, there's been a part, published articles, worldwide that says 257 Rivers or something like that, that has pharmaceuticals in them.
That's quite a staggering figure, to find medicines in the water I have, a dip in, a swim in. And what's that doing chronically to our fishes, and long-term. And microplastics. That's one thing that really, terrifies me. The long-term effect of microplastics are, but on a personal level. I've switched all my plastic Tupperware lunchbox to kind of, glassware bamboo wear already.
On professional level. so, one of the thing I've been campaigning my trust for two years is to switch out of using medicines plastic pots, for ward round. Because I asked casually my ward manager, how many away do we, throw away Adini little, measured graduated plastic pots a week. And she told me about a thousand of them.
A thousand of them just from my ward. One ward we’re throwing away. And these plastics, that end up anywhere eventually, I've gotten a seal of approval last month from our procurement team to switch these to paper ones, which is obviously not great in terms of, virgin, raw paper extraction, etc, with wax lined plastic still, but it's much better than, single use plastics.
That will end up in our environment causing pollution. and in terms of, air, we talked about nitrous oxide, already in Trust, but one thing when I worked in festivals recently as well, is the canisters of nitrous oxide that was available in the festivals. What are we doing to tackle that? I remember when I was in Glastonbury, this picture of a pile of gas canisters up the hill in a Glastonbury sign.
So yeah, the air pollution of gases, of medicines is something that we don't talk about enough of. So everywhere we look, Steve, there's some sort of, impact of medicines on our environment, isn't there?
[00:21:33] Steve: There is, I'll keep off of festivals in Glastonbury, we could have a whole conversation about that, I get exactly what you're saying and certainly it's the gases that's, probably one of the worst things that we've got within the, the NHS, in terms of that's environmental impact, but it is really interesting to hear about the water supplies and everything else, and I think they're the things which get forgotten. Yes. I know there's been quite a lot of discussion about even what happens with wastewater that goes from your toilet if you've been on medicines and the metabolites that you then wee out and I think there's lots and lots of conversations to have and to understand what is happening.
If you were going to just come up with a few things. You've mentioned about the plastic pots, but either the public or, practice can do within hospital, what would be those recommendations around that? I'm going to say the other side, not the carbon footprint side, but the other environmental impact.
What would you be suggesting to people?
[00:22:37] Minna: Absolutely. So, things like, returning medicines, very simple. You say it's simple, but people don't do this because it requires someone to leave their house to dispose of their medicines. Eyedrops, inhalers into your local pharmacies or, anywhere that would take them to dispose of them correctly, like your GP surgery. It requires the effort to speak to somebody just to take the waste in. So, for convenience, lots of people don't do that, and we need to change that mentality to, you know, ensure the medicines doesn't end up in our environment. And there are, lots of environmental regulations that prohibits kind of, you know, you see the donation boxes in and streets, where you can just put, you know, leftover medicines into, to your local supermarket or stores or even on the street. But you can't do that for medicines, because of, the potential harm to people that, people extract medicines from these boxes or theft of them that could be leading to all kinds of governance issues.
So, number one, so yeah, return medicines to the appropriate places to be discarded and think about medicines to use as well. So, if you're not using something, why are you ticking on a repeat list that to order it. And just have that honest conversation with your GP. I don't like it. I don't want to use it.
So, one way I've changed my consultation with patients now is rather than say, oh, this says you take adcal one twice a day. I almost encourage them to fess up to say, oh, these ones taste like chalk, don't they? The sand? Okay, taste horrible. Do you take these and then instantly you allow that space for the patient to go, oh, no, these, these have been going in my bin, I hate the taste of them. You can easily tell when you do a lot of, consultation with patients, which ones they do like and which one they don't like. So, again, shared decision making, to reduce medicine's waste to begin with so they don't end up in our environment.
Number three, I think the biggest one is to promotion. To help promotion to stay healthy, reduce the needs for pharmaceuticals to begin with, which is something that we don't often do enough. We do a lot of, promotional vitamins, but what about talking about, diet, exercise, and all the healthy living lifestyle advice, which we don't seem to talk a lot, the importance of it. The stops smoking advice, and vaccination on time.
All that advice adds up to reducing carbon footprint in the long run.
[00:25:00] Steve: Thank you. I think the last bit you talked about is so important, for all healthcare professionals, it's what their role is in ensuring health and maintaining health rather than treating. Once you're treating you’re in, carbon footprint expands enormously. Vaccination is a huge topic that's, on my mind.
We still see people come through with illnesses, which we know they shouldn't, be coming through with just because the vaccine uptakes aren't quite as they should be. I think there is a lot of promotion and reassurance of the public about things like vaccines, but also that encouragement to stay healthy and everything else.
So, I think they're really good topics. Just lastly, I want to pick up on the greener pharmacy toolkit from the Royal Pharmaceutical Society. I've looked at it, I've logged on. It's a vast, array of activities to support individuals, community pharmacies, Trusts to be better within their sustainability around medicines.
[00:26:10] Steve: Do you just want to say a little bit about the background, who's supposed to be doing it, how to get involved and what it's all about? I think it's a really nice way to finish off our chat here because it's such a tangible thing that people can get involved with.
[00:26:27] Minna: Yes, obviously. I'll just talk about the inception of the toolkit to begin with.
Many people, who has listened to this podcast, you, geared up now, you sold the agenda, but like, what do we actually go do next in our career? what next? So, the toolkit is geared for that. So for people who are new to the agenda. Wants to do something, not sure what to do.
So, the toolkit has three levels. It's bronze, silver, and gold level, and it's kind of not really a novel idea. It's aligned with other royal colleges. So, a Royal College of GP. they have the great impact for Health Toolkit, which also similarly has the different levels for self-accreditation.
And the actions in the greener pharmacy toolkit, are similar to, the RCGP one, similar to the R Chems, the Royal College of Emergency Medicines one. During scoping review, we're trying to align for the whole healthcare, system to work towards the same activity, the same direction, not, at doing work in silos so we can collaborate with each other to tick off our individual toolkits if you like.
That's the inception of it all. It's also something that's called for by our profession. So, people are saying we need some guidance, we need a toolkit, which is why the toolkit was commissioned, to begin with. It is currently for hospital and community pharmacy colleagues to take part with, with traction and resources.
In the future, we might develop it for other pharmacy sectors as well. colleagues working in, kind of your PCN. Your GP, colleagues as well as the different nations. Because currently the, toolkit was funded by NHS England, so, a lot of the metrics you might find are very English centric. So, I would like to see, some resources put in to make it say Welsh or Scottish or Northern Irish centric as well, just to, to make it localised and relevant to the working operations of, local pharmacy professionals. Have a look at the toolkit if you are new to the agenda, you're not really sure where to begin, and it's almost like a team building activity, Steve, that you and your colleagues can get together to do and tick off these for your department.
And the feel-good factor of getting a certificate at the end and a window sticker display for your pharmacy to say, we are, accredited gold. A chain of Superdrug pharmacy has taken part, I think, I believe multiple of their pharmacies have reached a bronze level already.
And that alone has changed where I go to get my prescription, the accreditation of it. So, you don't know what impact these toolkits might have. So certainly, for me, because of that, I have changed where I shop. So, consumers increasingly, who are green minded, if you like, look at these credentials or they look at what our businesses are doing, for sustainability.
So, I don't think there should be an underestimated, effort from, pharmacy colleagues because, I am mindful that our colleagues are really busy and this is something we ask them to do on top of their day job. It's not funded currently, we hope it might be funded in the future, but overall, it is a good thing to do, the right thing to do for our people and for the planet.
[00:29:33] Steve: Wonderful.
I love the way you're talking about it with, great gusto, it's something we should all be engaged with. I obviously feel that I need to be going for gold now. That sounds like the right way forward, but I'd like to say, thank you for sharing your insights. For those who are listening, please carry on with the series. There will be more around medicine sustainability, in terms of podcasts, looking slightly deeper into things like inhalers and waste and some of the topics that we've touched on. But I hope today's given you a good flavour of what the medicine sustainability agenda is all about and the fact that, whilst it's a big agenda and whilst we know the carbon footprint, and the sustainability issues are huge, many of them we can have an impact on by making small changes as well as big changes. But there are tangible things that we can get involved with. So, Minna, thank you very, very much, and goodbye everybody.
Speak to you soon.
[00:30:38] Minna: Thanks for having me.
[00:30:40] SA: Thank you for listening to this episode of GOSH Pods Goes Green. We would love to get your feedback on the podcast and any ideas you may have for future episodes. You can find a link to the feedback page in the episode description or email us at
[email protected] If you want to find out more about the work of the GOSH Learning Academy, you can find us on social media on Twitter, Instagram, and LinkedIn.
You can also visit our website at www.gosh.nhs.uk and search Learning Academy. We have lots of exciting new podcasts coming soon, so make sure you're subscribed wherever you get your podcasts. We hope you enjoy this episode, and we'll see you next time. Goodbye.
