Sustainability

Question 1

NHS carbon footprint

Answer 1

Medicines account for 25% of the carbon emissions within the NHS in England
* Environmental Risk Assessments:
○ Regulators in the US and the EU require an environmental risk assessment of a medicinal product before market entry.
* Life Cycle Impact:
Discussion: “How does this product affect the environment in its entire life cycle?”

Question 2

Types of Medicines Worst for Climate Change

Answer 2

• A small number of medicines account for a substantial proportion of emissions:
  ○ Anaesthetic gases and nitrous oxide: ~2% of NHS emissions.
  Inhalers: ~3% of NHS emissions.

Question 3

Sustainable Manufacturing & Blister Packs

Answer 3

• Astellas Carbon Neutral Blister Pack:
  ○ 85% of Europe’s tablets/capsules use blister packs (often single-use).
  ○ Challenges: Separation of metal and plastic for recycling.
  Innovation: A layer of plant-based polyethylene between two layers of polypropylene makes the pack carbon neutral (CO₂ emitted equals CO₂ absorbed during sugar cane growth).

Question 4

Impact of medicines wastage

Answer 4

Reducing Medicines Wastage
○ Annual NHS primary and community care prescription med wastage: £300 million/year.
○ Improving adherence can improve health outcomes.
Discussion: What is the carbon and environmental impact of this wastage?

Question 5

Causes of medicines wastage

Answer 5

• Patients recovering before the treatment course is complete.
  
  • Changes in therapy (inefficacy, unwanted ADR).
  • Progressive conditions requiring new therapies.
  • Patient death.
  • Prescribing/dispensing processes leading to excess supply.
    System failures in identifying vulnerable individuals.

Question 6

Case studies

Answer 6

• Leicester:
  ○ 56% of inhaler-users had poor technique; pharmacists provided proper use advice.
  
  • Medway:
    ○ Pharmacist intervention led to reduction/withdrawal of potent antipsychotics in 61% of care home residents.
  • Northumbria:
    For every £1 invested in pharmacist interventions, £2.38 was saved from the medicines bill at a care home.

Question 7

Routes into the Environment:

Answer 7

○ Water: Not fully removed by wastewater treatment; found in surface water, groundwater, and drinking water.
○ Soil: APIs accumulate via fertiliser (manure or sewage sludge) and can enter plants and food chains.
Air: On farms, APIs applied as powders become airborne and can be inhaled or deposit on soil/plants. ○ Water: Not fully removed by wastewater treatment; found in surface water, groundwater, and drinking water.
○ Soil: APIs accumulate via fertiliser (manure or sewage sludge) and can enter plants and food chains.
Air: On farms, APIs applied as powders become airborne and can be inhaled or deposit on soil/plants.

Question 8

Risk of pharmaceutical residues

Answer 8

• Wildlife Impact:
  ○ APIs like carbamazepine can damage fish organs.
  ○ Synthetic estrogen affects sexual characteristics in male fish.
  
  • Ecosystem Health:
    ○ Pharmaceuticals in mixtures can have long-term effects on aquatic life and biodiversity.
  • Antibiotic Resistance:
    Antibiotics in the environment (from humans, livestock, manure, wastewater) contribute to resistance gene transfer and multi-resistant bacteria.

Question 9

Vulture mortality (case study india)

Answer 9

• Diclofenac Use:
  ○ Used in cows; lethal to vultures ingesting carcasses.
  ○ Near extinction of Gyps species due to high toxicity (up to 99% mortality).
  
  • Regulatory & Industry Response:
    ○ Increased use of meloxicam as an alternative.
  • Wider Implication:
    Need for integration of human and veterinary health sectors.

Question 10

Antibiotic Resistance Development

Answer 10

• Statistics:
  ○ 600 trillion human antibiotics and 1700 trillion veterinary antibiotics dispensed (Germany, 2011).
  
  • Mechanisms:
    Horizontal gene transfer (transformation, conjugation, transduction) enables resistance spread.

Question 11

Reducing pharmaceuticals in the environment (PIE)

Answer 11

• Strategies for Sustainable Pharmacy:
  1. Minimise emission and resource/energy consumption during production.
  2. Prevent and minimise PIE.
  3. Optimise pharmaceutical care (e.g., deprescribing).
  Reduce other pharmaceutical waste (e.g., packaging).

Question 12

NHS Supply Chain Approach

Answer 12

○ Uses products from 80,000+ suppliers; non-medicines supply chain constitutes 42% of NHS Carbon Footprint Plus.
○ Measures include more efficient use, low-carbon substitutions, and ensuring supplier decarbonisation.
By 2030, NHS will not purchase from suppliers that do not meet net zero commitments.