Principles of sustainable healthcare in pharmacy practice

The earth is heating owing to the emission of greenhouse gases caused by human activity, including unsustainable energy use, land use and consumption^​1​. The consequences of this global heating include increasing frequency and severity of heatwaves, wildfires, drought, floods and storms; however, we may not associate provision of healthcare with this changing climate, nor recognise the health-related impacts of climate change^​2​.

The climate crisis negatively impacts the population’s health and wellbeing and adds to the burden on the health service in several ways^​3,4​. In the UK, one in three flood victims experience long-term mental health problems, including depression and post-traumatic stress disorder^​5​. Extreme heat in 2022 was associated with an additional 3,000 deaths in the UK³. Air pollution negatively affects health at every stage of life and is associated with up to 40,000 deaths annually in the UK^​6​. Poor air quality is also associated with emergency asthma admissions^​7​. The health impacts of climate change are exacerbated by rising health and social inequality, with the most deprived suffering the worst consequences^​4,8​.

Healthcare services are vulnerable to the impacts of the climate crisis. Global extreme weather events create pressure on complex supply chains, including pharmaceuticals, exacerbating existing medicine supply problems^​9​. Locally, extreme weather (both heat and flooding) present challenges within the day-to-day running of health services, impacting storage of medicines, operation of equipment and IT, maintenance of a healthy working environment and access to healthcare sites. The vast majority (90%) of NHS hospitals are at risk of overheating and 10% are at risk of flooding^​10,11​.

Sustainable healthcare has been defined as “the ability to provide healthcare to meet the needs of this generation without compromising the ability of future generations to meet their healthcare needs”^​12​. 

This article defines the relationship between health and climate. It introduces the principles of sustainable healthcare and explores how they can be applied to pharmacy practice.

Provision of healthcare contributes to the climate crisis 

The NHS is responsible for 4-5% of the UK’s carbon footprint (see Figure 1)^​13​. Of this, pharmaceuticals, inhalers and anaesthetics account for a quarter of the entire NHS carbon footprint^​13​. Pharmaceuticals also present a significant challenge in terms of pharmaceutical pollution of waterways and plastic pollution from packaging and disposable devices^​14​. 

These negative health impacts place an ethical and professional responsibility on us as healthcare professionals to minimise our contribution to the climate and ecological crises^​15,16​. The NHS is legally bound by the 2022 Health and Care Act to meet its target to be net zero by 2045, with an ambition to reach an 80% reduction by 2036 to 2039^​13​. In August 2024, the General Pharmaceutical Council published its ‘Net zero action plan for sustainable pharmacy regulation‘, which is aims to achieve carbon net zero 2040 for the organisation and sets out plans to embed environmental sustainability at every level of pharmacy regulation^​17​. In February 2024, the Care Quality Commission has introduced a requirement to address environmental sustainability within their single assessment framework via the quality statement on environmental sustainability^​18​. The Royal Pharmaceutical Society’s ‘Competency framework for all prescribers’, published in September 2021, asks prescribers to “consider the impact of prescribing on sustainability, as well as methods of reducing the carbon footprint and environmental impact of any medicine”^​19​.  

Pharmacy teams have a significant role to play in encouraging healthy living, streamlining prescribing processes, ensuring appropriate and sustainable use of medicines, avoidance of waste, and facilitating appropriate disposal of medicines to minimise their negative impact on the environment^​16​. Pharmacy teams already undertake much of this work as routine practice but may not recognise the significance of this work in relation to sustainability. The principles of sustainable healthcare enable us to view practice through the lens of sustainability^​20​. 

The principles of sustainable healthcare

In response to these challenges, the Centre for Sustainable Healthcare (CSH) developed the Principles of Sustainable Clinical Practice to enable health services to identify, prioritise and implement actions that drive sustainable clinical transformation (see Figure 2)^​20​. Applicable across any sector of healthcare, the principles are listed in order of their impact and importance in optimising the sustainability of clinical practice. 

Adapted from Centre For Sustainable Healthcare

These principles were further developed to encompass non-clinical activity within sustainable healthcare by including a fifth principle that addresses sustainable resource use. These five principles are shown in the form of a driver diagram in Figure 3^​21​. By considering the different drivers that lead to emissions and resource use, practitioners can start to identify change ideas designed to reduce carbon while delivering high-quality care. To see examples of pharmacy-related change ideas, click on the empty boxes in the diagram. Note that many ideas will align to more than one principle. There are many examples of practice that demonstrate the wide-ranging positive impacts of a sustainable approach, improving clinical and population health outcomes, while minimising environmental impacts, optimising social value and reducing costs.

Driver diagram templates are available on the SusQI website. 

To support the implantation of change ideas, the SusQI framework has been developed to support the adoption of sustainability into routine quality improvement^​22​. Examples of sustainable quality improvement are provided in the sections below.

Prevention

Prevention is the first and most impactful principle of sustainable healthcare. If we can prevent disease from occurring in the first place, this benefits the patient’s health and wellbeing, but also eliminates the carbon footprint of healthcare activity that would be required to manage that disease. It also avoids the cost and burden placed on NHS services. Similar impacts can be achieved by reducing progression of disease and avoiding exacerbations of disease and admission to inpatient settings where resource use and associated emissions are highest. 

The current health of the UK illustrates that more can be done to prevent disease^​23​. In May 2024, a report published by the Department of Health and Social Care highlights that healthcare demand is at an all-time high and is set to increase as the population ages and health needs become increasingly numerous and complex^​24,25​. Six conditions — cancer, heart disease, musculoskeletal disorders, mental ill-health, dementia and respiratory diseases — all of which are caused or exacerbated by lifestyle factors, account for 60% of ill health and early death in England^​26​. Applying evidence-based preventative interventions has been estimated to add 20 more healthy days per person, per year, in the UK — a 33% reduction in ill health^​24​. 

There is a need to normalise prevention and to make positive lifestyle choices in relation to diet and physical activity easy and accessible to everyone^​24,27​. Evidenced-based interventions on diet and physical activity to improve health and avoid disease can also have positive impacts on climate change. Limiting consumption of meat, particularly red meat and processed meat, which are known carcinogens, and increasing the proportion of whole food plants (fruit, vegetables, wholegrains, legumes, nuts, seeds) has proven health benefits in reducing the incidence of a range of conditions, including obesity, heart disease, diabetes and some cancers^{​28–30​}. It also enables us to reduce the amount of land and water use dedicated to food production while continuing to produce sufficient food for the world’s growing population^​31​. 

The health benefits of physical activity are well documented and can also have a positive impact on climate change^​27​. For example, individuals undertaking physical activity in place of using a car reduce their carbon footprint, contribute to a reduction in local air pollution and are likely to be increasing their time outside in green space, which is also known to be beneficial for mental health^{​6,32,33​}. 

Pharmacy teams already engage effectively in a wide range of preventative activities, including vaccination, screening for conditions such as hypertension and providing healthy living advice^​34​.  Pharmacy teams will be familiar with using the ‘Making every contact count’ approach to address harmful behaviour, such as smoking^​35​. More emphasis now needs to be given to using an informed and evidenced-based approach to recommending dietary changes and increased physical activity for disease avoidance in the general population^​23​.

Prevention activities should now be targeted so that people are able to benefit before the point at which medication is indicated. For example, women attending for HRT prescriptions can be advised to take preventative action against osteoporosis by undertaking weight-bearing exercise and ensuring they have sufficient calcium in their diet^​36​. The positive impact of improved diet, physical activity and mental health and wellbeing should be emphasised, ensuring that patients understand the potential that lifestyle change has to slow or reverse the progression of disease and reduce exacerbations^{​24,26,27,30–33​}. We can work more closely with colleagues such as social prescribers to enable patients to live healthily for longer. 

Patient empowerment

Closely linked to prevention, patient empowerment enables patients to take a more active role in managing their own health and health conditions. An engaged, informed and supported patient is more likely to undertake self-care and self-monitoring when their condition is stable and to access healthcare services appropriately when needed, as demonstrated by the appropriate use of asthma self-management plans^​37​.  Additional information on the significance of patient empowerment can be found in ‘Principles of person-centred practice for prescribing’. 

Evidence suggests that improvements can be made in decisions around medicines. Modern western lifestyle and culture is contributing to poor health outcomes for many people^{​24–30​}. The medical model and ever-increasing levels of prescribing is proving to be neither sustainable nor effective^{​38–41​}.  It has been estimated that £300m worth of medication goes unused annually in England and up to half of all medicines prescribed for long-term conditions are not taken as recommended^{​42–44​}. Medicines optimisation is an important responsibility for pharmacy teams and is one area where positive outcomes can be achieved for patients, NHS services and the environment. There are already some initiatives that have been started to improve this.

For example, in Gloucestershire, patients are encouraged to check their medicines before they leave the pharmacy so that any unwanted medicines can be returned for re-use^​45​.

In its Kapsule Kids project, Great Ormond Street Hospital used Kidzmed training to empower paediatric patients to take tablets or capsules instead of liquids. The initial project generated savings of £258,255 and saved the carbon equivalent of driving 972 miles in an average car. Pills are likely to have a reduced environmental impact compared with an equivalent dose of liquid medication, with less packaging and less wasted medicine^​46​.

Lean pathways

Streamlining systems — such as repeat prescribing — reducing waste of medicines, high-risk drug monitoring (aligning blood tests to minimise visits and use of consumables) and undertaking remote consultations where appropriate are all part of typical day-to-day practice for many pharmacy teams. These activities not only reduce cost and carbon emissions, but also streamline services and minimise the risk of avoidable harm from unnecessary interventions, prescribing and investigations. While the efficiency gains and patient benefits of more streamlined care are obvious, the environmental sustainability impacts are less commonly considered.

Medicines, including inhalers and anaesthetics, account for 25% of the NHS carbon budget, representing a ‘carbon hotspot’ that needs to be addressed^​13​.  Prescribing is the most common intervention in the NHS. In the 2022/2023 financial year, 1.37 billion prescription items were dispensed in the community in England, Scotland and Wales, at a cost of £12.3bn^{​38–40​}. The National Overprescribing Report, published in September 2021, revealed that at least 10% of prescription items in primary care need not have been issued. Medicines waste costs the NHS at least £300m per year^​42,43​.   

This represents significant waste of limited NHS resources and has widespread environmental impacts, including the energy and emissions involved in the development, manufacture, transport and use of medicines that have not been used; packaging waste (often single use plastic or difficult to recycle materials) and the risk of pharmaceutical pollution of waterways^​14​. Interventions to reduce unnecessary prescribing, undertake appropriate deprescribing and minimise medicines waste could have significant impacts in reducing the environmental impact of medicines use.

For more on this topic, listen the episode of the PJ Pod: ‘Effective deprescribing: getting the most from medicine’.

The NHS Dorset ‘Medicines waste’ campaign empowered patients to contribute to streamlining the repeat prescription process by only ordering the medicines that they need, resulting in a 2% drop in prescription requests across Dorset. In the first two months, approximately 65,000 prescription items were not requested because of the campaign, with associated savings of £475,000 in avoided prescription costs and 294,975kg of avoided carbon emissions^​47​. There are many examples of SusQI projects that illustrate a range of interventions that have been undertaken for cost or efficiency reasons but have resulted in significant carbon savings (see Box 1 for links to case study examples). 

Low-carbon alternatives 

Low-carbon alternatives are products or processes that emit minimal greenhouse gases. Metered dose inhalers (MDIs) and anaesthetic gases are two carbon hotspots, emitting high levels of greenhouse gases though their direct use^​13​. While there are alternatives and strategies that can be considered to reduce the use of both, it should be noted that a blanket approach for inhaler switching is not appropriate. 

For patients that use inhalers, a holistic person-centred approach that focuses on informed self-management, minimising exacerbations, optimising inhaled treatment and engaging in self-care, such as regular physical activity, will be more impactful in reducing the carbon footprint of that patient’s treatment through avoided exacerbations and admissions than could be achieved by simply switching to a low-carbon inhaler^​48​. It has been estimated that poorly controlled asthma generates three times the carbon footprint of well-controlled asthma^​48​.

However, MDIs represent 3% of the overall NHS carbon footprint^​13​. MDI propellant greenhouse gases are released each time the metered dose is used and if the inhaler is disposed of inappropriately^​49​. It is therefore essential that pharmacy teams are aware of the relative carbon footprint of inhalers and can contribute to high-quality, low-carbon respiratory care^​49,50​. 

Pharmacy teams should be aware of the different terminology used to describe inhalers; it should be noted that carbon neutral inhalers are not necessarily low carbon. Carbon neutral status can be obtained by buying carbon emissions offsets for avoided emissions in developing countries, rather than eliminating emissions or paying for removed emissions^​51​. In the case of carbon neutral inhalers, this does nothing to reduce the carbon footprint of the NHS. Greenhouse gases will still be released when the inhalers are used. Dry powder inhalers contain no propellant and are therefore the lowest carbon footprint inhalers available^​49​. There are many examples of initiatives to reduce the carbon footprint of respiratory care, including addressing excessive salbutamol use, optimising treatment according to current guidelines (early use of inhaled corticosteroids and ensuring that patients are using an inhaler that suits their intuitive breathing technique, see Box 2)^​52​.

Anaesthetics represent a further 2% of the overall NHS carbon footprint. Desflurane has been decommissioned by the NHS and replaced with the lower carbon emitting and clinically equivalent sevoflurane^​53​. Nitrous oxide is a potent greenhouse gas. The traditional manifold systems have been found to be highly inefficient, with up to 95% leakage of nitrous oxide from the pipes^​54​. Work is underway around the UK to address this waste^​54,55​.

Pharmacy teams should be aware of other low carbon alternatives, such as formulation considerations (switching IV to oral or liquids to tablets), reusable devices and non-pharmacological options, such as green prescribing and social prescribing^​46,56​.

Operational resource use 

Sustainable resource use focuses first on minimising resource use as much as possible and then ensuring that resource is used as sustainably as possible and reused or repurposed before recycling or disposal is considered. The aim is to minimise consumption, access renewable energy and promote the circular use of products.

Several recycling schemes are in operation for medicines devices and packaging in the UK. These include inhaler recycling schemes in Kent and Medway and South East London^​57​;  recycling schemes for insulin pens, such as Re-Pen and Pencycle;  and recycling of brand-specific plastic syringes and spoons.

Several high street pharmacies now provide medicines blister pack recycling collection boxes in some parts of the UK. While recycling is better than disposal and, in the case of inhalers, ensures that greenhouse gases are captured for reuse, NHS waste accounts for only 0.1% of the NHS carbon footprint^​58​.  Reduction of consumption, where appropriate, is a much more effective intervention. 

In pharmacy settings, sustainable resource use might include simple interventions, such as employing a switch-off checklist at the end of the day to ensure that lights, equipment, heating etc are turned off, switching to LED lighting, or streamlining deliveries to reduce the number of journeys and fuel consumption^​59​. Energy use can be addressed by switching utility provider and using a tariff backed by renewable energy production or investing directly in renewable energy through adoption of solar panels or heat pumps. It may also be possible to undertake actions to conserve energy use and consumption of consumables such as paper, single use plastic and PPE.

There are a range of recommendations available from SEE sustainability and the Green Impact for Health Toolkit^​59,60​. In May 2023, the Royal Pharmaceutical Society announced that it was launching its ‘Greener pharmacy toolkit‘, which provides a checklist of initiatives for community pharmacies and hospital pharmacies to consider.

Some examples of sustainable resource use initiatives can be seen in Box 4.

Signposting

Climate and Health

All Our Health — e-learning for healthcare: climate change and air pollution modules

Environmentally Sustainable Healthcare: e-learning for healthcare

Prevention

Plant-Based Health Professionals UK: a community interest company dedicated to providing education and advocacy on whole food plant-based nutrition and lifestyle medicine for prevention and treatment of chronic disease

British Society of Lifestyle Medicine — What is lifestyle medicine? 

Medicines Optimisation

PrescQIPP — Bulletin 340: Sustainability in medicines optimisation

PrescQIPP — Bulletin 295: Inhaler carbon footprint

NHS England — National medicines optimisation opportunities 2023/2024

Networks

Pharmacy Sustainability Network: Sustainable Healthcare Networks Hub

Pharmacy Declares: climate conscious pharmacy professionals based in the UK

Primary Care Pharmacy Association (PCPA) — Greener PCPA

Greener Practice: UK primary care sustainability network

Case Studies

Sustainable Healthcare Networks Hub — Resource library

Sustainable practice: what can I do?: Series published by The BMJ aimed to offer tangible actions clinicians can take to reduce the carbon footprint of healthcare

System progress: a collection of case studies highlighting sustainability work happening at all levels across the NHS

Greener NHS Knowledge Hub: FutureNHS Collaboration Platform (NHS registration required)

Centre for Sustainable Healthcare

Sustainable Quality Improvement

Centre for Sustainable Healthcare — Courses

Centre for Sustainable Healthcare — Newsletter