Environmental impact of medicine and the NHS push to net zero

Kevin Connolly, Department of Economics, undertook a research project into prescription drugs, the environmental impact of them and how this might impact on the NHS's commitment to reaching net zero.

The NHS has committed to reaching net zero, and medicines are a big part of that challenge as pharmaceutical use accounts for around a quarter of NHS carbon emissions. It is not only the carbon impact, medicine use also have a number of other up and downstream environmental impacts such as ending up in our river system. One recent study found residues of nine drugs in Scottish surface waters, including ibuprofen, metformin and several antibiotics.

The inefficiencies in how medicines are supplied and used are well known however what’s less well understood is the journey a medicine takes after it’s prescribed, and what shapes the choices made along the way. That’s what we set out to explore.

What we did

Using a two-stage stakeholder consultation we spoke to people at both ends of the prescription journey. First, we interviewed 12 current and future prescribers such as: pharmacists, doctors, nurses, to gain insights into their opinions on the relative importance of the environmental impact of medicines, how it impacts their prescribing practices, and how each stage of the medicine journey influences progress toward sustainability goals

We then interviewed six older adults aged between 67 and 96, as people over 65 take more medicines and we asked what they knew, what they thought, and how this could be handled better within the NHS.

These are small groups, so we can’t claim to speak for every prescriber or patient in Scotland. But what they told us fits closely with the wider evidence, and three themes came through strongly.

Theme 1: Nobody has told us

The strongest finding was how little anyone knew with all six older adults saying they had never received any information on the environmental impact of medicines. For prescribers there was a little awareness due to professional communications but this was limited and only linked to some larger well-know issues such as inhalers. Beyond that, one prescriber told us, “I can’t put the two together.”

Low awareness didn’t mean low interest, though with five of the six older adults wanting to learn more, especially when it was framed around visible, local harms like water pollution. One participant who was sceptical about climate change was still interested in the local issues. Prescribers also welcomed more information, with a catch: it must be practical rather than aspirational. Several called current NHS messaging “wishy washy” and patients noted that they wanted to hear it in person from someone they trust, often a pharmacist. They did not want it on a leaflet or website, partly because not everyone in their age group is online.

Theme 2: Health comes first, but people want a say

An other key theme from the interviews was that everyone was clear that patient health must come before environmental considerations. In the discussion older adults indicated that they would only consider switching medicines if the alternative worked just as well, and prescribers agreed. A recent inhaler campaign shows why these matters as two prescribers told us some older patients with weaker breath had been switched to devices that didn’t suit them, because of pressure to hit green targets.

Many older adults also felt they had little say over their medicines and had never been offered a choice and one made and interesting point that sustainability should be something done with patients, not to them. Prescribers were happy to raise the subject but worried about making patients feel guilty, so they’d only do it where the patient showed some interest.

Theme 3: There’s a lot of avoidable waste

Both groups pointed to repeat prescriptions as a major source of waste. Prescribers regularly meet patients with cupboards full of unused medicines, because repeat items keep being dispensed without review. One older adult had to stop the pharmacy from handing over a medicine that had already been cancelled, which shows how poorly GP practices and pharmacies can communicate. Prescribers also questioned the automatic use of single-use plastic dosette boxes as a one-size-fits-all answer to missed doses, since they have a bigger footprint and don’t always improve adherence.

Community pharmacies came up as well. Doing the right thing, such as running a medicine return service, costs them money that isn’t reimbursed, so the incentives don’t line up with NHS ambitions.

What needs to change?

Our findings point to three priorities. Environmental sustainability should be built into prescriber education, both at university and through ongoing training, and the guidance needs to be practical. Patients need clear, face-to-face information, ideally framed around things that matter to them locally. And the financial incentives for community pharmacies should be better aligned with the NHS’s environmental goals.

Greener prescribing isn’t about asking people to take fewer medicines than they need. It’s about making sure the ones prescribed are the ones used, and that patients and prescribers have the knowledge and the time to talk about it.

About Kevin Connolly

Dr Kevin Connolly is a senior Lecturer with the Department of Economics. His research interests centre around the economy and the environment.