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Technical Case Study

From: NHS Scotland

Approach:

  • As part of the Climate Emergency and Sustainability Strategy, NHS Scotland has been working to reduce emissions from inhaler propellant by 70% by 2030.   

  • The Quality Prescribing for Respiratory Illness Guide (2024-2027) has been updated to support clinicians and people with respiratory illness in the appropriate use of medicines, whilst applying the principles of value-based healthcare and realistic medicine. 

  • It supports person-centred medication review to optimise respiratory treatment, including environmental considerations, encouraging the use of lower global warming potential inhalers. 

Why take action?

Why we are focused on inhalers 

Propellant gases contained in metered dose inhalers are powerful greenhouse gases and approximately 3% of the carbon footprint of NHS Scotland results from these inhalers. However, just focusing on changing the inhaler type will not address respiratory outcomes along with environmental aims.  

70% of carbon emissions are associated with over-reliance on short-acting beta-agonist (SABA) inhalers in asthma. Optimised disease control has a significant impact on carbon emissions and improves outcomes for people with asthma.  

Listening to people with asthma 

The guide was updated, building on NHS Scotland’s 2018-2021 Strategy, to include environmental considerations in managing respiratory illness and to promote person-centered care, following the 7-step process for medicine reviews and shared decision making. 

Development has been supported by people with lived experience, patient organisations and the multidisciplinary team across primary and secondary care. Public consultation invited comments on the draft and subsequent publication of the completed guide, by the Scottish Government.  

Supporting clinicians and improving care 

This guide will assist clinicians to optimise respiratory care, supporting sustainable care and enabling effective use of existing resources. These key messages are encapsulated in this poster – the 7 Steps to Appropriate Polypharmacy. It articulates how the project supports our priorities in a way that is relevant, interesting and may bring new thoughts and ideas to delegates. 

The actions and clinical priorities promoted in the guide include: 

  • Improved outcomes by conducting person-centred medication reviews; 
  • Person-centred care: Optimising disease control; 
  • Minimising over-reliance on short-acting reliever inhalers; 
  • Ensuring inhaler technique is taught and checked; 
  • Supporting the use of propellant-free inhaler options where appropriate; 
  • Supporting safe disposal of inhalers. 

How to get started

As part of the NHS Scotland aim to achieve net zero carbon emissions by 2040, there is a specific aim to reduce carbon emissions from inhaler propellant by 70% by 2028. Propellants contained in the metered dose inhalers (MDI) are powerful greenhouse gases, accounting for approximately 3% of the total NHS carbon footprint alone. There are low carbon emission alternatives available, for example, dry powder inhalers (DPI) or soft mist inhalers (SMI), which do not contain propellant gas. Key lessons learned for the successful promotion of quality and sustainable respiratory prescribing in the NHS Scotland are outlined below.

  • Disease control lessens environmental impact: Improved disease control lessens the environmental impact of respiratory illness, contributing to achievement of net-zero targets in sustainable care by 2030. A patient with poor asthma control will be using three or more short-acting beta-agonist (SABA) inhalers – reliever inhalers - per annum. So, a patient using less than three of these inhalers, but with regular use of preventative inhalers, is managing their condition well. Those with poor control in respiratory conditions access both primary and secondary health care more regularly. Scotland data relating to this can be found on Public Health Scotland’s Therapeutics Dashboard. 
  • Education is needed: Education and support are being offered to all NHS Boards to assist in the implementation of the recommendations from the quality prescribing guide for respiratory conditions.  These resources include the Manage Medicines app for service-users and a respiratory toolkit to assist clinicians which is part of Healthcare Improvement Scotland’s Right Decision Service. 
  • Targeted communication is key: Providing the right information for clinicians and service-users - to understand how the decisions they take around healthcare and its management impacts the environment - is enabling. It leads to greater engagement with environmental concerns and deepens insight. For respiratory health there is a communications strategy, newsletter and local health champions who work constantly to ensure messages are reaching the target audiences. 
  • Funding supports action: This work was funded as Scottish Government core business with the heaviest cost being carried in salaries. Much use was made of existing available resources at no extra cost. 

Tracking progress

Measurement and Indicators: A suite of indicators has been developed to support the work - the National Therapeutic Indicators (NTIs). Case finding is supported by the Scottish Therapeutic Utility (STU), a programme using data from GP IT systems. 

The guide content has also been updated on the ManageMeds app and website, including an implementation toolkit. Quality Improvement methodology is being used to support clinicians with changes in optimising respiratory care. 

In practice

The guide is published and future changes in prescribing practice and outcomes will be monitored using NTIs. Progress can already be seen in target areas, such as use of SABA alone. The toolkit is active on the Manage Meds app and website and activity will be monitored. 

Key resources

More details about this project are available in this poster.

References

  1. Scottish Government. NHS Scotland climate emergency and sustainable strategy: 2022 – 2026.  August 2022. NHS Scotland climate emergency and sustainability strategy. Accessible from: https://www.gov.scot/publications/nhs-scotland-climate-emergency-sustainability-strategy-2022-2026/
  2. Janson, C, Maslova E, Wilkinson A, et al The carbon footprint of respiratory treatments in Europe and Canada: an observational study from the CARBON programme. European Respiratory Journal 2022 60:2102760. Accessible from: https://erj.ersjournals.com/content/60/2/2102760
  3. Wilkinson AJK, Maslova E, Janson C, et al Greenhouse gas emissions associated with suboptimal asthma care in the UK: the SABINA healthCARe-Based envirONmental cost of treatment (CARBON) study Thorax Published Online First: 27 February 2024. doi: 10.1136/thorax-2023-220259. Accessible from: https://thorax.bmj.com/content/early/2024/01/11/thorax-2023-220259.citation-tools
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