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Technical Case Study

From: NHS England

Approach:

  • Encouraging clinical best practice in respiratory disease management. For example: by improving inhaler technique, encouraging use of long-term prevention medications, and addressing over-reliance on avoidable short-acting beta agonist (SABA) medications
  • Supporting a move to lower carbon inhalers where clinically appropriate, and in a shared decision-making process with the patient. Lower carbon inhalers include dry powder inhalers (DPIs), soft mist inhalers (SMIs), or lower carbon metered dose inhalers (MDIs) where DPIs and SMIs are not clinically appropriate
  • Increasing sustainable disposal of inhalers
  • Supporting adoption and spread of innovations such as lower carbon propellants and alternatives

Why take action?

The propellants used in metered dose inhalers (MDIs) are powerful greenhouse gases, with a climate warming effect 1300-3350 times more powerful than carbon dioxide. As a result, MDIs have a direct and significant contribution to the emissions generated by a health service. In the NHS in England, inhalers account for around 3% of its overall carbon footprint.

Evidence from the UK and other countries suggests that respiratory patients do not always receive care in line with best practice, particularly around education and support on when and how to use their inhaler. As a result, inhalers are not always used in the best way, leading to poor disease control and avoidable deaths. Supporting clinicians and patients to choose the right inhaler and make sure it is used appropriately not only significantly reduces carbon emissions, but also provides an opportunity to improve patient care. As lung disease disproportionately affects disadvantaged groups and people living in areas of social deprivation, improving clinical outcomes for respiratory patients also helps address health inequalities.

Safe and lower carbon alternatives to MDIs – such as dry-powder inhalers (DPIs) and soft mist inhalers (SMIs) – are available and are clinically equivalent for many patients. Studies have estimated that the carbon footprint of a DPI is in the range of 20-200 times less than MDIs.

Rates of MDI prescribing vary across different countries. For example, Sweden prescribes 13% of inhalers as MDIs, compared with 70% in the UK. MDI prescribing is lower in many other European countries compared with the UK, and mortality rates for respiratory disease are also lower – demonstrating that high quality care can be delivered using low carbon inhaler devices.

DPIs are suitable for many patients, but some may continue to need MDIs. In the long term, some major pharmaceutical suppliers have committed to action on reducing the carbon impact of their MDIs and reformulating some inhalers so they can be used with low carbon propellants. Timelines for introduction to the market are currently being refined.

Tackling inhaler selection and use also supports patient choice. A study from Asthma + Lung UK (ALUK) indicated that most patients in the UK would like the environmental impact of inhalers to be a consideration in treatment choice.

In addition to improving patient outcomes and reducing carbon emissions, providing prescribing information and support for clinicians also creates an opportunity to find the most cost-effective product that is right for the patient – therefore potentially enabling cost savings to be made in the process.

Disposal also has an important role to play in tackling the climate impact of inhalers. When inhalers are disposed of with household waste they may end up in landfill and any remaining greenhouse gases from MDIs are released into the atmosphere. Inhalers that are returned to a community pharmacy can be incinerated with medical waste. In some cases in England, pharmacies have access to inhaler recycling, which means plastic and gases can be recycled.   

Key messages

  • The propellants used in metered dose inhalers (MDIs) have a significant contribution to the emissions generated by a health service.
  • Evidence suggests that inhalers are not always used optimally, leading to poor outcomes for respiratory patients.
  • Safe and lower carbon alternatives - such as dry-powder inhalers (DPIs) and soft mist inhalers (SMIs) - are available, and are clinically equivalent for many patients.
  • Promoting high quality, low carbon respiratory care by optimising the selection and use of inhalers could also help to:
    • improve patient outcomes
    • reduce health inequalities
    • support patient choice
    • potentially, improve cost effectiveness or reduce costs.
  • Countries with a high usage of MDIs are likely to achieve reductions in emissions and other benefits from taking action in this area.

How to get started

In 2020, the NHS in England committed to reach net zero by 2040 for the emissions it directly controls. This includes emissions from metered dose inhalers (MDIs), which happen at the point of use.

To tackle these and to help improve respiratory patient outcomes, an inhaler policy was developed for the NHS in England aimed at promoting high quality, low carbon respiratory care. A key focus of this is ensuring that patients are using the right device for them – and know how to use it to manage their respiratory condition effectively.

This section highlights the main actions that were important to put this policy into place and draws out key lessons for adaptation by other health services. Relevant resources are referenced and included in endnotes, and a list of key references are provided at the end of this case study.

About the NHS in England:

  • Managed through 1 national team, 7 regional teams and 42 local Integrated Care Systems*
  • Publicly funded through taxation – free at the point of use 
  • 229 healthcare provider organisations (‘trusts’) and 6,925 GP practices
  • Comprehensive service, including hospital, mental health, community & primary care

*Integrated Care Systems (ICSs) are partnerships of organisations that come together to plan and deliver health services locally. 

Key learning: Engaging stakeholders

The majority of inhalers are prescribed, dispensed and used in primary care. Early engagement with primary care clinicians, respiratory care professionals, patient groups and representatives from industry was vital in both developing the policy and securing support to put it into practice.

A national working group was set up at the outset with experts and representatives from all these groups, jointly coordinated by the national clinical respiratory team, medicines team and the Greener NHS team in NHS England and chaired by NHS England’s national clinical director for respiratory medicine. The group coordinated engagement activities and provided crucial clinical leadership which helped:

  • shape the policy;
  • define the resources and materials needed to put it into practice safely and effectively (see key learning “Working with key partners” below);
  • consider policy levers to support implementation; and
  • secure clinical support for the work.

Dedicated “Task and Finish” groups were set up with stakeholders to focus on specific areas of the policy such as education and training needs.

Engaging stakeholders: Clinical leadership was key to developing a safe and effective policy and securing support for change from the wider clinical community. Bringing clinicians, patients and industry representatives together from the outset supported evidence-based and practical policy development and implementation, as well as early buy-in.

 

Key learning: Maximizing opportunities to improve patient care

Improving patient outcomes and promoting high quality respiratory care formed the core of the policy - which also targeted specific actions to further reduce carbon emissions and deliver cost effective care.

A GP surgery in Coventry, England is one of many across the country improving respiratory illness management while reducing carbon emissions. © NHS England

A holistic approach was helpful to achieve this – including consideration of the impact of appropriate diagnosis of respiratory illness, condition management, prescribing decisions, inhaler use and device disposal.

It was vital to build on scientific evidence as well as existing evidence-based best practice. Recommendations and resources considered in the design of the policy included:

  • the British Thoracic Society’s Position Statement on the environment and lung health
  • the Primary Care Respiratory Society’s Position Statement on the environmental impact of inhalers
  • the NICE Decision Aid for inhaler choice (since updated in 2022)
  • the Asthma+Lung UK study, which indicates that most patients believe that the environmental impact of inhalers should be a consideration in treatment choices and would be willing to try a more environmentally friendly inhaler.

Maximizing opportunities to improve patient care: Policy design was holistic and built on existing best practice and scientific evidence. This maximized opportunities to improve patient outcomes while also reducing carbon emissions – creating a double win policy.

 

Key learning: Working with partners

A package of information, education, and training was essential to raise awareness and educate patients and clinicians, encourage shared decision making with patients on their treatment, increase patient choice and improve disease management.

NHS England worked with trusted partners, including patient and professional organizations to not only ensure the development of tailored resources and messaging, but also to identify the best channels to reach patients and clinicians.

A summary of the main resources and materials are below – links are provided in references. Those which are publicly available are also listed in the key resources section at the end of this case study.

 

Resources for clinicians and other healthcare staff:

The national working group identified the need for education and training material in tailored formats to suit different individuals’ learning style, as well as short, visual and practical resources to summarise key information in one place. Case studies were also extremely useful as they helped show how specific healthcare organisations practically implemented the changes recommended by the policy. Resources developed for clinicians and other healthcare staff are listed below.

Education and training:

  • The NHS England “High Quality and Low Carbon Respiratory Care” video summarizes in less than five minutes the key actions that teams can take to improve patient outcomes and reduce carbon emissions.
  • The Royal College of General Practitioners (RCGP), the professional membership body for GPs in the UK, proposes three training modules on its net zero healthcare educational hub. These modules are free for RCGP members to access, one of which is on high quality, low carbon respiratory care.
  • Elearning for healthcare (elfh) is a widely used training platform in England that provides online education developed in partnership with the NHS, charity and professional bodies. The module on “Administration of Drugs Using Inhalers”, was updated to include latest evidence and environmental considerations of inhaler prescribing.
  • PrescQIPP is an organization which provides evidence-based resources to improve medicines related care for patients. Their “Inhaler carbon footprint” briefing, bulletin and data table explains the environmental impact of inhalers and gives an estimated carbon footprint for each inhaler commercialised in England, based on a manufacturers’ survey.

Practical tools and guides:

  • The UK primary care sustainability network, Greener Practice, produced the guide “How to Reduce the Carbon Footprint of Inhaler Prescribing” which was reviewed and endorsed by the NHS England working group and Asthma+Lung UK. It provides practical advice on inhaler prescribing, implementation of best practice, answers to frequently asked questions and a table of inhalers which gives a visual guide to their carbon footprint category.
  • The “Greener Practice Asthma Toolkit” is an interactive website which includes educational videos and step-by-step quality improvement projects to improve asthma care and reduce carbon emissions. It provides practical tools and resources to implement the changes in practice, for example: IT resources to embed in primary care IT systems, links to patient resources, links to data sources and SMS templates.
  • The National Institute for Health and Care Excellence (NICE) is a public body which provides national guidance in England to improve health and social care.  Their “Asthma Inhalers and Climate Change Decision Aid” provides a visual guide to support conversations between patients and clinicians to select the right inhalers.

Case studies:

  • Case studies help to illustrate how the policy is being put into practice at a local level.

These resources were accompanied by a mix of webinars, blog articles, internal meetings and clinical networks.

 

Resources for patients:

Tailored resources for patients were also important and necessary, both for them to engage with on their own, and to support conversations with their healthcare professionals. NHS England worked in partnership with Asthma+Lung UK, a well-recognised charity advocating for better lung health in the UK, to develop and disseminate these resources.

A qualitative study helped in the development of these materials, in particular to ensure that the needs of more disadvantaged groups were considered and addressed.  Resources developed are summarized below.

  • Key messages for patients summarizing the four steps they can take to improve their lung condition and help the environment at the same time (available in 9 languages).
  • Posters and handouts, to be used by clinical teams before, during and after a conversation on inhaler choice and use (handout available in 9 languages).
  • Two videos, one with the advice explained by a Respiratory Nurse Specialist and one showing a patient’s story. These videos came in addition to existing Asthma+Lung UK videos on good inhaler techniques, which were already available.

These resources were distributed alongside the resources for clinicians, as well as directly to patients via Asthma+Lung UK networks and via social media.

Working with partners: Working with trusted partners allowed for the development of tailored resources that were well understood and easy to use by clinicians and patients. Resources were designed to be distributed through a greater range of targeted channels, which helped to reach a wide audience.

 

Key learning: Considering policy levers

The temporary use of financial incentives to encourage a change in prescribing culture helped raise awareness across primary care teams, while supporting dedicated time for clinicians to implement the proposed changes.

The policy was anchored during the first year of implementation by four new indicators in the Primary Care Network Investment and Impact Fund (IIF).  The IIF is an incentive scheme focused on supporting Primary Care Networks, which bring GP practices together on an area basis, to deliver high quality care to their population.

The indicators encouraged primary care teams to improve quality of care and reduce carbon emissions, by increasing the use of inhaled corticosteroids, tackling overreliance on short acting beta-agonists (SABA) and offering lower carbon inhalers to patients. As part of this scheme, Primary Care Networks were rewarded for: 

  • increasing the percentage of patients with asthma who are regularly prescribed an inhaled corticosteroid (ICS) inhaler;
  • reducing the percentage of patients with asthma who receive six or more short acting beta agonist (SABA) inhaler prescriptions per year;
  • reducing the number of MDI prescriptions for non-salbutamol inhalers, for patients over 12 years old, where clinically appropriate, and;
  • reducing mean carbon emissions per salbutamol inhaler prescribed.

These indicators have now been removed from the IIF scheme to allow focus on other priorities, but they continue to align with the NHS inhalers policy and remain an important consideration. They have enabled good awareness of the policy and rapid change – an example of this can be seen in the decrease of the mean emissions per salbutamol inhaler, achieved through the prescribing of lower carbon salbutamol inhalers.

Source: Open Prescribing

Incentives are also in place for pharmacies through the Pharmacy Quality Scheme to encourage inhaler technique checks and appropriate inhaler disposal.

Considering policy levers: The use of financial incentives during initial implementation helped raise awareness and support clinicians to protect time to implement key actions.

 

Tracking progress

Monitoring uptake and progress was essential in understanding the impact of action and which levers were most effective.

NHS England has set up and monitors metrics on volume, types and emissions of inhalers prescribed on a monthly basis. Data is segmented regionally and at Primary Care Network  level to enable each local system to monitor their progress and identify areas of good practice within the country. All NHS staff have access to these metrics.

Quantitative monitoring is also complemented with qualitative feedback to ensure the policy and the supporting resources are continually improved.

 

In practice

Local clinical networks have helped communicate and put change into action across the health service in England.  While limited clinical time can be a challenge, an effective approach has been to embed key principles for high quality, low carbon respiratory care in routine patient management - for example in annual asthma reviews - and to use existing clinician learning time to educate on best practice.

Innovation and change was also supported by the Healthier Futures Action Fund, which was launched in July 2022. This NHS competition provided small parcels of funding (up to £15,000) to support individuals and teams within NHS organisations to kick-start initiatives or ideas that would improve patient care, reduce inequalities, and deliver good value, while supporting a more sustainable health service. Local teams have used the funding to support projects to increase inhaler return to pharmacies, or to develop bespoke training for primary care teams on how to deliver high quality, low carbon respiratory care.

Local case studies are available illustrating implementation at practice level for Wyre Forest Health Partnership in the Midlands and for Kirkholt Medical Centre, a GP surgery in Rochdale in the north of England.

 

Key resources

 

More information

For more information, please contact the Greener NHS team at greener.nhs@nhs.net

 

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