With Earth Day having taken place on 22 April, the hefty targets and the pressure on the NHS to reduce its carbon footprint are a major priority for many. The NHS is the heaviest public-sector contributor to climate change, and the most recent figures show that the NHS in England alone is responsible for emitting 22.8 million tonnes of carbon dioxide equivalents (MtCO2e) (Sustainable Development Unit (SDU), 2019a; 2019b) and spending £50 million on carbon permits every year (King's Fund, 2019).
Carbon emissions from the NHS, public health and social care systems have reduced by 19% since 2007 despite activity increasing by 27% (NHS, 2019). However, there is some way to go in terms of meeting the targets to cut emissions by 34% by 2020, 51% by 2025 by and 80% (using 1990 as the baseline) by 2050 (NHS Digital, 2018; NHS, 2019).
Greener inhalers
In a bid to decrease the carbon footprint, National Institute for Health and Care Excellence (NICE) (2019) has produced a patient decision aid to support people living with asthma to choose inhalers that are right for them while also being better for the environment (Robinson, 2019). This is the first time that NICE has developed a tool highlighting the impact of a pharmaceutical or medical device on climate change.
There may be several viable options for a patient, but some of these have a much lower carbon footprint (NICE, 2019; Robinson, 2019). For example, a dry powder inhaler has an estimated carbon footprint of 20 g, whereas a metered dose inhaler has a carbon footprint of about 500 g—equivalent to 9 miles driven in an average car (NICE, 2019; Robinson, 2019). Metered dose inhalers contain hydrofluorocarbon propellants, which are potent greenhouse gases that contribute to global warming (Robinson, 2019). According to the NHS Long Term Plan, a move towards low-carbon inhalers will lead to a 4% reduction in the carbon footprint (NHS, 2019).
Another way for people with asthma to help reduce the carbon footprint is to return their used inhalers for recycling at participating local pharmacies. The recyclable parts of the inhaler can be used to generate energy, and non-recyclable materials such as spacers, which are often used together with inhalers, can be disposed of in an environmentally friendly way (Robinson, 2019). The patient decision aid is partially funded by the NHS SDU, which itself falls under the joint umbrella of NHS England and Public Health England.
Anaesthetics
The NHS Long Term Plan notes that the carbon footprint can be reduced by a further 2% if anaesthetic practices are transformed (NHS, 2019). Modern anaesthetic gases contain hydrofluorocarbons, sevoflurane and desflurane; the chlorofluorocarbon, isoflurane; and nitrous oxide (Charlesworth and Swinton, 2017). Desflurane is the most damaging of these agents and has been noted to be ‘rapidly increasing’ (Vollmer et al, 2015; Charlesworth and Swinton, 2017).
Across acute NHS organisations, anaesthetic gases make up 5% of the carbon footprint, and 50% of gas emissions come from heating these buildings and water (Charlesworth and Swinton, 2017). The use of sevoflurane via a modern anaesthetic machine is akin to driving 30 miles in a modern car; alarmingly, the use of desflurane from one of these machines is the same as travelling 230 miles (Ryan and Nielsen, 2010).
Benign by design
There are also drugs used to treat a variety of conditions that happen to be better for the environment than others. For example, a study found that the anti-cancer glufosfamide has been found to be biodegradable (Kümmerer et al, 2000). The lead researcher of this study, Klaus Kümmerer, believes strongly that chemists should be considering ‘benign-by-design’ strategies when designing drugs; however, perhaps it is more difficult than it appears to change the properties of a drug without also changing its effect or decreasing its stability (American Chemical Society, 2011).
Efforts to reduce drug dosages, for example, by targeting cells with precision rather than delivering the drug to the whole body or increasing the bioavailability of a drug's active ingredients that reach the relevant tissues, are approaches that result in fewer side effects for both the person and the environment (Tuhus-Dubrow, 2011).
As drugs are designed to have a biological effect on the body, it follows that they would have a similar impact on the environment. If, in fact, reducing a drug's carbon footprint also reduces its adverse effects on humans, this would not only make a case for reducing our carbon footprint for the benefit of patient health, but also motivate pharmaceutical companies to produce more environmentally friendly drugs, since although drug development is a costly affair, their ability to cause fewer side effects would make long-term financial sense (Tuhus-Dubrow, 2011).