Low carbon inhalers: an opportunity for much wider change

Emma Radcliffe is a GP at the Aberfeldy Practice; Primary Care Net Zero Lead for NHS North East London; and Clinical Lead for the London Sustainability Network.

General practice is in crisis, but the climate emergency and the urgent need to act cannot be put on hold while we wait for calmer times.

Inhaler prescribing alone accounts for approximately 3% of the NHS’s carbon footprint.1 Unsurprisingly, this has been targeted by Greener NHS as a priority area.

The majority of inhaler prescribing occurs in general practice and therefore the Investment and Impact Fund (IIF) introduced two incentives to reduce the carbon footprint of inhalers.2 There has been great progress made in the environmental sustainability (ES)-02 indicator, which encouraged changing high carbon footprint salbutamol inhalers to one with a lower impact. This demonstrates that change, if it is relatively easy, can be implemented at a rapid pace, even at a time when general practice is under unprecedented pressure.

Dry powder inhalers (DPIs) and soft mist inhalers (SMIs) have a much lower carbon footprint than the more commonly prescribed metered dose inhalers (MDIs). Among other European nations, the UK is an outlier in having such high rates of MDI prescribing.3 Changing patients to DPIs or SMIs from MDIs is incentivised through ES-01 of the IIF. However, this has presented us with more of a challenge and progress has been slow. It involves the patient being fully involved in the decision-making process and it may often be easier to carry on with usual care rather than make changes.

It is useful to look at this problem through the lens of a behavioural change model. COM-B4 describes three components that are required to change behaviour:

1) capability;
2) opportunity; and
3) motivation

The opportunity to effect changes in prescribing patterns is during the millions of asthma reviews that continue to take place each year. These are predominantly carried out by practice nurses and pharmacists. The question I want to ask is whether the primary care team has been provided with the tools (capability) and motivation?

Some practices, primary care networks (PCNs), and integrated care boards (ICBs) have been able to achieve significant reductions in MDI prescribing. Gloucestershire5 and Kernow6 ICBs have graphs that demonstrate reduced MDI prescribing, which is in stark contrast to other ICBs. They provided tools, such as formularies, and pathways for their primary care clinicians at an early stage. Leaders have engaged clinical staff at PCN and practice level, providing education and training around inhalers and respiratory care. Could this approach have provided additional capability?

“… change, if it is relatively easy, can be implemented at a rapid pace, even at a time when general practice is under unprecedented pressure.”

However, these areas have provided more than just practical tools, they have also done a significant amount of work raising awareness of the climate emergency and the importance of taking action. These interventions have been targeted at the whole primary care team. Many, if not all, practices in these areas are signed up to the Green Impact for Health Toolkit7 and this has been financially incentivised in at least one area. Many are achieving awards for their efforts. There is clinical and managerial support to aid the ‘greening’ of primary care. I believe that the success in a very limited measurement of inhaler carbon footprint maybe, at least in part, attributable to the broader approach to environmental sustainability taken in these areas.

The Greener NHS website has case studies of successful innovations. The example of Wyre Forest Health Partnership8 also demonstrates that it was not simply a policy around asthma and inhalers that induced change. ‘Sustainability was embedded into the culture of the organisation’ is the first step that is described and indeed, most case studies on the website demonstrate that a highly educated and motivated workforce is required.

We have been provided with substantial evidence that acting on the climate emergency will bring substantial health benefits.9 Greener Practice has produced an asthma toolkit that not only focuses on the carbon footprint of inhalers but highlights the improvement in asthma outcomes that high-quality and low carbon care can provide.10

Producing measurable change is important. To achieve the outcomes though, we not only need to focus on providing tools and training on inhalers but also the motivation to act. If we widen the scope and move the discussion from just around inhalers we might get some downward trending inhaler carbon footprint graphs but we also might get improved overall asthma care and a highly motivated primary care workforce who are ready to take on other aspects of the ‘greening’ of primary care.


1. NHS England. Areas of focus: medicines. (accessed 2 Mar 2023).
2. NHS England. Network Contract Directed Enhanced Service: investment and impact fund 2022/23: updated guidance. 2022. (accessed 28 Feb 2023).
3. Lavorini F, Corrigan CJ, Barnes PJ, et al. Retail sales of inhalation devices in European countries: so much for a global policy. Respir Med 2011; 105(7): 1099–1103.
4. The Decision Lab. The COM-B model for behavior change. (accessed 28 Feb 2023).
5. OpenPrescribing. NHS Gloucestershire: prescribing measures tagged Greener NHS. 2023. (accessed 28 Feb 2023).
6. OpenPrescribing. NHS Kernow: prescribing measures tagged Greener NHS. 2023. (accessed 2 Mar 2023).
7. Green Impact, Royal College of General Practitioners Net Zero, Greener Practice, Students Organising for Sustainability United Kingdom. Welcome to the RCGP’s Green Impact for Health Toolkit and awards. 2023. (accessed 28 Feb 2023).
8. NHS England. Improving health outcomes for respiratory patients while reducing carbon emissions. (accessed 28 Feb 2023).
9. Office for Health Improvement and Disparities. Climate and health: applying All Our Health. 2022. (accessed 28 Feb 2023).
10. Greener Practice. High quality and low carbon asthma care. (accessed 28 Feb 2023).

Featured photo by Michael Olsen on Unsplash.

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