Theo Bartholomew is a GP registrar based in Surrey, and National Medical Director’s Clinical Fellow for 2022–23.
Samuel Finnikin is an academic GP at the Institute of Applied Health Research, University of Birmingham. He is on Twitter: @sfinnikin
Recent heatwaves and droughts across the UK and Europe have once again refocused minds on the impacts of climate change. Health care contributes 4–5% to global greenhouse gas (GHG) emissions1 and questions over how practices should change are now gaining momentum in policy circles.
One way to reduce the carbon footprint of health care is to simply do less health care. Curtailing the detection and management of conditions that could be left safely undiagnosed and untreated is one way to achieve this without adversely impacting on health. Attaining this without inadvertently impacting on beneficial healthcare activities, however, is not a simple matter, and efforts to tackle overdiagnosis and overtreatment have had limited success.2 Here we argue that reducing overprescribing and increasing awareness of environmentally-friendly health care should be prioritised given the positive impact this could have on NHS emissions without adversely affecting health outcomes.
“… 10% of all medicines prescribed in primary care are overprescribed.”
Medicines and emissions
One component of the NHS sustainability strategy is to reduce the environmental impact of medicines, which contribute 25% to NHS emissions.1,3,4 Two main areas of focus for addressing medicines-related emissions are metered-dose inhalers (MDIs) and high-carbon footprint anaesthetic gases, which together account for 5%.1,3
Given, however, that the remaining 20% of medicines-related emissions are due to the pharmaceuticals and chemicals supply chain,1 it is clear that emissions in this area will need to be reduced drastically if the NHS is to realise its climate targets. Process and manufacturing improvements to the supply chain will be able to contribute to this reduction, but tackling overprescribing has the potential to vastly reduce emissions.
Overprescribing or inappropriate prescribing?
Overprescribing is the term used when people are given medicines that they don’t need or don’t want, or where the harm outweighs the benefits. A national review on overprescribing estimated that 10% of all medicines prescribed in primary care are overprescribed.4
Inappropriate prescribing, on the other hand, encompasses both potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs).5 PIMs refer to the subcomponent of overprescribing that relates specifically to medications that are significantly associated with adverse drug events (ADEs): these can be objectively identified through the Screening Tool of Older Persons’ potentially inappropriate Prescriptions (STOPP) criteria.5 In the US and Europe, the prescribing of PIMs in older people is highly prevalent, with estimates varying from 12% in community-dwelling older people to 40% in nursing home residents.6
Not prescribing in the first place
“One way to reduce the carbon footprint of health care is to simply do less health care.”
Medicines are an important tool in improving the health and wellbeing of our patients, but not every medication that is prescribed helps us achieve this aim. A medicine that is not prescribed has no impact on supply chain emissions. Reducing overprescribing is something all clinicians can contribute to through simple changes in practice. Optimising non-pharmaceutical management before reaching for the prescription pad is better for the environment and often better for patients.7
Supporting patients to reduce salt intake and exercise more may reduce prescriptions of antihypertensives. Promoting healthy sleep habits and psychotherapy may avoid the prescription of an antidepressant. Additionally, emphasis on non-pharmaceutical interventions, such as pulmonary rehabilitation or specialist pain physiotherapists, at a systems level can support clinicians and patients with alternative treatment options.8 In one recent example, reducing costs from low value prescribing for patients with chronic obstructive pulmonary disease enabled significant onward investment in pulmonary rehabilitation.8
It is of vital importance that patients are involved in genuine shared decision making when medications are initiated. This process must involve explaining to patients the benefits and harms of any medication in a way that they understand, as detailed within the General Medical Council’s decision making and consent guidance.9
These discussions should reduce the mismatch between what patients expect from their medications and what they deliver, and provide an opportunity to discuss non-pharmacological alternatives. Patient decision aids can support these discussions, with the National Institute for Health and Care Excellence’s (NICE’s) asthma inhaler aid a leading example.10 This aid details information on the respective carbon footprint of inhalers alongside their suitability for patients. Given that GPs’ confidence in their own knowledge of the absolute benefits and harms of treatment for many common long-term conditions is known to be poor,11 the support of decision aids is crucial.
“… physicians should be encouraged by evidence that suggests most adults with polypharmacy are willing to deprescribe if their doctor says it is possible.”
While many medications are initiated appropriately, patients’ preferences may change over time. Looking critically at whether a medicine is effective, its potential harms, and whether its ongoing use aligns with what matters to the patient is, thus, an ongoing process.
Across Europe, an estimated 20% of adults aged 70–74 years take ≥10 medications per day.12 In the presence of such polypharmacy, there is a high chance that some medications are of little benefit to the patient and accordingly there are opportunities to reduce their use. Furthermore, non-adherence in the context of polypharmacy is known to be high: in patients taking ≥4 medications, adherence is estimated to be only 50%.12
There are many instances where the prescribing of multiple drugs in combination is both appropriate and beneficial. Polypharmacy, however, is often inappropriate and harmful.12 Recognising and addressing overprescribing through regular review therefore reduces the potential for harm, as well as ensuring that the environmental impact of medications is justified.
“Clinicians must be given greater access to information detailing the environmental cost of the drugs they prescribe.”
The first component of a medication review should assess the use of PIMs through the STOPP criteria.13 Such PIM polypharmacy reviews are readily implementable by pharmacists, with the Northumbria SHINE quality improvement project finding that pharmacists undertaking structured medication reviews within a shared decision-making framework were able to safely reduce prescribing by 17.4%.4
The second component of a medication review should focus on whether there is scope to reduce any overprescribing beyond PIMs through further exploration of the patients’ values and preferences.13 This recommendation by NICE calls on physicians to consider how patients may be burdened by excessive medications and to stop medications that may be of limited benefit.13
Shared decision making should be central to this review process, and physicians should be encouraged by evidence that suggests most adults with polypharmacy are willing to deprescribe if their doctor says it is possible.14 Undertaking this kind of holistic, person-centred medication review in the context of multimorbidity and polypharmacy requires a great deal of knowledge and skill, and takes time. Doing this well is an important part of primary care and it benefits our patients as well as the environment. The high proportion of GHG emissions that primary care contributes to the pharmaceuticals and chemicals supply chain — and the fact that this part of the supply chain accounts for almost half of all primary care emissions — means it is only right that primary care should be leading by example.1
“The environment must rightly take its place within the heart of every patient if we are to achieve a greener NHS.”
Given: 1) the large environmental impact of the NHS medicines supply chain; 2) the known harms of polypharmacy; 3) the high prevalence of PIMs in older adults; and 4) the disutility of polypharmacy in view of the known high levels of non-adherence, it is clear that reducing overprescribing — focused especially on PIMs — should be a major healthcare and environmental priority.4
Informing patients about the benefits and harms of initiating and stopping medications, and adequately supporting decision making, is paramount. Healthcare professionals must assent to recognise the collective positive environmental impact that can be achieved through more person-centred and environmentally-minded prescribing. This, however, can only be achieved through raising clinician awareness of drug-related GHG emissions. Clinicians must be given greater access to information detailing the environmental cost of the drugs they prescribe. Further, they must have this alongside clear information on the respective benefits and harms of treatment that is readily understandable for patients.
Greater efforts must be made to raise awareness of the harms of polypharmacy and the environmental cost of prescribing, and to include deprescribing advice within guidelines. Future research should focus on quantifying polypharmacy harm within patient subpopulations, and on assessing how medicines wastage can be reduced.
The environment must rightly take its place within the heart of every patient if we are to achieve a greener NHS.
1. Tennison I, Roschnik S, Ashby B, et al. Health care’s response to climate change: a carbon footprint assessment of the NHS in England. Lancet Planet Health 2021; 5(2): e84–e92.
2. Barratt A, McGain F. Overdiagnosis is increasing the carbon footprint of healthcare. BMJ 2021; 375: n2407.
3. NHS England. Delivering a ‘net zero’ National Health Service. 2022. https://www.england.nhs.uk/greenernhs/wp-content/uploads/sites/51/2022/07/B1728-delivering-a-net-zero-nhs-july-2022.pdf (accessed 9 Sep 2022).
4. Department of Health and Social Care. Good for you, good for us, good for everybody: a plan to reduce overprescribing to make patient care better and safer, support the NHS, and reduce carbon emissions. 2021. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1019475/good-for-you-good-for-us-good-for-everybody.pdf (accessed 9 Sep 2022).
5. O’Mahony D, O’Sullivan D, Byrne S, et al. STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age Ageing 2015; 44(2): 213–218.
6. Gallagher P, Barry P, O’Mahony D. Inappropriate prescribing in the elderly. J Clin Pharm Ther 2007; 32(2): 113–121.
7. Naci H, Ioannidis JPA. Comparative effectiveness of exercise and drug interventions on mortality outcomes: metaepidemiological study. BMJ 2013; 347: f5577.
8. Lewis S, Reynolds J. Exploring allocative value at Aneurin Bevan University Health Board. 2020. https://www.europeanallianceforvalueinhealth.eu/wp-content/uploads/2020/11/COPD-Report-v1-3.pdf (accessed 9 Sep 2022).
9. General Medical Council. Decision making and consent. 2020. https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/decision-making-and-consent (accessed 9 Sep 2022).
10. National Institute for Health and Care Excellence (NICE). Patient decision aid: Inhalers for asthma. 2020. https://www.nice.org.uk/guidance/ng80/resources/inhalers-for-asthma-patient-decision-aid-pdf-6727144573 (accessed 9 Sep 2022).
11. Treadwell JS, Wong G, Milburn-Curtis C, et al. GPs’ understanding of the benefits and harms of treatments for long-term conditions: an online survey. BJGP Open 2020; 4(1): bjgpopen20X101016.
12. Mair A, Fernandez-Llimos F, Alonso A, et al. Polypharmacy management by 2030: a patient safety challenge. 2nd edn. 2017. https://ec.europa.eu/chafea/health/newsroom/news/documents/polypharmacy-handbook-second-edition_en.pdf (accessed 9 Sep 2022).
13. NICE. Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes. NG5. 2015. https://www.nice.org.uk/guidance/ng5 (accessed 9 Sep 2022).
14. Rozsnyai Z, Jungo KT, Reeve E, et al. What do older adults with multimorbidity and polypharmacy think about deprescribing? The LESS study — a primary care-based survey. BMC Geriatr 2020; 20(1): 435.