Author(s)

Laura Morgan

Why was it done?

Inhalers are the largest single contributor among medicines to the NHS carbon footprint, accounting for 3% of total NHS emissions. In 2020, the NHS became the first health system globally to commit to Net Zero, later formalised through the Health and Care Act 2022 and the Delivering a Net Zero National Health Service report, which provides statutory guidance to ICBs. This project responds to that call-to-action and aligns with South East London’s Green Plan, which pledges to reduce emissions within its footprint. It also serves as a proof-of-concept to inform NHS England’s assessment of the viability of nationwide, routine inhaler recycling.

What was done?

Developed as an innovative sustainable project in response to NHS Net Zero ambitions and SEL Integrated Care System’s (SEL ICS) Green Plan, SEL ICS launched the first fully NHS-funded, ICS-wide inhaler recycling pilot in England. The scheme is fully integrated across primary and secondary care and enables the public to recycle used inhalers at any participating site. The inhalers are then transported to a recycling facility (Grundon Waste Management) for up to 99.9% recovery of propellants, plastics, and aluminium. This pilot serves as a proof-of-concept to assess the feasibility of business-as-usual inhaler recycling in the NHS.

How was it done?

An inhaler recycling pilot is being delivered across 20 community pharmacies and five acute/mental health trusts in SEL. A project working group (PWG) and formal memorandum of understanding was established between South East London Integrated Care Board, NHSE, King’s College Hospital (KCH), SEL Pharmacy Alliance, Guy’s and St Thomas’ (Essentia), and other stakeholders to ensure structured, cross-sector collaboration. The project leveraged existing NHS clinical waste infrastructure to recycle pressurised metered dose inhalers (pMDIs), ensuring operational efficiency with minimal disruption. The PWG collaborated with behavioural science colleagues and patient engagement groups to develop public-facing communications that encouraged appropriate inhaler disposal. All activities were embedded into routine workflows without additional staffing. Monthly data submissions from participating sites enabled continuous monitoring and will inform a fully commissioned evaluation.

What has been achieved?

Over 16,000 inhalers have been collected so far, with more than 11,000 returned through community pharmacies. The current recoupment rate at community pharmacies is approximately 15%, i.e., the number of pMDIs reported returned is around 15% of the high-carbon pMDIs dispensed by that pharmacy in the same month. This figure will undergo further scrutiny in the final evaluation, after corroboration by Grundon data following the project’s last recycling cycle. The project has also seen strong patient and public involvement. A live public-facing survey on the SEL website has received more than 100 responses to date. Themes identified include low awareness of proper disposal routes, strong interest in inhaler recycling, and improved understanding and willingness to return inhalers after campaign exposure. These results demonstrate meaningful public input and are informing ongoing communication strategies. In terms of reach and influence, the pilot has attracted national and international interest with over 25 NHS providers across the country having contacted the SEL team for support with replication, and a Canadian research group has requested to learn best practice from the model. The project demonstrated high operational feasibility, environmental impact potential, and strong appetite for scale-up. Complete evaluation is ongoing.

What next?

This innovative project shows inhaler recycling can be embedded in existing NHS systems. It presents a replicable and scalable national model, supporting medicines optimisation, waste reduction, and sustainability; it stands apart by being completely publicly owned, leveraging existing NHS contracts and infrastructure, without the need to rely on external sponsorships. This pilot offers a practical blueprint for embedding environmental sustainability into medicines optimisation across the NHS and the outcomes will inform future commissioning and advance the NHS’s Net Zero goals.
An evaluation of the pilot is currently being developed with the last inhaler collection at all sites due January 2026; the evaluation is due to be published in the Spring of 2026.

Pdf

Author(s)

K. Joyce, D. Jukes, F. Stewart

Why was it done?

In 2023, the drug formularies across Northeast and North Cumbria integrated care system were merged, with amiodarone allocated an ‘amber’ shared care status.

NHS England guidance recommends that existing patients taking amiodarone in primary care should be reviewed to ensure prescribing remains safe and appropriate and that a shared care agreement is introduced.

The pharmacy team aimed to implement this guidance, with minimum impact on clinician workload. The approach was steered by NHS England’s comments, in June 2024, regarding the importance of teams working together to meet the pressures and demands of primary and secondary care under the direction of the integrated care board (ICB).

What was done?

County Durham and Darlington Foundation Trust (CDDFT) pharmacy team worked collaboratively across the primary-secondary care interface to implement shared care agreements.

How was it done?

The ICB medicines optimisation team worked with the CDDFT pharmacists to engage GPs and cardiologists across the interface, creating a work-plan to share resources.

An audit tool was designed to capture patients prescribed amiodarone in the 61 GP practices across County Durham, which was completed by pharmacy staff within primary care networks.

Cardiology pharmacists in secondary care reviewed the data, triaging patients according to: indication, monitoring requirements, those requiring consultant review and those who could potentially stop treatment.

What has been achieved?

The audit, returning data for 129 patients, identified 93 patients without shared care. For half of these, discontinuation was considered as the National Institute for Health and Care Excellence explicitly recommends against use in atrial fibrillation. For the remaining, shared care agreements have been implemented with minimal impact on clinician time, primary care capacity and secondary care referrals.

The audit found 21% of patients without a shared care agreement were not receiving the recommended monitoring, compared to 100% receiving correct monitoring when one was in place. It may be anticipated that implementation will improve patient safety and experience through detection and avoidance of adverse events.

What next?

This initiative demonstrates the ICB and pharmacy successfully bridging care settings to improve patient care and experience and overcome challenges.

Building on these established relationships across the interface this work provides a model for sustainable collaboration on future shared care work.

Pdf

Author(s)

Gillian Cavell

Why was it done?

Despite the availability of RTU and RTA formulations of high-risk injectable medicines they were not always used. We developed the metric, to compare the use of RTU and RTA injectable medicines with the use of concentrates requiring further dilution or manipulation prior to administration e.g. dilution of morphine 10 mg/ml to 10 mg/10 ml prior to intravenous administration, e.g. withdrawal of 5 x 10 ml fentanyl 500 mcg/10 ml into a 50 ml syringe for continuous infusion, and identify areas for improvement.

What was done?

We have developed a series of metrics to measure compliance with national guidance for the safe use of injectable medicines. The guidance recommends use of ready-to-use (RTU) or ready-to-administer (RTA) injectable products, where these are available, to reduce the risk of patient harm from errors in the preparation of injections and infusions on hospital wards.

How was it done?

The metric utilises pharmacy-issue data to compare the number of units of RTU or RTA formulations issued to wards and clinical areas with the numbers of units of alternative products of the same drug entity. Expressed as a percentage the metric informs the organisation of the extent to which safer injectable medicines are being used, providing a baseline against which to review practice and reinforce the need to use alternative, safer formulations. A high percentage indicates good compliance.

What has been achieved?

The metrics have been used to successfully maximise the use of a range of safer formulations including RTA potassium chloride, RTU fentanyl 2500 mcg/50 ml vials for critical care infusion, 100 mg/10 ml paracetamol in neonatal units and RTU magnesium sulphate 20% (50 ml vials) for obstetric emergencies. Since the introduction of the metrics in 2016 a monthly scorecard of performance is reviewed by the Hospital Medication Safety Committee to identify and account for deviations.

What next?

The metrics are being shared with other organisations to benchmark performance. Ideas to promote implementation and business cases can be shared between organisations who may find implementing RTA and RTU injectable medicines challenging, especially where these are more expensive than formulations in established use.