If some inhalers contribute to global warming, how should healthcare respond?

By Joshua Parker.

Most people are surprised to hear that if industrialised healthcare were a country it would be the fifth-largest emitter of greenhouse gases on the planet. In 2019, the NHS was responsible for around 7% of England’s total carbon footprint; approximately 25 million tonnes of CO2 equivalent. We can already see the effects of climate change. Extreme weather events like wildfires and floods are the norm in a world 1.2℃ hotter than pre-industrial times. There is an important question regarding healthcare’s role in curbing its emissions to avert disaster by keeping within 1.5℃ of global warming. The NHS has declared ambitions to be the first net carbon neutral healthcare system. Achieving this however raises ethical questions that are the focus of my PhD. I am also a General Practitioner and I wanted to explore the intersection of my research interests and my clinical work.

Medicines make up 25% of the NHS’ carbon footprint. Some medicines have a disproportionate environmental impact. Metered-dose inhalers are a prime example of this. Take a standard salbutamol “puffer” MDI. The hydroflurocarbon propellants in this mean that emptying one inhaler is about the same as driving a mid-sized family car 175 miles.

I prescribe a lot of inhalers. I prescribe them to help relieve people’s breathing problems and to treat conditions like asthma and COPD. Indeed, most inhalers are prescribed in general practice. Fortunately, however, there are inhalers that are just as good at managing people’s respiratory conditions but don’t rely on propellants that are greenhouse gases. The low hanging fruit in general practice reducing its carbon footprint is to shift away from metered-dose inhalers and towards dry powder inhalers that aren’t as bad for the environment but just as good for the patient. Unsurprisingly, the NHS has introduced targets for this. It seems like a win-win: a win for patients, as many people can use a dry powder inhaler and they are clinically equivalent to metered-dose inhalers, and a win for the planet.

As a win-win I changed my practice. I started to discuss the environmental impact of inhalers with patients when we were making decisions around their treatment. Most patients were concerned by the impact of their treatment on the environment and happy to try something different to help mitigate global warming. But I did wonder how I would respond to a patient who wasn’t so environmentally minded. Should a patient be able to choose a treatment that carries a higher carbon footprint if that treatment doesn’t carry any additional health benefits for them? I discussed this with my colleagues in general practice and those who are interested in sustainable primary care through the greener practice network. I felt it was important to understand how primary care practitioners balance their duties to the patient in front of them with the need to practice sustainably. I concluded my exploration of this in my JME paper and suggest a ‘principle of environmental prescribing’ to help guide practice in this balancing. In short this says that if two treatments are clinically equivalent doctors then patients should pick the one with the lowest carbon footprint unless this would either undermine trust or make the patient’s health worse.

It wasn’t always the case that metered-dose inhalers accounted for 70% of inhaler prescriptions in the UK. Dry powder inhalers used to be prescribed more, but cost meant that GPs tended towards the cheapest. If both inhalers are equally as good at doing the job the tiebreaker in the NHS is going to be cost. Knowing this, I started to question how much prescribing more dry power inhalers would cost the NHS. In clinic, when I prescribe, the computer tells me how much what I am prescribing costs and sometimes I’m alerted that I’m prescribing the more expensive option. Whilst I didn’t think I was going to blow the prescribing budget by trying to make my prescribing greener, I did wonder whether the increased cost was justified if it didn’t directly improve the health of my patients? The paper also explores this difficult question of distributive justice: if inhalers with a lower carbon footprint are more expensive and don’t provide additional health benefits to the patient being prescribed for, is this a cost the NHS should cover? Essentially, I answer that the NHS should cover this cost because the NHS exists within a wealthy country with an ability to cover this cost.

I think a 50% reduction in the carbon footprint of inhalers is too modest. There is scope for the NHS to revise its target to reduce the carbon footprint of inhalers. Perhaps we should aim to reduce metered-dose inhaler prescriptions as far as possible making exceptions where they are clinically necessary? This is one consequence of my arguments. Whilst it is important that we reduce the carbon footprint of inhalers, and I have provided moral arguments to support this, the process shifting away from metered-dose inhalers must be sensitive to the needs and concerns of patients.


Paper title: Barriers to green inhaler prescribing: ethical issues in environmentally sustainable clinical practice

Author: Joshua Parker

Affiliations: Lancaster Medical School, Lancaster University

Competing interests: None.

Social media accounts of post author: @joshp_j

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