Awareness and education about the issue

The participants in the public focus groups were already aware of some of the issues around pharmaceutical pollution, particularly the wild water swimmers present (eg, wastewater effluent discharge, potential impact on bathing water quality). However, they all felt there was a need for further awareness and education for all on the drivers, potential effects and possible interventions, starting at school and incorporating this topic into the curriculum.

Yeah. And again, that I think links back to schools and education because indeed, if you’ve got your young, enthusiastic small people coming out and saying guess what we did today, we did this and look, why don’t we? How do we do that at home? You know, that is a really good way to start that whole, yeah, being shamed by your nine year old, quite a thing. (Public 2,2)

If you’re going to have it through the education system you’re talking about, it has to be a policy that is going to be part of the education put into the curriculum. And so, they understand that. So, unless you get government support, it’s not going to happen. (Public 1,1)

They felt there was a need to educate adults through public health campaigns, perhaps using displays and posters in pharmacies and public areas (eg, libraries, bus stops). Community-based groups or public interest groups like the Women’s Institute, they discussed, could be a valuable resource for disseminating information.

So safe disposal of medicines, making sure that everyone public health campaign or something around that piece. (Public 2,1)

Some participants noted that they have seen this issue in the media and social media, where it is highlighted in headlines and then disappears again. A public participant (1,4) suggested that researchers should be involved in developing messages that communicate environmental information.

That’s why I think the researcher, if it comes to this environmental evaluation of drugs and the impacts and simplification from the researcher side, is extremely important that the public and the general public understands better. For example, what measures are taken to analyse certain toxicity of drugs and what effects they have? (Public 1,4)

Although the prescribers at each focus group were interested in the issue of pharmaceutical pollution, they admitted that they knew little about it. Some had heard about it in recent presentations, and they mainly felt that it was still in its infancy as an issue and was quite alarming.

I guess I find it quite shocking and it just worries me in terms of like extinction of species and stuff like that. If we feminise all our fish and the effect that will have on biodiversity and stuff like that. (Prescriber 7,2)

The prescribers wanted to do something about it though, noting healthcare has a responsibility to act.

And really quite shocking, actually. And upsetting and worrying. And yeah, none of none of it provokes good feelings. And so I would certainly and yeah, like I said, there are like really keen to try and to help as much as possible in, in making these, you know, reducing the impact of what we're prescribing because we have got responsibility for that, I think so. (Prescriber 3,1)

They discussed the complexity of the issue and that it was difficult to see where they could make an impact. They also thought that it was a cross-disciplinary issue involving numerous stakeholders who all need to communicate and share resources and information.

It’s definitely under the radar from a pharmacy perspective. As a pharmacist, you know, you know that these products do go into the environment, but it’s, I was kind of thinking, why is that not a thing? Because even within pharmacy, this subject is probably pretty niche, people aren't going and talking about it all the time. (Prescriber 5,1)

Several participants noted that the issue was not just about the patient in front of the prescriber, but also needs to be considered from a population perspective.

What I say and it’s we all, we all often have, like an obligation to the patient in front of us or we think a population level about a group of patients, hepatitis or respiratory and a kind of public health and environment. But these are downstream problems that affect everyone, but it’s almost too big to consider. (Prescriber 6,1)

According to those in the prescriber focus groups, prescribers and patients alike would all need to be educated.

But I think obviously patients or the general public need to be aware more because obviously it’s prescribers we’ve not been aware of this or the true impact either. So I’m sure patients don’t, I don’t either. So hence the reason a lot of patients will put things down. You know, a toilet or put them in their bins. They don’t realise maybe the implications that of what they’re doing. (Prescriber 7,1)

They all agreed that the environmental impact of healthcare and pharmaceutical pollution needed to be incorporated into the curriculum for prescribers. Those already in practice also needed educating perhaps via NHS Education for Scotland (NES) continuing professional development courses and NHS compulsory update modules.

I think you know putting it into this sort of curriculum for training for non-medical prescribers and also we get prescribing updates and you know working that into the updates to raise awareness of the issue. (Prescriber 4,1)

Otherwise I thought were like NES modules or we’ve got quite mandatory sort of NHS modules. You’ve got to do. (Prescriber 3,1)

Information provision and messaging

The public representatives stated that environmental information should be incorporated into existing information which is given out with medications.

You’ve got your summaries of product characteristics, patient information, leaflets, BNF [British National Formulary], whatever that environmental data then going to sit somewhere else, or can it be incorporated into some of these? Documents and information resources that already set out there. (Public 2,1)

Both public focus groups agreed that a simple red, amber, green labelling system for medicine packaging (to alert people about the environmental credentials of each medicine) would be extremely useful. It would be a simple way to get the information across as there was already so much information on medicine packaging.

You know, some of the people there was a traffic light system of red, yellow and green. You know, that would be a good thing. (Public 2,3)

However, they noted that some informed patients may not take their medicines for environmental reasons, as is the case for some patients when informed about potential side effects. Prescribers, they thought, should be educated and have the information available, and pharmacists could inform people about the environmental hazards and risks of medicines.

I think a lot of patients actually look at the side effects of these things and often they then decide not to take them. They might also want to look at what the risks are. Excretion or where it’s going to go, and also on the environmental reasons, decide not to take them, which is then a huge waste of course. Yeah, I think people have a choice and people have certainly younger people getting very much more aware of their effect on the environment, and rightly so. (Public 2,3)

They also discussed that the pharmaceutical industry needed to take responsibility in making information available.

In terms of what big pharma can do, I think there needs to be much more information available to healthcare professionals and to the public about environmental effects and the data they have. (Public 2,1)

The prescribers indicated a willingness to act, but difficulty in identifying how to make a meaningful impact due to the complexity of the issue and lack of information. All agreed that more education and information were needed to aid prescribing decisions which could help reduce the occurrence of pharmaceuticals in the environment.

I don’t know what is an environmentally negative medication. Don’t know what is harmful and what is not and I don’t know how you even find that that information out. (Prescriber 2,1)

They discussed that information could be included in prescribing updates, such as an environmental section in the formulary updates. According to the prescriber representatives, information and guidance from policymakers and national bodies like the Royal Pharmaceutical Society were also important.

For example, when we switched, everything went to using the Royal Pharmaceutical Society’s guidance and documentation on describing—so if we were going to be changing something, I think that that’s a good way to get it out to every prescriber as a higher level thinking. (Prescriber 8,1)

The prescriber representatives also noted that it was important to involve patients in making choices about prescribing and developing more sustainable approaches. Information should be available to all.

…It’s having that information so that the patients themselves can then get on board and make that sort of choice with you. Otherwise, it’ll probably just sit there and end up in the toilet or return to the pharmacy. (Prescriber 6,1)

One prescriber (5,1) noted that prescribing is done ‘in partnership with the patient’ and conversations with patients needed to reflect shifts in prescribing and be clear on expectations.

There’s almost different jobs that people have to do and obviously if we’re prescribing, we’re prescribing in like partnership with the patient, they should be aware of the goals of prescribing and the development of sustainability of what we prescribe should be part of that. (Prescriber 5,1)

Eco-directed formulary

The public representatives felt that an environmentally directed formulary was a good way to make an impact. The pharmaceutical industry must perform environmental risk assessments for all new medicines. However, this information is not used to support prescribing decisions. There was some discussion on the availability, completeness and robustness of environmental data, for example, if the same level of information is available to enable accurate comparisons between medicines.

…Create a list of good to bad. (Public 1,1)

Whereas an individual GP that’s like oh you know what I’d rather go for the cheaper one that’s going to work rather than eco-friendly one, because again if they’re patient-centred that’s what they’re going to look at. There may be some doctors that like do you know what, it’s cheaper, it’s good for the environment but it might not work for the patient. I’m going to try anyway, just in case. They’re not all going to be trained and the environmental impacts of these things as extra training, extra resources and teaching them. (Public 1,5)

Information regarding environmental risk is often not available for older medicines, and this would need to be clarified to patients by prescribers.

It does sound like a good idea. I would have thought the information would be rather patchy at the moment. So, whereas you might have good information for one drug and not so much for another, does it mean there’s better drugs or that you just don’t know yet? And I think that would be really important to make clear so that we’re not just choosing this one because it doesn’t have any bad stuff. (Public 2,1)

The prescriber representatives discussed an environmentally directed formulary and agreed that if prescribing was to become more environmentally informed, systems such as local formularies and decision support tools are needed to be in place on electronic prescribing systems. The British National Formulary (BNF) was considered to be an important resource which could provide this information, as it was widely used not only in the UK but globally.

And not only should we have the uses and the contraindications etcetera, you should have an environmental section on that where you can look up easily accessible and it’s a tool. Everybody uses every day and then of course you have all your local apps and whatever local formulary use, but it should be easy enough to put it onto BNF probably. (Prescriber 9,1)

If a medicine was determined to have an unacceptable environmental risk, they also discussed the need for a tool that would then highlight the alternatives at the point of prescribing. Again, a simple traffic light red, amber, green system was suggested by the focus groups. However, it was observed that even this may cause confusion and that maybe a simple yes/no or green/red flag may be better.

You don’t want to restrict their options, so some of might think well, I’ve got patient on a red medicine. I might be I might be reluctant to choose an amber. I might be hunting for a green, and if we just made it one or the other, it might be maybe easier for me that choice. As a prescriber, I think that would be, I think my mind might explode if I was on a ward round. (Prescriber 5,1)

Polypharmacy made this more complicated.

Only I was just thinking what about polypharmacy? Because patients are not just on one medication, so if you know most a lot of elderly patients are on five or six different types of medication, how are you going to, you know, they come becomes really complicated then because if one is a green or one is a yes and another one is a no. (Prescriber 2,1)

Switching to a more environmentally friendly medicine

The public representatives were given the following hypothetical scenario: ‘Imagine you've been using a medicine with a potentially negative environmental effect, and you were offered the opportunity by your healthcare provider to switch to a different medicine with a lower environmental impact. Would you be willing to do that?’. The public representatives were adamant that they would not want their prescription changed to a less effective but more environmentally friendly one if that was an option. If it had the same effectiveness, most would gladly change, but this may be dependent on the condition.

I want to be assured that it was going to be equally effective, equally as equally or even more safe than what I’d already been using. I may have to make an assessment myself as to which element of that is most important. Is it the efficacy? Is it the safety? Is it the environmental? I suppose that depends very much on what is this condition I have that I'm trying to treat and how well is that medicine I’ve been taking, been doing to help that and if it’s been brilliant then maybe I can take a little reduction in efficacy. (Public 2,2)

I think personally making a change in the medication if my doctors said to me, look you don’t bend the facts and but there’s other medication that’s got the exact in side effects, exact same interactions with other medications. Exactly. Medication, just different name, you know, would change. I would probably consider it. (Public 1,5)

They discussed that it was all about weighing up the pros and cons, and patients would require information to help with this decision.

And if I don’t like side effects, I’d go back, you know, and it’s, it’s one of those things where putting it into the patient’s hands but also giving them all the information you can in that short amount of time you have with them, you know, explaining to them the exact same medications on paper. (Public 1,5)

Certainly make you aware of another reason. You know if you're switching between simvastatin or atorvastatin whatever. Yeah. For example, if one had a green label and the other one had a red one, then yeah, you know, it would swing you. (Public 2,3)

However, the participants also noted that any decision would be influenced by the person’s relationship with and trust in their prescriber. A participant related it to their GP swapping from a branded inhaler to a generic inhaler and noted that they were not prepared to make that switch on the basis of cost as they had a medication that worked well for them. Some of the participants would prefer that someone else made certain decisions for them, noting patients may not know what to do and the pressure may be too much to contend with. But there was some concern about who was making these decisions for the prescriber, and several participants noted that evidence-based decision-making was key.

If I’m assured that they’re doing that on the basis of a complete and reliable data, yes and evidence-based decision. (Public 2,1)

For many, this decision would need to be underpinned by the relationship with the prescriber and a mutual understanding of the condition. The patient would need confidence that the prescriber would only consider switching medicines based on environmental effects if it was appropriate for the patient.

Yeah, I think if you’re more confident in those people then you’re more able to make those kind of decisions. (Public 1,6)

It’s also down to the clinician, whether it’s the doctor or anybody else understanding their patient because there have been times in my life where if somebody had given me a choice, I would have just not known what to do. Your clinician who is attending to you needs to understand when they can give you that choice and when it’s the time to see. I’m moving you to this because this is what you need, because the patient is incapable quite often of not all the time, but it’s quite often incapable of making the choice for themselves because it’s too much pressure. (Public 1,3)

The prescriber representatives also discussed the following hypothetical situation: ‘You have been prescribing a patient a medicine with a potentially negative environmental effect. You have the opportunity to prescribe the patient a different medicine with a lower environmental impact’. The participants likened this to conversations they had already been having with patients about switching to dry powder inhalers and suggested it fed nicely into discussions around health promotion and Realistic Medicine in Scotland. Additionally, they felt that it would depend on available alternatives and how the patient was doing on the medicine, noting that it may be easier when starting new medicines rather than switching from established prescriptions. It would also be easier if a patient was already interested in environmental issues, noting that environmentally aware patients are more likely to make changes to reduce their environmental impact.

I think the thing that patients you know they are interested in the environment and when you have the discussion and they want it to be as easy to use as the one they’ve already got. (Prescriber 3,2)

One participant (Prescriber 8,1) noted that if they had the backing of robust evidence and could say that this switch was supported by the health board or the Scottish Government, it would also help.

I think we’ve already sort of got that evidence for inhalers and we’re getting much better at having that conversation. So, we’re already doing it. It’s just building on what we’ve already started to say. (Prescriber 6,1)

You can easily switch them around, but if the patient was getting on really well with the medication and I'm I might be less willing to change them over and I think it'd be more like people always prescribing new medications too. (Prescriber 3,1)

One participant (Prescriber 5,1) noted that primary care teams may have more opportunity to consider environmental impact and long-term patient health outcomes, rather than acute care teams. It required choosing the right time to approach the subject, and other factors such as patient history, dosage, efficacy and polypharmacy must be considered.

Like if they had a really hard time, it’s probably it might not be the best time to kind of have that conversation with the patient. So I think it depends as well and what you’re treating the patient for, how they are as a whole and kind of mentally as well because I think that can totally change a patient’s perspective on things obviously as well. (Prescriber 7,2)

You know, they would be less keen to change to one that is has a lower environmental impact if for instance they had to go from taking something once a day to taking something four times a day or if it was less effective for them. (Prescriber 3,2)

They advocated for small changes, even changing one of a patient’s medicines may make a difference.

But I guess you know any change is better than nothing. So if you changed one, if you were able to change one medication. To have better an environmentally and better medication, and that would be a bit of a win. You wouldn't necessarily need to make everything 100% perfect, so just like small steps. (3,1)

Developing knowledge support tools

As part of this research, a framework was developed to collate and model environmental hazard and exposure data to predict the environmental impact of selected pharmaceuticals in freshwater bodies in Scotland.34 The prescriber representatives were shown the framework structure, and data as an example of how environmental information could be used to inform healthcare decision-making in Scotland. The participants felt that while they needed to have some basic understanding of what was behind the model (ie, the data used to calculate the environmental impact scores), it needed to be very simple at the front-end, so it could be interpreted with confidence and underpinned by robust evidence. It was felt that a classification system to present environmental impact should be developed, which could identify outliers using a similar system to that currently used to identify high prescribing volumes and costs.

…About environmental impact assessment that we need to develop a standardised methodology to assess the environmental impact of medicines…and this could involve assigning environmental impact scores. Impact score is based on factors such as chemical composition, potential for bioaccumulation, degradation rates, and known ecological effects…it’s about training health care professionals about the environmental impact of medicines and how to interpret those environmental impact scores. And this then would enable them to have informed conversations with patients about the ecological consequences of different medications. (Prescriber 2,2)

They discussed that changes in prescribing could then be communicated following processes already in place. Antimicrobial prescribing reports (for example) are used to compare performance towards prescribing targets between practices.

I think it’s quite complex. You’ve got things like some of the quarterly antimicrobial steward reports which show practices are clusters, practices are performing in comparison to like other practices within the local health board. (Prescriber 6,1)

The prescribers were also shown how environmental impact could be visualised and communicated through a Scotland-wide map which categorised geographical areas based on the likelihood of a pharmaceutical exceeding the threshold level where ecotoxicological effects are expected in freshwater. They felt a map of Scotland with levels of water pollution was useful but also had its limitations. For example, several participants discussed the difficulty in attributing direct outcome measures based on medicines when so many other factors were involved (eg, population demographics, prescribing trends, multiple pollutants, environmental conditions).

…It must be very difficult to pick an outcome measure in the environment and then isolate the impacts of pharmacology on that because I've obviously there’s other impacts such as what we talked about, I don't know, is it next to an oil plant or something like that? And it’s picking the right outcome measures that can be monitored that we know pharmacology’s impacting directly and then seeing over time is that improving with altered practice. (Prescriber 2,2)

Additionally, local guidance may be more appropriate, rather than Scotland-wide, due to location-specific or compound-specific conditions affecting how prescribers and patients should respond. There may be an opportunity to observe changes in the environmental impact over time with altered prescribing activities.

With the maps it you know, presumably because you know there’s less people in the Highlands, you know, I was looking at that map about where I live and then some things that might have an impact in Glasgow won't have an impact with me. (Prescriber 3,2)

Other options (regarding environmentally friendly prescribing) were suggested by both groups, including reducing the number of medicines prescribed per day (if appropriate), short courses for new medicines, regular medicine reviews to avoid unnecessary repeat prescriptions, deprescribing and social prescribing. While acknowledging the pressures on healthcare staff, the public representatives agreed that prescribers need to spend more time with patients discussing treatment options, including those other than medicine.

So we use ecotoxic medicines frequently, and most patients are commenced on methotrexate as their first line kind of treatment. So I’m very interested in how this has an impact on the environment and how we can obviously be helpful in that. We do try and give patients short prescriptions and try and reduce waste that way, but obviously I’d never thought about it. (Prescriber 7,1)

So our prescriptions at the moment are set up when you prescribe, you probably just prescribe a month’s worth and because you know that’s often if you’re trying a new thing, what you’ll do, whereas actually if we wanted to reduce waste, if you had a system where you could prescribe a week and then if you’re OK after the week, you pick up the other three weeks from the chemist. (Prescriber 3,2)

Whatever was done had to be easy and quick to do in a busy clinic.

Because people will do things that are easy, but if they’re difficult, there’s another barrier there and even though they might want to do the right thing and do the thing that is green and sustainable and better for the environment, if it’s not easy, they're not going to do it. (Prescriber 3,2)