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Uh you know, good morning everyone and welcome to this session on, you know, sort of part of this share sustainable healthcare academic research conference. And uh my name is Michael Korie. I'm a clinical academic with a background in clinical pharmacology and therapeutics. Hence being part of this session which is uh themed around medicines and sustainability. And I'm co chairing today with Bethan Davis, whose a, a consultant stroke physician, University Hospital Sussex, and also, uh you know, very uh you know, at the forefront of the green revolution when it comes to, you know, other aspects, not just medicines. So it's a welcome. We have all our speakers ready and fantastic talks to look forward to. And uh you know, without any sort of uh waste of time, we're going to start but feel free to put questions in the, in the chat facility. So we can talk about it. There will be time for questions after each speaker spoken. And at the end, we'll also have a time for a, you know, discussion. Okay. So I'm going to start by calling on Emily Emily Parker, who's going to talk to us about Echo Kids med that project Emily over to you. Hi. Just before I start, I've just seen that someone said in the chat that it says that the breakout session is starting soon for them. I don't know whether if they go back to the main stage and then try to come back in whether it would work or not. But I just wanted to, uh, and then I'll start now with the way. Thanks very much, Emily. I'm going to meet you. Won't hear any background. Okay. Can you see my slides? So, my name's Emily. Um I am a junior doctor in Newcastle, working in pediatrics and I'm going to present some research that we've been doing on comparing the carbon footprint of capsule and liquid amoxicillin. Firstly, I'd just like to say, thank you very much to the Center for sustainable Healthcare and Newcastle Hospitals, charity. Um Newcastle Hospitals, charity have funded my job this year. I'm really lucky to be doing a fellowship and I'm spending 50% of my time looking at sustainability in pediatrics and I've been very well supported by the Center for sustainable Healthcare. And if you just look at the names at the bottom, that's my team. So I also want to thank them and here's a photo of some of them. Um So MLM is here, that's Emma on the right. Nicola is a pharmacist and Jenson is a pediatrician. Emma's also pediatrician and this is the kids med team. Now, they've done some excellent work on teaching Children to swallow tablets. And that's kind of where this question came about, which is, is there an environmental argument that we can make to do this teaching? We know it's good for cost. We know that it's very acceptable to Children and young people and their parents. But can we also say that it's better for the environment? So just looking at the NHS carbon footprint, why are medicines important or are they important or how important are they? So I think Chantelle already showed this and you've probably seen it before. Um If you look on the top, right, you can see medicines and chemicals make up 20% of the NHS carbon footprint. Some places quote 25%. And I think if we look at things that clinicians can influence in their day to day decision making, then this is one of the most significant areas. So how do we decide what to prescribe? We don't really have a lot of evidence. Um There are lifecycle assessments looking at the carbon footprint and other environmental impacts of medicines, but very few of them are comparative. So very few of them give clinicians an idea of whether they, of what they should choose when they're wearing up different options. They're also not written in a very clinically relevant way. Um A lot of them look at batches, so 100,000 bottles or um tens of thousands of items, which doesn't really, it's not really relevant when you're thinking about what to prescribe for a patient. So for a study, we took the functional unit which was clinical of treating this six year old girl Josie who has strep tonsilitis. So she needs seven days of amoxicillin. A dose of 500 mg three times a day. So that's 21 doses of amoxicillin. That would be the minimum she would need. So what are we going to prescribe her? Are we going to prescribe a liquid? Are we going to prescribe tablets for our study? Um Sorry, this is a bit small on this, on this viewer. Um And we, this is just to show what we've been able to include in the carbon footprints. So this is a process map that looks at the production of the items. Um And we have been able to include the raw materials and energy for the packaging um and some of the production of that packaging. So for the plastics, it will include the molding of the plastics. But for the, for the cardboard, it won't include the printing of the cardboard. And then we've also been able to include the distribution use and disposal of these items. We haven't been able to include excipients because data on this is actually very difficult to get hold of. So these are the packages packages that we used. We managed to get our pharmacy colleagues from the M D T, which is very, very useful to um find packaging, uh find packets of liquids and tablets from the same pharmaceutical manufacturer. And that was to make sure that we reduced all all the variables we could possibly reduce. So 11 manufacturer, different types of the same medicine, we then deconstructed the packaging. So you can see on the previous slide that we've partially deconstructed. This is a slightly further stage in the deconstruction and um there were some challenges involved in this. So please ask me in the questions later if you're interested to hear more, but it was very difficult to deconstruct certain parts of the packaging, but we did manage the problem solve that. So for the foil, there was one packet that we could, we could deconstruct fully and that allowed us to calculate the rest of the emissions. The second challenge that we encountered was identifying the component parts of the packaging. So some packaging is very clearly labeled. It shows you exactly what plastic it is. It shows you exactly how you can recycle it but or maybe you can find it in the S P C. So sometimes it's detailed what the plastic is, but this isn't always that easy to find. And you can see here that it says five mil opaque spoon. It doesn't give you any information on what type of plastic that is where we didn't know what it was. We just said that it was a generic plastic and use that for our data. These two challenges. The challenge of deconstruction and the challenge of identification of the materials point towards a wider problem with packaging of medicines, which is that they're not really designed to be recyclable if we put the lid of a bottle in the recycling that's actually made of to plastics. And I and it's impossible to recycle that. So it just needs to change really when we're thinking about environmental impact. So these are the results. So after deconstructing and identify the materials, we then weighed each component part and we use the government greenhouse gas conversion factors to calculate the carbon footprint. So as you can see, um the carbon footprint for the bottles of oral suspension is 0.102 kg of carbon dioxide. And for the tablets, they're very similar regardless of the number of tablets in the packet. Um that was less than a third of the bottle. Now I've done a few calculations just to try and make this a little bit more understandable on a larger scale because obviously this is a very small difference when we're looking at 11 item. But if we multiply it a bit more, you can see the relevance. So firstly, if we apply it to the functional unit of treating Josie the six year old girl for her strep throat, if you dispense, if you want to dispense enough of a liquid to give her her full dose, even if you ignore the actual doses on here. So we've gone for 250 mg of orals have spent in five mil. But say it was 500 mg and five mil. That would be the best kind of um dose NG for her. You'd still have to have to dispense two bottles to give her her full dose because each bottle only contains 20 doses. So just to give her that extra one dose, she would need a whole extra bottle and the rest of that bottle would be discarded. Whereas with the capsules, they're in boxes which are much more suitable for prescribing. So 21 capsules in a box, 21 doses for a course and you only need to give one. So if you multiply the difference there, that's already a 6.5 times difference looking at the carbon footprint for the functional unit. But if we multiply that on a slightly larger scale, I've got the prescribing data for Northeastern Yorkshire for just amoxicillin, just oral amoxicillin. In the last year, 317,000, 293 items of oral amoxicillin suspension were prescribed. Now, if we assume that half of those Children could have had tablets, instead, that would be the equivalent saving to around 86 return flights between London and New York. And that's just for one oral medication in one year in one region of the NHS. So this is a small difference per patient. But on a large scale it could be a huge difference. So what are the next steps we'd like to fill in that process map and calculate the footprints of some of the other parts of the process. This photograph is medicines arriving in a hospital. So some of the things we haven't considered, uh the bigger boxes that the medicines arrive in. We'd like to look at things like that. We'd also like to look at patient journeys and how liquids and tablets change the emissions on patient journeys. And for you, I'd like you to consider which patient's you might be able to prescribe tablets for instead of liquids. Now, if this is Children and well, this may be relevant, not just two Children, there is evidence that shows that adults don't comply well with their medications potentially because they can't swallow tablets. So this learning is relevant to all people and the kids made e learning module. There's a link here. There's lots of information on kids med and M A limb and my colleague Matthew, both here to help with the questions about this. But Emma has been instrumental in this project. So if you want to ask any questions about teaching, you can ask her. Thank you very much, Emily. That was brilliant. Fantastic. Does anyone have any burning question? I'm conscious of time. Should I ask a very quick question, Emily, how, how would you suggest disseminating this to a wider population? Because I think it's really important for everybody to know if I think about, you know, as a parent, the amount of kind of cow pole that we get in liquid form and all the single use um, syringes that are dispensed. How could we make this sort of more better known? You know, beyond, beyond just, you know, a small group of healthcare professionals. Yes. I think that's a really good question. And luckily Emma and I have already had a meeting discussing what our next steps are for distribution. Um So the, the Kids Med project is quite well known already and quite well kind of promoted. But that is probably especially among clinicians. Um I think the information that we found needs to go out further and we have spoken about press releases and maybe talking to local press in the first instance to try and get this further further um known. Um We also with the Kids Med team have very good links with GPS and nurses and pharmacists in the area who can get this information out further to patient's. Um And I think there's probably an argument for teaching frontline clinicians to kind of always mention this when they're talking about prescribing. So I've changed my practice a little bit. And if I see a child in A and E I will mention it, I may not teach them immediately how to swallow tablets. But I will say, have you ever thought about this? It might be better for you and I'll point them towards the information so they can start thinking about it. Well, thanks very much. M E. That was brilliant. I, I think there are a couple of questions in the chat with facility, but we will defer those until we get to the end. Just, just so there's a bit of discussion. So I'm just going to call on, uh I think James's next James Heath to introduce share slides and, and introduce himself. Hi there. Yeah, thank you very much. Can you all see that? Yeah, that's great, James. Thank you. Amazing, brilliant. Thank you. Um So hello. Um My name is James, I'm uh medical student of the war it ca medical school in the Midlands. Um And I'm going to be speaking a little uh first of all, thank you for having me today. Um And the previous talk was really good and inspiring some good messages shared there. So, thank you for that. Um So I'm gonna speaking about factors influencing healthcare professionals choice when choosing which inhaler devices to prescribe. So to start with the NHS is committed to cutting carbon emissions and becoming net zero by 2040 inhalers make up 3.5% of all NHS greenhouse gas emissions. Um So targets have been set to reduce inhaler emissions by transitioning from high emitting metered dose inhalers, too low emitting dry powder inhalers M D I s use a high greenhouse potential gas propellant. Whereas D P I S are inhaled as a dry powder delivered through the patient inhaling. Um And we can see in the figures on the left that M D I s are more than 35 times greater have a 35 times greater environmental impact compared to D P I s which is comparable to 100 and 15 mile petrol car journey, which is, which is quite staggering really. So NHS England's aim is to reduce the number of prescriptions of meter dose inhalers, which are the high emitting ones down to 25%. Um But we can see in this graph that it's currently at 54% with not much of a downward trend. So why I M D I is still the most commonly prescribed inhaler studies show that it's not due to the patient's preference or the cost of the inhalers. Um But the healthcare professionals persisting to choose them when prescribing. Um and the research that we carried out was hoping to understand why this is so a bit about our methodology, we carried out a systematic literature review um that via database search, identified studies with healthcare professionals perspectives and factors that influence their decision when deciding which in head advice to prescribe, we analyze cross sectional studies and categorized information into groups allowing for a narrative synthesis to be carried out. Um And the study participants included healthcare professionals that are involved in the prescribing of inhalers, including participants from developed countries with similar healthcare systems to the UK. So a bit about the results um studies included data from nine different countries with over 35 factors. Um that, that came up in the surveys through all of the studies. Um We then categorized these into five different groups which are listed here on the right in order of priority assigned. So firstly, with the highest priority were patient's thoughts and preferences for the inhaler. Um This was then followed by inhaler attributes, patient characteristics, healthcare professionals, preferences for a device and then environmental considerations lastly. So for patient factors, the previous experience and preference of the patient for an inhaler device were identified as the greatest influence on inhaler choice in three of the five studies that were included inhaler attributes. So ease of use of the inhaler um was deemed most important in two of the studies. However, this is quite vague really as ease of use, doesn't actually outline any specific device features, just what the patient finds easiest to use, which could be different on a patient by patient basis. Other specific factors attributes were listed, for example, the size of the inhaler and the number of steps required to use it. But they were given less importance. Overall patient characteristics such as a a aged disease severity and dexterity were deemed less important. Um although one study found that the patient's coordination was more important than their experience or preference for an inhaler. Then healthcare professionals preferences. So the personal preference of the healthcare professional was chosen as the least important factor when considering the device type, which included their familiarity or experience with a device. And lastly moving on to the environmental and economical considerations. So unfortunately, only one of the studies mentioned cost or environmental considerations and found that overall cost was rated more important. However, data from just the European countries within this study showed that green factors did rank higher than cost, which shows that environmental considerations have been an important consideration for some time in Europe, which reflects the prescribing patterns of other European countries. Unfortunately, excluding the UK, we're not following this, which is unfortunate. Um And the data within that study for the UK specifically was unfortunately unavailable. Um So we can see that the emphasis within these studies is put on patient preference and not on inhaler characteristics. And this shows that patient centered shared decision making process should be carried out when we're choosing an inhaler. It's then the healthcare professionals responsibility to supply the necessary information for a patient to make an informed decision. However, our results show that only 29% of doctors actually felt confident talking to patient's about inhaler options. And a study by Walpole little looked more specifically at NHS doctor's confidence in explaining green inhaler options and found that only 8.8% found uh felt confident to do it. Um nice have developed a patient decision aid that explains the environmental considerations of inhaler devices which can be used to help bridge the gap in healthcare professionals knowledge. When explaining options to patient's, this should be more heavily recommended to use before prescribing to assist the healthcare professional and patient to choose the most appropriate inhaler device for them. A review by Star Panton, it'll also commented that prescribing guidelines should be made clearer that GPS should be the default inhaler options when this is clinically appropriate. So to conclude, looking at current inhaler prescribing, reaching the target of reducing MDI prescriptions to 25% does not really look promising. And this highlights the importance of this area and understanding why we are not transitioning more quickly from meter dose inhalers to drive powder inhalers. There's a lack of data for U K. Healthcare professionals views on environmental considerations when prescribing inhalers research should definitely be focused in this area to more specifically tailor interventions to help address this problem. Um But what we can do is we can broadly say based on this review that inhalers are chosen based on the patient's thoughts and preferences. This means healthcare professionals need to provide proper information about inhale eruptions which they currently struggle with. Therefore, patient decision aids should be more prominent and there should be a greater emphasis in the guidelines that dry powder inhalers are preferred when clinically appropriate. Thank you very much. That's brilliant James. Thank you so much. That was fantastic and apologies everyone for any background noise you're hearing. I'm not in a party, I'm at a conference in a hotel and it's just a bit noisy, but I'm pleased to see that there's already discussion's happening in the chat room, you know. So, you know, there's, you know, people raising queries and discussion's already happening. So, so thank you for that. Any, any burning questions for, for James at this stage. So James that, you know, we've been talking about this for, for a long, for many, many years, you know, and, and you said it yourself, you know, uh Continental Europe seems to recognize that this is an important thing in terms of inhaler, prescribing, what's holding things up in the UK, just so that other places where it's not happening, they can learn as well. So this, there's a really good question and from the research that I've been able to do and the data that's currently available, it seems as though there's, there's not really an obvious answer to this because as you said, in other places, they seem to be doing it already and getting it right. And the data is quite kind of fundamental when it comes to the difference in environmental impact between these two inhaler devices. And the literature seems to say that clinically they, they act equally um they're very comparable. Um But the, the literature really doesn't have any information in an NHS kind of like UK setting as to the um the perspectives of healthcare professionals and the people prescribing these um inhalers, there just doesn't seem to be the data as to why the why people choose one over the other. And as I, as I mentioned in a broader sense, in, you know, lots of different countries, people do tend to prefer dry powder inhalers over meter dose inhalers. But for some reason in this country, meter dose inhalers are still the most commonly prescribed. And I think this may just be kind of an anecdotal my opinion, but that it comes down to doing what's kind of always been done and a bit of uh just continuing to prescribe what people are comfortable with and what they have been prescribing for their practice is kind of thing. And as a, as a medical student, there really isn't much in the curriculum that addresses these problems. And so I don't think that it's really addressed early on and potentially not in clinical years either that thanks James, I agree with you, couldn't agree with you more. I think, you know, with education, you can change behavior and that that may well be. I used to think it was as simple as upfront costs, but it isn't actually. And uh you know, I think there's a lot to unpick with that. Well, thank you very much James. That was fantastic. We will move on to the next uh talk and so we can have time at the end uh for, for discussion, please keep the chat room live and, and continue to respond. Um And over to Santa, who's our next speaker, Hyah. My name's Sana. Can everyone see my slides? Yeah, great. Thank you. Brilliant. Thanks James for that. Really interesting talk. Mine follows on quite nicely from that. So I'm a GP trainee in North London and I did a little project just to see if we can reduce the carbon footprint from paper waste and inhaler use in my practice. Um And, and the first thing kind of alluding to what we were just talking about and like, why we can't make changes. Like I do just want to make the point that my project is looking at making tiny changes. Um Sometimes when thinking of something as big as the climate crisis, it can seem a bit overwhelming. But I do think we could all look at tiny changes we can make in our local practices which do do really add up. And I've certainly been inspired by small changes I've seen other people make. So my first part of the project was looking at paper waste. When I joined the practice, I was kind of struck by how freely everyone was just printing anything, throwing things away. Just, you know, there's just a culture of that. And I think it was just the fact that I was like the fresh pair of eyes and going back to this thing of like habits. They've been working there for years. It was all normal for them. Um One thing in particular I, you know, wanted to point out was that anyone um come into the practice who needed a blood test would have to have a form printed to then take with them for the test. And when we, when clinicians were having those telephone consultations, they would print them at that point, put them in the reception for patient's to come and collect afterwards to take them. But as we might all be familiar with patient's don't always follow our advice. And so a lot of those forms were just piling up and then ended up in the bin. Um So I thought I'd take a closer look at that. Um And, and so you can see this first bar chart just shows the number of pages printed from one of the printers, um one of the two printers and reception. And we also had printers in each of the 10 surgeries. So this is just one printer and it's an extraordinary amount of pages printed. And when I looked into it, it was things that didn't need to, things that could have been emailed or other process that could have been done. I looked at how many letters were posting just a small snapshot over a week. And obviously, that's the letter, that's the envelope, then that's the delivery costs as well. And only five of the 45 letters I thought were appropriate because patient's had specifically said they wanted to only to be contacted by post. And in terms of those blood tests and specimen forms that we were printing before patient's actually came to collect them, over 100 were thrown away in September and in 200 in December. So I took that back to the team, um just trying to, just trying to bring it to the forefront of people's mind to be more aware. Um And we decided we'd stop reprinting the forms and we talked about ways we could print less, send less letters. And I also noticed that we, we did have a recycling bin next to our waste bin. If you looked at the contents of them, you often didn't know which one is which. So I try to just declutter that area. I printed this little poster and put it above the recycling bin. Um Just to say what we should and shouldn't be printing. Um It took me 10 minutes of time. And so I don't have objective data on this. I can say, subjectively, it really did make a difference. Um And then other data I collected. So the I had the team meeting at the end of October and you can see the number of blood forms that we were printing and then throwing away really reduced. So by November, it halved. I then sent out another email just reminding everyone saying really good, it's been improvement. Let's see if we can go further and by December, there were only 16. And at this point, I felt I could just, the little filing system we had, I could just remove it completely throw it away. And that's pro that processes now stopped. Hopefully, no one will bring it back, but that, you know, 100 to 200 forms that we were throwing away on necessarily every month. Hopefully, that's now done with and just a small amount of data on the letters. But I just took another snapshot of a week and that had reduced too. So that's encouraging. Um And then on two inhalers, so James is really eloquently talked about the problem of inhalers, particularly with metered dose inhalers. And and I just like to point out one statistic, which I found quite staggering was that within primary care, meter dose inhalers contribute 22% of the entire carbon footprint of primary care. So it's 1/5 of all primary care just with these inhalers, which I thought was staggering. Um And so there is a lot of guidance of how we can optimize things and it's really based around these four, these four main points. So firstly, we want to optimize our patient's asthma and COPD control. So having those regular reviews, looking at patient's lifestyle factors, any triggers, um it's making sure they've got the right techniques you're gonna help the patient will help the planet. And then um as we've discussed offering dry powder inhalers where appropriate it's gone 18 times um lower carbon footprint than M D I s and I think James mentioned this to. But that illustration really shows that very well where you feel like a metered dose inhaler is required for your patient. There are certain brands that are a lot worse than others. So the Ventolin inhaler is the most prescribed salbutamol inhaler. But but it's the worst one and has doubled the carbon footprint of say this salam all easy hailer. So we should be trying to prescribe by brands. And then finally, we should be um inhaler shouldn't be going in the bin. We should be uh sent, giving them back to pharmacies where they should be either re cycled or incinerated because they can still reach out there propellant. Um The Hydrofluoroalkane, which is the real potent greenhouse that we were talking about before. It's more than 3000 times more potent than carbon dioxide. So those are the messages we should be trying to aim for. And this is just a little graph just to show, compare different interventions. So that final bar chart at the end that shows um an MDI for a salbutamol and a non salbutamol inhaler. And if we were able to change both of those two DPI inhalers, it's almost the same as going vegetarian. So really significant gains can be made. Um So again, took us back to the team and again, going back to, you know, why is England maybe not so as good as our European counterparts and even like Sweden in particular, they only prescribed 13% of their inhalers as M D I s. And I can tell you just from my small sample of my practice that none of the doctors had any awareness that this was even an issue, the pharmacists new, but the doctors, none of them knew that anything about the carbon impact of inhalers. So raised that we discussed that and we decided that what we would do is we would um just blanket change all of the Ventolin Halers to salome all these inhalers and just send a text message to let patient's no, we would slowly start trying to switch from mds to D P I S, but where appropriate. But we did recognize that this would be the most challenging one and difficult. Um And yeah, we can talk about at the end and finally, just again, a blank message to all patient's to tell them how to dispose of inhalers properly. Because again, I think the biggest barriers probably awareness. Most people just didn't know, I didn't know before I was doing this project. And I also just sent this round to everyone again. So one barrier for clinicians, I think, I think is this lack of time, lack of energy. You're not so familiar with the inhalers. And this is just a little tool to help you navigate your way through that. And there are other resources as Well, um and in terms of the results, it's not, it's not profound, especially in absolute numbers, but we did manage to get an eight times increase in the number of the lower carbon salable prescriptions over just a three month period. So it's, it is modest, but I think it is, it is encouraging and I would expect over time this to go forward. And if we look at the next slide, if we look at the bottom chart first, that looks at the decrease in the carbon emissions per salbutamol inhaler in our practice and the trajectory is definitely downward. So that again is encouraging. Unfortunately, the top graph shows um the number of MDI prescriptions um as a proportion that we're prescribing and that is still going up. Um That's the one we identified would be the most challenging and would hope to start improving soon. So just to wrap up again, going back to, you know, why, why are we, why is it so difficult to change it? I think the biggest barrier is just habits, habits unawareness. Um It's especially everyone is short of time. Everyone is, it's really difficult both for clinicians to try and learn about these things and then try and advocate for them. You obviously have to make sure the patient's are using the right technique as well. And the last thing you want to do is push some a change on to a patient. And then if they don't do it right, you know, worsening their asthma control, for example. And obviously for patient's as well, once they're used to something just making that change, it's just an extra effort. But what I would say is recognizing that one of the biggest barriers is a habit. We can also acknowledge that actually, once we make that first initial like really difficult push of changing that habit, it then becomes a lot easier and it becomes routine and then the gains will really, really add up. So I think it's just something we can all be mindful about. Um And yeah, just want to acknowledge greener practice a really great organization within primary care. Uh They've got really excellent resources and tools on their website for any clinicians and some other useful as brilliant Santa. Thank you so much. A fantastic talk again. Um Any, any burning questions for Santa, right? Um If it's a cat that I might just pick up on, on something with both Santa and James um said, and I see Louise has made a comment as well in the chat is when we talk about healthcare professionals, do you think we're targeting the right groups of healthcare professionals to make these changes? Because you mentioned that there seems to be good awareness amongst pharmacists but less amongst the doctors. I mean, do you, do you think that we ought to be sort of empowering other health care professional groups to support patient's and make the changes because it does take a long time to go through inhaler technique and discussing changing inhalers with patient's. Absolutely. And I think, I mean, it depends within primary care. It depends on how your practice does it. In our practice, most of the asthma reviews were done with the nurses. Actually, um, and in my practice, the nurses were also less aware, they had like some idea that there was something but they didn't really know very much. Um So yeah, I think your, your regular asthma reviews and your COPD reviews those, those times whoever's doing that would be the real time that you could, you could address this rather than just someone coming with like an acute event, for example. Um So yeah, any anyone who's involved in that process, I think they would be the people to target, but I didn't, everyone should go. Yeah, I, I agree and I would go as far as saying all stakeholders including patient's and the general public should know about this, you know, so we're all singing from the same hymn she and, and, and, you know, so I, I think you're right, you know, the, the change in behavior, not just behavior, you know, of clinicians, but also that the patient's is all around education, public enlightenment and training, you know, so it's really crucial aspect of this business. Um So it's fantastic. Thank you so much, you know, again, in the interest of time. Just so we have enough time at the end to talk. Well, we'll, we'll move on, keep the chat facility live, you know, quite a lot of, you know, comments and, and responses going on. They're fantastic, you know, just keep it live and then we're going to hand over to Amy is going to take us through the next, uh, just, uh, try and share my screen. Can you see that we can see your emails? Oh, well, you definitely don't want to see my N H S E mails. That's no fun at all. Uh One second. How about this? Mhm It just says uploading, sorry, do it. Uh just says it's processing the slides. Bear with me, right? Can you see that? Brilliant? Thank you, Amy. Thank you. Brilliant. Perfect. Sorry, not the most tech savvy. Thanks for uh thanks for having me along to present today. So I'm Amy and I'm one of the anesthetic trainees and the Thames Valley Dina Re. Um and I'm just going to talk today about project that we undertook to try and quantify our nitrous oxide usage, but largely wastage within the trust and the steps or actually, unfortunately, barriers um to mitigation of this waste just before I start, just want to kind of make a quick note. Um One of the issues that we found we have sort of rolling out these projects is that it's very difficult to United Dean Ary. Um And so we set up the Thames Valley Sustainable operating pathway. And it's really become an umbrella throughout the Dean Ary under which all of our green initiatives can take place. And it means it's just a slightly more effective way to mitigate that disjointed communication that so often happens in, in a large area. So we run an annual Green Day um where the next project is voted for. Um project. One was about dez fluoride mitigation, which has been pretty successful. Um Project too is the one that I'm going to talk about today. Um And each project consists of a sort of satellite team within the trust, usually an M D T approach. Um and then one central team to collate and analyze the data. This has been an infographic that's popped up on a previous presentation. So it's nice to see we're all singing from the same hymn sheet. I'm not going to dwell on the kind of undeniable climate crisis, but I do just want to highlight the nhs's contribution and targets. So we know that the NHS is committed to reaching net zero by 2040. And there are a number of strategies and focus points on that. Anesthetic gases were highlighted in scope one. Um And they make up 5% of the entire nhs's carbon footprint within that nitrous oxide constitutes 80% of that 5%. So 4% of the NHS is total carbon footprint. The really devastating reality is that the majority of this carbon footprint comes from wastage, not usage of nitrous oxide. Um And that's really from manifold systems that leak. Uh And I'll talk a little bit more about that. So the aim of our projects was, was fairly simple. Um It was first to establish how much nitrous oxide we procure every year across the Dean Ary, how much of that procured nitrous oxide is actually being used and then how much is wasted. We then aimed to quantify that in terms of environmental impact uh and financial losses. And we hoped that this would give some ammunition to make change. But as with everything in the NHS, it's very slow. Um And yeah, we're not, not quite as far ahead as we'd like to be. So from a project methodology point of view, there's um the A G B I. So the anesthetic Association has a sort of methodology that's been used by NHS in Scotland. Um And we had the satellite teams under are kind of Thames Valley framework who contacted pharmacy and the relevant nitrous oxide suppliers. So Bach or a liquid people we use and then we carried out an audit, a week long audit. So of a standard week, Monday to Friday, either of one week or of various days across multiple weeks. In the hope that we would um uh sort of gain a typical week. Basically, the data was then submitted to the central team for analysis and we worked out a few important parameters. So how much we were wasting what I've mentioned on the previous lives. But also how many cylinders of nitrous oxide would we need to supply our Dean Ary with to satisfy the usage? I appreciate that this is a bit of a busy slide, but it's really the two kind of highlighted columns that I that I want to look at. Um as appears to be the case nationally, the wastage is pretty staggering. So the average wastage of our entire dina re was 96% some as high as 99.5 and the lowest at Oxford which is our tertiary center was 89%. I just want to draw your attention to the number of E size cylinders. Um These are not absolutely vast, they're not particularly expensive that would be required to, to satisfy our entire Dina in a week would be seven, that's four for one tertiary center hospital. So it's a really small change that we could make that would reduce the carbon footprint by a huge amount, just a couple of points on our data. Um We appreciate that as anesthetist things seem to fall I/O of vogue quite quickly and no medical specialty seems quite as fatty as we are. So, of course, it is possible that we captured a week where the anesthetist who absolutely loves to use nitrous oxide was in or the anesthetist absolutely won't was in. Um But even if you take that into consideration the wastage is vast. We also didn't factor in enter Knox in maternity. And this is a really big problem for a number of reasons and remote areas such as MRI. Now, each of these have their own manifold system supply. So it would be remiss of us not to include it at all from a business case point of view. But we didn't include it for this project, as I've said, even if we make significant allowances for data variability that the wastage is still huge. Um And this is largely coming from are manifold systems and, and we've leaked tests have been performed to show how, how much is being lost really for a relatively small cost to decommission the manifolds and provide the cylinders, there would be an instant solution because unlike other anesthetic gases were not really asking people to change their practice in order to accommodate this, we're really only asking the actual structure of the system to change. This is probably the most important slide in some ways because we have lots of data that we've presented over the course of this breakout session that says we should be making these changes and there's always barriers even when that that data is undeniable. Um One trust has had the go ahead to decommission their, their theater nitrous manifold. That is partly because their anesthetic machines have a back bar that will fit a nitrous oxide cylinder. Um and lots of ours across the trust don't. Unfortunately. So the associated cost would be higher. There is also an unwillingness unfortunately, if someone just to take responsibility for who is able to make the decision. Um So unfortunately, the saga does continue. I did just want to mention the maternity department because there's actually been a lot of media coverage on BBC news about some hospitals that are completely removing nitrous oxide or enter knocks from their maternity wards. The concerns are not just the global environmental impact but the staff exposure and there exist through a company called Med Claire, some brilliant nitrous cracking devices that sit either on a the mouthpiece for the enter knocks or within the room. Um And again, the barrier is that they come at a cost. Um and that means that there's almost snail paced progress. MRI is a much smaller user of nitrous, but also still has this associated manifold that I've talked about. So really, um you know, the important point is that there's lots of these green initiatives happening within the N H S, but we need the leadership and the kind of decision making to actually decommission these manifolds and allow either cylinder or just remove nitrous oxide entirely. I think that's all for me. That's brilliant, Amy. Thank you so much. Gosh, four excellent presentations, you know. Fantastic. Thank you so, so much. Anyone have any burning question on particularly particular reference to what Amy's just told us. Now, before we just go into a kind of general discussion in this area. Okay. Well, I'll open up the general discussion because I know there's been a flurry of comments in the chat room facility and you know how we've been talking about things being slow in various, you know, mindful of the fact that we're talking to an international audience here. So it's not just the UK NHS, but things generally tend to be, uh, slow to, you know, for uh with regard to the uptake in, in healthcare. Um Would it be helpful to try and facilitate things by engaging a few more of our stakeholders? And I, I think about industry in this context, you know, what role can industry play in, you know, sort of sustainable medicines use which they are trying to do? But is there anything we can do to speed that process up? We talk about engaging with, you know, the trust authorities, with healthcare authorities and so on and how things are slow. But is there any way industry, you know, so, you know, I talk of medicines as a number of journeys, the first journeys actually getting the medicine to, to the clinician to, to, you know, either prescribe or dispense or whatever? So, so is there stuff that we can partner with industry on or, or encourage industry to do? It's an open question for discussion. So I think um that's a really interesting question and it's something that I've definitely been thinking about while I was doing the research into tablets and liquids. Um, so I mentioned the fact that the 100 mil bottles of liquid medication, it seems like there's not a clinical reason why they're 100 mil. And actually it would make a lot, they've just made it 100 because it's 100. That's what it seems because it doesn't really match onto any kind of dozing schemer. So I think it would make a lot of sense if we could have some, some discussion's with manufacturers to produce bottles, if we had to use bottles that actually worked clinically. Um And the same with the packaging um to kind of feedback. I don't think that's, that kind of thought has really gone into the packaging. And I think it's, you know, it's from a, a previous era when people didn't really think about the environment when they design things. And I think now we need to go back to the beginning again with the design process and look again at what we're doing and, you know, trying to design packaging that is easy to recycle or or potentially refill. One of our team had mentioned the idea of having amoxicillin dispenser in the zero waste shop, which obviously infection prevention control wouldn't like. But, you know, new ideas and innovation like that would be excellent. And I think clinicians have to work with industry, which is the biggest challenge. So the first contact that I've been able to really make with the pharmaceutical company was through our pharmacy distribution unit. Um and clinicians don't tend to have that much contact with those parts of the hospital. So I think it requires like a crossing of boundaries. That's quite unusual. Um Can I just add a point as well? I'm, I'm quite skeptical and I think about industry and companies making changes for the betterment of the world. And so I think a lot of it has to come from policy changes either at a local or regional national level. So for instance, I mentioned the some, some brands of inhalers are just significantly worse than their equivalent counterparts. Ventolin and Calomel. So why even have Ventolin as a, as an option? I think it should just be disbanded and maybe we need to do that by putting regulations on the manufacturers to say this is our carbon limit, for instance, or we're just going to pull the plug and I think that that would make then, then there would be no, even there'd be no thing of like, well, the clinician has to make a choice because the choices just the, the lower carbon ones. That's a good point. Sana, very, very good point. Thank you, Emily. Any, any other comments on that, Amy, what about your, your stuff? You know the stuff with the socks side? Yeah. So, um, I actually had a conversation with a lady who works in the kind of life cycle area of NHS England. And, and she was saying that uh in the same way as happens in other purchasing capacities where it's the consumers who put pressure on the suppliers if, if we start to say, well, actually, what is the provenance of the things that you're supplying? And, and rather than being the middleman who's talking about the environmental impact, where do your baseline raw materials come from? How do they travel here? What is the full life cycle, environmental impact of the things that you're providing and how do we change it? Um So I think the pressure has to come from both top down and bottom up. And I think the more awareness and more entrenched in our daily conversations, the environmental impact of things are the eventually I hope we'll get there. That's fantastic, James Any, any further comments on industry engagement, particularly restaurants, two inhalers, I would just say I personally haven't had much of an interaction with industry and prescribing and all of these kinds sorts of things as of yet. Um But I do think that a big influence will come from, it's, it's business and it's supply and demand. And so if there's a big change in the way that we systematically kind of prescribe and use inhalers specifically in this instance, then that will change the demand on the companies producing them. And we've seen that happen already historically, um inhalers, the propellant that was typically used in inhalers previously. Um I'm not after the top of my head, I can't remember what it was but it was a worse emitter um than the currently abused one. So they made a change from a high emitting gas propellant to a lower emitting one. It's still not very good, but they made that change because of the demand for lower emitting inhalers in the past. And so I think that that can continue if we continue to put that pressure on them and show them that that is the direction that we want to move. Thanks James. Thanks very much for fantastic comments. It's quite interesting, you know, in terms of if you look at health care, um you know, the biggest costs apart from human, the cost of human resources is, is is medicines um so surely directly or indirectly, we can make a big difference and, and you know, um the most common patient facing intervention is prescribing is the use of medicines, you know, so that there is something in that um any other comments, anyone want to raise any particular comments? If not, I'll go ahead and keep talking and wrote people in. So I know there's a lot of activity on the chat facility, please carry on. That's fantastic. Uh you know, carry on responding and so on. I just wonder, you know, so we've been talking about this and it sounds like acceptability is not the issue. Why is it so and, and you know, Santa um in particular we talked about every little helps. Why can't we scale all of these little bits and bobs that, you know, are good ideas and seemingly working. Uh Why can't we upscale it? Like, why can't we get other people involved? You know, just to make a bigger difference because if not, it's only, you know, your practice that would be talking about it, utilizing all the good ideas you, you've got across to us and and there'll be no upscaling of this sort of an approach. Any thoughts? Yeah, I mean, I, I would say that it is definitely happening slowly. So greener practices which I alluded to, I actually learned most of the things that I talked about from them and they had advice as well of what you can take to your practice and they had tools to make it easier. So they had like a already a text message that you can send to everyone. So I think things like that and collaborating with these networks and then share ing ideas does help. And I think lots of practices are learning from that. But I think again, I think the barrier, I think the barrier is, is time g 10 minute consultations in your GP practices and then cost of living crisis and all all of this, it just, it just builds um and can be very difficult to find like the mental energy to try and try and make those changes. But I think I think events like this um really help and I think it can upscale but in terms of how to do it more quickly, personally, I think, I think that's a bigger political project. I think um those, those interventions would have to be done more upstream trying to change the way we look at our society and how we try to improve things. But yeah, I don't know if there's a quick solution. What San are you suggesting that politicians globally are not doing enough? Um We'll definitely, nationally, I think the UK is behind Europe in a lot of things. Um So yeah, globally, but also specifically, I'm not so impressed with Britain's way at the moment. Any other comments along those lines, you know, in terms of implementation, you can get in getting it actually done. You know, we talk about all these great initiatives up and down the country, up and down the across the globe and yet it's still not happening. Any, any any other comments. I think one of the biggest challenges is also to do with the fact that is a kind of wider point about what sustainability means. So when we're talking about sustainability, this session has all been about the kind of materials that we use. But actually, the healthcare system is not designed in a way that kind of prioritize the sustainability along the whole patient pathway. So we we don't have enough resources that are put into preventative preventative things like in the chat, people have been talking about air pollution and asthma. And I think the, that, that kind of builds into the idea that clinicians and people in the NHS already so stretched that there isn't time in their work to, to do these things or at least there isn't the feeling of time. Um that is a false economy, but I think it does make change very, very challenging. I've been very, very lucky to have allocated time to engage with this and it is, it does help with work life balance, it helps with your enthusiasm for your work. But I think it's very hard to get people to see that when they already feel like they're on their knees. Um It's not really a practical answer about what we can change, but I think it does affect the whole system, this kind of attitude of not thinking about globally, globally in healthcare, in terms of the UK, the whole thing is a sustainable in a sustainable way, really, you know, cutting funding from all sorts of things that are going to help people be healthier, that's where it starts and then finishes with us, not feeling that we have time. That's good point. Emily, thanks very much and remember it's UK and beyond. Actually, it's, it's a global issue, you know, sort of sustainability and climate change. And any other comments I would say, I think I really agree with the comments that have been made so far. And I think that as like, especially at this point in time, healthcare professionals are busy and stressed and have lots and lots of things to think about. And I think that they the the practices of prescribing and I can only really speak from the point of view of inhaler prescriptions. Um is that the guidelines just aren't really clear enough to, to say like there's, it gives the prescriber the option to choose from a variety of devices. And I think classically the devices that have been prescribed and people are used to prescribing are the higher emitting ones. And in an ideal world, the prescriber would take the time to sit down with the patient and review them and review their capability like inhaler technique and capabilities to be able to use certain inhalers and then um decide based upon the put the patient's characteristics. But I think we've seen in the chat that often that isn't the case and that doesn't happen on an individual basis. Um And so I think that from my perspective, as a student, it would be really useful to have introduced um education into the medical curriculums and nursing and healthcare curriculums that enables, you know, the next kind of generation of healthcare professionals to be aware of the environmental considerations before there in that situation where they have to make a quick decision or someone's gonna inhaler. So I'll prescribe this default inhaler. They know that actually a dry powder inhaler, for example, is equally as effective for the majority of patient's. And so you don't just default to the, the less environmentally friendly one as people do at the moment for our kind of time saving. Uh, you know, practice, I feel. Well, thank you very, very much here. I think we have run out of time. Sadly, I suspect that if we carry on, we'll carry on for the rest of the day and that will put both Bethan, Bethan and, and myself into a lot of trouble. But thank you so much. Uh Start with Emily to James, to Sana and Amy for, for excellent presentations. I mean, look at the activity in the chat facility. Usually that's what happens when you have excellent speakers who have touched on a raw nerve. But, you know, all I would say is, you know, we should keep at it. Um And, you know, sort of keep the flag flying with particular reference to the use of medicines uh in a sustainable way. Uh Bethan, any, any final comments, parting comments, if not, we will just to say thank you yet to all of the speakers. It's been a really excellent session that and everybody for joining in the cap. That's fantastic. Thank you, everyone. Lots of love, Phil. You in the Chapel Hill. It, you can see and thanks very much and hopefully see you again soon. Take care.