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next up is Tracy Loins on the future of sustainable medicine. So Tracy is a medicines optimization pharmacist on lifelong environmentalist. In addition to being the pharmacy sustainability lead at trust. She's off the cof ound of pharmacy declares a group of like minded pharmacy professionals calling for a global, more sustainable approach to pharmacy to action and education. She's also a member of doctors for extinction. Rebellion Welcome. Thank you. Well, everyone, thank you so much for having me here today. I'm really, really delighted to be here on Dysport the last couple of years. I ng Teo raise awareness of the climate crisis. But I feel that if you're on ico medics conference, you probably you know, you've arrived at that station. So what I thought I do today is that you just take a chance to celebrate some of the advances we've made over the last couple of years, particularly here in the in the UK to make medicines use more sustainable because I think we have to really sees moments of joy where we can find them on DTaP. You in the people have done this amazing work. Um, I'm also going to look at exciting new possibilities that might be coming away and then talk about things that you could do Two more it when you go back to your baseline. So I'm gonna start with the established work streams. Just recap. What we've achieved on the way that I've seen is this is to look at for a gums that start off indistinct areas and then move onto projects, incorporate wider groups of people in different organizations. I think one thing we really need Teo realize is that as our projects expand, the success of them need to be celebrated even further because it celebrates any marked it disappear anywhere. So the first thing I want to talk about is the Desflurane reduction program. I don't know that, Nick, what's the said? He's completely boarded talking about this recently, but I think it really needs to be celebrated because desflurane is up to 20 times more impactful and hum from the climate that alternatives, um on, um, you know, it's Teo achieve our long term plan of completely overhauling anesthetic practice. We have to make sure that we can move away from this where possible. You can see since we started recording this, the use of desperation has dropped so significantly. It's like a really beautiful graph to look at on initially, the Standard and HS contract said. He tells Acute Trust, a target of having less than temporizing Deaths remain use out of state a lot volatile anesthetic use that was achieved so brilliantly and so quickly that the updated contractors now 5%. So this target needs to be written into our green plants. On Greeley. I stand in a war of my colleagues in any professional bodies. But the our CEO in the airway advocated for change, say, provide guidance. I provided education. Um, and I think the next thing that we need to do is work together. Look at those trust that still outliers because we've achieved the national target because some trust you completely stopped using that spray and they ditched it completely. Other trust your favorite quite strongly. So I think we need to work with those organizations and help them understand how they can switch away from it, because we know that's possible. Even in centers that have a high volume bariatric services, it is achievable, and I think over the next two years we'll see a stronger stance from the clinical bodies that will help us eliminate this. This drug nearly everywhere. The next thing ti celebrate is the nitrous oxide mitigation project. Um, and again, this is a step up from the desk. Very work because it's used in in more department, see on a Thetis D in dusky obstetrics etcetera. It's really important that we we take on this project because nitrous oxide is such a harmful agent. It's, um, around. It's just even 250 times warming on the environment than carbon dioxide and it it makes up the majority of the column of the print of anesthetic gases in the NHS. So I'm delighted Teo permitted the talk. It is available from Green or an HS, and I really want to permit it because I've recently discovered that some trust don't know about this. And what really sings to me about this This talk it is that it it applies lean methodology and just pure clear logic to achieve some really fantastic outcomes, say the nitrous oxide investigation projects identify that there was high levels of waste within the pipes nitrous system. On that there was a really large discrepancy between the amount of product that was being bought by a trust and actually being utilized clinically on the project broke down the causes. All of this into three key areas. One of them was, uh, Tegretol Interval problems with the system. So the gas was leaking. Uh, the next was stopped mismanagement, and the third was security issue. So the stock was actually been stolen for recreational use. Um, and using the talk it we we estimate that which will reduce emissions by 300 million miles in an average patrol car per year. It's really significant on dust is an anecdotal story. My trust have used to talk it. Um, we found out that we were actually using 3% of the product that we're actually buying. It's a huge amount of waste in the system. And I'd say, If you're in an acute trust and you're not aware of this, take it back on for me. So then we move on. T projects involve other arms of healthcare delivery in the UK, leaving out of the hospital into the primary care setting. I'm working with colleagues across the interface. Come on. I think the previous speakers outlined beautifully why we need to target green or respiratory cup. But as a system, we've realized there were three things that we need to be on city. Let's make sure patients can use their inhalers on really want to see incorporate them into shared decision making. Um, make sure that they have a green inhaler choice where that's clinically suitable and make sure they know when and how to displace of those a day. Say, I just want to describe will make you aware of some of the, uh, contractual drivers that helping bring this change about. We mentioned the investment and impact, and and this is an incentivization scheme to primary care networks. Um on the teams within a primary care network are incentivized or they're recommend if they achieve certain actions to do with inhaler therapy. So we're looking to make sure that patients who have asthma have a number off inhaled corticate steroid prescriptions every year, cause we know this helps with self management on to prevent exacerbations. We always they want to look at patients who are on high use of blue salbutamol, Sabirin halers because we know that high use indicates poor management, and it's more likely sleep. Hospital emission on them has high mortality rates associated with it, um, to trust the er three. The practices are also assessed for the percentage of meeting date inhalers they use as a taito of all of the inhaler. And they're looking at the carbon footprint, the southeast small that's given to the patient on. I don't know if anybody's aware, but a similar scheme exists for primary care pharmacists like High Street Community Pharmacy. It's part of the community farm Seacon, a contract whereby they're they're supported to provide clinical services outside of the mechanical dispensing of medications. I'm and so these the peak US system is there to support that I I. So High Street pharmacies are incentivized to make sure that all patients over the age of five have a personalized action plan. Um, all patients between the ages of five and 12 haven't action plan on going to have a spacer to use. And then if those patients don't have that in place, they are then referred to make sure that they're probably look off looked after. I'm, uh, High Street Pharmacists are also they're Teo. Make sure that anybody who was given a new inhaler during the pandemic is given a a a proper check to make sure that they can use the inhaler properly. And in order to do this, the the pharmacist have to want to take training so they can probably deliver the service. They also want to take training to make sure that patients know how to space of their their inhaler. So that's returned them to the pharmacy of the reasons you know, we have been described previously. I'm on the pharmacist themselves are given training about the environmental impact of improper to space a while. And we're hoping that this information will roll forward into the communities. Done. We should also celebrate some of the amazing clinical support that Excuse me, that and cup. Oh, sorry. Is that okay? But you told on dot we have a champion. The clinical support that is presented a long with the contractile drivers to enable a healthcare staffed have the education and the facilities to make this happens, A particular wanted to shout out the green or practice great for such a brilliant talk. It that was that husband deployed in same. Any of the services I know work with on call out to the conditions who are updating guidelines, and to make sure that when you we treat our spiritually patients, there is always a dry powder inhaler option available to patients, regardless of the level of their disease on by, just suitcase the door, said one, which was approved recently. I'm sure they are elsewhere, and then we come on two procurement, which I sometimes think doesn't get the attention that it needs. I think maybe because it has, it doesn't have a clinical shine to it. But procurement is key to making sure there are medicines. Use is really, really sustainable. Um, on the NHS think green run a chest team on the Central Medicines unit, have developed and launched this really ambitious pathway to help all of the any. Any chest is suppliers become a sustainable and a line without our net zero goals. So I'm already a neck chest framework is eyes made available? If anyone wants to tend to for it, they have to demonstrate that they have considered the social value of their operations on. That includes the environmental impact on over the next couple of years, all ulcer pliers you wish to access an HS contracts. We have to produce carbon reduction plans for their direct admissions. And then in 2027 regardless of the size of the supplier, everyone will have to produce carbon reduction plans for their direct on D in direct emissions. And so it will really change the way the company's orientate themselves. And this includes farmer companies. But the really, I think exciting one frost in terms of all you know, farmers, pharmaceuticals and farmer companies is that in 2028 we're expecting carbon footprint data for individual molecules, which will implicitly change the way that we look drugs on our formulary and the way that we use them. So that's everything we've achieved a far. It's all work that's going on. And I think, you know, we really need to give ourselves a pattern the back from having that and all of the work that's gone into it. Wait, you got to think, you know, we can't rest on our laurels. So what will happen over the next two years? For me, the big thing is carbon footprint. In information on I don't know if anybody has taken up this like they started to look at it, but I would really encourage everybody to do Teo develop a carbon instinct as it were because it would be so key to our understanding of sustainable medicines you use, um on on the screen is actually what we want to achieve. This is a whole life cycle analysis of a product on this is produced by a company called Orion for one of their inhalers. Ondas You can see they've broken down the emissions or satiated with everything from extraction of the pharmacy. It'll ingredient a way through to displays. Um, but unfortunately, this is quite a rare example Is quite difficult to track down on at the moment, we can't compare products we can't compare, like for like what we have currently with regards to carbon footprint sing to very useful but quite limited in in the limited application methods. So we can either use the top down method where we literally work out a carbon footprint bait based on the money that we've spent on a drug on. That's regardless of the drug involved in how complex it is on. You can imagine if you're looking at carbon footprints based on cost. Spend the difficulties that you come into an contracts change or products come off patient well. We used the bottom up method, which is more in depth on you, whereby you have to break down a product into it's constituent parts and apply carbon emission factors to those parts. But it still has room for improvement because they're all gaps in the carbon emissions that captured. So this is one thing I think might change in future. There is a process called process mouse intensity on, but we think this might be the way that carbon footprint in gays PMI a process mass intensity is is a green chemistry tour and it's been used for a number of years because it allows you to identify and benchmark the volume in quantity off a of the molecules needed to produce your end target. Drug people have used this to refine the process of reduce the amount off important. It is pretty sure and result molecule, but a group he received an HS funding Teo support RNA chest zero ambitions are using this and we think we might be able to develop this into a carbon footprint ng dl, which were give us a carbon footprint for the manufacture of each drug molecule. Um, and if you remember one of the previous lights that makes up the bulk of the emissions associate with drug production, Um, I would say that some of the other research projects are looking at a normal ways of delivering nitrous oxide to reduce the emissions. Associate with that on data drone technology to deliver drugs from two patients in the community. Um, other things that we need to count for all, uh, publications by governance on legislative bodies. So nice. A common working with your help York Health Economics Consortium on They're looking to include environmental sustainability into their decision making criteria. Thean issue publication was due to come out last month. So we're hoping it when it launches it, come out quite seen. Um, and that will change the way governments around the world looked at their decision making criteria and the drug bodies, because of the international reputation of Nice um, Differin are also looking teo review their legislation around F gases, which will impact, um, our inhaler therapy. Currently, the F gas is in medical devices aren't included in legislation, but we know that because if gas is elsewhere in our community are coming down and use the proportion. It's a shade is with inhaler Device is we'll go up over the next two years is that we think the next draft of this legislation might include thumb on what we think this might launch in 2024. Um, and then lastly, we need to look at to you the m h r a to see what they could do to support changes, because at the moment is quite difficult. Teo change a product or the packaging because of the license in restriction them on. They have said they have limited resources to do this, but they're just looking at their next two year delivery plan on the hope to include net zero deliverables within that. So, you know, this is what might happen in the next few years and what we should call for, but actually what now? But because, uh, you know, we can't wait for the next couple of years for the next stage in optimizing medicines use. Say, um, I would say the thing that we have to remember if we really want truly sustainable medicines use is that actually, we are the key to delivering it on. We can wait for the great and the good and the creative. Teo. Send us new information and new guidance. But actually we can make a change when we go back to our base sites tomorrow. So nice produced a medicines optimization guideline some years ago on, they said that there were approximately 375 hospital emissions every year due to avoidable avoidable medicines. Related events on that worked out about three million bed occupied days per year. And if I've done my math correctly, that's about 6000 bed days per trust in the UK because of medication related events on, they calculated that if we avoid 75% of those, um, we would avoid this 111,000 tons of greenhouse gas emissions, 180 million liters of water and that it's direct and indirect, so direct use and the water satiate within the supply chain and energy generation, that kind of thing 13,000 tons of waste. The report didn't even calculate the ambitions that we would save. I am from healthy and behavior outside of the hospital before patients got to worth you know. So it's just a phenomenal change that we can achieve by making sure that patients can use their medications properly on. I'm gonna put a call out here till working with your colleagues in a lot different disciplines, wherever you are. The's are a few of my pharmacy colleagues on at the trust where I'm back in Dorset. You know, we have a team of pharmacy staff that rain the hospital, looking for patients to make sure that there their medicines have been reconciled, identifying discrepancies and highlighting them to the the our clinical colleagues I'm. And what I would say is that we've really made progress in our ability to do this because we've started to work collaboratively collaboratively without nursing medical colleagues, and that has made a difference. So I'm sorry about two minutes left. The last thing I'd say to look up is the ability to look at your patients and see if any of their medication can be stopped. This was a review produced by the chief pharmaceutical officer last year, and we believe that 10% of items are actually not needed. Say this is our key Prince. For the most stable medicine is one that we do not need on this's me on Twitter a couple of days ago, and I had for me a lot of response of this because we did something that was really simple. We added the text in the second box on to our formulary application form, because if you think about if you start to get a car or bite, you learn to start or stop it. And we should be doing that with all of our drugs as well. It's just such a basic common sense that we need to incorporate that into all of our guidelines. Um uh, he's on else I took from Twitter, and it just goes to show you the difference you can make if everyone in your clinical team has the expertise on the framework with which to d prescribe, UM, necessary medicines. And you can see you know the sustainable benefits will be huge for this particular patient, which could be replicated elsewhere from the medication that's no longer needed and also from the theory would insert health seeking behavior from an over or under medicated patient. On Ultimate, the patient is so much happier, which is what we need to target in our everyday practice. So I will leave you with, um my My key message is Please follow green on hs use the resources that they have available. Also work with your your clinical teams in a little different specialities on professions to make medicines used to me the most sustainable possible. Thank you. Thanks very much for a C. Just before we go into questions. We've got a talk by the carbon literacy project in the other room, which is very good. So if you like, head over there, we've got a woman presentation after this for the great Um, thank you. Much sexier. That was very interesting. I think you're kind of some point where there was talking to the CEO of Green Energy UK. And he said, The greenest energy is the energy that you don't use on. I think that applies or yeah, you know, is very reiterated in what you said. So we do have a few questions. One question from from the online tap was It's our pharmaceutical companies doing anything to reduce packaging in the medications. So we know that from some of the bigger farmer companies, they're definitely looking at this. It's harder for the smaller companies. They don't have the resources. But this is another reason why we need support from the, um HR Ray. Because at the moment, if you have a company with a pre existing products, if they want to change the farm of packaging and they have to resubmit their whole life since again, which is obviously time consuming and very costly. So we need support. But going forwards. We're hoping that pharma companies will evaluate, you know, the cost of delivery as well as the environmental cost and transport of, you know, using a small package. And I was Well, I was talking to the GSK head of sustainability, a cop 26. And he said, as well, they're working on reducing the carbon footprint off the medication itself. So rather than like, excuse me, if I'm Richard this but like seven step process to create price seasonal, they're working on reducing it to two steps of the carbon footprint of each. You know, each tablet is a lot less and, you know, um, open question is the floor Anyone have any questions? One of them. Woman. Thank you very much. I really enjoyed that it's so many good initiatives going on. One of things about what next that you haven't touched upon is the area of pharmacogenomics, which I have a person interest in on. So I would declare that. But I think that is something that could impact very significantly. Like that last patient you showcased where they went from a whole bunch of tablets because of side effects. Down to a few pharmacogenomics. We have doctors that are prescribing the nurses that are prescribing on farm system looking after prescribing of patients. Thie tool where, by they can make intelligent choices about individual prescribing for patients. There was a publication put out by the Royal College of Positions at the end of March, which that lead or the one that was Professor ceremony a perm. A Hamad who leads on pharmacogenomics in okay on bat, was describing a scenario in three years' time where that the ability to check the genes that individual patients have, which impact on the medications they might be prescribed so the choices could be made very sent to me by by other prescribers. So I think that's something else that yes, it's not a very bunion HS as yet, but I suspect that within 5 to 10 years everybody will have a pharmacogenomics profile so that that can a very impact away. One example. Mental health drugs only working about 50% of people they prescribed. Um, if you know the pharmacogenomics profile of the patient that you'll get it right first time. Yeah, I couldn't agree more, So we had a slight mixup with timings to the talk. So I thought I had much longer to talk. That I did. So I'm sorry about that, but yeah, absolutely. I mean, that's the dream, isn't it? So that you know exactly what your patient needs right down on that very precise level on. Then you will have better outcomes, fewer side effects, except for except one thing I think we really need to push is that there's free pharmacodynamic training. Available free masters courses on the uptake is really, really low. So on over one's pressurized and were just recovering from the coated pandemic. But we need to make sure that people within our health systems take up that free training so we can utilize that. You know that that's the future of medicine. I think Yeah, absolutely. I think it's the next big thing in medicine. Thanks very much. Facing one more round of applause.