Roundtable report: Reaching net zero the healthy way

The NHS is Scotland’s largest employer, responsible for more than 185,000 staff in 1,250 buildings, and reliant on a complex global supply chain. As such, it’s a major contributor to Scotland’s carbon dioxide emissions.

Driving down those emissions has never been more urgent and the Scottish Government has set ambitious targets to reduce the NHS’s carbon footprint. 

To discuss how best to do this in lockstep with improving care, Holyrood brought together a panel of senior leaders in healthcare sustainability, the pharmaceutical industry, academia, government and politics. 

The round table event Accelerating the Delivery of Net Zero Healthcare, held in Edinburgh on 22 January, was sponsored by the pharmaceutical company AstraZeneca.

The central importance of green growth in tackling poverty, improving wellbeing and making healthcare more sustainable was a recurrent theme. 

Dr Fiona Adshead, a former deputy chief medical officer in the UK Government, set the scene, establishing from the outset that sustainable healthcare was about much more than recycling and solar panels. Preventing ill-health and promoting green growth were central. As well as a focus on prevention, self-care, low-carbon technologies and following science-based targets when pursuing emissions reductions, she stressed the importance of looking at systems in the healthcare sector.  

Matt Shaughnessy, head of operations sustainability at AstraZeneca, who leads a team of sustainability professionals in AstraZeneca, highlighted the work the company has done in waste reduction, water consumption and more recently energy use, but said that the discussion had shifted in AstraZeneca too towards thinking about the broader system in which the company operates, such as how to collaborate more to understand the opportunities around early diagnosis. 

MSP Paul Sweeney brought up the critical question of preventing ill-health and reducing demand on the NHS by tackling poverty and inequality, with a particular focus on urban planning. He pointed to the toll that deindustrialisation has taken on the health of communities in Glasgow.

Health secretary Neil Gray agreed. He said: “What is it that’s driving healthcare demand? It is poverty. It is environmental and social factors. So we need to be working across government and across society, across civic Scotland and the industry and academic sector, to look at answering those questions because that helps to drive down demand as well.” 

The event took place two and a half years on from the launch of NHS Scotland’s Climate Emergency and Sustainability Strategy. The far-reaching plan includes targets to use renewable heating systems in all NHS buildings by 2038 and become net zero in the supply chain by 2045. 

Senior leaders highlight the importance of green growth in decarbonising healthcare | Andrew Perry

Wendy Rayner, head of NHS Scotland’s Circular Economy Programme, discussed the global supply chain. NHS Scotland procures £4bn of goods and services. She noted that although there are data gaps, the supply chain is highly significant and is estimated to contribute between 60 and 80 per cent of NHS Scotland’s carbon footprint. She explained that, at present, it was linear, with goods being purchased, used and disposed of, but pointed out there are “massive opportunities for us to rethink and to challenge the current culture around that system” by applying the principles of the circular economy.

She went on to describe how moving away from Scotland’s over-reliance on single-use medical devices could help drive down emissions. 

She said that Scotland was working quite closely with the UK regulatory agency MHRA (the Medicines and Healthcare products Regulatory Agency) to look at remanufacturing opportunities – something that was already permitted in a number of countries including Australia.

Explaining the remanufacturing process, she said: “What you tend to do is change the system of procurement so you are paying necessarily for access to the device rather than ownership.” The device could then be remanufactured to the same if not a higher safety standard when needed. 
She added: “The circular economy and changing the way we do things is about reducing risk and increasing resilience, but on the back of that getting that economic development.”

The cabinet secretary pointed to other areas of progress: “We’ve got a good story to tell, particularly in the renewable energy generation space where I think we’re up by about 448 per cent across our NHS estate. There’s been a really concerted effort to use things like solar panels and heat pumps.” 

He added: “I think we’ve got more work to do particularly in the space around pharmaceuticals, around that very linear path that we’ve got at the minute from production, use and disposal.

“I’m interested in improving delivery for patients first and foremost, but I’m also interested in how we do that in a way that reduces our impact on our wider environment.”

He discussed the “double benefit” of promoting active travel – for wellbeing and for emissions reductions – and the important role of Realistic Medicine, where there is shared decision-making between patient and doctor, including about whether treatments are truly needed.

Rayner pointed out that community pharmacies around Scotland collect around one tonne of pharmaceutical waste returned by householders every day. She noted that while disposing of that waste costs the NHS money, the value of the wasted product is many times greater. Reducing that waste can bring financial savings. 

The subject of wastage of drugs was a significant part of the discussion. The cabinet secretary talked about polypharmacy reviews to make sure patients were being given medicines that were helpful for them. He added that some patients might be prescribed five, seven, 10 or 12 medicines over a period of time. He said: “We need to make sure we’re factoring in what the implications of each of those medicines is on each other, whether that can be reduced – that reduces demand that then reduces the carbon footprint as a result – and make sure that first and foremost we’re getting it right for those patients.”

I think we’ve got more work to do particularly in the space around pharmaceuticals, around that very linear path that we’ve got at the minute from production, use and disposal. I’m interested in improving delivery for patients first and foremost, but I’m also interested in how we do that in a way that reduces our impact on our wider environment.

He noted that the sustainability of medicines manufacture was a key area of interest to him. 
He cited the example of a jug of medicine being prescribed to a patient leaving hospital when all they needed was a few 10ml vials. 

Dr Camille Huser, deputy head of the undergraduate medical school at the University of Glasgow, made the point that a conversation with the patient might reveal that they didn’t want the medicine in the first place, because of the side effects, which underlined the importance of Realistic Medicine and bringing the patient into the discussion.

A number of examples highlighted the value of green growth to decarbonising healthcare. Matt Shaughnessy explained that AstraZeneca had an office in Portugal which was solar powered and can transfer and donate electricity to NHS hospitals at weekends when the office is closed. He added that in England, the company would soon start using biomethane. “Hopefully what we’ve done is stimulate that demand for biomethane, so excess biomethane will become available into the grid which will start to replace fossil gas.”

He added: “We’ve done that without any incentives, any support from government. We’re happy to do that, but that kind of stimulation of demand is an opportunity to say, how do we build on that and partner, perhaps, to use that more effectively.”

The critical role of public-private partnerships to make change happen quickly was one picked up by John Arthur, director of the Medicines Manufacturing Innovation Centre, CPI Ltd, in Glasgow. He said: “We’ve got to start driving innovation and we’ve got to drive it at pace, which means we cannot rely on a very binary, let’s see how quickly AstraZeneca or GSK or other companies can do it on their own. Where can we collaborate to drive improvements at a pace that no organisation can drive?” He mentioned the example of research into oligonucleotides where four companies, including AstraZeneca, and the UK Government jointly invested £21m. The key question he identified was “how do we work together as a system to identify how we share the costs and then reap the benefits in a big way”.

Attendees call for greater sustainability in medicines manufacture | Andrew Perry

Katie Murray, technology strategy and integration lead at AstraZeneca, pointed to new challenges in manufacturing. She said: “The new medicines that are coming along now, like the oligonucleotides, are a lot more complex than what we are used to and from a manufacturing perspective that brings a lot of challenges to make them sustainable. 

“I think there’s also a lot of opportunities there for companies to develop new approaches – biosolvents, biocatalysis – and there are lots of opportunities there that Scotland could capitalise on if they incentivise those companies to come, and help them meet that challenge.” 

She added: “The Manufacturing Innovation Centre is really important. Those technologies are difficult to implement in industry as well so it produces a training ground to reduce the barrier to implementation. It also produces a pipeline of workers to go and help run those facilities.” 
Gray stressed the need to ensure that industry, academia and public services are able to work well together.

Sweeney raised the issue of policy obstacles standing in the way of renewable initiatives with wider public benefits. He cited the example of the Queen’s Quay District Heating system in Clydebank using heat from the River Clyde to power homes, businesses and public buildings, and how it was not financially viable to repeat it due to UK’s obsolete electricity pricing model. This meant that renewable electricity, while cheap to make, was pegged to the much higher wholesale price of gas, making it too expensive to run the heat pumps.

The cabinet secretary agreed that policy barriers were problematic, giving as another example delays in hooking up projects to the power grid. He pointed to the need for “greater coordination” around net zero and economic priorities.

The discussion turned to the offshore manufacture of drugs. Arthur described how the manufacture of penicillin used to take place in the UK but moved to China for cost reasons. He suggested that using sustainability criteria instead of being entirely cost-driven could help ensure “the next pharma plants we put up are put up here, in this country”. 

He also talked about the importance of collaboration in research and innovation, rather than leaving it to individual companies, so as to drive innovation at pace.

The cabinet secretary said that collaboration between industry, academia, government and health to drive innovation in a sustainable way was “fundamentally important” and a key focus of the chief scientific officer. 

He noted that the Scottish Government’s economic agencies were working with the pharmaceutical industry and the biosciences sector to make sure their manufacturing bases were in Scotland.

We’ve got a good story to tell, particularly in the renewable energy generation space where I think we’re up by about 448 per cent across our NHS estate. 

The use of digital instead of paper patient information prompted much discussion. 

Shaughnessy described how leaflets have significant environmental implications arising from manufacture, packaging and transport. AstraZeneca has developed digital leaflets in some countries, as well as video information and talking leaflets. Concerns about patients lacking IT literacy are being met in Australia by pharmacies printing out leaflets for patients that require them.

In Egypt, health authorities have started incorporating their own health information onto AstraZeneca’s digital leaflets. 

Describing it as “a patient access opportunity”, Shaughnessy described the innovation as “transformative”, but noted that in the UK, the MHRA still requires a paper leaflet. 

Gray highlighted Scottish Government work on the “digital pharmacy” and “Digital Front Door” – a digital platform for people to access their health and care information directly – and said the idea of digital leaflets was “definitely something for us to take away”. 

Shaughnessy added that there was a Scottish leadership opportunity to set some global standards on digital patient information.

Further opportunities for Scotland to lead the way were identified. Huser said that with Scotland having only five medical schools, the nation could be “world-leading” in putting sustainability into the undergraduate and postgraduate curriculum for medical students, dentists, nurses and allied health professionals.

AstraZeneca’s Murray called NHS Scotland a “very flexible and progressive organisation” that it was attractive for pharmaceutical companies to work with.  She also saw opportunities to incentivise new companies and spin-outs from universities, with the goal of keeping the manufacturing base in Scotland.

Scotland is already a leader in joint working and collaboration, observed Rayner. She picked up on the theme of risk, raised by Arthur, and said that changing the ways things were done was typically seen as a risk but carrying on in the same way also represented a risk. She saw opportunities in “re-establishing where our risk baseline is”.

Gray noted that it was right there were audit processes, to make sure that on a cost basis the government was acting correctly. But he also agreed on the importance of looking at overall value as opposed to simply cost. He pointed to the role of the Scottish National Investment Bank in making risk-based decisions.

It was a discussion that exposed the challenges but also the enormous opportunities for Scotland in accelerating the delivery of net zero healthcare. 

This article is in assocation with AstraZeneca.