LAUNCH EVENT RECORDING: NHS Wales Green Agenda – Sustainable Inhaler Prescribing – ICST
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    LAUNCH EVENT RECORDING: NHS Wales Green Agenda – Sustainable Inhaler Prescribing

    On Friday 3rd December 2021 we held the launch event for NHS Wales Green Agenda – Sustainable Inhaler Prescribing

    Watch the recording of the event here.

    As part of the NHS Wales Decarbonisation Strategic Delivery Plan, this interactive 1-hour event focuses on how healthcare professionals involved in the care of respiratory patients, can help to tackle the climate crisis through sustainable inhaler prescribing.

    Foreword by: Eluned Morgan MS – Minister for Health and Social Services, Welsh Government
    *Due to the developing situation with the new COVID-19 variant, Eluned Morgan was unable to appear at the event.

    Chaired by: Natalie Proctor – Head of Pharmacy and Prescribing Branch, Welsh Government

    The expert panel includes:

    • Dr Stacey Harris – Paediatric doctor, Welsh Clinical Leadership Fellow in Sustainable Healthcare 2021/2022
    • Dr Richard Thomas – GP with special interest in sustainability
    • Dr Sarah Williams, Salaried GP Crickhowell, Bevan Fellow in Sustainable Healthcare, Chair of Greener Practice Wales, Member of the WONCA (World Organisation of Family Drs) Working party on the Environment
    • Sian Evans, Consultant in Public Health, Primary Care Division, Public Health Wales, overseeing the Greener Primary Care Framework and award scheme
    • Dr Simon Barry – Respiratory Consultant, National Respiratory Clinical Lead

    Thank you to everybody who submitted a question for the Q&A section of the event. Unfortunately a number of these questions were not answered during the event due to time limitations, but written responses have been submitted by the expert panel:

    How did you decide on the inhaler targets (reduce MDI use to less than 20% by 2025)?

    They were written by the National Respiratory Clinical Lead for Wales, to align Wales with the best performing EU countries like Sweden.

    I am massively in favour of the switch from MDI to DPI but, all inhalers are thrown away after a month or so of use. I know there is a plan to take back all inhalers through Community Pharmacy and burn them, but this is hardly recycling. Can we do anything to push big pharma towards making inhalers that we can recycle?

    We would still encourage the return of inhalers to the community pharmacy for safe disposal along with all other unused medicines. Discussions are happening which will take a while to implement about the disposal of inhalers returned to pharmacies. If we can encourage patients to return them now when any changes happen it will be easier to implement.

    Today you have told the story starting from the climate crisis. Another story starts from asthma care and outcomes need improving (more ICS, less SABA) . Both stories start in a different place but merge to a common solution. My feeling is we need to link high-quality and low-carbon asthma care as two problems with a common solution and tell these stories together from the start? Have patients been involved? IF so what has been the response. Any catchy phrases? Ditch the blue? No blue without brown? Good asthma control with preventer inhaler = few if any symptoms and no need for your reliever?

    Good asthma care means keeping people out of hospital which is the biggest carbon emitter of healthcare.

    Green care and good care are perfectly aligned:

    1. Getting the diagnosis right. 25% of COPD patients (ca 20,000) and 33% of asthmatics (ca 100,000) have an incorrect diagnosis and do not require inhalers. The cost is Ca £20 million and the carbon cost is ca 20,000 tonnes of CO<sub>2</sub> equivalent. We have national plans about spirometry and FENO moving into diagnostic hubs
    2. Good care involves doing the basics well. Stopping smoking and exercise are far more effective in COPD than inhalers and rightly get priority on the national guidelines. We have national Welsh standard educational packages to ensure that practice nurses and GPs (and pharmacists) are delivering important basic care (eg asthma self management plans)
    3. Patient involvement and empowerment in managing their own disease (and being aware of climate issues) is crucial. We have created a suite of bilingual apps for patients with asthma and COPD and asthma for parents, which align with the guidelines and the green agenda

    I've heard of Ventolin Accuhaler, what is it's carbon footprint? How is it different to Evohaler?

    Ventolin Accuhaler has a carbon footrpint of less than 1 kgCO2e. It is a Dry Powder Inhaler and doesn’t contain the propellant used in a pressurised Metered Dose Inhaler. These propellants are fluorinated alkanes and greenhouse gases. Vnetolin Evohaler is a pMDI with a carbon footprint of 28kg CO2e.

    What do you suggest in young children i.e. under 5 where we commonly use mdi plus spacer due to inability to use dpi inhalers?

    Children under 5 would need to continue on a MDI with spacer.

    Salamol has half the carbon footprint of Ventolin and is as efficacious. Salamol should be prescribed in preference to Ventolin.

    Good control of asthma, prevention of needing hospital admission and prevention of any asthma risk factors are the best way to improve the sustainability of respiratory care.

    Making sure that the family has the asthma patient app and has watched the inhaler technique videos and has had their inhaler technique checked.

    The child should have an asthma care plan completed and reviewed, a peak flow meter prescribed, if clinically appropriate a steroid inhaler. The steroid inhaler could be prescribed as a higher dose but fewer puffs.

    The family should have advice to tell if their inhaler is empty and to take to the pharmacy for disposal or recycling and not to dispose of in the household waste.

    Is there a difference between DPIs in carbon footprint?

    DPIs can range in their indicative carbon footprint from 0.003 CO2Kg per dose to 0.034 CO2kg per dose. Values are stated per dose since the number of doses per inhaler ranges from 30 to 200.

    Source of information: AWTTC

    How do we manage patients that are on maximum triple therapy and still over using saba and requesting more than two a month and threatening to go to the LHB to say that we are refusing medication? patient referred to secondary care numerous times and DNA'd, Thanks

    In general patient education and empowerment is the key. Most patients when they learn about the adverse effects of their MDI are very happy to change in my experience. Also focussing on non-pharmacological interventions, e.g. exercise.

    Resistance related to Dpi have always been part of why clinicians felt that prescribing dpi is not the best decision and went by aerosols. Salbutamol easyhaler has highest resistance for example

    Prescribing practice is about culture, not really about whether patients can or cannot use inhalers. The vast majority can use DPI when trained and there are plenty of options of different devices. SABA are the least effective inhalers of all used, and the majority who use an MDI SABA, do not use it through a spacer, so it is completely ineffective. Its true that the easyhaler has one of the highest resistance, and some more severe COPD patients may not be able to generate sufficient inspiratory flow, but that will be a minority. In addition, we no longer recommend SABA for routine COPD care, only for exacerbation

    Not a question but also important to get the message out that we also need to dispose of inhalers safely

    This is very true.

    The IPAC inhaler return campaign is as a social media campaign involving multiple inhaler manufacturers and aims to promote safe inhaler disposal by returning them to community pharmacies. Expect to hear more from them in the future. I (Dr Richard Thomas) also plan to stamp the right hand side of my surgery’s WP10s advising patients where they should dispose of their used inhalers and why.

    Could a chip be added to the inhaler to notify patient/GP practice via an App when dosage is reaching 20% to instigate a re-order? This would measure patient usage to plan for expenditure on a cluster-by-cluster basis.

    This is an innovative idea and one which is not as far as we are aware currently available.

    Health Technologies Wales could be a good place to suggest this to in order to assess for feasibility. There is a plan for sustainability innovation hubs to be set up as part of the decarbonisation delivery, this idea will be suggested there also.

    What measures are in place to regularly review and re-assess patient’s respiratory function to ensure appropriate prescribing and correct technique of administration? This could reduce number of inhalers needed. Role for an Advanced Physio Practitioner in GP surgeries.

    National Welsh Standards educational packages give advice as to what to do at annual reviews, including checking inhaler technique, self management plans etc. There is no need to repeat spirometry if there is a high quality baseline, unless there is a change in clinical status.

    Is exercise being looked at as an alternative to inhaler prescription? Role for an Advanced Physio Practitioner in GP surgeries.

    Exercise is recognised as more valuable than inhalers (as is vaccination and stopping smoking) in line with the QUALY pyramid for COPD care. There are exercise components within the apps. We recognise the adverse impact of COVID on pulmonary rehabilitation, and it is likely that a variety of different sorts of interventions focussed on life style changes will be needed going forwards

    What steps is NHS Wales taking to make DPI prescribing the default when patients are started on a new inhaler (unless there is a specific reason that the patient needs an MDI)?

    That’s what the Welsh guidelines explicitly state, and what BTS recommends. There is also a QI project from Welsh Government to support this move

    LAUNCH EVENT RECORDING: NHS Wales Green Agenda – Sustainable Inhaler Prescribing

    On Friday 3rd December 2021 we held the launch event for NHS Wales Green Agenda – Sustainable Inhaler Prescribing

    Watch the recording of the event here.

    As part of the NHS Wales Decarbonisation Strategic Delivery Plan, this interactive 1-hour event focuses on how healthcare professionals involved in the care of respiratory patients, can help to tackle the climate crisis through sustainable inhaler prescribing.

    Foreword by: Eluned Morgan MS – Minister for Health and Social Services, Welsh Government
    *Due to the developing situation with the new COVID-19 variant, Eluned Morgan was unable to appear at the event.

    Chaired by: Natalie Proctor – Head of Pharmacy and Prescribing Branch, Welsh Government

    The expert panel includes:

    • Dr Stacey Harris – Paediatric doctor, Welsh Clinical Leadership Fellow in Sustainable Healthcare 2021/2022
    • Dr Richard Thomas – GP with special interest in sustainability
    • Dr Sarah Williams, Salaried GP Crickhowell, Bevan Fellow in Sustainable Healthcare, Chair of Greener Practice Wales, Member of the WONCA (World Organisation of Family Drs) Working party on the Environment
    • Sian Evans, Consultant in Public Health, Primary Care Division, Public Health Wales, overseeing the Greener Primary Care Framework and award scheme
    • Dr Simon Barry – Respiratory Consultant, National Respiratory Clinical Lead

    Thank you to everybody who submitted a question for the Q&A section of the event. Unfortunately a number of these questions were not answered during the event due to time limitations, but written responses have been submitted by the expert panel:

    How did you decide on the inhaler targets (reduce MDI use to less than 20% by 2025)?

    They were written by the National Respiratory Clinical Lead for Wales, to align Wales with the best performing EU countries like Sweden.

    I am massively in favour of the switch from MDI to DPI but, all inhalers are thrown away after a month or so of use. I know there is a plan to take back all inhalers through Community Pharmacy and burn them, but this is hardly recycling. Can we do anything to push big pharma towards making inhalers that we can recycle?

    We would still encourage the return of inhalers to the community pharmacy for safe disposal along with all other unused medicines. Discussions are happening which will take a while to implement about the disposal of inhalers returned to pharmacies. If we can encourage patients to return them now when any changes happen it will be easier to implement.

    Today you have told the story starting from the climate crisis. Another story starts from asthma care and outcomes need improving (more ICS, less SABA) . Both stories start in a different place but merge to a common solution. My feeling is we need to link high-quality and low-carbon asthma care as two problems with a common solution and tell these stories together from the start? Have patients been involved? IF so what has been the response. Any catchy phrases? Ditch the blue? No blue without brown? Good asthma control with preventer inhaler = few if any symptoms and no need for your reliever?

    Good asthma care means keeping people out of hospital which is the biggest carbon emitter of healthcare.

    Green care and good care are perfectly aligned:

    1. Getting the diagnosis right. 25% of COPD patients (ca 20,000) and 33% of asthmatics (ca 100,000) have an incorrect diagnosis and do not require inhalers. The cost is Ca £20 million and the carbon cost is ca 20,000 tonnes of CO<sub>2</sub> equivalent. We have national plans about spirometry and FENO moving into diagnostic hubs
    2. Good care involves doing the basics well. Stopping smoking and exercise are far more effective in COPD than inhalers and rightly get priority on the national guidelines. We have national Welsh standard educational packages to ensure that practice nurses and GPs (and pharmacists) are delivering important basic care (eg asthma self management plans)
    3. Patient involvement and empowerment in managing their own disease (and being aware of climate issues) is crucial. We have created a suite of bilingual apps for patients with asthma and COPD and asthma for parents, which align with the guidelines and the green agenda

    I've heard of Ventolin Accuhaler, what is it's carbon footprint? How is it different to Evohaler?

    Ventolin Accuhaler has a carbon footrpint of less than 1 kgCO2e. It is a Dry Powder Inhaler and doesn’t contain the propellant used in a pressurised Metered Dose Inhaler. These propellants are fluorinated alkanes and greenhouse gases. Vnetolin Evohaler is a pMDI with a carbon footprint of 28kg CO2e.

    What do you suggest in young children i.e. under 5 where we commonly use mdi plus spacer due to inability to use dpi inhalers?

    Children under 5 would need to continue on a MDI with spacer.

    Salamol has half the carbon footprint of Ventolin and is as efficacious. Salamol should be prescribed in preference to Ventolin.

    Good control of asthma, prevention of needing hospital admission and prevention of any asthma risk factors are the best way to improve the sustainability of respiratory care.

    Making sure that the family has the asthma patient app and has watched the inhaler technique videos and has had their inhaler technique checked.

    The child should have an asthma care plan completed and reviewed, a peak flow meter prescribed, if clinically appropriate a steroid inhaler. The steroid inhaler could be prescribed as a higher dose but fewer puffs.

    The family should have advice to tell if their inhaler is empty and to take to the pharmacy for disposal or recycling and not to dispose of in the household waste.

    Is there a difference between DPIs in carbon footprint?

    DPIs can range in their indicative carbon footprint from 0.003 CO2Kg per dose to 0.034 CO2kg per dose. Values are stated per dose since the number of doses per inhaler ranges from 30 to 200.

    Source of information: AWTTC

    How do we manage patients that are on maximum triple therapy and still over using saba and requesting more than two a month and threatening to go to the LHB to say that we are refusing medication? patient referred to secondary care numerous times and DNA'd, Thanks

    In general patient education and empowerment is the key. Most patients when they learn about the adverse effects of their MDI are very happy to change in my experience. Also focussing on non-pharmacological interventions, e.g. exercise.

    Resistance related to Dpi have always been part of why clinicians felt that prescribing dpi is not the best decision and went by aerosols. Salbutamol easyhaler has highest resistance for example

    Prescribing practice is about culture, not really about whether patients can or cannot use inhalers. The vast majority can use DPI when trained and there are plenty of options of different devices. SABA are the least effective inhalers of all used, and the majority who use an MDI SABA, do not use it through a spacer, so it is completely ineffective. Its true that the easyhaler has one of the highest resistance, and some more severe COPD patients may not be able to generate sufficient inspiratory flow, but that will be a minority. In addition, we no longer recommend SABA for routine COPD care, only for exacerbation

    Not a question but also important to get the message out that we also need to dispose of inhalers safely

    This is very true.

    The IPAC inhaler return campaign is as a social media campaign involving multiple inhaler manufacturers and aims to promote safe inhaler disposal by returning them to community pharmacies. Expect to hear more from them in the future. I (Dr Richard Thomas) also plan to stamp the right hand side of my surgery’s WP10s advising patients where they should dispose of their used inhalers and why.

    Could a chip be added to the inhaler to notify patient/GP practice via an App when dosage is reaching 20% to instigate a re-order? This would measure patient usage to plan for expenditure on a cluster-by-cluster basis.

    This is an innovative idea and one which is not as far as we are aware currently available.

    Health Technologies Wales could be a good place to suggest this to in order to assess for feasibility. There is a plan for sustainability innovation hubs to be set up as part of the decarbonisation delivery, this idea will be suggested there also.

    What measures are in place to regularly review and re-assess patient’s respiratory function to ensure appropriate prescribing and correct technique of administration? This could reduce number of inhalers needed. Role for an Advanced Physio Practitioner in GP surgeries.

    National Welsh Standards educational packages give advice as to what to do at annual reviews, including checking inhaler technique, self management plans etc. There is no need to repeat spirometry if there is a high quality baseline, unless there is a change in clinical status.

    Is exercise being looked at as an alternative to inhaler prescription? Role for an Advanced Physio Practitioner in GP surgeries.

    Exercise is recognised as more valuable than inhalers (as is vaccination and stopping smoking) in line with the QUALY pyramid for COPD care. There are exercise components within the apps. We recognise the adverse impact of COVID on pulmonary rehabilitation, and it is likely that a variety of different sorts of interventions focussed on life style changes will be needed going forwards

    What steps is NHS Wales taking to make DPI prescribing the default when patients are started on a new inhaler (unless there is a specific reason that the patient needs an MDI)?

    That’s what the Welsh guidelines explicitly state, and what BTS recommends. There is also a QI project from Welsh Government to support this move

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