Identifying High Greenhouse Gas Intensity Prescription Items for NHS in England. Final Report. February 2014

Transcription

1 Identifying High Greenhouse Gas Intensity Prescription Items for NHS in England Final Report February 2014 Delivering sustainable solutions in a more competitive world

2 Sustainable Development Unit Identifying High Greenhouse Gas Intensity Prescription Items for NHS in England Final Report February 2014 Prepared by Tom Penny and Michael Collins For and on behalf of Environmental Resources Management Approved by: Charles Allison Signed: Position: Partner Date: 13 th February 2014 This report has been prepared by Environmental Resources Management the trading name of Environmental Resources Management Limited, with all reasonable skill, care and diligence within the terms of the Contract with the client, incorporating our General Terms and Conditions of Business and taking account of the resources devoted to it by agreement with the client. We disclaim any responsibility to the client and others in respect of any matters outside the scope of the above. This report is confidential to the client and we accept no responsibility of whatsoever nature to third parties to whom this report, or any part thereof, is made known. Any such party relies on the report at their own risk.

3 SUMMARY The greenhouse gas (GHG) emissions associated with procurement of goods and services account for a significant proportion of the climate change impact of global healthcare yet little is known as to which products should be prioritised as the most significant contributors to this impact, based on scale and intensity of their contribution. This report focuses on identifying the likely priorities from all the pharmaceutical prescription items procured by NHS in England. Once these items are identified, targeted measurement through their manufacture and prescription can be considered as a next step. Data to support this analysis is sourced from the NHS England 2011 Prescription Cost Analysis and Hospital Prescribing England, 2011 data. These data describe the quantity and cost of pharmaceuticals prescribed for NHS in England and capture over 80% of individual prescribed items in 2011 based on cost. From combining these prescription inventories it was possible to screen the data in a number of ways to identify the priority prescription items for further investigation. Volume and expenditure of prescription items were used as indicators of GHG emissions. Further refinement was possible based on understanding of the drivers for GHG intensity for pharmaceuticals established elsewhere. The type of pharmaceutical and quantity of active pharmaceutical ingredient (API) have been analysed as a result. The following high priority prescription items were identified for action. They are anticipated to account for more than 60% of the overall footprint of prescription items, expenditure on prescription items, and quantity of API procured. Priority List Identified for Further Investigation (in Alphabetical Order) BNF CHEMICAL NAME Adalimumab Amoxicillin Atorvastatin Beclometasone Dipropionate Budesonide Co-Codamol (Codeine Phos/Paracetamol) Co-Dydramol (Dihydrocodeine/Paracet) Enteral Nutrition Etanercept Fluticasone Propionate (Inh) Gabapentin Ibuprofen Metformin Hydrochloride Naproxen Paracetamol Salbutamol Simvastatin Sodium Valproate Sulfasalazine Tiotropium To explore reduction opportunities associated with the manufacture and use of pharmaceuticals a suggested route map includes the voluntary formation of groups of suppliers of common pharmaceuticals that commit to measuring the GHG emissions of the item across its lifecycle, using the GHG Accounting 1

4 Sector Guidance for Pharmaceutical Products and Medical Devices. Strategies to reduce the GHG intensity of those items that are confirmed to be high emitters could then be considered. Concurrently, reductions should be made in the way these pharmaceuticals are used as part of treatment pathways to reduce their wastage and improve efficiency. There is a strong need to develop guidelines to allow for consistent quantification of models of care so that options can be appraised and reductions properly quantified. This assessment has been undertaken to attempt to identify the most significant contributions of pharmaceuticals procured to the NHS carbon footprint. It is anticipated that this will be further refined and extended to include medical devices and their contribution to the GHG emissions estimated for NHS in England. 2

5 1 INTRODUCTION The Carbon Footprint updates for NHS in England 2012 report calculates the GHG impact of NHS in England to be 24.7 Mt CO 2e (1). The GHG emissions from procurement were estimated in the report as 15.2 Mt CO 2e, representing 61% of the total footprint. Of this, 5.1 Mt CO 2e is attributed to the procurement of pharmaceuticals representing 21% of the total footprint (2). A limitation of this assessment is that the carbon footprint estimate for pharmaceuticals does not distinguish between the thousands of prescription items procured and so cannot identify which of these items are the most significant contributors. For rapid cost effective reductions to be achieved it is necessary to prioritise the top contributors to GHG emissions, appraise where in the value chain (eg manufacturing, use, disposal, etc) those emissions occur, identify reduction opportunities and intervene. In 2012, the SDU initiated the creation of a GHG Accounting Sector Guidance for Pharmaceutical Products and Medical Devices (3), to allow for more consistent quantification of the GHG emissions of healthcare products from creation of the products, through use to disposal. The application of this guidance to priority pharmaceuticals will be a cornerstone of any reduction route map as it will identify where in the value chain, the specific processes, those emissions occur and identify reduction opportunities. (1) NHS in England Carbon Footprint, 2013, (2) GHG emission contribution is a function of life cycle GHG intensity through manufacture to use and disposal per item multiplied by the number of items purchased. (3) GHG Accounting Sector Guidance for Pharmaceuticals and Medical Devices, 2012, 3

6 2 METHOD FOR PRIORITISATION OF PRESCRIPTION ITEMS 2.1 PRESCRIPTION ITEM DATA The cost of prescription items procured by NHS in England in 2011 was 13.1 billion. There is no single inventory of pharmaceutical purchases by the NHS and a combination of two readily available data sets was necessary: 2011 Prescription Cost Analysis (PCA) data (1) ; and Hospital Prescribing England, 2011 data (2). The hospital prescription data were only available at time of assessment for PCA data for both 2011 and 2012 were available however 2011 data were used to ensure consistency between datasets when incorporating hospital prescription data. The objective is to identify prescription items for action as a function of scale and intensity of GHG emissions, the choice of 2011 over 2012 is considered reasonable in this context. NHS England PCA data describe the prescription of items written by general medical practitioners, non-medical prescribers and dispensed in England. Dentist and hospital doctor prescriptions are also included provided they are dispensed in the community. Items dispensed within hospitals or on private prescriptions are not included. Hospital prescribing data are combined with these data and include only National Institute for Health and Care Excellence (NICE) approved pharmaceuticals. Of the 13.1 billion spent on prescriptions in 2011, 10.6 billion is included in these combined datasets representing over 80% of expenditure on prescription items. The 2.5 billion of expenditure not accounted for in these datasets is believed to be associated with prescriptions written in England and dispensed elsewhere, where items were supplied in hospitals and no prescription is generated and items supplied via homecare. Items dispensed through private prescriptions are not included. Within the PCA data, relevant information associated with each individual prescription item includes the cost per item ( /item), total expenditure ( ) and total quantity prescribed. Total quantity prescribed is either by a unit (eg one tablet, capsule, pack, aerosol, etc), millilitres, grams or individually formulated unit. Hospital prescribing data are provided by total expenditure of NICE approved pharmaceutical categories only. These combined datasets represent 21,717 individual prescription items (Drug Name) that are split into 1,633 therapeutic classifications (BNF Chemical Name). (1) NHS England, 2012 Prescription Cost Analysis, (2) Hospital Prescribing - England, 2011, 4

7 2.2 PRIORITISATION From an inventory of procured prescription items it is possible to screen the data in a number of ways to identify key items for reduction. Mass and price are often used as indicators of environmental impact and as a mechanism for prioritisation. However, this is not necessarily fool-proof in that there are examples of where mass, price and life cycle GHG emissions do not correlate. As a general rule the production of the API is the major source of GHG emission for a pharmaceutical product, therefore total mass of API purchased is considered a better route to prioritisation than total product quantity. There are however exceptions to this rule and a notable example is the GHG emissions associated with propellant driven inhalers where the potent gases released during the use of the inhaler far outweigh the GHG intensity of manufacturing the item. The following prioritising approaches have been employed: Cost (expenditure); Quantity (mass of API); and GHG intensity x quantity. Where GHG intensity data are available for an API these have been applied to the relevant prescription item (eg paracetamol). Where the GHG intensity of API manufacture were not available an average GHG intensity has been used based upon expert guidance from pharmaceutical manufacturers, who have experience of carbon footprinting APIs, formulated and packaged products, and categories of products. For example, GlaxoSmithKline (GSK) have undertaken carbon footprint appraisals of a wide range of pharmaceuticals. Formulae to estimate the GHG emissions associated with broad categories of products have been kindly provided for use in this appraisal. Examples of categories include, metered dose inhalers, vaccines, patches and nebules. Furthermore, where prescription data did not include an API or allow the API to be identified and quantified (names did not include dose strength of active ingredient) Environmental Resources Management (ERM) has used its experience of footprinting thousands of food and consumer good products to estimate the GHG intensity of these items (eg for protein shakes, gluten free bread, etc). 5

8 2.2.1 Data Handling PCA data include cost and quantity of individual prescription items whilst hospital prescribing data provides pharmaceutical prescription categories by cost only. Estimates of quantities procured within the hospital prescribing data were determined by identifying the most likely prescription item within each category from PCA data and the British National Formulary (1) eg Gabapentin 300mg Capsules were used as an approximation for Gabapentin. Expenditure on each prescription item was summed by therapeutic classification (BNF Chemical Name). This priority list based on cost is presented in the results section of this report. Next a priority list was developed based upon quantity of prescription item. A range of units are used to describe the quantity of individual prescription items and so it was not possible to simply sum the quantity of prescription items as was possible when analysing cost. Knowing that API is often significant to the life cycle carbon footprint of pharmaceuticals, an estimate of the mass of API in each prescription item was calculated and summed according to therapeutic classification (BNF Chemical Name) and presented in the results section. To determine this API quantity priority list the dose strength of each individual prescription item was identified and multiplied by the quantity provided in the data to determine the total mass of API prescribed for each item. An example of this is below: Paracet_Tab 500mg : dose strength (500mg) * Quantity (1.94 billion units) = tonnes of API. Next, using the prescription item quantity data and mass of API data, the GHG intensity estimates per item type or API were applied to each prescription item and a priority list generated based upon an estimate of GHG emissions. These GHG estimates were summed and reported by therapeutic classification in the results section. An attempt was made to apply a GHG intensity estimate to all 21,717 individual prescription items. To do this the following method has been employed in the following hierarchy using API quantities, prescription quantities and prescription categories. Where an estimate of the GHG intensity of a prescription item is available this has been multiplied by the prescription item quantity to determine the item s total GHG emissions. Examples include metered dose inhalers (1) British National Formulary, 6

9 (where the majority GHG emissions from the product are known to be in use), protein shakes, gluten free bread, etc. Where an estimate of the GHG intensity of the prescription item is not available but where API quantity data have been calculated, the mass of API has been multiplied by an estimate of the GHG intensity of that API to calculate GHG emissions. Where neither an estimate of the GHG intensity of the prescription item nor API data are available, an estimate of the GHG intensity of the item is calculated from the pharmaceutical category equations provided by GSK. To match the prescription item to category of GHG estimate provided by GSK a semi-automated approach was used for item classification as shown in the example below: Salbutamol_Inha 100mcg (200 D) CFF was identified as being an inhaler due to the _Inha within the item name. Due to the large dataset size checks were made on individual prescription items with over 1 million expenditure to ensure their API is calculated and they are categorised appropriately. The total value of all 1,424 prescription items with over 1 million expenditure is 9.3 billion, representing 87% of total prescription expenditure considered in these data. Many of the GHG calculations for prescription items have a large degree of uncertainty due to the estimates of GHG intensity. This is considered below but some significant variation is likely to exist in the results. 7

10 3 RESULTS Three variants of top priority list are presented based upon cost, quantity of API prescribed and estimate of GHG emissions and further aggregated by therapeutic classifications (BNF Chemical Name). 3.1 TOP CONTRIBUTORS BY COST Cost associated with prescription items is considered to be a useful metric for broadly understanding the GHG impact of items. The most significant expenditure by each therapeutic classification are summarised below. Table 3.1 Top 20 Therapeutic Classifications (BNF Chemical Name) Contributions by Cost ( ) BNF CHEMICAL NAME Cost ( ) Percentage contribution to total (%) Fluticasone Propionate (Inh) 387,886, % Atorvastatin 317,849, % Adalimumab 225,834, % Etanercept 217,633, % Enteral Nutrition 212,836, % Budesonide 161,963, % Glucose Blood Testing Reagents 156,583, % Ranibizumab 155,163, % Pregabalin 153,244, % Tiotropium 149,814, % Olanzapine 132,819, % Quetiapine 112,818, % Infliximab 111,053, % Trastuzumab 107,619, % Rituximab 106,442, % Beclometasone Dipropionate 98,956, % Candesartan Cilexetil 86,157, % Insulin Glargine 79,194, % Donepezil Hydrochloride 78,139, % Ezetimibe 72,493, % Total of top 20 list 3,124,503,683 29% Total of all therapeutic classification categories 10,640,965, TOP CONTRIBUTORS BY ACTIVE PHARMACEUTICAL INGREDIENT Based on the names of individual prescription items, the dose strength has been multiplied by the quantity given in the prescription data to estimate the total quantity of API prescribed for each therapeutic classification (BNF Chemical Name). 8

11 Table 3.2 Top 20 Therapeutic Classification Contributions by Quantity of API (kg) BNF CHEMICAL NAME Quantity of API (kg) Percentage contribution by quantity % Ranking based on cost (1 being highest) Paracetamol 1,093, % 36 Co-Codamol (Codeine Phos/Paracetamol) 867, % 25 Metformin Hydrochloride 837, % 23 Co-Dydramol (Dihydrocodeine/Paracet) 181, % 194 Ibuprofen 108, % 118 Amoxicillin 100, % 140 Gabapentin 95, % 67 Naproxen 93, % 148 Mesalazine (Systemic) 87, % 30 Aspirin 83, % 87 Sodium Valproate 69, % 76 Sulfasalazine 52, % 185 Simvastatin 51, % 29 Flucloxacillin Sodium 49, % 95 Tramadol Hydrochloride 48, % 53 Carbocisteine 46, % 131 Carbamazepine 38, % 129 Ferrous Fumarate 38, % 371 Ferrous Sulphate 36, % 247 Gliclazide 34, % 114 Total of top 20 list 4,013,467 77% Total of all therapeutic classification categories (BNF Chemical Name) 5,239, TOP CONTRIBUTORS BY GREENHOUSE GAS EMISSIONS The top 20 estimates of GHG emissions for therapeutic classifications are shown below based upon the method described in Section 2. The total GHG emissions is estimated at approximately 5.9 Mt CO 2e based on the 10.6 billion of prescription items included. If this were scaled to account for the missing prescription items the total estimated GHG emissions would be 7.3 Mt CO 2e based on 13.1 billion expenditure on prescription items. The top 20 therapeutic classifications (BNF Chemical Name) represent 60% (3.5 Mt CO 2e) of the total estimated GHG emissions for the 10.6 billion of prescription items considered. Table 3.3 Top 20 Therapeutic Classification Contributions by GHG Emissions (in Alphabetical Order) BNF CHEMICAL NAME GHG Estimate Rank based on Quantity of API Rank based on Cost Allopurinol Beclometasone Dipropionate Carbamazepine Carbocisteine

12 BNF CHEMICAL NAME GHG Estimate Rank based on Quantity of API Rank based on Cost Co-Codamol (Codeine Phos/Paracetamol) 2 25 Enteral Nutrition Fluticasone Propionate (Inh) Gabapentin 7 67 Gliclazide Levetiracetam Mesalazine (Systemic) 9 30 Metformin Hydrochloride 3 23 Naproxen Ranitidine Hydrochloride Salbutamol Simvastatin Sodium Valproate Sulfasalazine Tiotropium Tramadol Hydrochloride Note: GHG estimate not known and top 20 BNF Chemical Name categories are listed in alphabetical order. 3.4 PHARMACEUTICAL GHG FOOTPRINT Although a preliminary estimate of GHG emissions, the total for pharmaceuticals procurement for NHS in England is estimated as 5.9 Mt CO 2e. Considering the total procurement expenditure of 10.6 billion, this gives a GHG intensity of 0.55 kg CO 2e/. Scaling to 13.1 billion the GHG emissions for all prescription items is estimated as 7.3 Mt CO 2e For pharmaceuticals procurement the Carbon Footprint Update for NHS in England 2012 reports a total of 5.1 Mt CO 2e. There is uncertainty related with the calculations described (discussed in the section below) and the small differences between bottom up and top down estimates to the pharmaceutical carbon footprint is reassuring. 3.5 SENSITIVITY OF RESULTS It is worth investigating whether the top 20 items would lose their significance with a change in the GHG intensity estimates. If the GHG estimated impact of each of the top 20 therapeutic classification categories (BNF Chemical Name) were halved, all of the categories would remain in the top 50 significant contributions and if they were reduced by a factor of 10 they would still be present in the top 150 categories out of a total of 1,633 categories. A specific example is the inclusion of metformin hydrochloride that would require a reduction in the GHG API estimate by a factor of more than 25 before it is no longer present in the top 20 list in Table

13 Although the order of the GHG impact list may change based upon variation of the GHG estimates used, it is likely that this list broadly covers the most significant pharmaceutical procurement categories for NHS in England. 11

14 4 PRIORITY PRESCRIPTION ITEMS It s likely that the most significant prescription items to the GHG emissions of NHS in England are a function of the total expenditure, quantity of materials procured and estimates of GHG emissions. The following list is a combination of all top 20 prescription items (BNF Chemical Name) for cost, quantity of API and GHG estimate. This represents 44 therapeutic classifications out of 1,633. Table 4.1 Priority List of Prescription Items Including Top 20 Items for Cost, Quantity and GHG Estimate (in Alphabetical Order) BNF CHEMICAL NAME Adalimumab Allopurinol Amoxicillin Aspirin Atorvastatin Beclometasone Dipropionate Budesonide Candesartan Cilexetil Carbamazepine Carbocisteine Co-Codamol (Codeine Phos/Paracetamol) Co-Dydramol (Dihydrocodeine/Paracet) Donepezil Hydrochloride Enteral Nutrition Etanercept Ezetimibe Ferrous Fumarate Ferrous Sulphate Flucloxacillin Sodium Fluticasone Propionate (Inh) Gabapentin Gliclazide Glucose Blood Testing Reagents Ibuprofen Infliximab Insulin Glargine Levetiracetam Mesalazine (Systemic) Metformin Hydrochloride Naproxen Olanzapine Paracetamol Pregabalin Quetiapine Ranibizumab Ranitidine Hydrochloride Rituximab Salbutamol Simvastatin Sodium Valproate Sulfasalazine Tiotropium Tramadol Hydrochloride Trastuzumab Furthermore, 20 prescription categories have been suggested below as requiring further investigation. This list has been identified by aggregating the ranking for cost, quantity and GHG estimate of all 44 categories above and reordering. This was undertaken to ensure significant items in cost, quantity and GHG estimate are included. The following list of 20 prescription categories includes at least the top three prescription categories and over 60% of the contribution for each of the cost, quantity of API and GHG estimate calculations. The BNF Section Name related to each high priority BNF Chemical Name is also included. 12

15 Table 4.2 Top 20 Priority List Identified for Further Investigation (in Alphabetical Order) BNF CHEMICAL NAME Adalimumab Amoxicillin Atorvastatin Beclometasone Dipropionate Budesonide Co-Codamol (Codeine Phos/Paracetamol) Co-Dydramol (Dihydrocodeine/Paracet) Enteral Nutrition Etanercept Fluticasone Propionate (Inh) Gabapentin Ibuprofen Metformin Hydrochloride Naproxen Paracetamol Salbutamol Simvastatin Sodium Valproate Sulfasalazine Tiotropium ASSOCIATED BNF SECTION NAME Drugs Used In Rheumatic Diseases & Gout Antibacterial Drugs Lipid-Regulating Drugs Corticosteroids (Respiratory) Corticosteroids (Respiratory) Analgesics Analgesics Oral Nutrition Drugs Used In Rheumatic Diseases & Gout Corticosteroids (Respiratory) Antiepileptics Soft-Tissue Disorders & Topical Pain Rel Drugs Used In Diabetes Drugs Used In Rheumatic Diseases & Gout Analgesics Bronchodilators Lipid-Regulating Drugs Antiepileptics Chronic Bowel Disorders Bronchodilators It is worth noting that some BNF Chemical Name categories contain multiple active ingredients that are not identified through BNF characterisation. For example, by cost 96% of the BNF Chemical Name category Fluticasone Propionate (Inh) are combination inhalers that contain both fluticasone propionate and salmeterol yet these are not accounted for under the Salmeterol BNF Chemical name. 13

16 5 DISCUSSION The purpose of this report was to prioritise 20 of the 1633 therapeutic classification categories (BNF Chemical Name) so target further investigation into the most likely significant prescription items to the NHS in England carbon footprint. This is seen as the logical next step following the determination of the significance of pharmaceuticals and medical devices in the NHS in England carbon footprint and the development of guidance on how to appraise the carbon footprints of these products. By combining the most significant prescription item categories for cost, quantity and GHG intensity a list of 44 categories were identified for further investigation. This list was further refined based upon the significance to cost, quantity of API and GHG emissions to produce a priority list of 20 prescription item categories as shown below. Table 5.1 Top 20 Priority List Identified for Further Investigation (in Alphabetical Order) BNF CHEMICAL NAME Adalimumab Amoxicillin Atorvastatin Beclometasone Dipropionate Budesonide Co-Codamol (Codeine Phos/Paracetamol) Co-Dydramol (Dihydrocodeine/Paracet) Enteral Nutrition Etanercept Fluticasone Propionate (Inh) Gabapentin Ibuprofen Metformin Hydrochloride Naproxen Paracetamol Salbutamol Simvastatin Sodium Valproate Sulfasalazine Tiotropium It is recommended to use this priority list to develop specific pharmaceutical reduction route maps. A suggested approach for each prescription item category is: to measure the GHG emissions of significant prescription items. For those items confirmed to by significant GHG emitters: identify the hotspots and reduction opportunities ; develop a reduction strategy; re-measure the GHG emissions of the prescription items; and re-prioritise the list of significant prescription item categories. We suggest lessons are taken from other sectors such as clothing and food where voluntary groups of suppliers of common pharmaceuticals are formed 14

17 to develop route maps, share experiences and quantify footprints and aggregate reductions. As example, for metformin hydrochloride we suggest manufacturers (eg Aurobindo Pharma - Milpharm Ltd, Boehringer Ingelheim Limited, Bristol Myers Squibb-AstraZeneca EEIG, Consilient Health Ltd, Merck Serono, Merck Sharp & Dohme Limited, Novartis Pharmaceuticals UK Ltd, Rosemont Pharmaceuticals Limited, Takeda UK Ltd, Wockhardt UK Ltd and Zentiva (1) ) are invited to form a group to commit to a route map that will see reductions achieved and the average GHG intensity to be calculated and reported periodically to the NHS. This will allow the NHS to capture more accurately the contribution of metformin hydrochloride to its footprint and to capture the reductions in line with its target to reduce its overall NHS carbon footprint. Finally it is recommended that a similar investigation is undertaken into medical devices procured by NHS in England to ensure that initiatives to achieve GHG reductions in medical device procurement are targeted at the largest contributors to the NHS footprint. (1) Electronic Medicines Compendium, search for Metformin Hydrochloride, accessed 23rd Jan 2014, 15