Challenge 10.8

Why does this Challenge need to be solved?

• NHS Scotland’s annual spend on pharmaceuticals is approximately £2.3 billion across primary and secondary care. This has a significant impact on NHS Scotland’s carbon footprint with pharmaceuticals being responsible for circa 25% of the NHS’s carbon footprint based on NHSE calculations.

• The vast majority of prescribed medicines are used outside NHS facilities, for example patient medicines on discharge, repeat and acute prescriptions are collected at community pharmacies and used in facilities like care homes or in the home.

• Waste of prescribed pharmaceutical items is a major issue in terms of financial cost and environmental impact. In 2015 NHS England conservatively estimated that at least £300 million is spent on unused medicines.

• During the 20-month period in NHS Scotland (from 28 February 2019 to 5 November 2020), 829.140 kg of pharmaceutical waste returns was collected from community pharmacies which equates to 1 tonne of medicines waste per day equating to 1.1 tonne of carbon dioxide emissions attributed to incineration.

• These figures do not include environmental impact and pollution which results from improper disposal of unused medicines e.g. in domestic rubbish or flushed down toilets.

• Unnecessary and excessive prescribing is harmful and costly. In Scotland adjusting or removing unnecessary/harmful medicine in the over 65 population is projected to conservatively reduce direct expenditure on medicines by £77 million & cost associated with hospital admissions due medicine harm by £36 million per annum based on Scottish population estimates.

• Based on pilot work undertaken in the Netherlands and in Europe but working within the current MHRA legislative constraints Scotland with appropriate innovation may be able to save GBP 20 million on restocking, reabsorbing and redistributing medicines.

There are two main interlinked components to this challenge that require addressing. Respondents to this challenge should consider tackling either singularly or both together, one being preventative and the other being a circular return of good to ensure every dose is utilised. 

1. Prevention (upstream): this workstream will look at work that can be done before or during the point of prescribing to prevent over or unnecessary dispensing of medicine. We are interested in tools, ideas and technologies that support the avoidance of superfluous prescribing, reduce over-ordering, improve stock control, prevent expiry, and allow rotation and redistribution of medicines of short dates medicines to high intensity areas and prevent medicines waste through improving patient adherence and promotion of non-pharmacological measures.

2. Returns (downstream): this workstream will explore ways of allowing dispensed but unused medicine back into circulation. Respondents should address the problem 1. within the context of legislative framework and 2. provide solutions that can support legislative changes for the reuse of medicines more widely. 

This is a highly regulated area, and strict controls are in place which prohibit the use of returned stock. Within Scotland there is no systematic opportunity to reintroduce unused medicines back into the pharmaceutical supply chain, due to legislative, industrial, and psychological barriers which are currently in place.

NHS Scotland and the Scottish Government are keen to assess technological solutions that can satisfy safety standards allowing unused agents to be reabsorbed into the supply chain for redistribution. These may include RFID sensing and IOT approaches to monitoring storage, traceability, stability and antitampering.

Opportunities for consideration:

• Review of meaningful expiry dates (could these be extended)

• Assurance of safe storage at the correct temperature

• Proof of nil-tampering

• Improved stock control procedures

• Opportunities to reduce unwanted / un-used medicines or inhalers, for example by ensuring appropriate prescribing and regular medication reviews

• Maximization of preventative treatment

• Solutions (potentially digital) that support sustainable prescribing

• How can NHS Scotland engage with people who order and use medication (including those in care homes) to reduce waste, ensure continued need for any medicine?

• How can we improve the patient experience using medication?

• What are the parameters and restrictions of any system?

• Can these solutions be used by health care services elsewhere, but also potentially marketed to pharmaceutical companies as they support circular economy initiatives. 

How will we know the Challenge has been solved?

There needs to be a clear downward trajectory against the following indicators -

• Medicines prescribed

• Hospital admissions associated with harm from medicines

• Medicine expenditure: GBP

• Pharmaceutical waste entering incineration via community pharmacy

• Pharmaceutical waste entering incineration from NHS hospitals

• Pharmaceutical waste other sources

Case study 1. Reduce medicines prescribed

An elderly woman returns a large bag of medicines to the pharmacy, which are not needed, including multiple packs of tramadol (a strong pain killer), tubes of emollients and lots of inhalers that have never been used. Currently, these medicines must be destroyed by incineration. A 20 item bag of high turnover items such as this would cost in the region of £200-300 and weigh about 2 kg releasing 2.2 kg of CO2e on incineration.

This situation has occurred due to automatic reordering of items that are not needed. Ideally, a medication review would identify what medication is needed for the desired outcomes, reducing the inadvertent over-stocking/ over-ordering of medication by the patient and avoid the return of unused medicines reducing the environmental impact of these.

Case study 2. Reuse in-date safe stock

A middle-aged man receiving biologic therapy for inflammatory arthritis, via home delivery prescription service. His therapy has been changed; now he has been left with two months of stock in his home refrigerator. This stock cannot at present be reused under current guidance and the lack of assurance of storage conditions. Once this stock is returned it will be treated as waste and incinerated. These are high value medicines amounting to £2500 not including carbon cost of manufacture, transport and disposal.

An ideal scenario would potentially include the home delivery team applying reverse supply logistics to enable the stock to be reissued, provided that there was a guarantee that the medication had been stored safely at the correct temperature and not been tampered with.

Case study 3. Reduce harm

A young man was prescribed Oramorph (morphine) liquid and diazepam tablets as a single prescription. However, the system defaulted to a repeat prescription and the patient received the morphine liquid and diazepam on a regular basis without review. This led to the ingestion of an overdose of morphine and diazepam and consequent medicine related harm. Ideally this should never have happened - how can we prevent this error with our prescribing system?

Who are the end users likely to be?

• Scottish Government and NHS Scotland initially but also the wider pharmaceutical supply chain, including manufacturers and/or distributors.

• Scottish public users of medicines, pharmacies (both primary and secondary care), pharmaceutical manufacturers and suppliers will be impacted in delivery of a system which allows the return of previously issued prescription medicines. There will be global interest in such solutions.

Has the Challenge Sponsor attempted to solve this problem before?

Due to the complex nature of this issue, there is little evidence of others trying to procure a solution for the challenge. Some initial schemes e.g. Netherlands have recently developed a protocol to allow for reuse high value oncology medicines. Additional academic analysis has been conducted to promote the reuse of medicines within a contained environment, such as Hospitals Trusts or Boards

Here is a list of resources for respondents to review and consider:

• Project against waste of expensive medicines will be followed up nationwide - Redistributing expensive medicines can save millions of euros - Radboudumc A project in the Netherlands to reuse and recycle expensive cancer medicines.

• https://www.mdpi.com/2226-4787/8/4/221 Can We Create a Circular Pharmaceutical Supply Chain (CPSC) to Reduce Medicines Waste?

• https://www.mdpi.com/2226-4787/8/2/58 - paper on Enhancing Pharmaceutical Packaging through a Technology Ecosystem to Facilitate the Reuse of Medicines and Reduce Medicinal Waste.

• Pharmacy | Free Full-Text | Can We Create a Circular Pharmaceutical Supply Chain (CPSC) to Reduce Medicines Waste? (mdpi.com) – 2023 academic paper considers various blockers to progress with creating a CPSC and suggests a system for beginning to address the issue, dealing with the various barriers encountered in relation thereto.

Are there any interdependencies or blockers?

• UK regulations regarding reuse of pharmaceuticals

• Falsified Medicines Directive, EU Directive not relevant to the UK but impacts EU market penetration

• Resource at pharmacy level and funding arrangements to community pharmacy

• Public behavior towards the reuse of medicines. Recent Citizen panel suggested public support for reuse of medicines

• Solutions that increase the workload of pharmacy services and other health worker are of low value

• Solutions that are difficult to navigate will have low value

• Solutions that induce a moral hazard – such as over prescribing are of low value

• Solutions that allow the cost benefit to be realized by both the NHS and the NHS provider (GP, Pharmacy) are of high value

Will a solution need to integrate with any existing systems / equipment?

Depending on the nature of the solution proposed applicants may need to align with existing systems and or infrastructure such as:

• UK regulations regarding reuse of pharmaceuticals

• Falsified Medicines Directive, EU Directive not relevant to the UK but impacts EU market penetration

• Scottish Therapeutic Utilities (STU) add-on software that interrogates GP system data to identify individual patients who may benefit from review of prescribed medicines within GP practices, GP data is due to be centralised by end 2026

• STU-MED-VIEW – extension of STU being developed that will enable prescribers to see a graphical representation on a patients adherence to medication (based on prescription history and dosage instructions). Due to be piloted in autumn 2024.

• PhD research project looking at the patients’ needs around adherence.

• High Risk Prescribing Clinical Decision Support – Software currently being piloted in two Health Boards warning prescribers of potential medicine harm from prescribed medicines or medicine combinations on opening the patient clinical record. Evaluation of pilot will be completed by end August 2026

• Rockwood Clinical Frailty Scale (CFS) is used to assess and record frailty in practice and there is an electronic frailty index (EFI) which is a public health tool, currently under review

• GP clinical prescribing systems (Vision and EMIS)

• Community pharmacy IT systems

• Resource at pharmacy level and funding arrangements to community pharmacy

Is this part of an existing service?

Pharmaceutical provision, improved clinical care and reduction of medicine related harm.

Any technologies or features the Challenge Sponsor wishes to explore or avoid?

CivTech is tech agnostic. As long as the proposed solution offers the opportunity to solve the Challenge in question, we will consider it.

That said, any proposed solution must be capable of integrating with existing systems as required by the specific Challenge and its Challenge Sponsor, and if appropriate be compatible with current and developing Scottish Government infrastructure.

Much is currently being made of the potential of advanced AI. In truth, just about all the products CivTech has developed over the past few years have AI as part of the tech stack but there is no obligation on your part to go down this route – either with componentry such as machine learning and pattern recognition, or indeed LLMs.

We are looking for the best solution, whatever technology used.

The Challenge Sponsor is looking for Technologies that do not add repetition to what is already there but enhance or simplify for example a novel idea in supporting adherence and ensuring continued need of a medicine for the individual should not duplicate  STU-MED-VIEW as mentioned earlier. above. In addition to STU-MED-VIEW a related

Evidence that a medicine has not been tampered with and stored correctly needs to be a simple, cost effective solution which minimises extra resource needed at a pharmacy and or manufacturer/supplier level.

What is the commercial opportunity beyond a CivTech contract?

There is a global need to reduce environmental impact of supply chains, hence there would be a worldwide potential to roll out this solution. Innovation may translate to other industries concerned with consumable safety including the food and beverages.

Who are the stakeholders?

• Scottish Government: Healthcare Infrastructure and Sustainability Division Alifia Chakera, Head of Pharmaceutical Sustainability

• Effective Prescribing and therapeutics Division (Dr Alpana Mair (Head of Division) Emily Kennedy, Karen Vint, , Dr Iain Wilson -Clinical team and Stuart Law -Policy)

• NHS Scotland: Sharon Pfleger, Consultant in Pharmaceutical Public Health, NHS Highland

• NHS Scotland Assure: Ruth Innes, National Waste Manager NHSS

• For later stages beyond exploration stage: Royal Pharmaceutical Society, Association of British Health Tech Industries and the Sustainable Healthcare Coalition, Medicines and Healthcare products regulatory agency (MHRA) Pharmaceutical PAGB: The Consumer Healthcare Association, West of Scotland Innovation Hub (supported by Chief Scientists Office)

Who’s in the Challenge Sponsor team?

All the above names and we will have additional data support from Public Health Scotland and Albert King the Chief Data Officer NHS National Services Scotland.

What is the policy background to the Challenge?

NHS Scotland is aiming to become a net-zero health service by 2040 at the latest. We are part of an international coalition of over 50 countries to date who have committed to developing low-carbon health systems.

The Scottish Government has established a NHS Scotland Circular Economy Programme to support the transition to more circular supply systems which will play a pivotal role in enabling NHS Scotland to reach net zero.

NHS Scotland is leading innovative work to manage the environmental impact of pharmaceutical pollution and has been involved in the development of a UK policy brief on eco-directed and sustainable prescribing of pharmaceuticals in the UK and are pioneers on the mitigation of anaesthetic gases especially nitrous oxide.

Much of the NHS's carbon footprint is created by the manufacture and supply of medicines. To become an environmentally and socially sustainable health service we need to embrace a circular economy and develop innovative solutions to increase the opportunities for reuse and recycling of pharmaceuticals.