Developing frameworks for eco-directed sustainable prescribing: Towards reducing environmental pollution from healthcare practices

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The prescription of a medicine to diagnose, treat, cure, and prevent disease is the most common intervention in healthcare - but this activity negatively impacts the environment, and pharmaceutical pollution is now a well-recognised global public health and environmental issue. Antibiotics, anti-inflammatories, antidiabetics, and antidepressants in surface water can negatively affect aquatic organisms, causing feminisation and reproductive failure, physiological and behavioural changes, immunodeficiency, and assistance in the spread of antimicrobial resistance (AMR - a critical public health issue). Healthcare sustainability targets call for improvements to prescribing and medicine selection, as current practices are environmentally, economically, clinically, and socially unsustainable. Improving medicine selection, use, and disposal can reduce pharmaceutical pollution from healthcare. This project seeks to develop and evaluate, for the first time in the UK, an eco-directed prescription framework that incorporates environmental sustainability alongside clinical and cost effectiveness. This proposes that if pharmaceuticals are of comparable medical efficacy, safety, and effectiveness, then the environmental impact (e.g., drug ecotoxicity, predominance towards AMR) should be considered during the formulary process to better inform prescribers, enabling them to make more sustainable prescribing choices. The research investigators (representing NHS Highland, University of Nottingham, and the Environmental Research Institute-University of the Highlands and Islands) have strong track-records and expertise in pharmaceutical public health, formulary development, qualitative health services research, environmental science, and cross-sector collaboration. The project will capitalise on the established networks and resources of national and international partners representing key stakeholders across the healthcare, prescribing, environment, and water sectors, including the Scottish One Health Breakthrough Partnership - a globally unique, cross-sector group which created an interactive visualisation tool comparing environmental pharmaceutical data and prescribing rates in Scotland (a world first) to progress prioritisation of formulary changes. Investigators will: interrogate environmental and prescribing data; evaluate ecotoxicological data for environmental hazard indicators; prioritise criteria through structured consensus and focus group activity; develop a robust decision-making formulary framework through novel application modelling techniques; and, engage with patients, practitioners, and prescribers to assess suitability. The investigators will work with networks/stakeholder groups to disseminate, educate, and develop post project activity for a pilot trial towards implementation. This project will meet the opportunities and challenges of this call, whilst also: enhancing research sustainability and generating innovation; integrating novel research methods; ensuring genuine PPI and cross-sector stakeholder engagement; supporting high-level dissemination and impact; and creating additionality through next-stage project planning of the framework, which can be piloted post-project and adopted at UK- and international-level.This project will be an innovation-first for the UK, identifying novel methods and data required for eco-directed prescribing and leading to new understanding and awareness of the environmental impact of pharmaceutical prescribing. It will create opportunities for a 'step change' in practice that improves the quality of medicine prescribing and use in Scotland, and benefits the NHS, practitioners/prescribers and patients through enabling better informed and more sustainable prescribing and medicine choices. The project will contribute to reduced environmental pollution from medicines, address sustainability targets, address biodiversity loss and AMR, and promote better health now and for the future.