New Research a First Step towards Sustainable Medicine Prescribing in Scotland

NHS Highland, UHI North Highland’s Environmental Research Institute (ERI), and the University of Nottingham have been awarded a £100,000 Medical Research Council grant to develop a framework for an eco-directed formulary that will incorporate environmental data on medicines into the prescribing process, alongside clinical and cost effectiveness. This is an innovation first in the UK!

Pharmaceutical pollution is a well-recognised global public health and environmental issue. This can negatively impact the environment through water pollution and large carbon emissions – medicines contribute 25% of the NHS carbon footprint. It can also exacerbate the spread of antimicrobial resistance (AMR) through the environment.

Professor Sharon Pfleger, Consultant in Pharmaceutical Public Health for NHS Highland and Principal Investigator for the research said: “Medicines have changed the face of healthcare and brought benefits to millions of people across the world. However, with the climate and biodiversity crises, healthcare has a moral and social responsibility to limit its environmental impact. This research will enable key disciplines and organisations to come together to pave the way for more sustainable prescribing in Scotland. It is the beginning of a journey to discover what’s good for our patients is also good for the planet.”

Pharmaceuticals enter the water environment when people taking medicines go to the toilet (between 30-100% of a dose is excreted), and when partially used or expired medicines are inappropriately flushed down toilets/sinks instead of being returned to a pharmacy for proper disposal. Wastewater treatment facilities were not designed to remove such pollutants from wastewater, and medicines like antibiotics, anti-inflammatories and anti-depressants have been detected in rivers and lochs in Scotland (see report ‘Pharmaceuticals in the water environment: baseline assessment and recommendations’ ). Medicines have biological effects on our bodies and may have similar effects on aquatic life.

Each health board has a list of preferred prescribing choices for clinicians called a formulary. Currently these formularies consider patient safety, clinical effectiveness, and cost effectiveness, but they do not consider the environmental impact of a medicine.

The research team will work in partnership with the James Hutton Institute, Scottish Water, the Scottish Environment Protection Agency (SEPA), and the University of Uppsala to embed effective cross-organisational engagement throughout this project. Project partners will provide valuable contributions, including technical expertise in environmental modelling, analysis of environmental impact data, and policy and regulatory guidance.

Scottish Water's Chief Scientist Elise Cartmell said: "We are very supportive of this research project. It will help improve our collective awareness and understanding of the impact of pharmaceuticals in the water environment, support development of sustainable solutions to reduce this type of pollution and ultimately protect both water quality and the efficacy of medicines."

This project builds on activity of the cross-sector One Health Breakthrough Partnership (OHBP) – a collaboration between NHS Highland, Scottish Water, SEPA, ERI, and the Centre of Expertise for Waters (CREW). It will use a novel visualisation tool launched by SEPA on behalf of the OHBP, which includes data on medicines detected in the Scottish water environment and NHS Scotland prescribing data. The tool was designed to help develop a better understanding of the link between medicine use and pharmaceutical pollution in the environment, and support activity to address this environmental issue.

With this funding, the research team and partners will adopt a novel, trans-disciplinary approach integrating public health, prescribing, environmental science, and social science methods and data. A framework will be developed to help decision makers take account of the environmental impact of a medicine, along with environmental monitoring data, excretion profiles, and wastewater information (e.g., how much gets removed during wastewater treatment). The framework will enable better informed and more sustainable prescribing choices, while at the same time ensuring the chosen medicines will result in the desired clinical outcomes.

Professor Claire Anderson from the University of Nottingham’s School of Pharmacy, and president of the Royal Pharmaceutical Society said: “With climate change and our impact on the environment in the spotlight this week during COP27 I am delighted to be working on such an important project for healthcare. This research has the potential for both UK and global impact on the choices that health professionals make about which medicines to include in formularies.”

This work is a first step towards improvement of medicine prescribing in Scotland to reduce pharmaceutical pollution. The research will generate new knowledge sharing and awareness of the environmental impact of medicines, and help develop new solutions to complex sustainability issues while benefitting the NHS, prescribers, patients, and the environment we rely on.

For more information, please visit the project page:

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NHS Highland Sharon Pfleger ( and Erin Greig (, the University of the Highlands and Islands (, and the University of Nottingham Jane Icke (