Delivering sustainable respiratory care for greener ICBs

The evidence is undeniable that climate change is an immediate and growing threat to public health and the NHS.¹ More than 12 million people in the UK have some form of respiratory disease – that is one in five of the population.² These individuals are among the most vulnerable to the effects of climate change, with increased air pollution, heatwaves and allergens exacerbating respiratory illnesses, pushing more people into accident and emergency (A&E).³ While the NHS provides essential care for these patients, the care itself generates greenhouse gases (GHGs) through clinical appointments, hospital stays and medicines, contributing to the NHS’s overall carbon footprint.⁴ This creates a harmful cycle that must be broken.

Against the backdrop of the government’s 10-Year Health Plan and as NHS trusts and integrated care boards (ICBs) refresh their green plans, there is a timely and strategic opportunity for respiratory care to take a leading role in sustainable healthcare, delivering improved patient outcomes and contributing towards the delivery of a net-zero NHS.^5,6

Innovation without compromise: next-generation propellant pMDIs

In the UK, millions of people living with chronic respiratory diseases, such as chronic obstructive pulmonary disorder (COPD) and asthma, rely on pressurised metered-dose inhalers (pMDIs) to deliver essential medicines to the lungs.⁷ These medicines, which account for 70 per cent of all inhalers used in the UK, are listed as essential by the World Health Organization and are an important therapeutic option for patients.^8,9 pMDIs are particularly vital for certain groups, including children, older adults, individuals with limited lung function, and those requiring rapid symptom relief in emergencies.¹⁰

However, pMDIs also have a detrimental impact on the environment and currently represent 3 per cent of the entire carbon footprint of the NHS, with the majority resulting from the propellant gas used to deliver drugs to the airway.¹¹ Each full pMDI commonly has a carbon footprint equivalent to 28kg of CO₂ or to put it another way, the same as driving 175 miles in a petrol car – the distance from London to Sheffield.¹² Optimising inhaler choice away from pMDIs to reduce emissions is therefore highlighted as a key area for action for the integrated care systems and trusts under the NHS’s Green Plan Guidance. ⁶

To address this challenge, AstraZeneca has committed to transitioning its portfolio of pMDIs to a next-generation propellant, with near-zero Global Warming Potential (GWP), ensuring that clinicians can continue to select the most appropriate medication and device for their patient without compromising the environment. ¹³

Optimising inhaler choice should be a shared decision between a patient and their healthcare provider and based on clinical need first and foremost, as the medicines in the devices are not interchangeable.^14,15 With a next-generation propellant-based pMDI, it has been shown that the carbon footprint is comparable to that of a dry powder inhaler (DPI), meaning clinicians no longer need to choose between the most appropriate treatment and supporting environmental sustainability.¹⁶ This shows it is possible and essential to deliver sustainability without compromising safety, quality, or clinical benefit.

Prioritising patient outcomes reduces resources and environmental burden of care

While tackling inhaler emissions is important, we must recognise that the largest driver of the respiratory care carbon footprint stems from poorly controlled disease, which leads to exacerbations (flare-ups) and hospital admissions.¹⁷ For example, in cases like COPD, the EXACOS CARBON study in the UK demonstrated that in-patient care accounted for 75 per cent of GHG emissions due to healthcare resource utilisation, and emissions increased with exacerbation frequency and severity.¹⁸

To break this cycle, a fundamental shift in focus is required – from treating respiratory illnesses in acute settings to preventing them – as set out in the 10-Year Health Plan.⁵ Implementing evidence-based guidelines into clinical practice can reduce exacerbations and unscheduled healthcare utilisation, resulting in improved patient outcomes and a decreased overall carbon footprint associated with respiratory care.^4,17

Collaboration for change

Delivering high-quality, low-carbon respiratory care will take a collective approach, from the NHS, system partners, industry and patients. As NHS trusts and ICBs refresh their green plans, prioritising strategies that improve disease control and embrace sustainable inhaler innovations will be critical to achieving net-zero targets.

References  

¹ NHS England. Delivering a ‘Net Zero’ National Health Service. Available at: www.england.nhs.uk/greenernhs/wp-content/uploads/sites/51/2020/10/delivering-a-net-zero-national-health-service.pdf. Last accessed: July 2025.

² NIHR. Air pollution and respiratory health in the UK. Available at: https://bepartofresearch.nihr.ac.uk/news-and-features/air-pollution. Last accessed: July 2025.

³ UK Health Security Agency. Chapter 4: Impacts of Climate Change and Policy on Air Pollution and Human Health. Available at: https://assets.publishing.service.gov.uk/media/6570a68b7469300012488948/HECC-report-2023-chapter-4-outdoor-air-quality.pdf. Last accessed: July 2025.

⁴ Faculty of Public Health Special Interest Group – Sustainable Development. The NHS Carbon Footprint. Available at: https://www.fph.org.uk/media/3126/k9-fph-sig-nhs-carbon-footprint-final.pdf. Last accessed: July 2025.

⁵ GOV UK. 10 Year Health Plan for England: Fit for the Future. Available at: https://assets.publishing.service.gov.uk/media/6866387fe6557c544c74db7a/fit-for-the-future-10-year-health-plan-for-england.pdf. Last accessed July 2025.

⁶ NHS England. Green plan guidance. Available at: https://www.england.nhs.uk/long-read/green-plan-guidance/. Last accessed: July 2025.

⁷ Health Innovation North East and North Cumbria. Improving Outcomes for Respiratory Patients. Available at: https://healthinnovationnenc.org.uk/what-we-do/improving-population-health/respiratory/improving-outcomes-for-respiratory-patients/. Last accessed: July 2025.

⁸ NHS South East London. Reducing the Greenhouse Gas Emissions Associated with Inhaler Use. Available at: www.selondonics.org/icb/healthcare-professionals/medicines/transforming-and-integrating-medicines-optimisation/sustainability/reducing-the-greenhouse-gas-emissions-associated-with-inhaler-use/. Last accessed: July 2025.

⁹ World Health Organization. Model List of Essential Medicines – 23rd List, 2023. Available at: https://iris.who.int/bitstream/handle/10665/371090/WHO-MHP-HPS-EML-2023.02-eng.pdf?sequence=1. Last accessed: July 2025.

¹⁰ Asthma + Lung UK. Choosing the right inhaler device for your patients. Available at: https://www.asthmaandlung.org.uk/healthcare-professionals/adult-asthma/choosing-inhaler-device?utm_source=chatgpt.com. Last accessed: July 2025.

¹¹ NHS England. Delivering high quality, low carbon respiratory care. Available at: https://www.england.nhs.uk/blog/delivering-high-quality-low-carbon-respiratory-care/?utm_source=chatgpt.com. Last accessed: July 2025.

¹² NHS Sussex, Brighton and Hove CCG and West Sussex CCG. Green Inhalers Guide: Reducing the Environmental Impact of Metered Dose Inhalers (MDIs). Available at: https://int.sussex.ics.nhs.uk/wp-content/uploads/2021/08/BHWSx-Green-Inhalers-guide_Final_2.pdf. Last accessed: July 2025.

¹³ AstraZeneca. Our Sustainability Impact. Available at: https://www.astrazeneca.com/content/dam/az/Sustainability/2025/pdf/AZ-Sustainability-Impact-Publication_May2025Final.pdf. Last accessed: July 2025.

¹⁴ Hurst, J, et al. Prioritising patients and planet: advocating for change in respiratory care. EMJ Respiratory. 2024;12(1): 51-62.

¹⁵ Bjermer L. The importance of continuity in inhaler device choice for asthma and chronic obstructive pulmonary disease. Respiration. 2014;88(4): 346-352.

¹⁶ Hargreaves C, et al. A new medical propellant HFO-1234ze(E): reducing the environmental impact of inhaled medicines. Abstract presented at British Thoracic Society 40^th Winter Meeting 2022. (Abstract S60).

¹⁷ Wilkinson AJK, et al. Greenhouse gas emissions associated with suboptimal asthma care in the UK: the SABINA healthCARe‒Based envirONmental cost of treatment (CARBON) study. Thorax. 2024 27;79(5): 412-421.

¹⁸ Bell J, et al. A54 EXACOS CARBON: Describing the Greenhouse Gas Emissions of Healthcare Resource Utilization by Frequency and Severity of COPD Exacerbation in England (abstract). American Journal Respiratory Critical Care Medicine. 2024;209: A2113.