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Greening community pharmaceutical supply chain in UK: a cross
boundary approach
Abstract
Purpose
This research aims to design a green Pharmaceutical Supply Chain (PSC1 ) that
reduces preventable pharmaceutical waste and effectively disposes of inevitable
pharmaceutical waste. The main output of this study is the formulation of an
integrated green PSC model involving all critical stakeholders, leading to improved
environmental, economic and safety performance in medication management and
delivery.
Design/Methodology/Approach
The research is based on literature and on secondary resources.
Findings
To green the PSC, every producer of waste is duty bound to facilitate the safe
handling and disposal of waste. A Cross boundary Green PSC (XGPSC) approach is
proposed to identify participants’ contribution to the PSC. Peripheral influences are
also recognised from professional and regulatory bodies.
Research limitations/implications
This study focuses solely on community PSC in the UK where patients receive
medication from local community pharmacies and thus may be limited. The proposed
XGPSC approach also needs to be tested and validated in practice. It may also be
difficult to transfer some of the environmental practices proposed in this research into
practice.
Practical implications:
The environmental practices and actions proposed provide invaluable insight into
various PSC activities, including purchasing, product design, prescription patterns and
processes, medication use review, and customer relationship management.
Social implications:
The proposed environmental actions encourage firm commitment from everyone to
reduce, recycle or effectively dispose of pharmaceutical waste, with patients
becoming stewards of medication rather than only consumers.
Originality/value:
A cross boundary approach is developed to green the PSC, and it encourages total
involvement and collaboration from all participants in PSC.
Keywords:
Green supply chain, pharmaceutical supply chain, environmental practices.
Paper type:
Conceptual
1 The acronyms used in the paper are listed in the Appendix at the end of the paper.
1. Introduction
Awareness of the world’s environmental issues such as global warming, carbon
emissions, toxic substance usage, and resource scarcity has escalated over the past
decades. Policy makers and activists are advocating for going green, and many
organisations throughout the world have responded to this by applying green
principles. Wu and Dunn (1995) designed an environmentally friendly supply chain
(SC) for a single organisation where greening starts from procurement and works its
way through to storage, distribution and end-consumers. However, the chain does not
include cross company activities. To effectively manage products from start to finish,
green principles must be embedded and evident across the entire SC. Printing
industries such as Hewlett-Packard, IBM, Xerox and Digital Equipment Corporation
have made their SC green via integrating suppliers, distributors and relocating
facilities (Ashley, 1993; Bergstrom, 1993; Gillett, 1993 and Maxie, 1994). Xerox
have taken environmental consciousness a step further by supporting more
environmentally friendly decision-making in the integrated SC and reducing the
negative impact from the SC (McIntyre et al, 1998).
The concept of Green SC Management (GSCM) emerged in the late 1990s, and
encompasses the reactive monitoring of general environmental management programs,
moving to more proactive practices such as the recycling, reclamation,
remanufacturing and reverse logistics (RL), as well as incorporating innovations (Zhu
and Sarkis, 2004). For the last 20 years, GSCM has been adopted by the companies to
lower environmental risks and raise ecological efficiency, therefore to achieve profit
and increase market share (Van Hoek, 1999). Realising the significance of the GSCM
implemented by organisations, Sarkis (2003) developed a strategic decision
framework that aids managerial decision making in selecting GSCM alternatives. The
foundations of this decision framework are: product life cycle, operational life cycle
(including procurement, production, distribution and RL), organisational performance
measurements and environmentally conscious business practices. Considering the
literature that addressed various elements of GSCM (Carter et al., 1998; Walton et al.,
1998; Zsidisin and Hendrick, 1998), Zhu and Sarkis (2004) developed four categories
of GSCM practices, i.e., internal environmental management, external GSCM,
investment recovery, and eco-design or design for environment practices. The
relationship between the practices and environmental and economic performance were
examined through empirical studies in the Chinese manufacturers.
The Pharmaceutical SC (PSC) is a special SC in which medications are produced,
transported and consumed. Academic researchers and practitioners believe that
“pharmaceuticals are different; they cannot be treated like other commodities”
(Savage et al, 2006, p12). The reasons for this sentiment were the high cost and long
duration for research and development, and the repercussions of the product not being
available, hence again its criticality. Other unsupported perception-based factors that
appear to make this SC distinctive include: the level of regulation in the product
production, storage, distribution, consumption and the complexity of the fabric of this
SC (Knight, 2005).
Medication is produced and prescribed in large volumes every year, e.g., over 100
tonnes of medications were prescribed in Germany in 1995 (Ternes, 1998), and over
100 tonnes of the top three compounds medications (paracetamol, melformin
hydrocholoride and ibuprofen) are prescribed in the UK each year (Jones et al., 2002).
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Disposal of expired/unwanted medication can be very costly and harmful to the
environment, and medications have been detected in sewage effluent (Ternes, 1998,
Ternes et al., 1999; Daughton and Ternes 1999), surface water (Buser et al., 1998),
groundwater and even drinking water (Halling-Sorensen et al., 1998; Heberer 2002).
To help healthcare organisations and other producers meet legislative environmental
requirements, the Department of Health produced a series of guidance on best practice
waste management, e.g., “Disposal of Pharmaceutical Waste in Community
Pharmacies” (Department of Health, 2007), and “Safe Management of Healthcare
Waste” (Department of Health, 2006). In line with the guidance, community
pharmacies are bound by contractual obligation to offer a returns service for
medication (Department of Health, 2008; Bellingham, 2004), the strategic aim of
which is to facilitate safe disposal, remove excessive storage of medicines in the home
and to reduce the environmental damage from inappropriate disposal methods.
However, the research shows that customer compliance in returning the medicines is
low, which becomes an obstacle to develop effective healthcare waste management in
the community PSC. According to an investigation into the disposal habits of the
American public, only 1.4% of people return unused drug to the pharmacy, while 54%
throw them away and 35.4% flush them into the sink or toilet (Kuspis and Krenzelok,
1996). Similarly, a survey conducted in south eastern England revealed that 63.2%
people discard unwanted drugs in household waste, 21.8% return them to a
pharmacist, and 11.5% empty them into the sink or toilet (Bound and Vouvoulis,
2005). The survey indicates that the predominant method of disposal
expired/unwanted drug in the UK is via household waste, which causes environmental
pollution.
Globally, in 2003 at least £0.56 billion worth of unused medications were flushed
down the toilet (Van Eijken, et al., 2003). From an economic point of view,
efficiencies can be made in the form of potential savings in pulling back stock from
patients. Medication retrieved from patients cannot be re-used and must be disposed
of. It does however provide vital information and can encourage more prudent
prescribing. Safety is also paramount when broaching pharmaceutical management
and storage. Accidents can happen if products fall into the hands of children or
individuals who wish to abuse the product themselves or support a ‘grey’ market for
product exchange/sale for cash.
With the increasing focus on pharmaceutical waste management (Breen and Xie,
2009), there is more pressure than ever to effectively green the PSC i.e., correctly
disposing of expired/unwanted medications and reducing the level of preventable
pharmaceutical waste. As a result of greening processes, the PSC will become safer
when hazardous medications are removed from the SC and kept away from vulnerable
people, like children. However, there is very little research and practice on medication
recycling (Ritchie et al., 2000) or greening the PSC.
As explained above, it is vitally important to properly dispose of expired/unwanted
medication because of its hazardous nature, and it is even more critical for every
producer of medication to take actions on reducing waste. The fate of unused
consumer pharmaceuticals is an issue that has reached public consciousness more
recently. There is emerging concern about the potential impact of pharmaceuticals
that reaches lakes and rivers via sewage plants and other sources (New Hampshire
Department of Environmental Services, 2009).
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This research aims to design a green community PSC that reduces preventable
pharmaceutical waste and effectively disposes of inevitable pharmaceutical waste,
using a XGPSC approach that requires every participant in the PSC to take
environmental practices. In Section 2, the research framework and methodology are
established; then a community PSC encompassing a RL system is designed in Section
3; and the XGPSC approach is proposed in Section 4. Section 5 concludes the paper
summarising the findings, and research limitations. Future research is identified in
Section 6.
2. Research framework and methodology
The objectives to meet the research aim are: i) design a physical network for
community PSC incorporating a RL system; ii) explore the roles of individual
participants in delivering environmental practices within the PSC; and iii) develop a
XGPSC approach, in which the environmental practices underpinning greening the
PSC are identified from a broad perspective.
The proposed research framework is shown in Figure 1. It supports the proposition
that a RL system needs to be incoporated into the PSC network and each participant in
the PSC adopts the XGPSC approach, undertaking necessary environmental practices
to green the PSC. Such a combination of a PSC network and environmental practices
can be complex, collaborative, costly and different from other business sectors on the
basis that the PSC is a special SC. As such it would be impossible to conduct any
empirical study to test any practice prior to a systematic conceptual approach being
formulated. Therefore, the community PSC network incorporating a RL system and
the XGPSC approach are designed as theoretical models, and developed from the
literature review and other secondary resources.
Take in Figure 1
A research literature review is defined as “ a systematic, explicit, and reproducible
design for identifying, evaluating, and interpreting the existing body of completed and
recorded work produced by researchers, scholars and practitioners” (Fink, 2005, p3).
A literature review has been well adopted by the researchers in the field of SC and
logistics management to summarise the existing research findings (e.g., Fleischmann
et al, 1997, Croom et al, 2000, Power, 2005, Burgess et al., 2006), to evaluate the
research methodologies (e.g., Croom et al, 2000, Burgess et al., 2006), or to develop
theories and conceptual models (e.g., Seuring and Muller, 2008).
In this research, a comprehensive literature review was conducted with the aim of
constructing the theoretical foundation for the development of the physical PSC
network and the XGPSC approach, as shown in Figure 2. The theoretical foundation
is composed of four parts: Part A: the drivers and pressures for pharmaceutical waste
management, the current service provision (including the guidance and regulations
provided by the professional bodies), and future expectations; Part B: the obstacles,
restrictions and limitations encountered in current provision; Part C: the RL system
design and applications; and Part D: the GSCM practices serving as the evidence base
from which appropriate environmental practices are to be adopted or moderated for
the participants in the PSC. The PSC network incorporating the RL system and the
XGPSC approach are developed from Part C and D respectively, while Parts A and B
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have the influences on the development.
Take in Figure 2
2.1 Literature search and categorisation
To ensure the quality of the articles selected, the literature review focused on peer
reviewed journals that were retrieved from electronic journal databases, publications
from professional bodies that are accessible from their websites, and survey reports
provided by pharmacies.
Part A of the theoretical foundation was identified by reviewing the literature in the
areas of pharmaceutical waste management, which were mainly sourced from
professional pharmacy journals. The authors also analysed the results of the
pharmaceutical waste audit conducted by Rowlands Pharmacy covering 462 branches
in England and Wales. The audit outputs identified costs attributed to wastage and
reasons for waste levels. This information has been incorporated into this study. The
negative environmental impacts of pharmaceutical disposal were investigated using
environmental science journals.
The publications, surveys and legislations on pharmaceutical waste management were
sourced from the websites of the National Health Service (NHS), the Department of
Health, and the Royal Pharmaceutical Society of Great Britain (RPSGB), in order to
obtain an overview on the current service provision of the pharmaceutical waste
management for Part A, and identify the obstacles, restrictions and limitations for Part
B. The Department of Health is a UK government department with responsibility for
health, social care and the NHS. The RPSGB is the statutory regulatory and
professional body for pharmacists and pharmacy technicians in UK, with the main
objectives to lead, regulate, develop and promote the pharmaceutical professions.
These bodies have a peripheral influence on pharmaceutical waste management, and
the information acquired from these bodies provides insights into the current
pharmaceutical waste systems, contemporary regulations and improvements.
Information and data was also collected from other reliable internet resources, such as
environmental companies who provide services for environmental improvement e.g.
the PHS management group plc. The collation and triangulation of multiple sources as
identified present a realistic portrayal of the stakeholders in the PSC and the current
status quo.
Part C focuses on the definition of RL, the theoretical framework of RL design, and
case studies of RL application. Due to the limitation of literature on PSC, the forward
logistics of the PSC network is designed by specifying the roles of the participants in
the generic SC network. The prevailing RL theories and the successful RL
implementations in other industrial sectors enable the current RL models to be revised
and built into the PSC network, focusing on establishing returning channels, to
achieve research objective i). The RL functions and roles within the operational
product life cycle are also reviewed to understand the environmental practices that the
participants in the PSC can take, which will be addressed in research objective ii).
Furthermore, the GSCM literature is reviewed to construct the evidence base in the
Part D. To achieve the research objectives ii) and iii), the GSCM practices are
reviewed for all the participants in the SC, from suppliers to the end customers. To
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identify the most appropriate environmental practices for the XGPSC approach, the
organisational research and implementation of GSCM are analysed and compared,
and the prescriptive models evaluating the GSCM practices and technologies are also
reviewed.
2.2 The development of the PSC network and the XGPSC approach.
Considering the individuality of the PSC, the roles and interactions of the participants
in the PSC, a RL system is built into the PSC network to deliver Part A, solve the
problems in Part B, and provide a physical network to realise the XGPSC approach,
as shown in Figure-2.
Regarding the XGPSC approach, it is found that there is strong relationship between
the GSCM practices and positive environmental and economic performance (Zhu and
Sarkis, 2004), and the further studies compare the drivers, practices and performances
of GSCM in different Chinese industrial sectors (Zhu and Sarkis, 2006, Zhu et al.,
2006). These studies indicate that environmental and economic performance are not
greatly improved if the GSCM implementation is poor, especially when the cross
functional cooperation is weak. The research outcomes from Zhu and Sarkis (2004)
and Zhu et al. (2006) are in line with the aim of this research and their research
findings are validated in the follow-on research, so the GSCM practices developed in
Zhu and Sarkis (2004) are adopted, moderated and customised for the participants in
the GPSC. Zhu and Sarkis (2004) also highlight that GSCM practices are integrative
and are not oriented to a single function or department, which underpins the
philosophy of the XGPSC approach that encourages cross functional cooperation
among the participants in the PSC.
3. A community PSC network with reverse logistics
As identified in Sarkis (2003), RL is one of the most important but least developed
operational functionthat serves as a foundation for GSCM practices. RL is defined as
“the process of planning, implementing and controlling the efficient, cost-effective
flow of raw materials, in process inventory, finished goods and related information
from the point of consumption to the point of origin for the purpose of recapturing or
creating value or for proper disposal” (Rogers and Tibben-Lembke, 1999, p2). RL
facilitates return of products for recycling in many sectors, like automobile (Lebreton
and Tuma, 2006), electronic waste (Lau and Wang, 2009; Nagurney and Toyasaki,
2005), computer (Shih, 2001), paper (Pati et al., 2008), packaging material
(González-Torre et al. 2004), bottling or glass (González-Torre and Adenso-Díaz,
2006) and batteries (Zhou et al., 2007); this can be both for re-use or disposal. As one
of the few research studies applying RL in the medical area, Breen and Xie (2009)
proposed an integrative customer relationship management (CRM) facilitated RL
system in UK community pharmacy for environmental, economic and safety reasons.
Considering the operations of a community PSC in UK, a preliminary community
PSC network is designed and presented in Figure 3, where a forward logistics network
is depicted in which medication is produced by the pharmaceutical manufacturer,
transported by the logistics providers to community pharmacies, and finally is
consumed by customers who can be patients or buyers. The figure also incorporates a
RL network for the expired/unwanted medications to be returned to the manufacturer.
The expired/unwanted medications are encouraged to be returned for two reasons
(Breen and Xie, 2009): i) it removes the product from circulation and from the
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domestic environment therefore reducing the risk of accidental injury or planned
product abuse; ii) it provides valuable information which can be used to assess the
efficiency of the prescribing process (who the prescriber is, the nature of the product
and the quantity dispensed).
Take in Figure 3
As shown in Figure 3, a RL network is one of the key resources needed to facilitate
product recycling. A channel must be available for the expired medication to be sent
back to manufacturers, and can be built in a number of ways: i) customers return the
expired/unwanted medication to the pharmacies or the GPs in person, and the
pharmacies or the GPs return them back to manufacturer via the logistics providers; ii)
the pharmacies return the unsold or expired medications to manufacturer when
appropriate; and iii) logistics providers or wholesalers get involved in the system
acting as either independent operators, carrying out functions such as collecting,
sorting, recycling and disposing, or cooperating with other actors in the system (de la
Fuente et al., 2007; Krumwiede and Sheu, 2002). The dashed line in Figure 3
represents the recycling channel for expired medication.
In the process of recycling, logistics providers or wholesalers take the role of
collecting from the community pharmacy and transporting to manufacturers or
suitable places for disposal. The manufacturers, logistics providers/wholesalers, GPs
and community pharmacies are classified as direct participants in the PSC because
their roles and activities have a direct impact on the performance of the PSC, while
the professional and regulatory bodies influence PSC indirectly via offering
suggestions to the direct participants. In the middle of Figure 3, guidance and
instructions from professional and regulatory bodies (RPSGB, Department of Health,
or waste management agencies etc.) will be given to the direct participants in the PSC,
and have a peripheral influence on the actions taken by direct participants.
Although RL has a great influence in greening the SC, recycling behaviours are
classified as proactive green approaches, and the most far-reaching approach is
value-seeking (Van Hoek, 1999). This is where companies consciously integrate
environmental practices into their business strategy (Kopicki et al., 1993).
Medications returned by customers cannot be re-used and must be disposed of,
therefore they have no residual value. The value therein in effectively recycling such
products is increased environmental protection, economic savings (in using the
information retrieved to manage future prescribing) and safety considerations. As
illustrated in the shaded boxes in Figure 3, the participants in the PSC are expected to
reduce medication waste by integrating environmental practices into their ‘normal’
activities. The specific actions to be taken by the participants to reduce waste will be
discussed in the next section.
4. A Cross boundary Green PSC (XGPSC) approach
To green the community PSC, not only a physical PSC network needs to be
constructed, but also GSCM practices should be implemented by all participants in the
chain from the holistic system perspective, to minimise the total environmental impact
of a business (Van Hoek, 1999).
From the literature, the drivers of green PSC are summarised as environmental,
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economic and safety considerations, the supposition being that instigating greener
practices will improve performance in these areas. It has been argued that new
opportunities of competition can be realised (Hansmann and Kroger,2001) and
organisations can benefit if environmental actions are undertaken (Alvarez Gil et al.,
2001). The opportunities and benefits can be improved organisational reputation
(Welford, 1995), reduced cost, improved organisational efficiency, increased market
share, getting ahead of competitors and legislation, access to new markets, and
increased employee motivation (Porter and van der Linde, 1995; Shrivastava, 1995;
Beaumont et al., 1993; Guimaraes and Liska, 1995).
Using empirical results from 186 respondents on GSCM practice in Chinese
manufacturing enterprises, Zhu and Sarkis (2004), found that an organization’s
environmental and economic performances are improved if they apply the four GSCM
practices, i.e., internal environmental management, external GSCM, investment
recovery, and eco-design or design for environment practices. Internal environmental
management requires commitment and support from senior managers in the
organisation, as well as the implementation of total quality environmental
management and audit programmes. The external GSCM practices focus on
cooperation between suppliers and customers for environmental objectives, e.g.,
communication on product design, clean production and green packaging. The
investment recovery is a traditional business practice in which excess
inventories/materials are resold, or the scrap/used materials are resold. The eco-design
requires organisations involved in manufacturing processes to design products which
consume less new materials by adopting reusable or recyclable materials, and reduce
the use of hazardous components. The investment recovery practice is not applicable
to the PSC as returned medication to community pharmacies cannot be reused or
resold. So the three categories of GSCM practices except investment recovery (i.e.,
internal environmental management, external GSCM, and eco-design) will be used to
develop a XGPSC approach.
As shown in Figure-1 participants are encouraged to adopt environmental practices to
green the PSC, and to improve environmental and economic performances.
Considering the hazards that the out-of-date and unused medicines pose on children
and other vulnerable people, a green PSC reduces excess medicines in households,
and therefore reduces the propensity for these groups to take the expired/unwanted
medications, which ultimately leads to improved safety performance of the PSC.
Based on the three categories of GSCM practices adopted from Zhu and Sarkis (2004),
the XGPSC approach is proposed in Figure 4 to encourage participants to adopt
environmental practices in order to convert the community PSC in Figure 3 to be a
green PSC. The XGPSC approach recommends the adoption of the following four
environmental practices: i) top management commitment: each participant in the
PSC commits to GSCM, as evidenced by the top management team and
environmental management system; ii) supplier certification and cooperation: each
participant should evaluate their suppliers’ environmental practices and work with
suppliers in developing joint environmental objectives; iii) customer cooperation:
each participant should cooperate with customers or support them critical processes
such as proper recycling or disposal; and iv) eco-design: the participant should
become involved in the manufacturing process, designing products for reduced
materials/energy, for reuse, recycle, recovery of materials, and for the reduced use of
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hazardous components.
Take in Figure-4
Recommendations i) and iv) are classified as internal environmental management that
take place inside an organisation and play key roles in improving the orgnisational
performance (Carter et al., 1998). Recommendations ii) and iii) are external
environmental practices that are more difficult to implement and require information,
support and collaboration from other participants. However, to successfully green the
PSC, the recommended practices are integrative and need cross-functional
cooperation (Xie, 2009). The recommendations are henceforth applied to the various
participants in the PSC as detailed below.
4.1 The Manufacturer
i) Top management support: As the producer and designer of pharmaceutical
products, manufacturers can contribute to the green PSC through innovative and
environmentally friendly medication designs. The commitment to GSCM from the
management team is essential to realise and ensure total green operational processes
covering procurement, production, distribution and RL. It is also recommended that
an environmental management system should be designed to improve the total quality
environmental management and ISO14000 certification achieved (GEMI, 2001). To
monitor and evaluate the organisation and its suppliers’ practices, a series of
environmental compliance and auditing programmes should be set up (Zhu and Sarkis,
2004).
ii) Supplier certification and cooperation: Florida (1996) claims that close bonds
with suppliers facilitate cleaner production. Supplier selection and procurement
decisions have a positive impact on the GPSC through the procurement of materials
that are hazardous or non-hazardous, recyclable or reusable, or have already been
recycled (Sarkis, 2003). Therefore manufacturers are encouraged to develop green
purchasing strategies (Green et al., 1998, Murray, 2000) that add environmental,
health and safety elements to their strategic sourcing initiatives, and provide a
practical resource for procurement staff to understand and pursue opportunities that
will add business value to their companies (GEMI, 2001). In choosing new suppliers,
those with ISO14000certification are preferable to lessen the environmental risks
associated with material procurement.
iii) Customer cooperation: By collaborating with customers (the wholesalers or the
pharmacies in this research) and increasing transparency regarding design
specifications and recycling opportunities (of products), manufacturers can contribute
to innovative medication designs, cleaner production methods/processes and green
packaging (Zhu and Sarkis, 2004).
A strong relationship with wholesalers and pharmacies will encourage recyclable
packaging provided that this RL channel is available. Manufacturers can also support
this if they provide effective RL channels and communicate the essential nature of this
activity to their customers.
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iv) Eco-design: According to Kreisberg, 2007, medication can be designed to be more
ecologically sensitive, e.g., biodegraded more quickly, more efficient for lower doses,
or less harmful. The shelf life of medication can be brought into closer alignment with
real time by refining the expiration dates. In terms of medication packaging,
recyclable materials can be used; the package can be designed by adding more
complete/direct information about proper ways of disposal; and the package shapes
and sizes can be designed for easy returning and transportation (e.g., mail back
returning). In addition, multiple choice of packaging size can be made available for
the GPs or pharmacists to minimise prescription quantity.
4.2 The wholesaler and logistics providers
The development of a RL system enables pharmacies to transport all unsold or
expired medications as products back through these firms to the manufacturer for
credit. The activities of transportation in the RL system can be implemented by the
wholesaler, or the logistics providers including third party logistics (3PL) companies
(Meade and Sarkis, 2002). Any expired items that do not meet the manufacturers’
return policies are automatically disposed of (Smith, 2002). Waste movement and
disposal in the RL system needs to be effectively managed by wholesalers and
logistics providers, for the purpose of greening PSC.
i) Customer cooperation: The role of the wholesaler is to support manufacturing
operations through warehousing and distributing stock to community and hospital
pharmacies. They have an established logistics network and so are well placed to
enhance their service package through RL activities (Breen, 2004). They provide such
a service for their own products (manufactured by their company or their customers)
in retrieving defective products e.g. short-dated or incorrect items. The role of a 3PL
has been investigated in a hospital pharmacy with a view to consolidating deliveries.
Wholesalers can provide such a service in their current position in the PSC (Breen,
2004).
The services provided by the wholesaler and logistics providers can go beyond
transportation (Dowlatshahi, 2000), and include gatekeeping (Caldwell, 1999),
collection (Schwartz, 2000; Rogers and Tibben-Lembke, 1999), classification,
warehousing (Dowlatshahi, 2000), manifestation, destruction, and disposal of
medications (Schwartz, 200). If the wholesalers or the logistics companies act as the
waste management brokers, they are expected to classify and segregate the medication
according to the hazardous or non-hazardous characteristics, and then manage them
under appropriate streams (Smith, 2002). Employing them in the RL network can
reduce the amount of pharmaceutical waste generated and disposed improperly. But it
is important to select a wholesaler or logistics provider that complies with
environmental regulations, and acquires licenses for these services before they are
contracted.
4.3 General Practitioner
i) Supplier certification and cooperation: General Practitioners (GPs) should
evaluate their pharmacy suppliers’ environmentally friendly practices and support
them in developing greener processes/systems/activities. MURs are thought to have a
vital role to play in medication management (Lammy, 2007), and Dispensed Review
of the Use of Medicines (DRUMs) are regularly conducted by GPs and community
pharmacies (as part of NHS contract obligations) to improve the way that medications
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are used, to reduce unnecessary medication in circulation and to make informed
decisions regarding pack sizes and synchronization as advised by the National
Prescribing Centre etc (NHS Cumbria, 2009). The DRUM can be conducted based on
the medication and patients’ information recorded in the GPs’ databse.
ii) Customer cooperation: A GP plays an important role in the community PSC, as
s/he is the first point the patient (customer) contacts in the chain, providing an ideal
point to educate the patient as to how to properly dispose of or return the unused
medications.
According to a waste audit conducted by Rowlands Pharmacy (2009), GPs sometimes
might have prescribed medication for a longer period than customers’ need, which
results in unused medication accumulating in households. Therefore, GPs need to
consider the timeframe needed for prescriptions prior to dispensing. Shorter periods of
prescriptions have been trialed in Canada based on 7-14 days (Paterson and Anderson,
2002). Haughton (2003) suggested the development of a database to monitor the
distribution of prescription and Over-The-Counter (OTC) medications (information
on the OTC medications is difficult to obtain at the present), which can more
accurately predict the presence of medication waste in households. Therefore, it is
proposed that an efficient Management Information System (MIS) is developed for
GPs, with a database built in, where patients’ consultation and personal details will
also be recorded, together with Medicines Use Reviews (MUR) results, to facilitate
GPs to monitor patients’ progress and remind them to return pharmaceuticals via text,
call or email.
4.4 Community Pharmacies
Community pharmacies play different roles in the process of greening the PSC: i) they
are customers of the pharmaceutical manufacturers, and are responsible for
communicating with manufacturers or wholesalers regarding product information; ii)
they are a communication point with customers for advice and education on the
proper disposal of medication; iii) they act as an accessible site for customers
returning back unwanted/unused medication; iv) and they act as a site where
pharmacists conduct repeating or supplementary prescription to reduce unnecessary
medication entering the PSC. So the environmental practices to be taken by
community pharmacies will be:
Supplier certification and cooperation: Community pharmacies are also
encouraged to adopt green purchasing strategies in their sourcing to improve their
environmental performance and sustainability (Green et al., 1998, Murray, 2000) in
the PSC. As the end-retailers in the PSC, these pharmacies are the companies that
most strategically influence the environmental behaviour of suppliers upstream in the
PSC (Green et al., 2000). In keeping with the ethos of XGPSC they are advised to
evaluate suppliers’ environmental practices and choose those with ISO14000
certification or higher environmental compliance. In addition, they can manage their
inventory with manufacturers, and collaborate on operational activities such as
planning, forecasting and replenishment to minimise the amount of expired
medication. They should also collaborate with manufacturers to support ecological
medication design, and provide feedback to manufacturers regarding package sizes
and labeling information on recycling.
i)
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Efforts can be made to introduce supplier development initiatives which would
encourage interaction between suppliers and customers and facilitate knowledge
exchange (Breen, 2004b). It could also allow for development opportunities such as
vendor managed inventory services where pharmaceutical companies can share their
SC management expertise.
ii) Customer cooperation: As seen in Figure 2 it is clear that community pharmacy
is closer to the customer so has greater opportunity to build relationships with these
parties. They act as a site to communicate with customers about the proper disposal of
expired/unwanted medication, and provide facilities for customers to drop off those
medications. According to previous studies, 95% of pharmacies in British Columbia
have recycle bins, which allow consumers to bring their expired/unwanted medicines
back (Kreisberg, 2007). There is no comparable figure for this in the UK, so it is
recommended that similar provision is made to facilitate this practice. In addition,
open events for returning medications can be organised by the pharmacies in
collaboration with local councils, to launch a public campaign on reducing medication
waste and protecting the environment e.g. Calderdale Primary Care Trust (2006)
Wasted and Dangerous Campaign.
The information obtained from pharmacist-led and GP-collaborated MURs can be sent
to GPs for proper description and manufacturers for medication design and it also can
be used by pharmacies to identify the reason for return and take appropriate actions to
reduce waste. MURs completed in Huntingdonshire for 100 patients indicated that 49%
of patients were found to have medicines that could be stopped and 430 interventions
were made to reduce wasting these no longer needed medicines (Lammy, 2007).
Similar conclusions regarding medication reviews were raised by Braybrook et al
(1999) and Boivin (1997). Effective MURs in community pharmacy have also been
linked to a reduction in hospital admission for asthma patients (Jerram, 2009).
More advanced systems are being launched in the NHS medication management
system, such as repeating dispensing (Department of Health, 2007) and
supplementary prescribing (PSNC, 2005; RPSGB, 2006), and these services are
treated as essential steps in green PSC.
Repeat dispensing in community pharmacies allows patients to collect their repeat
medication directly from their chosen pharmacy without consulting with a GP each
time (Department of Health, 2007). Supplementary prescribing revolutionised the way
medicine management was traditionally organised allowing more flexible team
working. Supplementary prescribing allows pharmacists to prescribe medications
within the context of a Clinical Management Plan which is signed and agreed with a
patient’s GP prior to the consultation (PSNC, 2005; RPSGB, 2006). The two systems
allow patients improved access to medicines and is seen as an important advance in
the management of patient’s long term conditions. The service offered by the two
systems allows community pharmacists to engage in a two way conversation with
patients to ascertain that they are taking their medication as they should be and/or if
they are experiencing any side effects (concurs with Jesson et al’s findings, 2005). If
designed in this way, this will reduce unnecessary medications entering into the RL
pharmaceutical system.
12
4.5 Professional and regulatory bodies and waste management companies
The professional and regulatory bodies and waste management companies are
treated as indirect participants who have a peripheral influence on the direct
participants in the PSC. Public awareness of the importance and necessity of
pharmaceutical recycling can be raised, and advice, instructions and support given
from professional and regulatory bodies to individual organisations will have a
positive impact on greening the PSC. Such practices have been adopted in the United
States (Practice Greenhealth, 2009). Waste management companies can also make
suggestions and advice on improving practice.
i) Customer cooperation: In 2006, the Department of Health and RPSGB in UK
produced guidance on best practice pharmaceutical waste management (Department
of Health, 2006) and regulations on hazardous waste (RPSGB, 2005), which provides
practical advice and guidance for waste producers in the healthcare system.
Pharmacists within the PSC are required to understand and ensure compliance with
said guidance and regulations. However, legislation is also required to ensure that
manufacturers comply with environmental protection in terms of procurement,
production, distribution, RL and packaging.
Waste management companies provide services and advice to their customers on
secure disposal of pharmaceutical waste and compliance with legislations (PHS
Group, 2007; Veolia environmental services, 2007). It is expected that waste
management companies propose reasonable suggestions that would reduce medicinal
waste.
The data collated from MURs and DRUMs can be fed back into the PSC via
professional bodies and associations e.g. RPSGB and Association of the British
Pharmaceutical Industry (ABPI), and they can make suggestions to manufacturers on
medication design and package or to GPs on prescription quantities or further
medication monitoring.
4.6 Customers
To green the PSC, the role of the customer is not only as a consumer of
medication/healthcare service, but also as an actor to reduce unneeded medication and
return the unwanted medication. They need to be educated to manage unwanted
medication differently e.g. to bring the medication to a collection site or hazardous
waste facility rather than dispose of medication into water or domestic waste systems.
They can also buy smaller quantities of medication if possible, and buy products with
recyclable packaging. There is a need, therefore, to raise awareness of the impact of
medication on the environment and effective disposal methods.
i) Supplier cooperation: The management of returned medication cannot happen
unless the customer is compliant and becomes involved, e.g., to return the
expired/unwanted medication to the suppliers (either GPs or pharmacies). Breen and
Xie (2009) recognise that the customer operating in this new role is the only party in
the PSC who pays for a product but is then expected to act altruistically for the good
of the PSC by initiating product recycling. Any guidance and support infrastructure
put in place by the government and regulatory bodies will not ensure success in
medication recycling unless the customer participates. Unlike the traditional model of
recycling, e.g. where goods can be recovered and reused, pharmaceutical products
13
take a different recycling pathway, which is final disposal by a third party. The value
of the product return in this case is based on the reduction of risk due to the product
being taken out of circulation and no longer being a safety hazard.
Patient engagement with healthcare is sometimes purely on a transactional basis or if
there has been a length of servitude, it can result in something akin to loyalty. It is this
element that community pharmacy management needs to secure and build upon to
ensure the success and sustainability of returning medication in the PSC. This can be
facilitated by a CRM system which places customer involvement at the forefront of
this system, but also prompts and supports customer involvement by the use of
information systems and technology (Breen and Xie, 2009).
4.7 A Green PSC
The cost of recycling medication in the PSC is difficult to quantify. The cost of
final disposal is easy to identify but the cost of retrieval is a different matter. What is
the price of an effective RL system which facilitates effective customer management
and ensures recycling behaviour? How much does it cost to raise awareness and
educate/energise customers to want to bring back unwanted medication? Regardless
of cost, the message is clear. For economic, environmental, and safety considerations,
medication within the PSC needs to be reduced in order to reduce the quantity of
stock destined for final disposal. The effective delivery of this objective requires the
efforts of the complete PSC. Successful contribution of all participants will lead to a
greener and more sustainable PSC.
5. Conclusion
There are increasing concerns regarding the adverse environmental consequences of
inappropriately disposed medications, the economic loss caused by the preventable
medication waste, and the safety problems caused by the expired or hazardous
medications. To address these concerns, proper medication waste management
becomes a new frontier in health care system design. This is investigated in this paper
limited to community PSC in UK, which is one of the most frequently participated SC
by patients and medication buyers. Effective pharmaceutical waste management
requires the involvement of the entire SC, from manufacturers, through
wholesalers/logistics providers, to GPs, community pharmacies and finally to
customers to green the PSC. This will result in reducing preventable pharmaceutical
waste and more effective recycling and disposal of inevitable pharmaceutical waste.
To provide a channel for taking back the expired/unwanted medication, a PSC
network is designed encompassing RL to enable community pharmacies and
customers to recycle medication. However, the recycling behaviour is only counted as
a proactive environmental practice, and a XGPSC approach is designed as a
far-reaching approach to integrate environmental practices into the business strategy
and co-ordinate companies in the PSC to reduce their negative impact on the
environment. The environmental practices and actions which should be employed by
participants in the PSC are identified in the XGPSC approach. Such an approach
requires total involvement and cross-sector collaboration from participants.
Four environmental practices are recommended: top management commitment,
supplier certification and cooperation, customer cooperation, and eco-design. Under
these environmental practices, specific actions are addressed for direct participants
14
including manufacturers, wholesalers/logistics providers, GPs, community pharmacies,
and customers. The key actions include committing to developing environmental
objectives, evaluating and selecting suppliers with ISO14000 certificate, educating
patients for proper disposal of medication, reducing medication in circulation through
MURs, changing prescription period, and designing ecologically sensitive medication.
Indirect contribution is also recognised from peripheral influences from the
professional and regulatory bodies and waste management agencies.
The proposed XGPSC approach identifies environmental practices from a holistic
perspective, and adds valuable knowledge to the existing academic research on
GSCM practices. It can act as guidance for all those involved in the management of
medication waste, and provide practical advice and guidance for waste producers.
With a firm commitment from participants to take action reducing and recycling
medication waste, and becoming stewards of medication rather than only consumers,
the PSC will become greener in the future. Professional bodies or government may
use this approach as a reference to define regulations and instructions for best practice
of medication waste management. The PSC network incorporating the RL system
bridges the gaps between the current RL theories and its application in the
pharmaceutical area.
6. Limitations and future work
The research work is built on a contemporary literature review, so the applicability of
the XGPSC approach is not tested or verified. The XGPSC approach needs to be
further validated and improved in the future through empirical study. Also, the scope
of the research is limited to the community PSC in the UK, and future research will
investigate the pharmaceutical waste management in NHS hospitals and care homes
(NHS and private providers).
The success of the XGPSC approach requires total involvement of all the participants
in the chain, therefore weak cooperation from some of the PSC parties in practice may
become an obstacle in greening the PSC. For example, the less environmentally
conscious manufacturers or pharmacies may be reluctant to make ongoing
commitment to the environment in their production and supplier selection; the GPs or
pharmacies may be unwilling to accept responsibility for educating customers in
recycling medication; and customers may be incompliant in returning medication; all
of the above will undermine the efficacy of the XGPSC approach. Research on
improving the cooperation among PSC parties will be the cornerstone of this study
and will be developed further.
The most contentious aspect of the XGPSC approach is the cost: who should pay?
There may be reluctance from any of the PSC participants to pay the additional cost
for proper medication disposal, especially when returned medications cannot be
reused. Future investigations into this area will examine whether the cost of disposal
should be included in the cost of the medication or become part of mandatory tax. The
recycling of medication needs to be performed for all of the reasons discussed in this
paper. This is a non-profit practice. Adopting the proposed XGPSC approach will
ensure that action and practice reduces the accumulation of unwanted medications and
the need for disposal, reducing environmental risk and safety hazards, and economic
loss.
15
Figures:
XGPSC approach
·
·
·
A PSC network with RL
Green PSC
·
Internal environmental
management
External GSCM
Eco-design
·
·
Improved environmental
performance
Improved economic
performance
Improved safety
performance
Participant in PSC
Figure 1: Research framework for greening PSC using an XGPSC approach
Influences
research objective i):
a PSC network
incorporating a RL
system
Moderation and revision
Theoretical
foundation
·
·
·
Part A:
Drivers and pressures
Current service
provision
Future expectations
·
Part B:
Part C:
·
the RL system design
and applicaitons
·
GSCM practices
Obstacles, restrictions
and limitations
Part D:
Influences
Moderation and revision
Influences
research objective ii):
customised
environmental practices
for partipants in the PSC
Integration and cross functional cooperation
research objective iii):
XGPSC approach
Figure 2: Research design and processes
16
General Practice
Pharmacetutical
manufacturer
Logistics
provider/
Wholesaler
Professional and regulatory
bodies, and waste management
agencies
customer
Community
pharmacy
Logistics
provider/
Wholesaler
Forward logistics
(product flow)
Reverse logistics
(product flow)
Guidance, policy
and legislation
Reduce waste
Figure 3: A community pharmaceutical supply chain with reverse logistics
17
Provide advice & suggestions
on reducing medication waste
Produce guidance and legislation on
pharmaceutical waste managment
Professional & regulatory bodies, and waste
management agencies
Top
management
commitment
Supplier
certification &
cooperation
·
·
·
General
practitioner
Community
pharmacy
Environment
management system;
environmental
compliance audit
·
Select supplier who
are have ISO14000
certification
Medication use
review
·
·
·
·
Customer
cooperation
·
·
Eco-design
·
Communicate with
wholesalers or
pharmacies for
recycling feasibility
and product designs
·
·
Stock and
transport returned
medication;
Classification,
storage,
segregation,
destruction
disposal
·
·
·
Educate patient of
proper disposal of
medication;
Prescribe for
reasonable
periods;
Remind patients
returning
medication
·
·
·
·
Evaluate and select
suppliers with high
environmental
compliance;
Manage inventory with
suppliers to minimise
expired medication;
Collaborate with
suppliers for eco-design,
packaging, and labelling
Communicate with
customers for proper
disposal of medication
Collect returned
medication
Repeat or
supplementary
prescription
Medicine Use Review
Ecologically sensitive
design;
refine the expiry date;
use recyclable
packages;
design multiple
package sizes
Figure 4: The Cross boundary Green PSC (XGPSC) approach
18
Customers
·
·
Get compliant
and involved in
returning
medication;
Reduce wasting
medication
A Green PSC
Logistics
provider/
Wholesaler
Pharmaceutical
manufacturer
Appendix: Acronyms
3PL:
ABPI:
CRM:
DRUM:
GP:
GPSC:
GSCM:
MIS:
MUR:
NHS:
OTC:
PSC:
RL:
RPSGB:
SC:
XGPSC:
19
Third Party Logistics
Association of the British Pharmaceutical Industry
Customer Relationship Management
Dispensed Review of the Use of Medicines
General Practitioner
Green Pharmaceutical Supply Chain
Green Supply Chain Management
Management Information System
Medicines Use Review
National Health Service
Over The Counter
Pharmaceutical Supply Chain
Reverse Logistics
Royal Pharmacy Societies of Great Britain
Supply Chain
Cross boundary Green Pharmaceutical Supply Chain
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