Abstract Number: 015-0318

Green Community Pharmaceutical Supply Chain in UK: Reducing and

Recycling Pharmaceutical Waste

Ying Xie*, Liz Breen**

*Business School, University of Greenwich, Maritime Campus,

London, SE10 9LS UK,

Email: y.xie@gre.ac.uk, Tel: +44 (0)20 83317956

** Bradford University School of Management

Emm Lane, Bradford, West Yorkshire

BD9 4JL UK,

Email: L.Breen@bradford.ac.uk

POMS 21st Annual Conference

Vancouver, Canada

May 7 to May 10, 2010

Abstract

The Pharmaceutical Supply Chain (PSC) is a SC where pharmaceutical medications

are produced, transported and consumed. Disposal of the medication waste is harmful

to the environment and costly, therefore, greening the PSC by properly managing the

medication waste is investigated. A Cross Boundary Green PSC (XGPSC) approach is

proposed to design a green PSC that results in fewer preventable medication waste

and more recycling of inevitable medication waste, therefore improved environmental,

economic and safety performances. This study focuses on the community PSC in UK

where patients get medication from local community pharmacies. To green the PSC,

every producer of waste is duty bound to ensure the safe handling and disposal of

waste. This duty of care spans throughout the chain and includes all participants. This

approach is drawn from the contemporary literature and our collaborative research,

and can be used as a guidance to establish a waste management network in

community PSC.

Keywords:

Green supply chain, pharmaceutical supply chain, environmental practices

1. Introduction

There has been increased consciousness of the environment in the last few

decades. More people realise the world‟s environmental issues such as global

warming, carbon emissions, toxic substance usage, and resources scarcity. There is

global advocation for going green, and many organizations respond to this by

applying green principles to their company. In addition to the mandatory regulation

driven programmes, numerous environmental programmes are introduced by

organisations voluntarily. The British supermarket chain Sainsbury‟s has expanded its

trials running vehicles on biogas made from landfilled waste, with an order for five

more of its vehicles to be converted (Navarro, 2009). Pepsi-Cola saved $44 million by

switching from corrugated to reusable plastic shipping containers for one litre and

20-ounce bottles, conserving 196 million pounds of corrugated material. Wu and

Dunn (1995) designed an environmental friendly chain for a single organisation where

greening starts from procurement and work its way through to storage, distribution

and to end-consumers. However, the chain does not include the cross company

activities. In fact, not only within a single organization, the green principles are

extended to the whole supply chain (SC). Printing industries like 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). Green SC Management (GSCM) emerged in

late 1990s, and it ranges from reactive monitoring of general environmental

management programs to more proactive practices, such as the recycling, reclamation,

remanufacturing, reverse logistics of environmental management and incorporating

innovations (Zhu and Sarkis, 2004). For over 10 years, GSCM has become an

important environmental practice for companies to achieve profit and increase market

share in such a way that environmental risks are lowered and ecological efficiency are

raised (Van Hok and Erasms, 2000). Realising the significance of the GSCM

implemented by the organisations, Sarkis (2003) developed a strategic decision

framework that aids managerial decision making in selecting GSCM alternatives, and

product life cycle, operational life cycle (including procurement, production,

distribution and reverse logistics(RL)), organisational performance measurements and

environmentally conscious business practices serve as the foundations for the decision

framework. Considering the previous 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 (internal

environmental management, external GSCM, investment recovery, and eco-design or

design for environment practices), and examined the relationship between these

practices and environmental and economic performance 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). 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 supply chain distinctive include; the level of regulation in the

product production, storage, distribution, consumption and the complexity of the

fabric of this supply chain (Knight, 2005). Disposal of medication can be very

harmful to the environment and costly. Vast arrays of drugs are entering 41 million

Americans‟ drinking water from people disposing the unused/expired drugs in the

domestic rubbish or waste water (USATODAY, 2009). Globally, in 2003 at least

£0.56 billion worth of unused drugs are 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 the pulling back of stock from patients. Medication retrieved from

patients cannot be re-used and must be disposed. 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/sales. Global and

domestic pressures on environmental, economic and safety considerations (Breen and

Xie, 2009) drive us to manage PSC greening, i.e., improve the PSC economic and

environmental performance by recycling the unused/unwanted medications and

reducing medications that need disposal As a result of greening processes, the PSC

will become safer when hazardous medications are removed from the supply chain

and be kept away from vulnerable people, like children. However, there is very little

research and practice on drug recycling (Ritchie et al., 2000) or green PSC (GPSC).

As explained above, it is vitally important to properly dispose expired 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 medicine that reaches lakes

and rivers via sewage plants and other sources (New Hampshire Department of

Environmental Services, 2009).

This research aims to design a green PSC that results in fewer preventable drug

waste and more recycling of inevitable drug waste, using a cross boundary green PSC

(XGPSC) approach that requires every participant in the PSC to take environmental

practices to improve the economic and environmental performances of the chain. In

order to achieve the aim, the research framework and objectives are established in

Section 2, then a community PSC with reverse logistics is designed in Section 3; and

the XGPSC approach is proposed in Section 4 where participants are recommended to

take environmental practices and actions to green PSC. Section 5 concludes the paper

summarising the findings and potential for future research.

2. Research framework and methodology

The objectives to meet the research aim are: i) design a physical network for

community PSC with RL built in; ii) develop a XGPSC approach, in which the

environmental practices playing important roles in greening PSC are identified from a

broad perspective; iii) under the environmental practices identified in ii), the specific

the actions to be taken by each participant in the PSC are addressed from a detail

perspective.

The research framework is shown in Figure 1, illustrating that each participant in

the PSC network is recommended to adopt the XGPSC approach and take necessary

environmental practices to green the PSC. The environmental practices to be

conducted by the participants in the PSC are complex, collaborative, costly and

different from other business sectors provided that PSC is a special SC, it would be

impossible to conduct any empirical study to test any practice prior to a systematic

conceptual approach is formulated. Therefore, the XGPSC approach is developed

from the literature that identified the practices in the area of environmentally

conscious business practices and from the authors‟ collaborative research in the area

of pharmaceutical supply chain. The recommended practices are made by the authors

after consultation with academic experts, medication users, pharmacists, and

professional and regulatory bodies like Royal Pharmacy Societies of Great Britain

(RPSGB), Department of Health, and London National Health Service (NHS) London

Procurement Programme(LPP). The authors also reviewed the regulations, guidance,

audit results and other publications from the RPSGB and NHS to understand the

current progress and expectations for medication waste management, and developed

the environmental practices incorporating with the good experiences from other

countries.

The drivers of green PSC are summarized as the environmental, economic and

safety considerations and it is expected that the environmental, economic and safety

performances of the chain can be improved when it is becoming green. It has been

argued that new opportunities of competition (Hansmann and Kroger,2001) and many

benefits can be brought to the organisations if environmental protection activities are

taken (Alvarez Gil et al., 2001), including 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 motivations (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 take the four GSCM practices, i.e., internal

environmental management, external GSCM, investment recovery, and eco-design or

design for environment practices. The internal environment management requires

commitment and support from senior managers in the organisation, as well as total

quality environmental management (TQEM) and audit programme to be set up. 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 the organisations involved in manufacturing processes to

design products for reduced consumption of materials by adopting reusable or

recyclable materials, and reducing use of hazardous components. The investment

recovery practice is not applicable to the PSC as returned medication cannot be reused

or resold. So the three GSCM practices except investment recovery will be used as

foundations to develop a XGPSC approach, in which the environmental practices and

specific actions are recommended to be taken by PSC participants in order to green

PSC with improved environmental and economic performances. Considering the

hazards that the out-of-date and unused medicines pose on the children and other

vulnerable people, the green PSC reduce the excess medicines in households and

therefore reduce the propensity for these groups to take the out-of-date or unused

medications which ultimately lead to improved safety performance of PSC.

· Internal environmental

management

· External GSCM

· Eco-design

See Figure-2· Improved environmental

performance

· Improved economic

performance

· Improved safety

performance

XGPSC approach PSC Green PSC

Participant in PSC

Figure 1: Research framework for greening PSC using an XGPSC approach

3. A community PSC network with reverse logistics

As identified in Sarkis (2003), RL is one of the most important but least

developed operational functions that serve 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, pp2). 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 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 2, where a forward logistics network

is depicted in which medications are produced by the pharmaceutical manufacturer,

transported by the logistics providers community pharmacies, and finally consumed

by the customers who can be the patients or the buyers; also a RL network is designed

for the unused/unwanted medications to be returned to the manufacturer. The

unused/unwanted medications are encouraged to be returned for two reasons (Breen

and Xie, 2009): i) it removes the product from circulation and from the 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).

As shown in Figure 2, a RL network is one of the key resources needed by the

customer, pharmacy, GP and manufacturer to conduct recycling behaviour. A channel

must be available for the expired drugs to be sent back to manufacturers, and can be

built in a number of ways: i) customers return the unused/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 such as

collection, sorting, recycling and disposal or cooperating with other actors in the

system (de la Fuente et al., 2007; Krumwiede and Sheu, 2002). The dashed line in

Figure 2 represents the recycling channel for the expired drugs. In the process of

recycling, logistics providers or wholesalers take the role of collection from the

community pharmacy and transport 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

direct impact on the performance of the PSC, while the professional and regulatory

bodies influence PSC indirectly via giving suggestions to the direct participants. In the

middle of the figure (Figure 2), guidance and instructions from professional and

regulatory bodies (like Royal Pharmacy Societies of Great Britain (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 in which companies have the strategic initiative to integrate

environmental practices into the business strategy and operate the company to reduce

impact on the environment (Kopicki et al., 1993). Community pharmacies are bound

by contractual obligation to offer a returns service for medication; this action is

therefore built into their service provision (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 (Primary Care Commissioning, 2009).Also,

medications once returned by customers cannot be re-used and must be disposed

therefore they have no residual value. Strategically action must be taken to reduce the

medication waste entry to the PSC for environmental protection, economic savings

and safety considerations. As illustrated in the shaded boxes, the participants in the

PSC are expected to reduce the medication waste by integrating environmental

practices in their main activities. The specific actions to be taken by the participants to

reduce waste will be discussed in the next section.

Pharmacetutical

manufacturer

General Practice

Community

pharmacy

customer

Logistics

provider/

Wholesaler

Professional and regulatory

bodies, and waste management

agencies

Forward logistics

(product flow)

Reverse logistics

(product flow)

Reduce waste

Logistics

provider/

Wholesaler

Figure 2: A community pharmaceutical supply chain with reverse logistics

4. A Cross Boundary Green PSC (XGPSC) approach

To green the community PSC, not only a physical PSC network needs to be

constructed in Figure 2, but also GSCM practices should be implemented by all

participants in the chain from the holistic system perspective, which is the

far-reaching approach that will minimise the total environmental impact of a business

(Van Hoek, 1999).

A cross boundary green PSC (XGPSC) approach is proposed in this section (as

shown in Figure 3) to propose environmental practices to be adopted by participants

in the PSC, in order to convert the community PSC in Figure 2 to be a green PSC.

Based on the three categories of GSCM practices in Zhu and Sarkis (2004), the

XGPSC approach recommend the four environmental practices in Table 1: i) top

management commitment: each participant in the PSC make commitment to GSCM

from top management team and setup environmental management system; ii)

supplier certification and cooperation: each participant should evaluate his

suppliers‟ environmental practices and cooperate with suppliers for environmental

objectives; iii) customer cooperation: each participant cooperate with customers or

support them for eco-design, cleaner production, green packaging and 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 reduced use of hazardous components. The

recommendation i) and iv) are classified as internal environmental management that

take place inside an organisation and plays key roles in improving the performance of

individual organisations (Carter et al., 1998). The ii) and iii) are external

environmental practices that are more difficult to be implemented and require the

information, support and collaboration from other participants. However, to

successful green the PSC, the recommended practices are integrative and need

cross-functional cooperation rather than oriented towards a single department or

organisation (Xie, 2009).

Under the environmental practices recommended above, the specific actions to be

taken by each participant vary along the chain and are illustrated in Figure 3.

Table 1: environmental practices recommended in XGPSC approach

XGPSC approach

Internal Environmental

practices

Top management

commitment

Eco-design

External environmental

practices

Supplier certification and

cooperation

Customer cooperation

4.1 The Manufacturer

i) Top management support: As the producer and designer of the pharmaceutical

products, the manufacturer can contribute to the green PSC through innovative and

environment friendly medication designs, so the commitment of GSCM from the

management team are essential to realise and ensure total green operational processes

ranging from procurement, production, distribution and reverse logistics. It is also

recommended that an environmental management system should be designed to

improve the TQEM and make the ISO 14000 certification the target of the

organisation and its suppliers (GEMI, 2001). To monitor and evaluate the organisation

and its supplier‟s practices, a series of environmental compliance and auditing

programmes should be set up (Zhu and Sarkis, 2004).

ii) Supplier certification and cooperation: Florida (1996) claimed that close bonds

with suppliers facilitate cleaner production. The supplier selections and procurement

decisions have an impact on the GPSC through purchase of materials that are

hazardous or non-hazardous, recyclable or reusable, or have already been recycled

(Sarkis, 2003). The manufacturers are encouraged to add environmental, health and

safety elements to their strategic sourcing initiatives, and provides practical resource

for procurement staff to understand and pursue opportunities that will add business

value to their companies (GEMI, 2001). The suppliers who have ISO 14000

certification are recommended to be selected to lessen the environmental risks

associated with the materials procurement.

iii) Customer cooperation: By collaborating with the customers (the wholesalers or

the pharmacies in this research) and communicating for design specifications and

recycle feasibility of products , the manufacturers can contribute to innovative

medication designs, cleaner production and green packaging (Zhu and Sarkis, 2004).

A strong relationship with wholesalers and pharmacies will encourage the returnable

packaging adopted by them provided that reverse logistics channel is available.

iv) Eco-design: According to (Kreisberg, 2007), medications 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. It is also recommended in

(Breen and Xie, 2009) that medication product life cycle can be maximised so that

customers will feel it is worth returning them back for economic benefits.

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 the

packaging size can be made available for the GPs or pharmacists to minimise the

unused portion of prescriptions.

4.2 The wholesaler and logistics providers

The development of a RL system has enabled pharmacies to transport all unsold

or expired drugs as products go back through these firms for the purpose of returning

them to the manufacturer for credit. The activities of transportation in the RL system

can be implemented by the wholesaler, or the logistics providers including the third

party logistics (3PL) company. Any expired items that do not meet the

manufacturers‟ return policy become waste at the RL which becomes the waste

generator, since this is where the decision to discard the item is made (Smith, 2002).

Waste need to be properly dealt with by the wholesalers and logistics providers in

collaboration with manufacturers and community pharmacies, 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. 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 hospital pharmacy in consolidating deliveries. Wholesalers can

provide such a service in their current position in the PSC (Breen, 2004).

The service provided by the wholesaler and logistics providers can go beyond

transportation, and include classification, storage, manifest, destruction, and disposal

of medications. 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, 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 the licenses for these services before they are

contracted in the RL network.

4.3 General Practitioner

i) Customer cooperation: A General Practitioner (GP) plays an important role in

the community PSC, as s/he is the first point the patient (customer) contacts in the

chain, and it is an ideal time point to educate the patient how to properly dispose or

return the unused medications when the GP prescribes the medications.

According to waste audit conducted by Rowlands Pharmacy (2009), GPs might

prescribe medication for a longer period than customers‟ need, which results in

unused medication accumulating in household. 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). GPs should also be consulted regarding patients involved, and an efficient

Management Information System (MIS) is proposed to facilitate GPs to monitor

patients‟ progresses and remind them to return pharmaceuticals via text, call or email.

In the MIS, patients‟ consultation and personal details will be recorded, together with

Medicines Use Reviews (MUR) results.

ii) Supplier certification and cooperation: The GPs should evaluate their

pharmacy suppliers‟ environment friendly practices and make proper suggestions or

support to help them go green. Medication Use Reviews (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

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 information recorded in the GPs‟ MIS which are appropriately shared

with pharmacies to facilitate the whole process.

4.4 Community Pharmacies

Community pharmacies play different roles in the process of green 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 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:

i) Supplier certification and cooperation: The pharmacies are supposed to

evaluate suppliers‟ environmental practices and choose the one with ISO14000

certification or higher environmental compliance. In addition, they can manage their

inventory with manufacturers, and launch collaborative planning, forecasting and

replenishment (CPFR) to minimise the amount of expired medication. They also

should collaborate with manufacturers for ecological medication design, and feedback

manufacturers on the package sizes and labelling information on recycling, etc.

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

supply chain 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 proper disposal of

unused/unwanted medication, and provide facilities for customers to drop off those

medications. According to the research, 95% of pharmacies in British Columbia

have recycle bins, which allow consumers to bring their unused/expired medicines

back (Kreisberg, 2007). While in UK, there is no figure showing the percentage of

pharmacies providing drop in/recycle boxes, and it is recommended the pharmacies

acting on the provisions. 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 Wasted and Dangerous Campaign (2006).

The information obtained from pharmacist-led and GP-collaborated MURs can be sent

to GP for proper description and manufacturers for medication design and it also can be

used by pharmacies to identify the reasons of returning 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 drugs 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). It also

increases the patient convenience and will help develop good links between

pharmacies and GPs. If designed in this way, this will reduce unnecessary

medications entering into the RL pharmaceutical system.

4.5 Professional and regulatory bodies and waste management companies

The professional and regulatory bodies and waste management companies are

treated as indirect participants and have peripheral influences on the direct

participants in the PSC. Public awareness on the importance and necessity of drug

recycling can be raised, and advice, instructions and support from professional and

regulatory bodies given to individual organisations will have positive impact on

greening the PSC, and these practices have been conducted in the United States

(Practice Greenhealth, 2009). The waste management companies can make

suggestions and advice. In this case, the PSC participants who are guided and

instructed are treated as the customers, and the prior communications and cooperation

with them are essential to define the guidance and instructions.

i) Customer cooperation: In 2006, the Department of Health and Royal Pharmacy

Society of Great Britain (RPSGB) in UK produced guidance on best practice

pharmaceutical waste management (Department of Health, 2006) and regulations on

hazardous waste (RPSGB, 2005), which provide practical advice and guidance for

waste producers in the healthcare system. The pharmacists in the PSC are required to

understand and ensure their compliance with the guidance and regulations. However,

legislations are also required to oblige manufactures to make compliance on

environmental protection in terms of procurement, production, distribution, reverse

logistics and packaging. The rules defining customer compliance in returning the

unused/unwanted medication will also facilitate the success of green PSC.

Waste management companies are providing services and advice to their customers

on secure disposal of medication waste and compliance with legislations (Phs

management, 2007; Veolia environmental services, 2007). It is expected that waste

management companies propose reasonable suggestions that would reduce medicines

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 period or further medication

monitoring.

4.6 Customers

To green the PSC, the role of the customer is not only a consumer of

medication/healthcare service, but also an actor to reduce unneeded medication and

return the unused medication. They need to be educated to manage unwanted

medication differently e.g. rather than dispose of medication into water or domestic

waste systems, bring the medication to a collection site or hazardous waste facility.

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 and effective disposal methods.

i) Supplier cooperation: The management of returned medication cannot happen

unless the customer is compliant and becomes involved, e.g., corporately or

proactively return the unused/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 PSC by initiating product recycling. Any guidance and

support infrastructure put in place by the government and regulatory bodies will not

ensure success in this area, unless the customer participates. Unlike the traditional

model of recycling, e.g. where goods can be recovered and reused, pharmaceutical

products take a different recycling pathway, that is, final disposal by a third party. The

customer, as an existing patient, can also hold a strong position on an individual basis,

as determined by the potential risk attached to the medication that is returned. The

value in this case is based on the reduction of risk due to the product being taken out

of circulation and no longer a hazard to patients or extended family etc.

Besides this, the patient engagement with the service 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.

Professional & regulatory bodies, and waste

management agencies

Pharmaceutical

manufacturer

General

practitioner

Logistics

provider/

Wholesaler

Community

pharmacyCustomers

· Communicate with

wholesalers or

pharmacies for

recycling feasibility

and product designs

· Select supplier who

are have ISO14000

certification

· Environment

management system;

· environmental

compliance audit

· Ecologically sensitive

design;

· refine the expiry date;

use recyclable

packages;

· design multiple

package sizes

· Educate patient of

proper disposal of

medication;

· Prescribe for

reasonable

periods;

· Remind patients

returning

medication

· Medication use

review

· Stock and

transport returned

medication;

· Classification,

storage,

segregation,

destruction

disposal

· Communicate with

customers for proper

disposal of medication

· Collect returned

medication

· Repeat or

supplementary

prescription

· Medicine Use Review

· 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

· Get compliant

and involved in

returning

medication;

· Reduce wasting

medication

Produce guidance and legislation on

pharmaceutical waste managment

Provide advice & suggestions

on reducing medication waste

A G

reen PSC Top

management

commitment

Supplier

certification &

cooperation

Customer

cooperation

Eco-design

Figure 3: The cross boundary green PSC (XGPSC) approach

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 and are investigated in

this paper limited to community PSC in UK, which is one of the most frequently

participated SC by the patients and the medication buyers. The medication waste

management requires the involvement of the entire supply chain, from manufacturers,

through wholesalers/logistics providers, to GPs, community pharmacies and finally

to customers to green the PSC that results in fewer preventable drug waste and more

recycling of inevitable drug waste.

To provide a channel for taking back the unused/expired medication, a PSC

network is designed encompassing the 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 operate the companies in the PSC to reduce impact on the environment. The

environmental practices and actions to be taken by the participants in the PSC are

identified in the XGPSC approach that requires total involvement and cross-sector

collaborations 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 including manufacturers, wholesalers/logistics

providers, GPs, community pharmacies, and customers. The key actions include

making commitment to environmental objectives, evaluate and select suppliers with

ISO14000 certificate, educate patients for proper disposal of medication, collaborate

with customers for medication use review, change prescription period, and

ecologically sensitive medication design. Indirect contribution is also recognised

from peripheral influences from the professional and regulatory bodies and waste

management agencies.

The proposed XGPSC approach can act as the guidance for all those involved in

the management of medication waste, and provides practical advice and guidance for

waste producers. With a firm commitment to take actions reducing and recycling

medication waste, like changing habits, becoming stewards of medication rather than

only consumers, the PSC will become greener in the future. Professional bodies or

government may use it as a reference to define regulations and instructions for best

practice of medication waste management.

The research work is built on the contemporary literature review and the

collaborative research, so the proposed XGPSC approach needs to be further

validated and improved in the future through empirical study.

References:

1. Alvarez Gil M.J., Jimenez J.B. and Lorente, J.C. (2001), “An analysis of

environmental management, organizational context and performance of Spanish

hotels”, Omega: International Journal of Management Science, Vol. 29 No. 6, pp.

457–471.

2. Ashley S. (1993), “Designing for the environment”, Mechanical Engineering,

Vol.115 No. 3, pp.52–55.

3. Beaumont, J.R., Pedersen, L.M. and Whitaker, B.D. (1993), Managing the

Environment: Business Opportunity and Responsibility, Butterworth-Heinemann,

Oxford.

4. Bellingham C. (2004), “How to dispose of unwanted medicines”, The

Pharmaceutical Journal, Vol.273 No. 7324, pp.686.

5. Bergstrom RY. (1993), “An annotated essay: environmental affairs”, Production,

Vol.105 No. 4, pp.36–41.

6. Boivin, M. (1997), “The Cost of Medication Waste”, Canadian Pharmaceutical

Journal, May, pp. 32-39.

7. Braybrook, S., John, D.N. and Leong, K. (1999), “A survey of why medicines are

returned to pharmacies”, The Pharmaceutical Journal, Vol. 263, pp. 7063.

Pharmacy Practice Research. Papers presented at the British Pharmaceutical

Conference, Cardiff, September 13 to 15 1999 pR30.

http://www.pharmj.com/editorial1999/19990918/pharmacypractice/braybrook2.ht

ml

8. Breen L, (2004a) “Is there a place for Third Party Logistics providers in the NHS

Pharmaceutical Supply Chain in Hospital Pharmacy? - the case of Central

Manchester and Manchester Children‟s University Hospitals NHS Trust

(CMMC)”, Hospital Pharmacist, Vol. 11, pp. 33-36

9. Breen L, (2004b) “Does Supplier Development benefit Hospital Pharmacy? - The

case of Central Manchester and Manchester Children‟s University Hospitals NHS

Trus”, Pharmacy Management, Vol.20 No.3, pp.1-14.

10. Breen L. (2006), “Give me back my empties or else! A preliminary analysis of

customer compliance in reverse practices (UK)”, Management Research News, Vol.

29 No. 9, pp. 532-551.

11. Breen L. and Xie Y. (2009), Examining the role of the customer in facilitating

reverse logistics system in NHS community pharmacy in the UK, proceeding of

the Logistics Research Network annual conference, 9-11 September, 2009,

Cardiff, UK, 588-591.

12. Calderdale Primary Care Trust (2006), “Wasted and Dangerous”, available at:

http://www.calderdale.nhs.uk/public-information/publication-scheme/disclosure-l

og/disclosure-log-item/article/28/545/neste/5/ (accessed 26 September 2008)

13. Carter C.R., Ellram L.M. and Kathryn L.M. (1998), “Environmental purchasing:

benchmarking our German counterparts”, International Journal of Purchasing and

Materials Management, Vol. 34 No.4, pp.28-38.

14. de la Fuente, M.V., Ros, L. and Cardós, M. (2007), “Integrating Forward and

Reverse Supply Chains: Application to a metal-mechanic company”, International

Journal of production Economics, Vol. 111 No. 2, pp.782-792.

15. Department of Health (2006), Health Technical Memorandum 07-01: Safe

Management of Healthcare Waste.

16. Department of Health (2007), “NHS repeat dispensing schemes in England:

Department of Health – Health care”, available at:

http://www.dh.gov.uk/en/Healthcare/Medicinespharmacyandindustry/Prescription

s/DH_4000157 (accessed 3 December 2009)

17. Department of Health (2008), “Pharmacy Contractual Framework. Briefing

Paper for website. February 2008 – Gateway reference 9484”, available at:

http://www.dh.gov.uk/en/Healthcare/Medicinespharmacyandindustry/Communityp

harmacy/Communitypharmacycontractualframework/index.htm (accessed 20

October 2008)

18. Florida, R., (1996), “The Environment and the New Industrial Revolution”,

California Management Review Vol. 38 (Autumn), pp. 80–115.

19. González-Torre, P.L. and Adenso-Díaz, B. (2006), “Reverse logistics practices in

the glass sector in Spain and Belgium”, International Business Review, Vol. 15

No.5, pp.527-546.

20. Gillett J. (1993), “Ensuring suppliers‟ environmental performance”, Purchasing

& Supply Management, pp.28-30.

21. GEMI (Global Environmental Management Initiative) (2001), New Paths to

Business Value. GEMI, Washington DC.

22. Guimaraes, T. and Liska, K. (1995), “Exploring the business benefits of

environmental stewardship”, Business Strategy and the Environment, Vol. 4 No.1,

pp. 9–22.

23. Hansmann, K.W., Kroger, C. (2001), “Environmental management policies”, In

Sarkis, J. (Ed.), Green Manufacturing and Operations: From Design to Delivery

and Back. Greenleaf Publishing, Sheffield, UK, pp. 192–204.

24. Jerram, P. (2009), “Medicine Use Reviews Reduce Asthma Admissions”,

Pharmacy Management, Vol. 25 No.3, pp. 15-19.

25. Jesson, J., Pocock, R. and Wilson, K. (2005) “Reducing waste in community

pharmacy”, Primary Health Care Research and Development, Vol. 6 No.2, pp.

117-124.

26. Knight, L.K. (2005) Roles, Relationships and Dynamics of the Pharma Network.

A discussion document on opportunities for supply research, Draft internal report

to the NHS Purchasing and Supply Agency 2005.

27. Kopicki, R., Berg, M.J., Legg, L., Dasappa, V. and Maggioni, C. (1993), “Reuse

and Recycling –Reverse Logistics Opportunities”, Council of Logistics

Management, Oak Brook, IL.

28. Kreisberg J. (2007), “Green pharmacy: preventing pollution, a cross sector

approach” The Journal of Ecologically Sustainable Medicine, Spring/Summer

2007, pp.25-29.

29. Krumwiede, D.W. and Sheu, C. (2002), “A model for reverse logistics entry by

third-party providers”, OMEGA: International Journal of Management Science,

Vol. 30, pp. 325-333.

30. Lammy D. (2003), “Speeches on 5th March 2003: Medicine Management”,

http://www.dh.gov.uk/en/News/Speeches/Speecheslist/DH_4000633 (Accessed 3

December, 2009)

31. Lau, K.W. and Wang, Y. (2009), “Reverse logistics in the electronic industry of

China: a case study”, Supply Chain Management: An International Journal, Vol.14

No.6, pp. 447-465.

32. Lebreton, B., Tuma, A. (2006), “A quantitative approach to assessing the

profitability of car and truck tire remanufacturing”, International Journal of

Production Economics, Vol. 104 No.2, pp. 639-652.

33. Maxie E. (1994), “Supplier performance and the environment”, In proceedings of

International Symposium on Electronics and the Environment, IEEE, San

Francisco, CA, pp.323-327.

34. Nagurney, A. and Toyasaki, F. (2005), “Reverse supply chain management and

electronic waste recycling: a multitiered network equilibrium framework for

e-cycling”, Transportation Research Part E: Logistics and Transportation

Review, Vol. 41 No.1, pp.1-28.

35. Navarro X. (2009), “British supermarket chain Sainsbury‟s to use biomethane in

its trucks”, available at:

http://green.autoblog.com/2009/02/23/british-supermarket-chain-sainsburys-to-use-

biomethane-on-truck/ (accessed on 3 December 2009)

36. New Hampshire Department of Environmental Services (2009) “How to address

unwanted medicine disposal in New Hampshire”, available at:

http://des.nh.gov/organization/commissioner/pip/publications/wmd/documents/un

used_medicine.pdf (accessed 28 May 2009)

37. NHS Cumbria (2009), “Dispensing review of the use of medicines (DRUM)”,

available at:

http://www.cumbria.nhs.uk/ProfessionalZone/MedicinesManagement/DispensingD

octors/Home.aspx (accessed 3 December, 2009).

38. Paterson J.M. and Anderson G.M., (2002) “Trial Prescriptions to reduce drugs

wastage: results from a Canadian program and a community demonstration

project”, American Journal of Managed Care, Vol. 8, pp. 151-158.

39. Pati, R.K., Vrat, P. and Kumar, P. (2008), “A goal programming model for paper

recycling system”, OMEGA: International Journal of Management Science, Vol.

36 No.3, pp. 405-417.

40. PSNC (Pharmaceutical Services Negotiating Committee) (2005), NHS

Community Pharmacy Contractual Framework Enhanced Service – Supplementary

Prescribing by Pharmacists

41. Phs Management (2007), Environment and sustainability: health technical

manual 07-06, disposal of pharmaceutical waste in community pharmacies.

42. Porter, M.E. and van der Linde, C. (1995), “Green and competitive: ending the

stalemate”, Harvard Business Review, Vol. 73.5, pp.120–134.

43. Practice Greenhealth (2009), “Pharmaceutical waste minimisation, why should

pharmaceutical waste be minimised?” available at:

http://cms.h2e-online.org/ee/waste-reduction/waste-minimization/pharm

(accessed 24 November, 2009)

44. Primary Care Comissioning (2009) “NHS Community Pharmacy Contractual

Framework Essential Service – Disposal of Unwanted Medicines”, available at:

http://www.pcc.nhs.uk/uploads/Pharmacy/march_08/disposal_of_unwanted_medic

ines.pdf (accessed 14 December 2009)

45. Ritchie, L., Burnes, B., Whittle, P. and Hey, R. (2000), “The benefits of reverse

logistics: the case of the Manchester Royal Infirmary Pharmacy”, Supply Chain

Management: An International Journal, Vol. 5 No. 5, pp. 226-233.

46. Rogers, D.S. and Tibben-Lembke, R.S. (1999), “Going Backwards: Reverse

Logistics Trends and Practices”, Reverse Logistics Executive Council Press,

Pittsburgh, PA.

47. Rowlands Pharmacy (2009) “Waste Audit – Summary of Results”.

48. RPSGB (Royal Pharmaceutical Society of Great Britain), (2005), The hazardous

waste (England and wales) regulations 2005, interim guidance for community

pharmacists for England and Wales and information for Scotland.

49. RPSGB (Royal Pharmaceutical Society of Great Britain), (2006),

Supplementary prescribing one year on.

50. Sarkis J. (2003), “A strategic decision framework for green supply chain

management”, Journal of Cleaner Production, Vol. 11, pp. 397-409.

51. Savage, C.J., Roberts, K.J., and Wang, X.Z. (2006), “A holistic analysis of

pharmaceutical manufacturing and distribution: are conventional supply chain

techniques appropriate?” Pharmaceutical Engineering, July/August, pp. 10-18.

52. Shih, L.H. (2001), “Reverse logistics system planning for recycling electrical

appliances and computers in Taiwan”, Resources, Conservation and Recycling, Vol.

32 No.1, pp. 55-72.

53. Shrivastava, P. (1995), “Environmental technologies and competitive advantage”,

Strategic Management Journal, Vol.16 (Special issue, Summer), pp. 183–200.

54. Smith C.A. (2002), „Managing pharmaceutical waste-what pharmacists should

know‟, Journal of the Pharmacy Society of Wisconsin, Nov/Dec 2002, pp. 17-22.

55. USA TODAY (2009), “AP: Drugs found in drinking water”, available at:

http://www.usatoday.com/news/nation/2008-03-10-drugs-tap-water_N.htm,

(Accessed 31 May, 2009)

56. Van Eijken M., Tsang S., Wensing M., De Smet P.A.G.M., and Grol R.P.T.M.

(2003), “Interventions to improve medication compliance in older patients living

in the community: A systematic review of the literature”. Drugs & Aging., Vol. 20

No.3, pp. 229-240.

57. Van Hoek R. and Erasms I. (2000), “From reversed logistics to green supply

chains”, Logistics Solutions Issue, Vol. 2, pp. 28-33.

58. Van Hoek R. I., (1999), “From reversed logistics to green supply chains”, Supply

Chain Management, Vol. 4 No.3, pp. 129-134.

59. Veolia environmental services (2007), “Birmingham clinical waste”, available

at:

http://www.veoliaenvironmentalservices.co.uk/birmingham/pages/publications.as

p (accessed 19 November 2009)

60. Walton S.V., Handfield R.B. and Melnyk S.T. (1998), “The green supply chain:

integrating suppliers into environmental management process”, International

Journal of Purchasing and Materials Management, Spring, pp. 2-11.

61. Wu, H.-J. and Dunn, S.C. (1995), “Environmentally responsible logistics

systems”, International Journal of Physical Distribution & Logistics Management,

Vol. 25 No. 2, pp. 20-38.

62. Xie Y. (2009), “Greening pharmaceutical supply chain in China”, In proceedings

of the 20th International Conference on Production Research, 2nd-6th August,

Shanghai, P.R.China, pp137.

63. Zhou, L., Naim, M.M. and Wang, Y. (2007), “Soft systems analysis of reverse

logistics battery recycling in China”, International Journal of Logistics: Research

and Applications, Vol.10, No.1, pp. 57-70.

64. Zhu Q.H. and Sarkis J. (2004), “Relationships between operational practices and

performance among early adopters of green supply chain management practices in

Chinese manufacturing enterprises”, Journal of Operations Management, Vol. 22,

pp. 265-289

65. Zsidisin G.A. and Hendrick T.E. (1998), “Purchasing involvement in

environmental issues: a multi-country perspective”, Industrial Management and

Data Systems, Vol. 7, pp. 313-320.