NHS England and NHS Improvement are aware of and have considered the study referenced. The findings are being taken into account alongside other evidence in understanding the impact on patient care, the environmental impact and the costs involved in a change in the mix of inhalers to lower carbon alternatives.

As set out in the NHS Long Term Plan, the National Health Service restated its commitment to the carbon targets in the UK Government Climate Change Act 2008, reducing carbon emissions, on a 1990 baseline, by:

- 34% by 2020; and

- 51% by 2025

In particular, the NHS Long Term Plan commits that a substantial reduction in the carbon impact of inhalers and anaesthetics over 10 years, will contribute to the overall NHS carbon reduction targets. The propellants used in pressurised inhalers are potent greenhouse gases.

It has not proved possible to respond to this question in the time available before Dissolution. Ministers will correspond directly with the Member.

It is the intention of the National Health Service, as set out in its Long Term Plan commitment, to reduce the use of traditional inhalers with higher levels of fluorinated gases. There are devices available which use significantly less fluorinated gases and dry powder devices, which do not use fluorinated gases, unlike traditional metered dose devices.

This year, the National Institute of Health and Care Excellence has published a Patient Decision Aid to help people with asthma, alongside health professionals, to identify which inhalers could meet their needs and control their symptoms. Where several inhalers could be viable options, the decision aid helps clinicians and patients choose the more environmentally friendly option, with a lower carbon footprint. The British Thoracic Society have included device carbon impacts in their recently published asthma guidelines.

Implanted technology, that meets the definition of a medical device, is regulated by the Medicines and Healthcare products Regulatory Agency (MHRA), which ensures that such devices meet applicable standards for safety, quality and efficacy.

The Department, the MHRA and other national health and care bodies are engaging with partners across Government to ensure that our system of regulation keeps pace with new developments in technology.

As in preparation for 29 March and 12 April, our contingency plans for 31 October will cover the National Health Service, social care and the independent sector and covers all medicines, medical devices and clinical consumables, supplies for clinical trials, vaccines and countermeasures, and organs and tissues for transplants.

The Department has continued to work closely with the devolved administrations, industry trade bodies and suppliers, the NHS and other key stakeholders. Prior to 29 March, the Department analysed the supply chains of 12,300 medicines, close to half a million product lines of medical devices and clinical consumables, vaccines used in national and local programmes, and essential non-clinical goods on which the health and care system relies. These analyses and assessments have been updated where necessary and will continue to be refined while a ‘no deal’ European Union exit remains a possibility. This work has informed our plans.

We are asking suppliers to analyse their supply chains and to make alternative plans if they anticipate disruption, including rerouting to alternative ports or using airfreight where necessary. Our contingency measures aim to support industry-led measures and, where required, act as a ‘last resort’ to be used only when a supplier’s alternative arrangements encounter difficulties, to ensure uninterrupted supply.

While we never give guarantees, we are confident that, if everyone – including suppliers, freight companies, international partners and the health and care system – does what they need to do, the supply of medicines and medical products should be uninterrupted in the event of a ‘no deal’ EU exit.

Respiratory disease is a clinical priority within the NHS Long Term Plan.

The NHS Long Term Plan sets out how the National Health Service will take action in a number of areas, including managing inhaled medications. Pharmacists in primary care networks will undertake a range of medicine reviews, including educating patients on the correct use of inhalers and contributing to multidisciplinary working.

Data on inhaler technique is not routinely collected in England. The national asthma and chronic obstructive pulmonary disease audit programme will include data on asthma from 2019. This will include data on inhaler technique and will enable monitoring in England.

Respiratory disease is a clinical priority within the NHS Long Term Plan.

The NHS Long Term Plan sets out how the National Health Service will take action in a number of areas, including managing inhaled medications. Pharmacists in primary care networks will undertake a range of medicine reviews, including educating patients on the correct use of inhalers and contributing to multidisciplinary working.

Data on inhaler technique is not routinely collected in England. The national asthma and chronic obstructive pulmonary disease audit programme will include data on asthma from 2019. This will include data on inhaler technique and will enable monitoring in England.

Respiratory disease is a clinical priority within the NHS Long Term Plan.

The NHS Long Term Plan sets out how the National Health Service will take action in a number of areas, including managing inhaled medications. Pharmacists in primary care networks will undertake a range of medicine reviews, including educating patients on the correct use of inhalers and contributing to multidisciplinary working.

Data on inhaler technique is not routinely collected in England. The national asthma and chronic obstructive pulmonary disease audit programme will include data on asthma from 2019. This will include data on inhaler technique and will enable monitoring in England.

The National Institute for Health and Care Excellence (NICE) published an online only patient decision aid for inhalers used in the treatment of asthma on 8 April 2019.

The purpose of this aid is to help people with asthma and their healthcare professional to discuss the different inhaler devices that are available to treat their condition and where appropriate, to consider the environmental impact of the inhaler. The patient decision aid has been downloaded over 1,500 times since its publication.

To encourage use of the decision aid, NICE is contributing to an expert working group on sustainable inhalers led by the Sustainable Development Unit which is actively promoting this work. The working group members include clinicians and patient organisations, such as Asthma UK and the British Lung Foundation. NICE has also shared the patient decision aid through its network of NICE associates - a network of National Health Service professionals who support implementation of NICE guidance across the NHS.

NHS England has been in regular dialogue with industry over the last 18 months about the need to reduce the environmental damage caused by asthma inhalers. As a result, an industry working group on this has been formed, chaired by the Industry Pharmaceutical Aerosol Consortium (IPAC). IPAC has now accepted an invitation to join the national Low Carbon Inhalers Working Group, chaired by the Sustainable Development Unit, to represent industry. This working group has been asked to provide proposals from industry on reducing the carbon impacts of inhalers to support the NHS Long Term Plan target.

We are informed by NHS England that its joint Public Health England funded Sustainable Development Unit (SDU) has reviewed a scheme operated by GlaxoSmithKline that encourages return of inhalers for recycling. The scheme is very welcome but limited in scope, currently recovering around 1% of all inhalers.

All used inhalers can already be returned to all pharmacies to be disposed of by incineration with the medicines waste streams.

NHS England has invited industry suggestions to the national Low Carbon Inhalers Working Group established by the SDU, on ways to increase recovery for environmentally safe disposal and recycling.

We have made no such assessment on the proportion of the National Health Service carbon footprint made by hydrofluorocarbon in metred dose inhalers or of the impact of the use of metred dose inhalers containing hydrofluorocarbons in releasing greenhouse gases. However, we are informed by NHS England that the National Atmospheric Emissions Inventory calculated the carbon emissions from inhalers in England as 850,000 tonnes of carbon dioxide equivalents. This is equivalent to approximately 4% of the entire carbon footprint of the NHS in England.

We have made no such assessment on the proportion of the National Health Service carbon footprint made by hydrofluorocarbon in metred dose inhalers or of the impact of the use of metred dose inhalers containing hydrofluorocarbons in releasing greenhouse gases. However, we are informed by NHS England that the National Atmospheric Emissions Inventory calculated the carbon emissions from inhalers in England as 850,000 tonnes of carbon dioxide equivalents. This is equivalent to approximately 4% of the entire carbon footprint of the NHS in England.

A range of diabetes technologies and methods of glucose monitoring, such as continuous glucose monitoring or blood glucose test strips, will continue to be available to those meeting the relevant clinical criteria.

One of the long standing and fundamental principles of the National Health Service is that the best way to address local challenges is through clinically-led decision-making, as close to patients as possible.

Clinical commissioning groups (CCGs) are responsible for commissioning diabetes services. In doing so, CCGs need to ensure that the services they provide are fit for purpose, reflect the needs of the local population, are based on the available evidence, and take into account national guidelines. This should include consideration of access to diabetes technologies such as FreeStyle Libre.

Clinical commissioning groups (CCGs) are primarily responsible for commissioning diabetes services to meet the requirements of their populations. In doing so, CCGs need to ensure that the services they provide are fit for purpose, reflect the needs of the local population, and are based on the available evidence, taking into account national guidelines. This should include consideration of access to continuous glucose monitoring for people with type 1 diabetes who might benefit from it.

The Care Quality Commission (CQC) is responsible for ensuring that requirements under the Health and Social Care Act 2008 are met by the providers of termination of pregnancy (ToP) services including meeting the fundamental standards of quality and safety as set out in Part 3 to the 2014 Regulations, and Regulation 20 of the Care Quality Commission (Registration) Regulations 2009, which is specific to independent sector termination of pregnancy providers.

In addition, the Department has oversight and the Secretary of State for Health has the power to approve independent sector providers to perform termination of pregnancy.

All approved clinics must agree to comply with the Secretary of State’s requirements in the form of Required Standard Operating Principles (RSOPs). The CQC assists the Secretary of State in his functions by inspecting against all of the Department’s RSOPs when it inspects an independent sector provider. Safety, infection control procedures and resuscitation are included in the CQC’s ToP inspection framework and are areas that are considered during an inspection based on an assessment or identified risk at any individual location. The CQC has a wide set of powers that allow them to protect the public and hold registered providers and managers to account.

The CQC’s enforcement policy sets out their approach to taking action where poor care is identified, or where registered providers and managers do not meet the standards required in the regulations. The CQC use their enforcement policy to:

- Protect people who use regulated services from harm and the risk of harm, and to ensure they receive health and social care services of an appropriate standard; and

- Hold registered providers and managers to account for failures in how the service is provided.

Following inspections of independent sector places that perform ToP in 2016, Marie Stopes International suspended specific types of termination between 19 August and 7 October 2016, while it worked with the CQC to address these concerns. The CQC also issued four warning notices to Marie Stopes International to support improvement. The Department and the CQC continue to closely monitor the progress of Marie Stopes International to ensure that ongoing improvements are made and maintained.

Individual treatment decisions should be made by clinicians who are best placed to assess the most appropriate course of action for their patients. Patients receiving oxygen treatment are first assessed by an oxygen clinic that will determine if this treatment is suitable and how the oxygen is best supplied.

The National Institute for Health and Care Excellence (NICE) is developing a medtech innovation briefing (MIB) on FreeStyle Libre which it expects to publish in May 2017. NICE MIBs provide information on device and diagnostic technologies to aid local decision-making by clinicians, managers and procurement professionals. They contain no judgement on the value of the technology and they do not contain a recommendation from NICE.