Greening community pharmaceutical supply chain in UK: a cross boundary approach

Abstract PurposeThis 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/ApproachThe research is based on literature and on secondary resources.

FindingsTo 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/implicationsThis 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:Conceptual1. Introduction

1 The acronyms used in the paper are listed in the Appendix at the end of the paper.

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). 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),

2

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).

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

3

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 methodologyThe 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 have the influences on the development.

Take in Figure 2

2.1 Literature search and categorisationTo ensure the quality of the articles selected, the literature review focused on peer reviewed journals that were retrieved from electronic journal databases, publications

4

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 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,

5

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 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

6

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) approachTo 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, 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

7

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 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

8

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.

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 providersThe 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

9

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 Practitioneri) 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 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

10

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:

i) 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.

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

11

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.

4.5 Professional and regulatory bodies and waste management companiesThe 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

12

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 CustomersTo 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 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 PSCThe 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

13

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 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

14

(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. Figures:

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

15

Figure 2: Research design and processes

Figure 3: A community pharmaceutical supply chain with reverse logistics

16

Figure 4: The Cross boundary Green PSC (XGPSC) approach

17

Appendix: Acronyms

3PL: Third Party LogisticsABPI: Association of the British Pharmaceutical Industry CRM: Customer Relationship ManagementDRUM: Dispensed Review of the Use of MedicinesGP: General PractitionerGPSC: Green Pharmaceutical Supply ChainGSCM: Green Supply Chain ManagementMIS: Management Information SystemMUR: Medicines Use ReviewNHS: National Health ServiceOTC: Over The CounterPSC: Pharmaceutical Supply ChainRL: Reverse LogisticsRPSGB: Royal Pharmacy Societies of Great BritainSC: Supply ChainXGPSC: Cross boundary Green Pharmaceutical Supply Chain

18

References:

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.

Ashley S. (1993), “Designing for the environment”, Mechanical Engineering, Vol.115 No. 3, pp.52–55.

Beaumont, J.R., Pedersen, L.M. and Whitaker, B.D. (1993), Managing the Environment: Business Opportunity and Responsibility, Butterworth-Heinemann, Oxford.

Bellingham C. (2004), “How to dispose of unwanted medicines”, The Pharmaceutical Journal, Vol.273 No. 7324, pp.686.

Bergstrom RY. (1993), “An annotated essay: environmental affairs”, Production, Vol.105 No. 4, pp.36–41.

Boivin, M. (1997), “The Cost of Medication Waste”, Canadian Pharmaceutical Journal, May, pp. 32-39.

Bound J.P. and Voulvoulis N. (2005), “Household disposal of pharmaceuticals as a pathway for aquatic contamination in the United Kindom”, Environmental Health Perspectives, Vol.113, No.12, 1705-1711.

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.html

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

Breen L, (2004b) “Does Supplier Development benefit Hospital Pharmacy? - The case of Central Manchester and Manchester Children’s University Hospitals NHS Trust”, Pharmacy Management, Vol.20 No.3, pp.1-14.

19

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.

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.

Buser H.R., Muller M.D. and Theobald N. (1998), “Occurrence of the pharmaceutical drug clofibric acid and the herbicide mecoprop in various Swiss lakes and in the North Sea”, Environmental Science & Technology. Vol.32, No.1, pp.188–192.

Calderdale Primary Care Trust (2006), “Wasted and Dangerous”, available at: http://www.calderdale.nhs.uk/public-information/publication-scheme/disclosure-log/disclosure-log-item/article/28/545/neste/5/ (accessed 26 September 2008)

Caldwell B. (1999), “Reverse logistics”, Information Week, No.729, pp.48-56.

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.

Croom S., Romano P., and Giannakis M. (2000), “Supply chain management: an analytical framework for critical literature review”, European Journal of Purchasing & Supply Management, Vol. 6, pp.67-83.

Daughton C.G. (2003), “Cradle-to-cradle stewardship of drugs for minimizing their environmental disposition while promoting human health. I. Rationale for and avenues toward a green pharmacy”, Environmental Health Perspectives, Vol.111, pp.757–774.

Daughton C.G. and Ternes T.A. (1999), “Pharmaceuticals and personal care products in the environment: agents of subtle change?”, Environmental Health Perspectives, Vol.107, pp.907-938.

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. 

20

Department of Health (2006), “Health Technical Memorandum 07-01: Safe Management of Healthcare Waste”, available at:http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_073328.pdf (accessed 06 April 2010)

Department of Health (2007), “Environment and sustainability Health Technical Memorandum 07-06: Disposal of pharmaceutical waste in community pharmacies”, ISBN 9780113227976.

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/Prescriptions/DH_4000157 (accessed 3 December 2009)

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/Communitypharmacy/Communitypharmacycontractualframework/index.htm (accessed 20 October 2008)

Dowlatshahi S. (2000), “Developing a theory of reverse logistics”, Interfaces, Vol.30 No.3, pp.143-155.

Fink A (2005), Conducting research literature reviews: from paper to the internet. 2nd Edition, Thousand Oaks: Sage Publication, California.

Fleischmann M., Bloemhof-Ruwaard J.M., Dekker R., van der Lann E., van Nunen J.A.E.E., and Van Wassenhove L.N. (1997), European Journal of Operational Research, Vol.103, pp. 1-17.

Florida, R., (1996), “The Environment and the New Industrial Revolution”, California Management Review Vol. 38 (Autumn), pp. 80–115.

GEMI (Global Environmental Management Initiative) (2001), New Paths to Business Value. GEMI, Washington DC.

Gillett J. (1993), “Ensuring suppliers’ environmental performance”, Purchasing & Supply Management, pp.28-30.

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.

21

Green K., Morton B. and New S. (2000), “Green purchasing and supply policies: do they improve companies’ environmental performance?”, Supply Chain Management: An International Journal, Vol.3, No.2, pp.89-95. 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.

Halling-Sorensen B., Noris-Nielsen S.N., Lanzky P.F., Ingerslev F., Holten Lutzhoft H.C., and Jorgensen S.E. (1998), “Occurrence, fate and effects of pharmaceutical substances in the environment-a review”, Chemophere, Vol. 36, No. 2, pp.357-393.

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.

Heberer T. (2002), “Occurance, fate, and removal of pharmaceutical residues in the aquatic environment: a review of recent research data”, Toxicology Letters, Vol.131, Issues.1-2, pp.5-17.

Jerram, P. (2009), “Medicine Use Reviews Reduce Asthma Admissions”, Pharmacy Management, Vol. 25 No.3, pp. 15-19.

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.

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.

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.

Kreisberg J. (2007), “Green pharmacy: preventing pollution, a cross sector approach” The Journal of Ecologically Sustainable Medicine, Spring/Summer 2007, pp.,25-29.

Kreuger R.A. (1988) Focus groups: a practical guide for applied research. London: Sage.

22

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.

Kuspis D.A. and Krenzelok E.P. (1996), “What happens to expired medications? A survey of community medication disposal”, Veterinary & Human Toxicology, Vol.38, pp.48–49.

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)

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.

Lebreton, B. and 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.

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.

Meade L., and Sarkis J. (2002), “A conceptual model for selecting and evaluating third-party reverse logistics providers”, Supply Chain Management: An International Journal, Vol. 5, No.5, pp.283-295.

McIntyre K., Smith H., Henham A. and Pretlove J. (1998), “Environmental performance indicators for integrated supply chains: the case of Xerox Ltd”, Supply Chain Management: An International Journal, Vol. 3 No.3, pp.149-156.

Murray G.J. (2000), “Effects of a green purchasing strategy: the case of Belfast City Council”, Supply Chain Management: An International Journal, Vol. 5 No.1, pp.37-44.

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.

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

23

unwanted medicine disposal in New Hampshire”, available at:http://des.nh.gov/organization/commissioner/pip/publications/wmd/documents/unused_medicine.pdf (accessed 28 May 2009)

NHS Cumbria (2009), “Dispensing review of the use of medicines (DRUM)”, available at:http://www.cumbria.nhs.uk/ProfessionalZone/MedicinesManagement/DispensingDoctors/Home.aspx (accessed 3 December, 2009).

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.

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.

PHS Group (2007), “Environment and sustainability: health technical manual 07-06, disposal of pharmaceutical waste in community pharmacies”, available at: http://www.phs.co.uk/15754.file.dld (accessed 3 November 2009)

Porter, M.E. and van der Linde, C. (1995), “Green and competitive: ending the stalemate”, Harvard Business Review, Vol. 73.5, pp.120–134.

Powell R.A., Single H.M., Lloyd K.R. (1996) “Focus groups in mental health research: enhancing the validity of user and provider questionnaires”, International Journal of Social Psychology, Vol.42 No.3, 193-206.

Power D. (2005), “Supply chain management integration and implementation: a literature review”, Supply Chain Management: an International Journal, Vol.10 No.4, pp.252-263.

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)

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_medicines.pdf (accessed 14 December 2009)

24

PSNC (Pharmaceutical Services Negotiating Committee) (2005), “NHS Community Pharmacy Contractual Framework Enhanced Service – Supplementary Prescribing by Pharmacists”, available at:http://www.psnc.org.uk/data/files/PharmacyContract/enhanced_service_spec/en10__supplementary_prescribing.pdf (accessed 06 April 2010)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.

Rogers, D.S. and Tibben-Lembke, R.S. (1999), “Going Backwards: Reverse Logistics Trends and Practices”, Reverse Logistics Executive Council Press, Pittsburgh, PA.

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

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”, available at:http://www.rpsgb.org.uk/pdfs/hazwastecommphguid.pdf (accessed 06 April 2010)

RPSGB (Royal Pharmaceutical Society of Great Britain), (2006), “Supplementary prescribing one year on”, available at:http://www.rpsgb.org.uk/pdfs/supplpresconf05.pdf (accessed 06 April 2010)

Sarkis J. (2003), “A strategic decision framework for green supply chain management”, Journal of Cleaner Production, Vol. 11, pp. 397-409.

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.

Schwartz B. (2000), “Reverse logistics strengthens supply chain”, Transportation and Distribution, Vol.41, No.5, pp.95-100.

Seuring S. and Muller M. (2008), “From a literature review to a conceptual framework for sustainable supply chain management”, Journal of Cleaner Production, Vol. 16, pp. 1699-1710.

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.

25

Shrivastava, P. (1995), “Environmental technologies and competitive advantage”, Strategic Management Journal, Vol.16 (Special issue, Summer), pp. 183–200.

Smith C.A. (2002), ‘Managing pharmaceutical waste-what pharmacists should know’, Journal of the Pharmacy Society of Wisconsin, Nov/Dec 2002, pp. 17-22.

Ternes T.A. (1998), “Occurrence of drugs in German sewage treatment plants and rivers”, Water Research, Vol.32, No.11, pp.3245-3260.

Ternes T.A., Stumpf M., Mueller J., Haberer K., Wilken R.D., Servos M. (1999), “Behaviour and occurrence of estrogens in municipal sewage treatment plants-inviestigations in Germany, Canada and Brazil”, Science of the Total Environment, Vol.225, pp.91-99.

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.

Van Hoek R. I., (1999), “From reversed logistics to green supply chains”, Supply Chain Management, An International Journal, Vol. 4 No.3, pp. 129-135.

Veolia environmental services (2007), “Birmingham clinical waste”, available at:http://www.veoliaenvironmentalservices.co.uk/birmingham/pages/publications.asp (accessed 19 November 2009)

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.

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.

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.

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.

26

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

Zhu Q.H., and Sarkis J. (2006), “An inter-sectoral comprison of green supply chain management in China: drivers and practices”, Journal of Cleaner Production, Vol.14, pp. 472-486.

Zhu Q.H., Sarkis J. and Lai K.H. (2006), “Green supply chain management: pressures, practices and performance within the Chinese automobile industry”, Journal of Cleaner Production, Vol.15, pp. 1041-1052.

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.

27