Feature / Operation green

30 May 2022

RT_shutterstock_theatre_landscapeThe NHS has set itself challenging targets to have net zero carbon by 2040 for the emissions it controls directly, and by 2045 for the wider emissions it can influence. All parts of the NHS will need to examine their established ways of working and make wide-ranging changes to deliver these ambitious goals. Operating theatres – major users of resources and energy and big contributors to NHS waste – will be a critical area for transformation.

Opportunities to improve the environmental performance in the NHS supply chain, particularly operating theatres, were the focus of an HFMA roundtable in May. Supported by surgical endoscope and medical device manufacturer KARL STORZ Endoscopy (UK), the event brought together clinicians, finance leaders and procurement specialists to share current work and highlight opportunities for improvement.

The wide-ranging discussion highlighted lots of good practice in the NHS – for example, in reducing the use of environmentally damaging anaesthetic gases. But there is potential for much wider cross-fertilisation between organisations and systems.

Nicky Lloyd, chief finance officer of Royal Berkshire NHS Foundation Trust and the roundtable chair, said the challenge was to kick start activity to reduce the service’s carbon footprint and help organisations just starting the journey. ‘We need to have a dramatic impact on the pace at which the net zero agenda progresses within the NHS,’ she said.

Procurement requirements should help push progress on improving sustainability. For example, the NHS has decided to adopt and extend the public policy note PPN 06/20 requiring NHS bodies to take account of net zero and social value when awarding contracts from April 2022. And from April 2023, building on the further PPN 06/21, any supplier to the NHS with a contract over £5m must have its own carbon reduction plan to achieve net zero (see the net zero supplier roadmap).

‘The procurement standard for the supply chain will actually help to drive a lot of the sustainability requirements,’ said Alexis Percival, environmental and sustainability manager at Yorkshire Ambulance Service NHS Trust and net zero lead for the Humber Coast and Vale Integrated Care System. ‘The problem is I’m already seeing that the procurement and finance leads don’t understand what needs to be asked or how to interpret the answer. So, lots of work needs to done working with supply chains.’

The focus increasingly had to be on sourcing sustainable products, she said. These may be more expensive in terms of upfront cost, but deliver savings in the long term because of their impact on waste reduction, reuse and whole life-time costs.


Supply chain accountability

Lynne Beedle, head of procurement at Rotherham, Doncaster and South Humber NHS Foundation Trust and procurement lead for sustainability at South Yorkshire ICS, agreed that suppliers had to be accountable for sustainability if the NHS was to meet its broader carbon footprint plus goal (the emissions it can influence). ‘It’s not just the direct supplier you are working with, it’s their supply chain, and making sure that when you do a procurement, you dig into that,’ she said.screen grab rt theatres

Social value, which includes net zero progress and tackling economic inequality, must now be worth 10% of any tender evaluation under the new net zero and social value guidance. ‘You have to not only ask them what they are doing at present, but what additionally they are going to do over the life of the contract to contribute to net zero and social value,’ added Ms Beedle. ‘And then you need to manage that through the whole life of the contract and make sure they are accountable on a six-monthly and 12-monthly basis for what they promised at the outset.’

Ms Lloyd questioned whether all organisations were fully aware of, and compliant with, the new requirements.

John Graham, deputy chief executive and director of finance at Stockport NHS Foundation Trust, said an enhanced focus on the environment should be clearly supported by boards and written into governance processes such as the scheme of reservation and delegation.

‘There is a real opportunity for us at the moment to influence some of the decision-making principles at the integrated care system (ICS) level,’ he said. There needs to be more consistency in organisations in putting together business cases with an emphasis on sustainability, he added.


Business cases

David Moon, strategic finance adviser for the foundation group that includes South Warwickshire NHS Foundation Trust and the Wye Valley and George Eliot Hospitals NHS trusts, said sustainability should be a clear mandatory consideration in business cases as well as in tender evaluations. The five-case model for business cases is supported by the Treasury’s Green book and includes an economic dimension that should cover social value. But there is an argument for further emphasis.

‘The NHS would benefit from really clear direction on the need to consider sustainability in business cases,’ said Mr Moon. ‘It should become custom and practice that you include the sustainability piece in any case you write.’

Mr Graham pointed out that, in recent approval processes for business cases at regional and national level, the Stockport trust was quizzed about the environmental impact. But he agreed this should be backed up by a formal requirement to address sustainability in business cases.

Tsanko Dimov, a senior net zero delivery manager at Greener NHS, within NHS England and NHS Improvement, stressed the opportunity of looking at full lifecycle costs in all procurement decisions.

‘It can be difficult to demonstrate a saving,’ he said. A product may appear more expensive in terms of the upfront price, but if you factor in a reduction in waste, for example, it can change the balance. The saving might be in a different department to the one making the purchase. Value, not cost, should be the goal.

There can also be other benefits too – for example, with personal protective equipment. ‘One thing we see when we invest in reusable items, which can offer greater value over their lifetime, is that we can have better produced items,’ he says. This could mean masks that fit a wider variety of face types better and so are more effective, enhancing staff safety while also improving sustainability.

‘If we discuss the value that products are creating and how effectively they’re doing their job, even if there is still an increase in cost over their lifetime, the value we might be getting may be much greater,’ he said.

Chantelle Rizan said there was a growing body of research to support the lower environmental impact of reusable items using a lifecycle approach. Dr Rizan is in the final stages of a PhD at Brighton and Sussex Medical School and is a former sustainable surgery fellow at the Centre for Sustainable Healthcare. She echoed the importance of capturing the costs of single-use items incurred in different departments. ‘There is also an issue with accurately predicting the number of users over a product’s lifespan,’ she said. ‘Often business cases try to account for the cost over a short period, when in reality the product may last for 10 years or more.’

She suggested that procurement catalogues could be sectioned to highlight the choice of reusable or more sustainable items, where these offered the better value solution.

Daren Subar, a hepato-pancreatic-biliary service surgeon at East Lancashire Hospitals NHS Trust, said that more formal proof-of-concept would be helpful. ‘If we could get 10 to 15 hospitals to explore sustainability programmes and monitor them over a period of time, that could be helpful,’ he said.

Having evidence about the things that deliver results in practice could short circuit the decision-making process and galvanise a lot of trusts. This may not currently be happening on a national level – although best practice is shared via the Future NHS platform – but there are examples on a smaller scale within the West Midlands.

Paul Southall is a consultant anaesthetist at Worcestershire Acute Hospitals NHS Trust and its lead for clinical sustainability. A local anaesthesia theatres network looks to establish best sustainable practice across the region and then roll-out what has been shown to work.

The trust was also one of five hospitals to pilot the social value procurement changes. ‘We are trying to put in a minimum of 10%. For a couple of contracts, we’ve specifically stipulated a reduction in single-use plastics and packaging over a defined period,’ he said. ‘And that has to be auditable.’


Making an impact

His tip for engaging clinical and managerial colleagues is to convert kilogrammes of carbon dioxide to miles driven in a car. ‘When you can say some of our anaesthetic gas capture will save five million miles in a car every year, it makes a big impact on people.’

Naomi MacKenzie, consultant colorectal surgeon at Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust, said infection control and sterile services teams were often barriers to change in theatres.

To counter this, Dr Southall said it was important to involve them at the outset. In Worcestershire, the aim is for the head of infection control to sit on the trust’s sustainability working group. ‘This won’t mean objections disappear, but if you can get to them straight away, it’s easier than trying to sort it when you’ve got everything 90% done,’ he said.

Dr Rizan said that environmental accounting was the elephant in the room that needed to be addressed. ‘A growing body of people want to support the transition to sustainable models of healthcare delivery,’ she said. ‘But we need to ensure they are delivering a true net benefit in terms of environmental impacts.’

She cautioned against relying on detailed and specific carbon footprint figures and impacts provided by industry, which often relied on different assumptions. ‘I’d even be cautious about comparing figures derived by different research groups,’ she said.

Instead, she wondered if a simpler ‘tick-box’ approach could be taken to support decision-making, encouraging changes that would definitely have an impact on greenhouse gas emissions.

‘I did a full lifecycle assessment of PPE used in the first six months of the Covid-19 pandemic, which equates to more than 100,000 tonnes of carbon dioxide equivalents,’ she said. If this had been brought in by air rather than shipping, it would have increased the carbon footprint by 50% – and domestic manufacture would have provided a huge environmental benefit.

‘Instead of relying on carbon footprints to make decisions, there may be some principles we can use instead,’ she said. For example, trusts could ask suppliers about how much air freight is used in their supply chain. Eliminating use of air freight in NHS procurement would provide a major environmental dividend. She added that requiring suppliers to detail all the materials used in their products would help the NHS in identifying options for onward processing and recycling.

Dr Southall added that Worcestershire Acute was working with a local supplier and Loughborough University to analyse the trust’s non-contaminated clinical waste to provide it with better information in this area. The aim is to explore the potential to develop a bespoke recycling service. While he said the ideal situation was to be provided with this information by suppliers, this two-pronged approach could give the trust a way to move forward with such a scheme more quickly.

Ms MacKenzie said steps could be taken in theatres to improve sustainability. These ranged from very small steps, such as wearing reusable hats, to addressing the use of greenhouse gases in anaesthesia and ensuring supplies are only opened when needed, rather than opening everything in advance. ‘We should have a sustainability checklist at the beginning of every operation to support a discussion about what equipment you are going to be using,’ she said.

Some changes related to clinical practice and custom – the overuse of unnecessary surgical drapes, for example – and Ms MacKenzie stressed that reducing resource usage was always better than recycling. She also suggested that some open surgery procedures might be more environmentally friendly where they are clinically appropriate, enabling the use of more reusable instruments.

Ms MacKenzie also wondered whether surgeons were given too much flexibility and choice when specifying the equipment they needed. ‘I think that culture within a department needs to stop,’ she said. ‘We should be told that this is the most sustainable piece of equipment.’ 

Others agreed with the aim, but underlined that clinicians needed to take the lead role in specifying equipment. However, procurement and finance managers should be empowered to challenge existing products and offer possible alternatives. For this to be achieved, clear board commitment to sustainability was vital. And Ms Lloyd said that this support needed to be visible, with organisations’ green plans backed up with actions on the ground.

‘It is so important to get board-level sign-up and to get sustainability written into the trust strategies and objectives,’ said Samantha Holmes, finance manager at South Warwickshire NHS Foundation Trust. ‘If you have environmental sustainability as one of the key targets for a trust, then that will naturally feed through into decision-making processes. But it absolutely needs to be top-down.’

Board support was important, said Dr Southall, but it was a two-way street. In Worcestershire, progress had often involved ‘punching up to the board’, rather than responding to its demands. Environmental champions from numerous disciplines continue to play a major role in pushing the sustainability agenda.

Mr Subar said that the sustainability movement needed to be broader with a ‘paradigm shift’ needed in attitude. Until more people recognised that fixing the environment was an individual responsibility, he suggested some of the required changes would need to be mandated – such as the procurement of sustainable products. And given the urgency of the agenda, the NHS approach would need to involve more stick than carrot.


Cost of waste

There was certainly a danger that clinicians didn’t appreciate the financial cost of waste, according to Ms MacKenzie. ‘There is a problem in the NHS that consumables are seen as free – maybe we could learn from practice in the private sector,’ she said, pointing out that most things were chargeable in the independent sector creating a different level of awareness.

Mr Dimov was concerned about forcing sustainability onto people and wondered if measurement and transparency could instead be used to encourage greater engagement.

‘One thing that might be quite interesting would be to measure waste and use a leaderboard to celebrate and learn from surgical teams making meaningful reductions,’ he said.

Dr Rizan said appealing to surgeons’ competitive nature could help – the Centre for Sustainable Healthcare’s green surgery challenge had been very successful. But she warned against too big a focus on waste.

‘Waste isn’t the problem,’ she said, ‘as it is less than 5% of the carbon footprint of the whole of the NHS. Even if we recycle to the maximum, we won’t get anywhere near our target of meeting net zero. The real value of recycling will be when we start to increase the recycled content within healthcare products.’

Measuring waste was useful as a proxy for the quantity of consumables being used – with the real issue being the carbon associated with the raw material extraction, product manufacture and distribution. However, she said that further metrics, covering and going beyond waste, would be useful if they could be collected by all hospitals.

Roundtable attendees also pointed at more tangential ways to reduce the contribution operating theatres make to global warming. ‘It is a bit more of a nebulous connection than reducing consumables,’ said Ms Holmes. ‘But with theatres being such a resource-intensive area, getting the maximum efficiency and productivity from your theatres means you are getting the most out of your equipment, estate and staff – and that has an environmental impact.’

Mrs Percival said avoiding the need for surgery could have the biggest environmental impact of all. ‘We always concentrate on acute trusts, but in reality a lot of our carbon footprint is in primary care,’ she said.

Primary care has not been required to produce green plans, she said, and there was limited support for general practice and dental surgeries on environmental issues. However, an increase in green social prescribing and more of a focus on prevention could have environmental benefits for hospitals in lowering activity as well as being better for patients.

‘Models of care are really fundamental to changing everything in the whole of the system,’ she said. ‘And a lot of it is about de-prescribing and re-educating people. There is a lot we can do to eliminate interventions all the way through the system.’

Ms Lloyd said she was encouraged by the range and extent of work under way in many of the attendees’ organisations. And she said there was a pressing need to expand the circle of environmental champions and to improve communication and the spreading of good practice organically across the whole of the NHS.

There were real opportunities to implement ideas that had already been shown to work elsewhere and so provided little risk for organisations.

However, she said that the finance community has a key role in measuring in monetary terms the environmental impact of decision-making and to ensure this was reported simply to those committing resources. ‘And we all need to move at pace, right now,’ she added.




  • Lynne Beedle, Rotherham Doncaster and South Humber NHS FT
  • Tsanko Dimov, NHS England and NHS Improvement
  • John Graham, Stockport NHS FT
  • Samantha Holmes, South Warwickshire NHS FT
  • Nicky Lloyd (chair), Royal Berkshire NHS FT
  • Naomi MacKenzie, Wrightington, Wigan and Leigh Teaching Hospitals NHS FT
  • Mark Martin and Ben Pinder, KARL STORZ Endoscopy (UK)
  • David Moon, South Warwickshire, Wye Valley, George Eliot foundation group
  • Alexis Percival, Yorkshire Ambulance Service NHS Trust
  • Chantelle Rizan, Brighton and Sussex Medical School
  • Paul Southall, Worcestershire Acute Hospitals NHS Trust
  • Daren Subar, East Lancashire Hospitals NHS Trust



Managed services: green benefits 

RT mark martin_landscape

Could the adoption of managed equipment services help deliver greater supply chain sustainability?

Under such deals, a supplier provides equipment as a service and takes responsibility for the maintenance, support, replacement and disposal of equipment that would otherwise be bought. Typical benefits claimed for the arrangements include reduced costs, risk transfer and operational efficiencies. But could they also have a green upside?

Research fellow Chantelle Rizan suggested that such deals may incentivise the manufacturer to design products that are durable and repairable. ‘Then it is in their interest to really try to maximise the number of uses for that individual item,’ she said. ‘And that could be really powerful in terms of driving the transition to sustainable models of healthcare delivery.’

KARL STORZ Endoscopy (UK) sales and marketing director Mark Martin (pictured) said there were financial and operational benefits to a managed service and one of the ways it could help was in reducing the amount of travel associated with NHS services.

Around 3.5% of all road travel in England relates to the NHS, including patients, visitors, staff and suppliers. ‘We already have onsite endoscopic support in some hospitals,’ he said.

 ‘This means that instead of 10 or 15 people coming into a hospital, we actually have somebody on site who works in the hospital – works in theatres, sterile services, outpatients, day surgery and medical engineering – and actually supports the hospital from the inside.

‘That saves all the transportation,’ Mr Martin added. ’And using reusable surgical products can really improve things operationally and from an environmental aspect.'



Green inspiration
  • De-steaming hospitals (Royal Berkshire) has saved millions of litres of water and 800 tonnes of carbon a year.
  • Uniform recycling (Royal Berkshire) – staff returning unused uniforms that no longer fit has put 600 uniforms back into circulation.
  • Convert all carbon reduction figures to miles driven in a car.
  • Work with anaesthetists to audit and reduce or eliminate desfluorane and nitrous oxide use.
  • Share ideas and get inspiration from the Greener NHS knowledge hub and procurement transformation pages on the Future NHS workspace.
  • Include infection control sterile services representatives on sustainability working group.
  • Establish clinical consensus on the preferred use of sustainable or reusable equipment.
  • Consider onsite oxygen generation – giving surety of supply and eliminating significant amounts of transportation.
  • Sustainability awards to showcase best practice.
  • Explore whole lifetime costs including waste reduction and reusability.
Supporting documents
15-21_jun22_RT final