Environment: reduce, reuse, recycle, reward

The NHS is a significant polluter and user of natural resources. In 2017, its carbon footprint was just over 27 mega tonnes of CO2 or 6.3% of the total carbon footprint of England, according to the NHS Sustainable Development Unit (SDU). Health and care related travel accounts for around 5% of all road journeys in England each year.

The NHS generated nearly 590,000 tonnes of waste in 2016/17. But while this may all sound negative, the NHS is addressing and reducing its impact on the environment.

The figures mentioned above are significant improvements on the picture in 2007 – since that year, the carbon footprint has been cut by 18.5%, equivalent to the annual emissions of Cyprus. This was despite a 27% increase in patient activity over the decade. Most of the service’s waste is incinerated or used for energy generation.

However, the focus on further reductions will remain. The NHS long-term plan said the service faced a significant challenge to deliver the Climate Change Act 2008 target of a 34% reduction in the carbon footprint by 2020 and 51% by 2025. A shift to lower carbon inhalers alone will deliver a 4% reduction (see box) and, overall, the UK is committed to net zero carbon emissions by 2050.

Some individual trusts have made good progress – Guy’s and St Thomas’ NHS Foundation Trust, for example, says its sustainability programme has reduced its carbon emissions by 15% since 2007, exceeding the 2015 target of 10%. Its energy efficiency projects will save £1.5m a year and reduce carbon emissions by a further 10%. Overall, the sustainability programme saves the trust £3m a year.

Recently, three trusts (North Bristol NHS Trust, University Hospitals Bristol NHS Foundation Trust and Newcastle upon Tyne Hospitals NHS Foundation Trust) and the Greater Manchester Health and Social Care Partnership declared a climate emergency, recognising the impact of climate change on the world. All four bodies have made progress on limiting their impact on the climate. In Greater Manchester, Wrightington, Wigan and Leigh NHS Foundation Trust and Bolton NHS Foundation Trust have cut their annual carbon emissions by 11,000 tonnes, saving £1.7m a year, by installing combined heat and power systems and LED lighting.

The Newcastle trust also has a combined heat and power system and, when it needs this on-site generation to be topped up, buys additional energy from 100% renewable resources. No waste goes to landfill.

North Bristol NHS Trust has taken action on energy use, getting energy from sustainable sources, reducing vehicle emissions and using sustainable food sourcing.

Chief executive Andrea Young says: ‘To provide high-quality care, the NHS uses huge amounts of energy, food, water, medicine and equipment – all of which contribute to our carbon footprint.

‘We can also harness the power of thousands of staff who are highly motivated to make a difference and improve people’s lives. We want to publicly acknowledge the huge threat of climate change, do as much as possible to tackle it ourselves and, as anchors in our community, encourage collaborative action.’

The Bristol trusts are also reducing their use of Desflurane, an anaesthetic gas that has a greater environmental impact than alternative anaesthetics. Reducing use of the gas could contribute to a 2% reduction in the overall NHS carbon footprint. In September, NHS Greater Glasgow and Clyde said its switch to Sevoflurane – which releases 60 times less CO2 – was the equivalent of 350 fewer cars commuting to its hospitals each day. NHS Highland has reportedly seen a 75% reduction in Desflurane use since January, saving £73,000. 

With plastic pollution reaching alarming levels globally, NHS England and NHS Improvement are focusing much of their efforts on cutting up to 100 million plastic straws, cups and cutlery from hospital canteens. Last year, the NHS bought at least 163 million plastic cups, 16 million pieces of plastic cutlery, 15 million straws and 2 million plastic stirrers.

From April, high-street outlets found in hospitals, such as Marks & Spencer, have committed to avoid the use of plastics, starting with straws and stirrers. Plastic cutlery, cups and plates will be phased out by 2021.

NHS chief executive Simon Stevens said: ‘It’s right that the NHS and our suppliers should join the national campaign to turn the tide on plastic waste. Doing so will be good for our environment, for patients and for taxpayers who fund our NHS.’

Plastics pioneer

NHS England has highlighted Yorkshire Ambulance Service NHS Trust (YAS) as a pioneer in reduced use of plastics. But Alexis Percival, the trust’s environmental and sustainability manager, says it has a wide range of environmentally friendly schemes that it has been implementing over many years. Having completed her own plastic-free year, Mrs Percival began to look at alternatives to plastic used in the trust’s canteen in September 2018. The first step was to replace plastic milk cartons with glass bottles. This was achieved within two weeks. In total, the trust 

has eliminated 200,000 plastic items a year, of which 104,000 were plastic-lined paper cups.

Paper cups have now been replaced with reusable mugs – users pay a £1 deposit, which is repaid when the mug is returned. Ceramic bowls and plates, and metal knives and forks have been introduced, while paper and cardboard have replaced plastic wrapping – for sandwiches, for example – for those leaving the canteen.

The trust has reduced its plastic use by four tonnes a year, though it still uses around half a tonne. However, as Mrs Percival points out: ‘We are saving about £5,000 in procurement costs a year through reduced use of plastic. It’s not just about consumption, but also about disposal – so we are not double-paying for something that has a single use and then gets thrown in the bin.’

‘The only product we need to dispose of now is the plastic cups for water dispensers, which we will probably be able to do over two weeks as well – these single-use plastics are relatively easy to replace, but it’s more problematic to remove plastics in the rest of the NHS. There are a lot of challenges as we now package products that historically we would have autoclaved – we now have them as single-use products to prevent the spread of infection, such as MRSA and other infectious diseases.’

Plastic is a major presence in frontline healthcare – from surgical gloves to the wrappers of small, high-use items such as syringes. Mrs Percival says the trust is working on a national project with the Royal College of Nursing and the College of Paramedics to reduce the eight billion single-use plastic gloves used in the NHS every year.

The Gloves Off campaign has run for a number of years and serves to remind staff when they should wear gloves, but also when gloves are not needed, and effective hand hygiene is preferable. This will mean reduced glove use and best practice care for patients, and is also likely to reduce issues with skin health for staff, such as contact dermatitis. ‘We are different from acute care, but there is a lot of plastic in the system that doesn’t need to be there, Mrs Percival adds.

Needles, for example, are wrapped in plastic that cannot be recycled – the need to reduce carbon emissions for deliveries has led to a focus on lighter packaging, but the plastic is now too thin to recycle.

She says: ‘You have to go back to the system and ask why these things are being put in plastic packaging or even packaging at all. Are there alternatives? Can we create a circular economy with returnable packaging?  Unfortunately, we are so used to having things packaged up. I am working closely with our infection prevention and control lead in the trust to ensure we review the plastic use, but maintain safe standards of practice for our patients.’

Travel impact

The NHS accounts for almost 10 billion journeys each year – around 7% of all road travel – as staff and patients travel to work and appointments and medical supplies are delivered. Some trusts have taken steps to reduce the environmental impact of this. Guy’s and St Thomas’, for example, recently set out plans to cut 36,000 truck deliveries each year. Now, these supplies are delivered to a hub close to the M25 and only supplies needed each day are sent to the hospitals. The trust is due to pilot electric delivery vehicles early in 2020.

The trust says the new hub will reduce deliveries by 90% and is part of its ‘ambitious strategy to reduce our carbon footprint and improve our sustainability while ensuring critical deliveries are made every day across our central London hospitals’.

The NHS long-term plan commits to cutting mileage and air pollution from rapid response vehicles, patient transport and staff journeys by a fifth by 2024 and ensuring nine out of 10 vehicles are low emission within a decade.

The long-term plan also pledges to use technology to make 30 million outpatient appointments redundant, sparing patients unnecessary trips to and from hospital.

However, speaking at a clean air summit earlier this year, Simon Stevens said he wants to go even further and called on vehicle manufacturers to seize the opportunity provided by plans to upgrade the ambulance fleet. In his words, the NHS would turn blue lights green.

Yorkshire Ambulance Trust has three support vehicles powered by a hydrogen fuel cell and battery. Mrs Percival says it has ordered a further 10 vehicles so 1% of the fleet will be electric and hybrids by the end of this financial year.

YAS has signed up to the Clean Van Commitment, which works towards eliminating the emissions from all vehicles below 3.5 tonnes by 2028. The trust aims to make its entire fleet as environmentally friendly as possible, but there are issues to resolve for frontline, rapid-response vehicles, which can do up to 400 miles in a 12-hour shift. 

Changing lightweight vehicles to electric would be relatively easy – in financial terms leasing of electric vehicles is now comparable to diesels as lease car companies are dropping the monthly lease charges. Swapping from diesels to vehicles powered by alternative fuels, as leases come up for renewal, is a reality now, she says.

The biggest challenge is to create a zero-emission frontline ambulance ensuring that there is the necessary range needed to perform as a functional vehicle within the ambulance service. Pure electric battery vehicles would have a range of around 100-120 miles before refuelling is required, but when the equipment, crew and patients are added, the range is reduced to 50 miles.

While this might work in a city such as London, alternatives are needed for the urban/rural mix covered by other ambulance services. Hydrogen fuel cell/battery technologies may well provide the only option for a frontline zero emission ambulance for the future.

Vehicle limitations

There are other practical issues – electric vehicles have speed limiters to give them a greater range, which would have to be removed to ensure emergency ambulances and first responders could reach patients as soon as possible. However, this would reduce the range of the vehicles.

Electric charging infrastructure is also critically important. Currently, ambulance stations across the country hold 20 days’ fuel as a resilience measure so an electric fleet would require an equivalent recharging infrastructure. On-site and off-site charging will be critical to ensuring that the ambulance service can function in an electric-centric future.

Hydrogen is a viable option for zero emission vehicles as hydrogen takes the same length of time to refuel a vehicle as diesel/petrol.

Mrs Percival has been designing the ambulance station of the future, which would ensure that stations will have to generate electricity on site and have battery storage capability. Renewables would be an essential part of the energy infrastructure.

‘Our estate is a critical part of the ambulance service refuelling network. How will we charge or refuel the zero emission vehicles of the future? We need an estate that supports and provides us with resilience in the case of a power cut, for example,’ she adds.

Despite these issues, the trust is looking at other ways of reducing the impact of its vehicles on the environment. More than 110 ambulances in Leeds have solar panels on their roof to provide energy to the auxiliary – potentially another source of power when the trust moves to electric hybrid vehicles.

Over the past 10 years, YAS has been working to reduce its carbon footprint by: implementing LED lighting across the estate; upgrading boilers; creating aerodynamic lightbars for ambulances, increasing the efficiency; installing insulation and solar panels; trialling and testing new vehicles to the market; as well as plastic reduction programmes and behavioural change programmes. 

Implementing green technologies in organisations makes good business sense and into the future will make a lot of financial savings, Mrs Percival adds.

As part of the NHS commitment to sustainable healthcare, health service bodies are expected to produce sustainable development management plans (SDMPs). These identify waste reduction opportunities, financial savings and address national priorities, such as carbon reduction, and outline plans to tackle these issues. While many trusts have produced SDMPs, clinical commissioning groups are less likely to approach environmental sustainability in this way.

However, some are developing SDMPs, including Dudley Clinical Commissioning Group. Finance manager Paul Sharkey, who has produced a draft plan for the CCG, says trusts have a greater impact on the environment due to their estate and workforce. ‘This has contributed to a view that SDMPs are something that trusts need to do and that CCGs do not need to be particularly concerned about them,’ he says. 

He believes commissioners should be taking a stand on environmental sustainability. ‘Providers have done lots of great work to date – for example, in how they heat and light their estate. But in co-operation with providers, CCGs can lead in establishing new models of care.

‘By taking many aspects of healthcare out of expensive and over-stretched acute and other large provider settings and nearer to the patient, we can realise the congruent benefits of improved health outcomes and general population wellbeing, reduced costs, and reduced environmental impacts associated with transportation and hospital admissions and attendances. Linking improved patient care to financial sustainability is not new but perhaps we should add an ‘E’ for the environment to QIPP?’

The CCG and local providers have been looking at reducing non-elective admissions of frail elderly people from care homes to acute providers by providing wraparound services in the community. Patients benefit – close-to-home or at-home services can prevent emergency situations – it can save money and the environmental impacts of ambulance use and hospital admissions are avoided.

Mr Sharkey says: ‘CCGs should seek to reduce the environmental impacts of their business activities and lead by example in their local economies.’

The NHS, like many other areas of the economy and private households, is keen to take action to reduce its impact on the environment. Not only is it the right thing to do, saving on some costs now, but it could also contribute to better public health, potentially avoiding costs in the long-term.