Tackling a throwaway healthcare economy

Image credit: University Hospitals Sussex NHS Foundation Trust

Single-use products are widespread in health settings and contribute significantly to the carbon footprint of health systems. Many products could be reused or replaced with reuseable alternatives, so why aren’t they?

Start looking into this area and pretty soon you will find Professor Mahmood Bhutta. Mood is Chair in Ear, Nose and Throat (ENT) Surgery and Professor of Sustainable Healthcare at Brighton and Sussex Medical School, and Clinical Green Lead at University Hospitals Sussex.

His work in this area is determined and energetic, persistently finding new ways to approach the problem. I spoke to Mood about our problematic supply chains and how we can begin to transform them.

Single-use products seem to be the norm in health settings. What’s the scale of the problem and the carbon cost?

We know that 10% of the carbon footprint of health systems in high-resource settings is due to medical products. We also know that 4 or 5% of the carbon footprint of an entire nation is due to health systems. That means 0.5% (1 in 200) of all carbon emissions are due to medical products. As far as we can tell, around three-quarters of all medical products are single use. That translates to 240,000 tonnes of medical waste produced by the NHS every year, the vast majority of which (96%) comes from hospitals. For example, in England we get through more than 93 million drapes and gowns annually, more than 1.7 billion gloves, and 52 million metal instruments.

Of course not all, but quite a lot of these could be replaced by reusable equivalents. For example, a study we published last year, looked at the equipment being used in the most common surgical operations and found we could cut the carbon significantly just by slightly changing what we were doing, with no special new products or methods.

What have you found in your work on labour rights in the supply chains of these products?

Nearly 20 years ago, I was travelling through the north of Pakistan, which is where my parents are from. One of my cousins asked, ‘do you want to see how surgical instruments are made?’

I wasn’t aware that the town produced 70% of the world’s surgical instruments. It was shocking. It was sweat-shop labour, child labour, making instruments we were using in the NHS, as well as supplying health systems all over the world.

That’s where my interest in supply chains started, and since then we’ve found a number of issues. We’ve found widespread abuse of migrant workers in the manufacture of gloves in Malaysia, and we think there are similar issues in glove manufacturing in China.

Migrant workers pay illegal recruitment fees, work horrendous hours, and live in squalid accommodation, making the gloves we put on our hands every day. Wherever we have looked at the production of high through-put, low complexity medical products we have found issues.

Earlier this year we published an analysis of the origin of medical products. Where we could find the data – and that was difficult – we found that half the products are made in countries with a known high risk of labour rights abuse.

Some colleagues successfully prosecuted our government for buying gloves knowingly made using forced labour, and that has made the NHS start to recognise the problem. Since then, NHS England has published a risk assessment of labour rights issues in our supply chains.

In the US, they have enacted laws to say that gloves manufactured under forced labour are illegal goods and cannot be sold. My colleagues there managed to get over US$150 million repaid to migrant workers for illegal recruitment fees.

But it’s not enough. We should say that it is a condition of supply that a company meets International Labour Organisation standards, otherwise you can’t come to the table.

What are the barriers to reducing single-use medical products?

One barrier that can seem difficult to overcome is the perceived infection risk. For some items that is a legitimate concern, but for others it is bizarre. People will throw away a blood pressure cuff after one use.

The problem is, if someone clinical says, ‘I don’t think that is safe to reuse’, nobody else can argue against that. But I will! And actually, so will senior infection control people who know their science.

Another barrier to change is behaviour. Behaviour can be determined by convenience or because the infrastructure is not there to support an alternative.

There can be economic barriers. People may argue that it’s cheaper to throw things away, but all the evidence we have says that’s simply not true. If you go green, you will almost always save money.

I’ve made a few changes in the hospital I work in, and we estimate an annual saving of about a quarter of a million pounds. If nothing else, we can’t afford not to be green.

For example, in our outpatient clinics in ENT and ophthalmology, we were using disposable metal instruments and we moved to reusable. That’s saving a lot of money, because we buy them once and they last a long time. We sterilise them and use them again. Everybody is happy, because the quality of the instruments is so much better.

We’ve also moved to using ultraviolet light to disinfect endoscopes and that has massively reduced the cost of sterilisation and damage to our endoscopes, which were previously sterilised in harsh chemicals and temperatures. That alone saves over £70,000 per year.

Then we have to look at the other side, the suppliers. Some suppliers are fantastic and support the idea of a reuse economy. They say they want to produce a high-quality product which we can use for a long time. Other suppliers are wedded to the linear economy model, where their entire business model is built on perpetual sales, and so of course they want us to throw things away.

Some products are designed to be thrown away and are labelled as such. I have a pair of scissors here on my desk, in packaging which labels them single use only. It would be against regulations for me to use these scissors more than once – 5.9 million of these are used in the NHS every year.  

Another barrier has been a lack of institutional support. The government has not put this on the agenda or committed to building the infrastructure to support it. They have asked suppliers to look at how they can reduce their carbon footprint, but that detracts from the bigger agenda of making things reusable, which would save way more carbon than anything else. We were commissioned by Greener NHS to produce a report into how we decarbonise our supply chain and that was our strong recommendation – that we move first of all to minimising single-use equipment.

What work are you currently doing to support change?

We need to win minds as well as hearts. I talk about the issues with our supply chain in terms of the throwaway economy, throwing away carbon, money, and human dignity. That wins some of the hearts.

For the minds, we’ve been demonstrating the scale of the problem through publishing carbon footprints, such as of PPE [personal protective equipment] or surgical procedures. We have proved the principle that reuse is better for the planet.

We’ve produced the Green Surgery Report, an example of how a specialty can move to more environmentally friendly care. It is an evidence-based review of everything from public health, to care pathways, to the equipment we use.

Earlier this year, we launched the Circular Economy Healthcare Alliance, through which five large healthcare trusts have committed to the ethos that we will always use reusable products where it is clinically safe to do so. I am now looking at how we embed that into our policies so it becomes the norm.

And I’m speaking with governments abroad, because these are international markets. I’ve been in conversation with national procurement leads in Denmark, Norway, Sweden, and soon Canada. We need an international movement on this.

What advice would you give for people interested in tackling these issues?

It can feel very difficult to change institutions and I would say ‘start the conversation’. Once you start the conversation, you often find other people think the same way.

Get a group of friends together with the will and the drive, and then take it up to the people who make the decisions. I took this initially to my chief executive and I was supported. That may not be everybody’s experience, but if you get a group of like-minded people together and go and speak to the other key parts of the jigsaw – for example your infection control team, your sterile services team, your procurement team – you can make change happen.

Find out more about the Brighton and Sussex Medical School (BSMS) Sustainable Healthcare Group on its website.

Earlier this month, the UK’s Department for Health and Social Care set out its intention to support a circular economy approach to medical products. Find out more about the Design for Life Roadmap on the government website.