With 1.6 million patient interactions a day, it will come as no surprise that the NHS generates a vast quantity of waste across a variety of healthcare premises.
According to NHS England’s Clinical Waste Strategy, published in March 2023, there were some 12,500 community pharmacy sites, 7,353 general practice sites and 1,139 hospital trust sites generating clinical waste in 2020. And to that, we can add the waste produced in NHS dentistry, optometry, care homes and prison services, as well as in patients’ own homes.
Every year, providers in secondary care alone produce approximately 156,000 tonnes of clinical waste that is sent either to high-temperature incineration or for alternative treatment (AT), such as sterilisation. As the strategy clearly states: ‘This has a significant environmental impact, substantial running costs and high carbon emissions.’ The estimated carbon impact of this waste is approximately 100,000 tonnes of CO2e per year.
In fact, water and waste make up 5% of the NHS’s carbon footprint, as explained in the government’s Delivering a ‘Net Zero’ National Health Service report which set out the health service’s overarching sustainability targets.
Linking to this, the Waste Strategy highlights, as a priority, the need to ‘achieve a 50% reduction in the carbon emissions produced from waste management by 2026, and an 80% reduction by 2028-32’.
Reducing waste in primary care
Meeting this target means improving waste management practices among NHS trusts, foundation trusts and primary care, through always seeking ‘to avoid waste production, and to reuse, repair and remanufacture products (where safe and practical to do so)’.
The ‘waste hierarchy’ for healthcare ranks management options according to what is best for the environment – from prevention to disposal – adding ‘correct segregation’ of clinical waste at level two; this refers to items such as used dressings and needles, and anything that might contain human tissue, blood or drugs. Only waste with the highest risk to health or the environment needs to be treated using high-temperature incineration (HTI), which is associated with the greatest costs and carbon footprint.
While secondary care is by far the biggest generator of clinical waste (for example, producing a total of 233,000 tonnes in 2018/19), general practice sits in second place (generating 7,500 tonnes over the same period).
But reducing waste in primary care is no easy task for ICBs in a world where independent contractor GPs negotiate their own contracts with individual waste providers, making it harder to evaluate or standardise processes and monitor outputs.
‘Waste is a complex beast in the NHS, and especially in primary care, in terms of who is responsible (and who pays) for what,’ attests former GP, Dr Matthew Sawyer, who runs SEE Sustainability, an environmental sustainability consultancy. He is also co-chair of the Greener Practice primary care sustainability network for York and North Yorkshire.
‘The rules around waste also change,’ he adds. ‘So, what was true even only a couple of years ago has been superseded.’
For example, in May last year, the government introduced the compulsory ‘offensive waste stream’ for primary care settings, making it their main route of waste disposal. Surgeries were required to introduce new arrangements for segregating waste by providing black and yellow ‘tiger’ bins, signage and labelling. The move is designed to reduce the amount of healthcare waste that goes to incineration or landfill (saving £2 million a year and lowering carbon emissions).
Unlike clinical waste, offensive waste has no hazardous properties and can be treated or disposed of in a similar manner to municipal waste, which may include conventional ‘energy from waste’ treatment. Due to the infrastructure and energy that is needed for HTI and AT, treating clinical waste has a higher cost, and produces more carbon than offensive waste.
This means there are now three main waste streams for general practice – offensive waste, infectious waste and domestic waste – collected via a plethora of bins: there are yellow-lidded sharps bins, purple-lidded bins for contaminated sharps and vials with cytotoxic and/or cytostatic medicinal products and their residues, blue bins for non-hazardous medicines and denatured drugs that pose no risk of containing cytotoxic or cytostatic properties, and orange clinical waste bags for infectious waste.
In addition, there must be separate bins for ‘confidential waste’ – patient identifiable papers and sensitive information – plus recycling bins for all recyclable materials. Domestic waste bins are for all non-recyclable waste.
Sharing clear guidance
This complexity can confuse even the greenest of clinicians in a busy surgery environment. Recognising the need for clear guidance, at Gloucestershire ICB primary care, infection prevention and control lead nurse Regina Kageni has presented a simple and visual guide to the different types of waste to primary care colleagues, explaining how they should be disposed of, and their relative carbon and cost implications.
According to her calculations, disposal of infectious waste costs £500 per tonne compared to £360 per tonne for offensive waste, £120 a tonne for domestic waste and £80 per tonne for recycling. Clinical waste that requires high temperature incineration costs £1,500 per tonne. This highlights the savings practices can generate by improving their waste management.
Similar educational work has also been done at a grassroots level by York GP Dr Rumina Önaç, author of ‘The Greening of Life’ eco blog, who co-chairs Greener Practice York and North Yorkshire. She set up Sustainable Practices York (SPY) – a group of 18 GP surgeries across the Vale of York – which aims to support changes in practice by lowering the carbon footprint of health services in a way that also improves the health of patients; until recently, she was also sustainability lead at the local Nimbuscare federation.
‘I produced a poster which highlighted the cost differences in a bid to persuade people that it was more cost-effective to do the right thing with their waste and also there would be carbon savings,’ she says. ‘With all of these projects, if we can save people money, it’s hugely attractive and then they’ll do it – whether they believe [in sustainability] or not.’
‘In the educational talks I do around the country, I say that even simple things such as having labels on bins and a short explanation of what goes in each, or moving bins around the room can make a difference,’ she adds. ‘I show a photo of my consulting room and point out that the only bin that’s next to the sink is the domestic waste bin because the temptation is that you clean your hands with paper towels and you’ll put those in the clinical waste bin. That’s much more expensive.’
Overcoming barriers
Although savings can be made by practices that dispose of waste efficiently, there are some perverse incentives that need to be addressed.
‘One big problem is that both the offensive and infectious waste is collected by the NHS from GP surgeries – so the practice doesn’t pay for the disposal,’ explains Dr Sawyer. ‘However it does pay for the commercial waste and recycling through contracts with local waste collectors. Each practice will have its own contract with its own provider.
‘But this means that if a practice put all its waste in tiger or orange bags, it would pay nothing for disposal, but the costs to the NHS are much higher. And, if a GP practice wanted to recycle, it would be an extra expense as it’s an extra contract with their waste provider.
‘Ultimately, the financial cost to a practice does not equate to the financial cost of waste disposal. If they were linked, there would be more incentive to change behaviour in a positive way.’
By contrast, appropriate incentives at a local or national level and can help to prompt behaviour change.
‘There are things that can cause big change with small levers,’ says Dr Frank Swinton, climate change lead for West Yorkshire Health and Care Partnership. ‘The landfill tax, for example, has driven huge changes in recycling.’
He describes the value of cross-sectoral and organisational working to address systemic issues. ‘Waste, estates and travel and transport are all examples of classic wicked problems that each and every individual primary care provider is not going to resolve on their own. We’re trying to approach this in two or three different ways,’ he says.
‘One is that there’s quite a lot of primary care activism among primary care staff in West Yorkshire. But we’re also working to incorporate sustainability thinking as a strategic issue rather than as an operational issue.
His two-day-a week ICS role, which he combines with his job as a consultant anaesthetist at Airedale NHS Foundation Trust, involves building relationships, developing local partnerships and sharing funding or other opportunities.
‘A big part of my role is communications and networking: have you met ‘X’ who does ‘Y’ with his waste? Here’s ‘Z’, who’s about to renew her waste contract,’ says Swinton. He reaches out to GPs via a weekly communications mailshot and by tapping into existing networks, including the Greener Practice network.
‘The leadership ethos with West Yorkshire is very much one of subsidiarity and partnership working,’ he says. ‘There’s very little telling people what to do. It’s much more, “here’s our problem; what are we going to do about it?”.’
Prioritising prevention
Strategic thinking also lies at the heart of Suffolk and North Essex ICS’s approach to carbon reduction. Andrew Urquhart, who has a background in waste management and leads on sustainability, aims to adopt the four principles set out by the Centre for Sustainable Healthcare across strategies, including in primary care. These are:
- prevention
- patient empowerment and self-care
- lean systems, and
- low-carbon alternatives.
‘I want sustainability to become business as usual, rather than a bolt-on’ he stresses. ‘It should be in our DNA. We’re embedding this at the very beginning of everything we do.’
In line with the four principles, prevention should be first line for managing waste.
‘It’s getting people to think: don’t create waste; is it reusable?’ says Urquhart. ‘We’re doing some great work with trusts on reusable tourniquets and catheters – and then considering how we take that experience into primary care.’
While direct work with general practice is at an early stage (‘we’re going to look at doing something really systematic for primary care in the next six to eight months’) the ICS has been coordinating a variety of simple-but-effective waste-reduction initiatives.
The first was to encourage people to return their inhalers to pharmacies for safe disposal.
‘When we did our training for inhaler switches, there was no national recycling scheme for inhalers,’ Urquhart explains. ‘But we worked with the local pharmaceutical committee and pharmacies because we knew there was a potential recycling scheme in the offing.
‘We thought “let’s still get the message out there during patients’ asthma or inhaler reviews”. Of course, the first thing to do to reduce the waste is check: is the patient using their inhaler properly? Why do they have six inhalers?’
Partnership working helps to garner engagement: ‘We work with patient participation groups and with respiratory consultants from our trust so we’ve got a really collective approach and everyone’s talking about it,’ says Urquhart.
Meanwhile, a scheme encouraging patients to return their pulse oximeters after use is achieving a 90% return rate, saving significant sums while reducing waste from single-use plastic, and similar work has been done around walking aid reuse. ‘We’re just tightening that up and making sure the message is dropped into the physio conversation,’ says Urquhart, adding that most patients have been more than happy to return their aids and devices. ‘We’re pushing against an open door.’
A gloves and PPE campaign is also underway, led by the ICS’s infection control lead nurse, in a bid to reduce single-use plastic – while improving staff wellbeing.
‘So far we’re recruited eight general practices and a couple of care homes to pilot it,’ says Urquhart. ‘It’s not a case of trying to save carbon or money at the cost of patient care. But since Covid-19, the amount of PPE has sky-rocketed and, actually, in a lot of instances, good hand hygiene will suffice.
‘There’s also evidence from the RCN that staff are experiencing more dermatological problems because they’re wearing gloves all the time,’ he adds. ‘So there’s a staff health aspect, a resource aspect, a single-use plastic aspect and a carbon-reduction aspect.’
A shared responsibility
On top of all this work comes a system-wide medicines waste project, led by the medicines management team. It aims to achieve consistent messaging across hospitals, general practice and pharmacies; for example, reminding patients not to flush spare meds down the toilet, to attend medication reviews and to avoid stockpiling. This all feeds into the concept of empowering patients and encouraging self-care.
‘It has to be done with our communications team in such a way that people don’t feel threatened,’ says Urquhart. ‘But since 60% of a general practice’s carbon footprint is down to prescription medication there’s real skin in the game here.’
On a final note, while it’s clear that both health professionals and patients have a role in disposing of healthcare waste responsibly, so do pharmaceutical companies argues Dr Onac. Greater accountability must be taken for the type of packaging designed and used.
While she has taken the initiative by coordinating a blister pack recycling scheme in York over the past year, she feels the onus for managing this waste should not be on the NHS.
‘Manufacturers have a massive producer responsibility,’ she concludes. ‘I find it really difficult when I speak to them and they want to collaborate with the NHS by giving matched funding for disposing of packaging; my personal belief is they should be taking the entire responsibility. And hopefully that’ll lead to them redesigning packaging in the first place.’
Case study: Frome Health Centre, Somerset
Case study: Frome Health Centre, Somerset
Among the many sustainability initiatives implemented by Frome Medical Practice are practical interventions designed to improve waste management – reducing costs as well as carbon emissions.
The practice – which is a platinum award-winner under the RCGP’s Green Impact for Health Toolkit – has embedded ‘green impact’ into its organisational culture. ‘We’re taking a preventive approach,’ explains GP Dr Helen Kingston. ‘With waste, look at what can be reused or where we can reduce use our use of items such as couch roll.
Other initiatives include using tiger bins for offensive waste, removing individual desk bins for general waste and instead installing central waste stations for general and recyclable waste. This, along with clear labelling of all bins, helps to encourage better segregation.
Going paperless
In a bid to become paperless, staff no longer use a fax machine and set photocopiers to print double-sided by default, also scanning and emailing documents where possible. To reduce leaflets, health education messages are promoted to patients via patient information screens in waiting areas, while patient registration packs have also been condensed.
There are even systems in place to collect non-confidential documents printed only on one side so this paper can be used as note pads and to collect and reuse envelopes.
With the support of local organisation Loop, food waste – including from the public-facing café on the premises – can be put into the practice’s hot composters and then used on the allotment in the practice’s wellbeing garden.
We have a patient population of around 30,000 so we have a big team, admits Dr Kingson. ‘That can be a challenge with communication but it’s also a great strength because you have a team of people with specific jobs. Our ICB is very supportive; we’re currently trying to roll out the Health Impact Toolkit across Somerset with its help.’
This case studyis extra in terms of word count (I understood that it would be ok to do this; you could cut it if not). Frome HC literally does everything a green practice should do, so if you wanted a wider case study that included all its green initiatives (to span chapters/the whole report), we could rework this?
