The NHS, supported by the UK Health Alliance on Climate Change, has shown leadership, pledging to meet a ‘net zero’ carbon target by 2045 through its Greener NHS campaign1.
Surgery is a resource-intensive healthcare activity2 using huge quantities of single-use consumables and generating associated waste3, disproportionally contributing 70% of hospital waste4. The carbon footprint of a surgical procedure is typically equivalent to that of driving 2,273 miles in an average car5.
Approaches to reducing environmental harm centre on surgeons making changes in the operating room (OR)3. However, there is a necessity to adopt a holistic strategic approach extending more broadly than the OR to incorporate the entire surgical pathway3. The principles in order of importance are; prevention e.g., disease prevention, patient self-care e.g., promotion of health, lean service delivery e.g., optimising resource use, and low carbon activities e.g., prioritising technology with lower environmental impact.6
All surgically associated modifications should of course be supported, ideally by local level real world evidence or through formal academic analysis3. Granular level data of waste volumes or single use devices use, for example, will contribute towards developing an understanding of wasted finances, opportunities to reduce clinical waste streams and further optimise surgical protocols.7 Moreover, aggregated data characteristics for life cycle assessment modelling can be more successfully achieved through the use of granular data collection.8 All contributing towards greener surgery and an accurate census of the NHS carbon footprint.9
In the UK, the NHS Confederation reported a volume of 10.119 million surgeries for the financial year 2015–2016, an increase of 40% from 2005 to 2006.10 Furthermore, the demand for surgery overall is increasing11,12 potentially heightening its future environmental impact. In relation to primary hip operations (PHOs), this number is expected to also rise significantly from an average of 96,000 in the UK NHS, due to an increasingly ageing society.12,13 Corroborate this with research reporting PHOs are considered to be one of the largest generators of waste in surgery, with one study reporting a single PHO generates greater than 13 kg of waste.14 PHOs may therefore be defined as a “carbon hotspot” of surgical procedures.14,15
Consequently, the research by Pegg et al.7 examines waste management within an orthopaedic operating room at the Freeman Hospital, Newcastle Hospitals NHS Foundation Trust, measuring the volume and type of waste produced for primary hip operations (PHOs), and estimating the total waste produced across the United Kingdom by the procedure. Using the UK National Joint Registry12 data figure for annual PHOs reported in the NHS, it was calculated approximately 1043 tonnes of waste is produced annually by PHOs alone.7 In addition, this study highlights the burden of single use device consumption in surgery16 and reporting a significant volume of this waste could be prevented through improved recycling and reduced use of single-use devices.7,16
Environmental harm attributed to surgery, and unnecessary resource consumption is every surgeon’s responsibility.3 There is a prescient need to partner with surgical colleagues globally, and to provide health care professionals with the tools required to change the impact of surgical care pathways.3 Further, leadership for implementing change will be critical for overcoming current hyperbole surrounding reuse of devices5,17 and textiles18, for example, and paramount to the success of mitigating the carbon footprint associated with surgical practice.3,18
In support of NHS Net Zero targets and initiatives, a partnership between the UK Health Alliance on Climate Change (UKHACC), Brighton and Sussex Medical School (BSMS) Sustainable Healthcare Group and the Centre for Sustainable Healthcare (CSH) has been created to produce a landmark Green Surgery Report for the NHS. The Green Surgery Project will bring together key stakeholders from a number of national institutions, and harness existing evidence and knowledge to deliver recommendations for policy makers, institutions, and individuals.
The research paper by Pegg et al., (2022) can be accessed at the University of Derby repository at; Operating room waste management: A case study of primary hip operations at a leading national health service hospital in the United Kingdom : University of Derby Repository
Journal: Journal of Health Services & Research Policy
Publisher: SAGE Journals
This piece is written by Melissa Pegg, Fellow in Sustainable Surgery, UKHACC
- England NH, Improvement NH. Delivering a ‘net zero ‘national health service. NHS England and NHS Improvement, London. 2020 Oct 1.
- MacNeill AJ, Lillywhite R and Brown CJ. The impact of surgery on global climate: a carbon footprinting study of operating theatres in three health systems. Lancet Planet Health 2017; 1: e381–e388.
- Rizan C, Bhutta MF. Strategy for net-zero carbon surgery. British Journal of Surgery. 2021 Jul;108(7):737-9.
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- Pegna V, McNally SA. Are single use items the biggest scam of the century?. The Bulletin of the Royal College of Surgeons of England. 2021 Jul;103(5):233-5.
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- Pegg M, Rawson R, Okere U. Operating room waste management: A case study of primary hip operations at a leading national health service hospital in the United Kingdom. Journal of Health Services Research & Policy. 2022 May 30:13558196221094488.
- Mayer M, Bechthold M. Data granularity for life cycle modelling at an urban scale. Architectural Science Review. 2020 Jul 3;63(3-4):351-60
- Salas RN, Maibach E, Pencheon D, Watts N, Frumkin H. A pathway to net zero emissions for healthcare. Bmj. 2020 Oct 1;371.
- National Statistics. Hospital Admitted Patient Care Activity. Report. Health and Social Care Information Centre, UK: November 2016.
- Shrime MG, Daniels KM and Meara JG. Half a billion surgical cases: Aligning surgical delivery with best-performing health systems. Surgery 2015 1;158: 27- 32
- National Joint Registry. 17th Annual Report 2020. Surgical data to 31 December 2019. Registry for England, Wales, Northern Ireland, and Isle of Man https://reports.njrcentre.org.uk/2019 (2020, accessed 15 June 2022)
- Patel A, Pavlou G, Mújica-Mota RE, et al. The epidemiology of revision total knee and hip arthroplasty in England and Wales: a comparative analysis with National projections for the United States. A study using the National Joint Registry dataset. Bone Joint J. 2015; 97: 1076-81
- Southorn T, Norrish AR, Gardner K, et al. Reducing the carbon footprint of the operating theatre: a multicentre quality improvement report. J Periop. Pract. 2013; 23: 144-6.
- Bhutta MF. Our over-reliance on single-use equipment in the operating theatre is misguided, irrational and harming our planet. The Annals of The Royal College of Surgeons of England. 2021 Nov;103(10):709-12.
- Rizan C, Mortimer F, Stancliffe R, Bhutta MF. Plastics in healthcare: time for a re-evaluation. Journal of the Royal Society of Medicine. 2020 Feb;113(2):49-53.
- Association of Surgeons of Great Britain and Ireland. Consensus statement on cost-effective and sustainable surgery, https://www.asgbi.org.uk/userfiles/file/consensus/asgbi_consensus_statement_o n_cost-effective_surgery.pdf (2012, cited February 2022)
- MacNeill AJ, Hopf H, Khanuja A, Alizamir S, Bilec M, Eckelman MJ, Hernandez L, McGain F, Simonsen K, Thiel C, Young S. Transforming the medical device industry: Road map to a circular economy: Study examines a medical device industry transformation. Health Affairs. 2020 Dec 1;39(12):2088-97.