ABSTRACT
A large, multi-site NHS trust piloted switching from single-use pulp to reusable plastic trays for use in clinical care. This mixed-methods analysis combines quantitative cost-effectiveness and greenhouse gas (GHG) emissions calculations with a stakeholder analysis and user survey to not only ascertain the cost and climate implications of this intervention, but to also better understand the use of trays across the trust to improve staff buy-in and, ultimately, the feasibility and success of the policy. We show that the plastic trays are both more cost-effective and climate friendly compared with the pulp trays, even using an annual replacement rate of 50% (higher than our anticipated rate of 5%), and that staff and key stakeholders would support the policy. Our analysis is one example of a larger trend in the return to reusable items, as awareness grows of the significant GHG emissions and waste produced from disposable, single-use items in healthcare.
Introduction
Guy's and St Thomas' (GSTT) is a large NHS trust that delivers inpatient and outpatient services to adults and children across five hospitals and multiple community centres in central London. In 2019, the NHS in England was responsible for 25 Mt of carbon dioxide equivalent (CO2e) emissions, making it one of the most significant public sector contributors to greenhouse gas (GHG) emissions and climate change in the UK.1 As a result, the NHS has both the opportunity and responsibility to decrease its own emissions. Efforts to curtail the NHS' climate impact have resulted in a 26% reduction in CO2e emissions since 1990, a feat largely driven by decarbonisation of the energy supply, reduced consumption of anaesthetic gases and the phase-out of chlorofluorocarbons (CFCs) from metered dose inhalers.1 The NHS ‘Net Zero’ initiative aims to reach net zero by 2040 for all emissions directly controlled by the NHS, encompassing all scope 1 and scope 2 emissions and some scope 3 emissions.2 By 2045, the NHS plans to reach net zero for the remainder of its scope 3 emissions.2 In 2019, the supply chain accounted for 62% of NHS emissions,1 which includes the production of pharmaceuticals, chemicals, medical and non-medical equipment, business services, and food and catering.1 Beyond the national-level policy changes occurring to decarbonise the NHS, GSTT has a dedicated quality improvement programme to trial new and innovative approaches toward climate and environmental sustainability.
Solution
GSTT sustainability and procurement teams identified the need to switch from single-use to reusable items as part of the NHS Net Zero initiative. Single-use pulp trays are prevalent throughout the trust in wards, theatres and the emergency department. These are used for clinical procedures, such as medication administration and phlebotomy, and are disposed of in the clinical waste following this. The proposed solution was to switch these to reusable plastic trays, which can be cleaned between clinical interactions, thereby substituting single-use pulp with reusable plastic throughout the trust. We conducted a literature search and found no examples of other hospitals or healthcare facilities adopting and evaluating a similar product switch. However, the Intercollegiate Green Theatre Checklist recommends the use of reusable trays.3
The carbon intensities of the pulp and plastic trays were compared by taking into account the entire product life cycle from primary material production to disposal. The pulp and plastic trays were individually measured and weighed to ensure accuracy in the results. The UK Government GHG Conversion factors for mixed paper and board, and polypropylene plastic were used for the pulp and plastic trays, respectively. To account for the correct form of waste disposal, conversion factors for combustion were used, because both pulp trays and plastic trays are incinerated as clinical waste at the end of their use. Calculating the carbon footprint of the trays required both the weight of the tray and the quantity used. For the pulp trays, we used actual procurement amounts of pulp trays for the past three financial years, obtained from the GSTT sourcing team. The quantity of plastic trays that would need to be initially procured to replace the use of pulp trays across the trust was extrapolated from a pilot study conducted in the anaesthetics department of St Thomas' Hospital.
The pilot study was conducted during the first quarter of 2022. Based on these results, the procurement team has been conducting analyses of the supply chain and disposal requirements of the switch from pulp to plastic. The quantitative and qualitative analyses in this study were conducted in July 2022. In the same month, the study team met with the infection control team, who gave approval for the use of reusable plastic trays in theatre. In October 2022, the proposed switch was presented to the anaesthetic managers' hub to get broad buy-in from the anaesthetics team. Following a meeting with the general managers in April 2023 to discuss the procurement switch, a change in trust policy is expected in the near future.
Outcome
Quantitative component
During the 2021–2022 financial year, the trust spent just over £14,000 on the procurement of 527,000 pulp trays, resulting in a carbon footprint (CO2e) of 5.3 t, which includes primary material production and waste management through incineration. All carbon emissions were calculated using the UK Government GHG Conversion Factors.4 The trust's plan to phase out pulp trays and use polypropylene-based medical plastic trays instead was analysed for both its carbon and cost impacts. The procurement team estimated that an initial 6,000 trays (T3025 model, SASCo) would need to be purchased to replace the pulp trays; this would cost £10,500 and result in 5,852 kg in CO2e emissions. A 5-year comparative analysis compared continued procurement of pulp trays (no plastic trays) with full replacement of pulp with plastic in clinical care across the trust. Plastic trays were cost leaders: procuring plastic trays for the trust was always cheaper than procuring pulp trays, even in the year of the initial up-front purchase (Fig 1). During the first year, plastic trays would have a slightly higher carbon footprint compared with pulp trays because of the higher initial purchase, but, by the following year, plastic trays would have a lower carbon footprint, even with an annual replacement rate of 50% (Fig 2). All calculations are shown in Box 1.
Comparative analysis of pulp and plastic trays by (a) annual cost and (b) cumulative cost. Percentage figures represent different rates of annual replacement of plastic trays to account for loss and damage. Pulp-tray figures assume the amount procured during the 2021–2022 procurement year remains unchanged for the next 5 years.
Comparative analysis of pulp and plastic trays by carbon dioxide equivalent (CO2e) emissions, shown (a) annually and (b) cumulatively. Percentage figures represent different rates of annual replacement of plastic trays to account for loss and damage. Pulp-tray figures assume the amount procured during the 2021–2022 procurement year remains unchanged for the next 5 years.
Methodology to calculate carbon dioxide equivalent (CO2e) emissions from the production and disposal of pulp and plastic trays, using UK Government Conversion Factors
Qualitative component
We conducted a stakeholder analysis to find that pulp trays were predominantly used by doctors and nurses. We subsequently carried out a survey across all GSTT departments to better understand the use cases of pulp trays in everyday clinical practice, as well as staff willingness to engage in the switch to plastic trays. The survey found that the most common uses of the pulp trays were for medication administration (36%, 18 users out of 50), cannulation (24%, 12/50) and disposable use following body fluid exposure (22%, 11/50). Most users (80%, 40/50) were in favour of switching from the disposable pulp to the reusable plastic trays. However, we discovered several misconceptions, including the common belief that the production of plastic trays has a greater environmental impact compared with that of pulp trays (the production of one plastic tray does have a higher carbon footprint than a single pulp tray, but, as demonstrated in Fig 2, this effect is quickly reversed because the plastic trays are reused and the pulp trays are not). A further major misconception was that the pulp trays are recyclable, which was substantiated by the survey finding that 22% (11/50) of users disposed of pulp trays in recycling bins. Both of these misconceptions could be addressed through improved staff education. Overall, the stakeholder analysis and survey demonstrated that most users were on board with the proposed switch. We believe that there is scope to educate the minority who were opposed to the switch, to facilitate uptake and improve appropriate waste segregation.
Conclusion
Our analysis has shown that switching from single-use pulp to reusable plastic trays is cost-effective and carbon saving in the short- and long-term, as well as being supported by key stakeholders and product users. Given the findings from this analysis, GSTT plans to continue rolling out the replacement of single-use pulp trays with reusable plastic trays across its other sites, in conjunction with further audits of the success of this switch in terms of cost, emissions and user satisfaction. However, although our results are promising, we expect that single-use pulp will not be phased out entirely, because certain uses involving offensive bodily fluids (urine, vomit and faecal matter) would most likely be too unpleasant to manage with reusable trays and would impact employee well-being and job satisfaction.
Paper and pulp are often advertised as the solution to plastic pollution;5 however, the paper and pulp industry is a significant emitter of GHG and contributes to the emission of toxic pollutants into the air and environment across its life cycle.6 Single-use, disposable items have become increasingly ubiquitous in clinical care, largely because of convenience and lower cost per item. Our analysis is one example of a larger trend in the return to reusable items, as awareness grows of the massive amounts of waste produced from manufacturing and using disposable single-use items, in conjunction with inadequate recycling practices.7–9 Other life-cycle analyses have demonstrated both the significant carbon footprint associated with single-use items, and that reusable items can be cost-neutral or even cost sparing when considered over the lifetime of their use, rather than just the up-front investment.10–15
Healthcare's supply chain is carbon intensive and accounts for 71% of the global healthcare climate footprint.16 The biggest contributors to this supply chain footprint are pharmaceuticals, medical devices and instruments, as well as the energy consumed transporting goods and services to and from health centres. In the NHS, in 2019, supply chains for acute trusts resulted in 7,915 kt of CO2e emissions, 61% of total emissions, of which medical equipment accounted for 1,930 kt (24% of the supply chain emissions).1 Therefore, reducing the emissions from medical equipment by switching to more sustainable, reusable options offers the opportunity to substantially reduce the carbon impact of the NHS.1
Although policies and initiatives to reduce overall consumption and enable switches to less carbon-intensive products are important, it is nevertheless crucial to emphasise that over half of healthcare's global carbon footprint derives from energy production, primarily from the combustion of fossil fuels.16 Therefore, the greatest single action to reduce healthcare's climate impact would be a concerted global effort to keep fossil fuels in the ground and invest in carbon-neutral, renewable energy sources.
- © Royal College of Physicians 2023. All rights reserved.
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