This is an opinion piece co-authored by two surgeons. Victoria Pegna is a Colorectal and General Surgery registrar at Sussex University Hospital and co-founder of the Sustainability in Surgery Committee. Vittoria Bellato is Clinical Research Fellow at St Mark’s Academic Institute and member of the European Society of Coloproctology. Here they give us their take on the lack of sustainability in hospitals and what we should do about it.
Since the 1980s, surgeons have witnessed a rapid transformation in the tools we have access to. As a colleague put it, “over the course of my career we have gone from solely using reusable devices, to today, where almost everything we use is single use.”
This is not the norm all over the world - there is far less waste when resources are poor.
But in developing countries across Europe and North America, new processes have been introduced to simplify surgical procedures that claim to eliminate the risk of infection, such as rigorous hand scrubbing, the use of individually packaged, single-use tools and anaesthetic gases.
However, there is a lack of recent evidence that single use items are any better than sterile reusable equipment. These new methods have been taken on by both the medical community and the public because only the health, and outcome of the patient, has been considered.
What about the health of the planet?
These practices are having a devastating impact on the environment. In fact, a recent Lancet report estimated that the healthcare sector represents almost 5 per cent of all global carbon emissions, and the operating theatre is the worst offender.
How can we improve the sustainability of surgery?
That’s not to say that there aren’t opportunities to improve the sustainability of our surgical practice. Water usage can be cut dramatically with the use of alcohol-based hand gel (instead of scrubbing) without increasing the risk to patients, but policies and surgeons have yet to adapt.
The sterilisation and repair of reusable tools in surgery - versus disposing of single use versions - not only reduces the environmental impact of an operation but saves healthcare services money in the long-term too. Indeed, the wider cost of disposal, transportation and burning of medical waste often isn’t even considered in the same procurement budgets.
A pressing challenge is the lack of awareness, even among surgeons and health workers.
Doctors have the power to vote with their feet and make small changes in the operating theatre and beyond. However, global research conducted by the European Society of Coloproctology (ESCP) found that while around half of surgeons are eager to make changes, such as foregoing non-sterile gloves and reducing the use of anaesthetic gases during surgery, most surgeons (57 per cent) were not even aware of the scale of surgical practice’s carbon footprint.
Three-quarters had never received any guidance on making their surgical practice more sustainable from their employer or at a national level. Sadly, there is limited research to enable change to the narrative.
8 in 10 surgeons agree surgical guidelines are urgently needed, yet the evidence base is currently limited and so guidelines have yet to be made. Certain institutions, including the ESCP and the specialist Centre for Sustainable Healthcare in the UK, are making progress to conduct the necessary research.
However, we still need many more experts from different specialties to drive more sustainable and innovative approaches in the field.
Why change must come from the top
In the meantime, system-wide changes are long overdue and must come from the top. Surgeons themselves must play a role, but hospital leadership has the greatest potential to create lasting impact.
Ethical procurement must be prioritised moving forwards; healthcare leaders can drive this change by signing contracts with companies that have good ethical and sustainability principles, and that source materials locally.
They can also make decisions about procuring single use or reusable instruments, keep energy-use to a minimum and change hospital policies to reflect the latest research and practices for both patient safety and sustainability. Meanwhile, governments also have a responsibility to promote, facilitate and fund such efforts.
We rarely hear about the environmental burden of surgery in the media because the finger is usually pointed at large corporations. Surgeons and hospitals purchase from manufacturers too, and sadly it’s not in the financial interests of these companies to make reusable medical equipment like laparoscopic ports.
Companies can, however, make a difference by funding research into reusables, minimising packaging, reducing the use of resource intensive materials, introducing biodegradable packaging, and innovating new, more sustainable solutions.
Importantly, by taking these steps, they can also make tools more affordable for surgeons working in low-income countries.
Some might argue that the health of the patient must be our only priority, but in the long-term, global warming will have severe implications on people’s health, with the World Health Organisation estimating 250,000 additional deaths per year throughout 2030-2050.
The UK National Health Service’s (NHS) aim of becoming net zero by 2040 is admirable yet feels like a distant reality. As we look to rebuild and strengthen our health systems in the recovery from COVID-19, we have a unique opportunity to establish more sustainable health services.
To protect the lives of our patients, the health sector needs to make changes now – 20 years from now is too late.