We must not let our reliance on single-use plastic in healthcare become the “new normal” or set-back the strides taken prior to the covid-19 pandemic to address the primary existential crisis concerning our environment.

The covid-19 pandemic has highlighted the huge material footprint required to support frontline healthcare in the NHS. The NHS contributes 5.4% to the UK’s climate footprint. [1] Pre-covid, the NHS had made great strides in tackling waste and contributing to its goal of a net-zero future. In 2019, the NHS had achieved an estimated 62% reduction in its 1990 emission levels. [2] 

However, six months after the initial outbreak of covid-19, the UK government had procured 32 billion items of personal protective equipment (PPE) worth £12.5 billion. [3] Between February 2020 and February 2021, the NHS used more than 1 billion surgical masks. [4] This would generate nearly 3 million kilograms of waste according to a recently published study, which estimated that 123,000 tonnes of unrecyclable plastic waste would be generated in a year if every person in the UK used one disposable surgical mask per day. [5] 

To support the long term plan of achieving net-zero and other sustainability commitments, more systemic approaches to designing out waste and greenhouse gas emissions are needed within the NHS. Current practices of incineration, landfill, and low-value recycling need to be replaced by a “circular” mind-set, where everything is designed, procured, and used for as long as possible, at their highest value, only then recycled back into new products or for alternative high-quality uses. [6] Such approaches are available even during a pandemic. 

For example, a Sterimelt machine, which aims to recycle and repurpose wasted surgical masks and other plastic, was installed during the pandemic at the Royal Cornwall Hospitals NHS Trust. [7] A recent study found that the carbon impact of anaesthetic gases can be as small as intravenous anaesthetics, by shifting from desflurane to sevoflurane and employing effective vapour capture technologies. [8] A trial of world’s first bespoke net-zero clinical laundry study for Personal Protective Equipment (PPE) piloted across a range of NHS sites for gowns, aprons, coveralls and surgical masks found that the service has the potential to save the NHS an estimated £9m per annum, displacing 5% of the disposable market share in 2022. [9] At a product level, the re-manufacture of electrophysiology catheters was found to reduce its carbon emissions by a minimum of 50% [10]; while a “circular” mindset led to the development of a technology that can transform materials of clinical wastes into feedstock chemicals. [11] At an organisational level, monitoring and increasing the use of building space, shifting to performance-based business models for expensive equipment and lighting, and altering procurement rules to favour remanufactured products are all actions that are needed to create large scale system changes to break out of the current linear model and ways of thinking. 

However, the human element is crucial during this transition. Continuous monitoring and widespread education and awareness training are needed to ensure the correct choices are made and implemented on a daily basis. A recent study highlights that the long list of factors that have contributed to the embedding of single-use practices and norms in US healthcare including: just in time purchasing systems to minimise storage; planned obsolescence from manufacturers and suppliers; mistaken belief that re-use impacts risk and patient safety; concerns about liability and cost; confusing classificatory and asymmetric regulatory frameworks; and split roles and incentives for taking action. [12]

Currently, most medical sites do not have a post-consumption treatment system for composting plastics. The popularity of single-use compostable plastics in a pandemic is understandable, but concerning, as single-use plastic could become a regrettable and expensive option. [13] While staff perceptions of what products can and cannot be recycled in the local area is an on-going issue within the NHS irrespective of the covid-19 pandemic, re-use approaches would remove much of the complexity and confusion about legacy recycling models. 

Some may consider that the plastic crisis caused by the need to use large volumes of PPE during the pandemic is an environmental “price worth paying” during an unprecedented public health emergency; however, the reality of the climate and environment emergency means a step-change is required across the NHS irrespective of the global pandemic. While the process will be difficult, evidence from other resource and asset-heavy sectors demonstrates the positive business cases and low costs of a circular economy approach towards net-zero. [14] It requires leadership from the NHS to hold the corporate and suppliers accountable, and the ambition to create large scale improvement. 

Peter Hopkinson is the co-director of the Exeter Centre for Circular Economy. 

Richard Smith is the inaugural deputy pro-vice Chancellor for the University of Exeter Medical School. 

Lora Fleming is based at the European Centre for Environment and Human Health (University of Exeter Medical School). 

Karyn Morrissey is a Professor at the Department of Technology, Management and Economics Sustainability, Technical University of Denmark.

Xiaocheng Hu is a research fellow at the Environment and Sustainability Institute, University of Exeter.

Competing interests: none declared.

References:

1. Health care climate footprint report. Health care without harm. 2019. https://noharm-global.org/documents/health-care-climate-footprint-report (Accessed: 21/03/ 2021)
2. NHS report. Delivering a ‘Net Zero’ National Health Service. 2020. https://www.england.nhs.uk/greenernhs/publication/delivering-a-net-zero-national-health-service/ (Accessed: 21/03/ 2021)
3. National Audit Office report. The supply of personal protective equipment (PPE) during the COVID-19 pandemic. Department of Health and Social Care. National Audit Office. 2020. https://www.nao.org.uk/report/supplying-the-nhs-and-adult-social-care-sector-with-personal-protective-equipment-ppe/ (Accessed: 21/03/ 2021)
4. Experimental statistics – personal protective equipment distributed for use by health and social care services in England: 31 May to 4 July 2021. Department of Health and Social Care. 2021. https://www.gov.uk/government/statistics/ppe-distribution-england-31-may-to-4-july-2021/experimental-statistics-personal-protective-equipment-distributed-for-use-by-health-and-social-care-services-in-england-31-may-to-4-july-2021 (Accessed: 21/03/ 2021)
5. Allison AL, Ambrose-Dempster E, T Aparsi D, Bawn M, Casas Arredondo M, Chau C, Chandler K, Dobrijevic D, Hailes H, Lettieri P, Liu C. The environmental dangers of employing single-use face masks as part of a COVID-19 exit strategy. UCL Open: Environment Preprint. UCL Press. 2020.
6. Hopkinson P, Zils M, Hawkins P, Roper S. Managing a Complex Global Circular Economy Business Model: Opportunities and Challenges. California Management Review. 2018;60(3):71-94.
7. Hu X, Davies R, Morrissey K, Smith R, Fleming LE, Sharmina M, Clair RS, Hopkinson P. Single-use plastic and COVID-19 in the NHS: Barriers and opportunities. Journal of Public Health Research. 2021 Aug 4.
8. Hu X, Pierce JT, Taylor T, Morrissey K. The carbon footprint of general anaesthetics: A case study in the UK. Resources, Conservation and Recycling. 2021 Apr 1;167:105411.
9. Dawson T. UKRI Revolution-ZERO NHS PPE Feasibility SBRI. 2019. 
10. Schulte, A., Maga, D., Thonemann, N. Combining Life Cycle Assessment and Circularity Assessment to Analyze Environmental Impacts of the Medical Remanufacturing of Electrophysiology Catheters. Sustainability. 2021;13(2): 898.
11. Oster K, Tedstone A, Greer AJ, Budgen N, Garforth A, Hardacre C. Dehydrochlorination of PVC in multi-layered blisterpacks using ionic liquids. Green Chemistry. 2020;22(15):5132-42.
12. 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.
13. Goel V, Luthra P, Kapur GS, Ramakumar SS. Biodegradable/Bio-plastics: Myths and Realities. Journal of Polymers and the Environment. 2021 Mar 6:1-26. 
14. EMF. Universal circular economy policy goals: enabling the transition to scale. The Ellen MacArthur Foundation. 2021. https://www.ellenmacarthurfoundation.org/publications/universal-circular-economy-policy-goals-enabling-the-transition-to-scale (Accessed: 21/03/ 2021)