UCLH’s 10-point climate action plan commits us to cutting energy emissions by 80 per cent by 2025, moving faster than even the ambitious target of the NHS as a whole. As well as reducing our environmental impact, this will lead to direct benefit for patients. Research suggests that, nationally, up to one third of new asthma cases might be avoided as a result of efforts to cut emissions. In a city like London, which suffers from high levels of traffic-related pollution, the potential benefits are clear.
UCLH is reducing its environmental footprint by switching to cleaner energy, eliminating harmful anaesthetic gases, promoting active travel and reducing waste.
Taking a moment to reflect on how the team could do things differently has led to eliminating the use of over 5000 plastic bottles of sterile water a year in UCLH’s endoscopy department.
According to a report in The Lancet, endoscopy is the third largest contributor of waste in hospitals, due to the vast amounts of disinfecting and flushing required in the diagnosis of gastrointestinal problems. Historically, sterile water has been used to flush out the bowels and stomachs of patients in readiness for endoscopic testing. That’s equivalent to around 200 plastic bottles of sterilised water being used every week.
“If I am honest, I never used to see environmental impact as part of my role as departmental lead for endoscopy,” said consultant in gastroenterology, Ed Seward. Once I started to see a focus on environmental issues in the wider endoscopic community it made me rethink my responsibilities.”
Ed had become aware of data suggesting that tap water was of no greater risk to patients than using the sterile water to do the same job. Clearly, this presented a massive opportunity for achieving green savings.
“I realised how easy it is for everyone to contribute to positive change – it just meant taking the time to look at how things have been historically and whether there is any opportunity to change that,” said Ed.
With the support of UCLH’s infection control team, the project was enthusiastically embraced by the wider endoscopy team, led by ward sister Edilyn Maceda. In a short space of time, their use of bottles of sterile water halved. The overall aim is to eliminate the use of sterile water entirely, but there are a few incidences where sterile water will continue to be used until further research proves otherwise.
“There is so much more we can do – for example, as a team we are getting so much better at general waste segregation in the department, which not only increases the amount we can recycle but has a direct impact on the amount of money we spend on waste disposal,” said Ed.
“The team are really enthusiastic about continuing the trajectory to become a greener department; we just needed a nudge in the right direction.”
UCLH has introduced new, innovative and eco-friendly waste management technology into our theatres at University College Hospital at Westmoreland Street, improving safety for theatre staff and reducing our carbon footprint.
The hospital is largely dedicated to the care of patients with urological issues - problems with the bladder and urinary system. Many operations require the need to “irrigate” the urinary system and flush out unwanted waste products such as blood and urine.
Until recently, waste was removed from the patient’s body and into a series of interconnecting plastic cannisters. These were pre-filled with a liquid gel which solidified when it came into contact with waste product. These plastic cannisters were single use, so would need to be changed between each patient and put into infectious waste bags. With up to eight operations taking place in each theatre per day, the amount of plastics waste soon added up.
In 2022, University College Hospital at Westmoreland Street invested in seven new enclosed waste systems called Stryker Neptune. This filters the fluid which is collected inside the unit, enabling it to be safely disposed of down the drain rather than using waste bags. These new, self-contained units are able to hold significantly more fluid than the previous system, so they can safely be used for multiple operations before they need to be emptied.
When it is full, the unit is attached to a docking station where the waste is safely drained away, eliminating not only the need for all the plastics and cardboard waste, but also a lot of the heavy lifting work that was needed to manage the old system.
“With the previous system some of the filled fluid bags could contain three litres or more”, said Nicola Sabey, service manager at the hospital. “Staff were lifting some seriously heavy weights to get rid of the waste, which can potentially lead to back injuries. We also had occasional spillages with the old system so it also improved our overall infection control. Plus of course, sending away less waste is also saving UCLH money in waste disposal costs.”
From a green perspective, Nicola estimates that replacing the units has saved over 60 tonnes of carbon from entering the atmosphere each year, compared with the previous system.
“Staff have been really supportive of the changes”, said Nicola. “It has been a really positive investment for the team.”
Between April 2021 and March 2022, 40% of UCLH outpatient appointments took place virtually - a total of 484,872 appointments. Based on an average journey, this saved 13 million miles of patient travel, reducing local traffic pollution and congestion, and saving over 1,300 tonnes of CO2 from being released.
Patients have still been able to see a clinician when they have not been able to travel
and clinicians have been able to run clinics from home, even when self-isolating during the pandemic.
One area that has embraced video appointments is the paediatric psychology department at University College Hospital. It offers a service for young people who are living with a chronic or acute health condition, such as diabetes, chronic fatigue or cancer. The team works with children, young people and their families to help them to navigate their relationship with their health condition.
Prior to 2020, the team were seeing a lot of young people and families in person on a one-to-one basis and running a number of in-person groups. However, the service changed very quickly once the pandemic hit. As well as dealing with their illnesses, these children and young people were experiencing added isolation and other challenges, meaning that the psychological services became even more vital.
The paediatric psychology team responded by setting up video clinics, for patients, parents, families and peers. They employed a lot of creative ways of working: being playful where possible, using whiteboards and emojis online and sending out packs in the post before a group session, which might include play dough or craft activities to do together. Although there are circumstances where seeing patients face-to-face is important (something the team still offers) the virtual service has been well received.
20 year old Bella Matthews is one patient who has benefited from the change. When she was 15 years old, Bella was diagnosed with a round cell sarcoma, and was treated by the team at University College Hospital due to the specialised nature of her condition. Bella is now in remission, but still accesses UCLH’s psychology service.
“I have been having my appointments virtually for about a year now, both with my personal psychologist and also in virtual groups with other young people who have gone through cancer.
“I'm studying paediatric nursing in Bristol at the moment and I'm on placement for half of the year, so if I had to come down to London multiple times for appointments, life would be much more stressful.
“If I didn't have the online aspect, I just wouldn't be able to use the service any more. It's also the cost of getting to London every three weeks. It’s also lovely to speak to people while in my own home where I'm very comfortable.
“The virtual service means I have been able to meet and make friends with people that I would have never been able to speak to before, which has been amazing. I actually met somebody through the sessions who also goes to the same university as me. We have since met up in person and become great friends.
“As well as the personal benefits, climate change is massively important to me. So these virtual appointments also don’t make me feel guilty about the travel miles. I just press a button and I’m there.”
Watch our film about video clinics:
“Being able to cut down the number of face-to-face appointments can be really helpful for our patients, who appreciate being able to take far less time out of their day. It's a valuable tool to be able to offer, so patients can choose what's right for them.”
Dr Toby Hillman, Consultant in Respiratory Medicine
Patients visiting the emergency department at University College Hospital or The Grafton Way Building are now able to return their crutches to UCLH if there comes a time they are no longer needed.
Historically, walking aids were considered a single-use item by suppliers, but with a carbon footprint of between 3 and 8 kilograms for each crutch, it was clear that a new process was required to support UCLH in its mission to become a net zero organisation by 2031. These have now been re-categorised so they can be re-used.
As well as saving both money and carbon emissions, reusing walking aids is also likely to also be safer. Rather than patients passing them on to friends, all walking aids will be checked before going out again and those that are deemed not safe will be removed from circulation.
Based on data from other NHS Trusts, it is estimated that could save up to £27,000 and 6,760 kg from entering the atmosphere per year. If successful, UCLH will look at rolling out the scheme to other departments and expanding the range of walking aids in the scheme to include wheeled walkers and walking sticks.
By its very nature an emergency department, or ED, can generate significant amounts of both waste and carbon emissions.
As part of her placement on UCLH’s graduate management programme Lizzy Cubitt recognised that with some focus, there were a range of opportunities to reduce the environmental impact of emergency care
Working on the back of a pilot project which began at The Royal Free Hospital, Lizzy, with the support of UCLH’s sustainability team, introduced the Greener ED Framework to the team.
This simple document encouraged the department to consider all the ways that their impact on the environment could be improved. These areas were then banded into bronze, silver and gold categories, depending on how complex the issues would be to solve.
Lizzy then set up a working group with ED colleagues across both clinical and operational teams to look at tackling some of the more challenging aspects. All the opportunities were listed in a tracking document, so that mini projects could be assigned to individuals and progress could be reported on. “It was a really visual way to focus everyone’s minds on the task”, said Liz.
So far 14 mini projects have been assigned to the team to tackle.
“We started with issues that we could control in-house, like recycling bins being positioned in the most appropriate places. This means we will maximise the number of items we can recycle, and also, minimise the amount of contamination in the bins with non-recyclable materials”, said Lizzy. “We have completed an audit and these bins are now on order. We anticipate that this will significantly improve waste disposal in ED. We also know that this is a really popular solution with staff.”
Other wins for the team have been adding a sustainability module into the departmental induction programme, and replacing single use cutlery with stainless steel cutlery. They are also looking to install a dishwasher in the department to ensure there is an incentive to continue to use it. “We have to consider how easy we can make it to remain a greener department”, Liz explained. “There is no point in fixing a problem if we made it harder for staff to make it part of business as usual. So this has all been taken into account.”
Larger scale areas to address include the department adopting a model of sustainable procurement and an audit to see how much nitrous gas was being leaked into the atmosphere. Happily, the audit has shown that UCLH has no nitrous leaks, which means that this project can be set to complete. The team are also supporting UCLH-led initiatives, such as encouraging cycling to work.
The programme has been well received by colleagues and is well supported by senior management. There is now a plan to extend the framework for use more widely across UCLH, as with a bit of tweaking it can be used for teams working in office areas as well as in clinical spaces.
UCLH has declared a climate emergency and is committed to cutting carbon emissions by 80 per cent by 2025. With anaesthetic gases contributing around five per cent of the carbon footprint across all acute NHS organisations, and well over two per cent across the whole of the NHS, a natural place to focus has been on our operating theatres. A cohort of theatre staff has come together to create the UCLH Green Theatre Group to tackle this problem, among others which can support UCLH’s climate action plan.
The team have outlined a local action plan to reduce carbon emissions in our hospitals, including a review of our use of anaesthesia, minimising our reliance on single use materials, improving waste management, reducing electricity and an education programme to encourage personal responsibility for action on climate change. While climate action is the driver for the work, improvements to patient and staff experience remain central to any activity.
“The climate crisis means we all have to reduce our carbon emissions to zero. Every action counts and the time to act is now”, said consultant anaesthetist and Green Theatre Team member, Damon Kamming.
The team’s starting point was to reduce reliance on the anaesthetic gas desflurane, which has the highest carbon emissions of all anaesthetic gases This has historically been a commonly used anaesthetic gas, but it releases a lot of greenhouse gases and is actually one of the most environmentally harmful. One hour’s use of Desflurane emits the same carbon emissions as travelling 230 miles in a petrol car and is 2,500 times more damaging to the environment than carbon dioxide. If everyone in our hospitals stopped using Desflurane, its carbon emission contribution from anaesthesia would decrease from five per cent of the total to just 0.5 per cent.
UCLH is now committed to eliminating the use of desflurane across its sites in 2023. The team have made some relatively simple changes in the meantime, such as removing desflurane from our theatres and storing them in pharmacy cupboards instead. Staff are then prompted to use sevoflurane, a less environmentally damaging gas, instead.
The team is also promoting the use of Propofol Total Intravenous Anaesthesia (TIVA), which has a greenhouse gas impact of 10,000 times lower than desflurane. They have already purchased 138 new pumps to allow anaesthesia to be administered this way more often. The benefits of TIVA are far-reaching: patients also report a better experience, since intravenous anaesthesia reportedly leads to less nausea and vomiting.
“The key is to make it easy for staff to do the right thing and harder to make choices that are bad for the planet”, said Damon. “This small change is 'win-win', because we also have the chance to make things better for patients as well as the environment.”
Reducing single-use plastics in theatres
This project is looking at installation of a kit that changes the way UCLH disposes of surgical fluid. It both cuts out the need for single-use plastics for storage, and reduces the amount of manual handling required of staff for disposal.
Additional changes are smaller, but no less valuable. Currently UCLH is incinerating over 1,000 tons of clinical waste a year at a cost of £1 million. A focus on the correct disposal of clinical waste across the department has the potential to dramatically increase the amount of waste that can recycled, which offers the potential to reduce both costs and carbon emissions.
“The climate crisis is here and this is a once in a lifetime opportunity to innovate and collaborate with a shared purpose to make it easy to do the right thing for patients, staff and the planet”, said Damon. “There are so many ways we can make a difference.”
Having been inspired by the visible focus on sustainability in the workplace in his home country of the Philippines, Robert Vincente, deputy charge nurse on ward T8, recognised that his team could make a big impact on reducing the use of disposable items with a little effort and forward planning.
The NHS uses 1.4 billion disposable gloves every year, and although the majority of these are essential for safe patient care, there are still plenty of opportunities to safely reduce their use. “Unless a patient is infectious, there are a number of nursing activities that really don’t need to be done while wearing gloves” explained Robert. “For example, changing the beds or helping to feed someone who is not contagious.”
Robert identified a number of instances where staff were reaching for gloves where they were not required for infection control. In response, he implemented a “Gloves Off” campaign on the ward. In fact, research shows that good hand hygiene is much safer for patients than routinely wearing gloves, which can result in cross-contamination and healthcare-acquired infections.
With the support of UCLH’s infection control team, Robert identified when it was better for staff members to avoid using gloves all together. The team then actively promoted excellent hand hygiene instead of wearing unnecessary gloves.
“We did have some concerns in the team to begin with, especially as COVID became an issue”, said Robert. “The key is in identifying where patients are likely to be infectious, Of course, in those instances it is sensible to retain the use of disposable gloves, but with some planning we were able to recognise where there was a genuine risk to staff and patients, and where it was a safe option to work without gloves.
“We also appointed a nursing assistant in charge to take overall responsibility for managing any stock we had on the ward, which really helped as we had oversight of the items that were being used and where they were stored. This stopped accidental reordering.”
The trial was incredibly successful, with the ward reducing usage by 36,500 gloves over a four-month period, compared to the previous year. To give that some context, over a year the weight of the unused gloves would be more than the weight of a highland cow!
As well as seeing this impressive reduction in glove usage, the team started to see other benefits. Approximately one in five nurses are known to develop hand dermatitis – a painful, debilitating condition that may require nursing staff to be moved out of clinical areas due to the risk of infection from damaged skin. Gloves are known to be a contributing factor with this problem. During the course of the trial the team reported a drop in the number of cases of hand dermatitis in the nursing team.
The ward is now looking at other ways they can reduce their carbon footprint, including eliminating plastic cups and assessing the use of patient transport more effectively. “Good housekeeping is the precursor to sustainability”, said Robert. “It just takes focus.”
In January 2021, UCLH began its COVID-19 vaccination programme. Naturally the initial focus was on getting the programme up and running as speedily as possible; but now it is in full flow, the team have been looking at ways to reduce their carbon footprint while they continue to safely deliver vaccines to Londoners.
“When we first started the vaccination programme it all happened so fast. We were sent mountains of leaflets to hand out to patients – more than we could possibly use. We were also less certain about how high the risks were with spreading COVID-19 via surfaces like clothing, so we were using the same personal protective equipment (PPE) as other staff in our hospitals at the time. We were using up to 2,000 plastic aprons a day.” said operational lead for the vaccination centre, Carlo Cavalli.
With the support of UCLH’s infection prevention and control team, it was agreed that there was minimal risk to patients and staff if the team stopped using the aprons all together. With over 400 vaccinations taking place a day, that adds up to saving almost 150,000 aprons a year from disposal. The team also reviewed how often they were handing out sticking plasters to patients and now only use cotton wool after the initial injection unless there is a need for a plaster.
The next thing to tackle was the leaflet mountain. The centre is now looking into having these offered to patients via a QR code to encourage patients to download information leaflets on smart phones wherever possible. This will not only reduce the amount of paper that is being used, but also means that any information updates are instantaneous, rather than waiting for another round of printing to occur. It also makes it easier to provide patient information in a wide range of languages and easy-read formats.
The team has also considered the impact of waste management. “As our yellow sharps bins are full of needles they clearly need to be disposed of safely, so each night the domestic team were replacing the bins and sending the used ones to be incinerated,” said Carlo. “In many cases those bins might have been less than a quarter full, so we were incinerating far more plastic than we needed to. Now we are only disposing of the physical bin when it is more than three quarters full. It still means everyone remains safe; although there is currently no other alternative than to burn them, we are still reducing our carbon emissions from incineration.”
The amount of disposable water cups being used was also an issue. Although cups are still available in patient areas, staff have been encouraged to bring their own water bottles or mugs to work.
Even though this marks a great start, there is recognition that there is still more to be done. At the Bidborough House vaccination centre, Deenesh Dabydoyal, one of the deputy operations managers, has been enlisted as the on-site sustainability champion, with responsibility for looking for opportunities to make the site even more environmentally friendly going forwards.
“We will only make changes where it is clinically safe for us to do so, but we are mindful that we can still make a difference.” says Carlo.
Professor Sanjay Sisodiya, consultant neurologist at the National Hospital for Neurology and Neurosurgery and UCL Queen Square Institute of Neurology Deputy Director with responsibility for sustainability and climate change, is concerned about the impact of climate change on people with neurological conditions.
Aware of anecdotal evidence of difficulties experienced during heatwaves by people with some of the more severe forms of epilepsy, he consulted colleagues to see if they had come across similar issues. Everyone he spoke to shared his concerns about the environment, and acknowledged that they needed to think more seriously about the issue with regard to their patients. Other diseases of the brain and nervous system, including stroke, may also be sensitive to temperature changes.
Professor Sisodiya said: “We do think that climate change is going to be an important challenge for people with neurological diseases. In the case of some people with epilepsy, their families have noted over the past few years that during the heatwaves their condition has become worse.”
To address these issues, Professor Sisodiya established a consortium of neurologists, scientists, epilepsy nurses, representatives from industry and charities supporting people with epilepsy, called Epilepsy Climate Change (EpiCC). It is a global initiative to foster research and share knowledge in this area. He has also been awarded a grant from The National Brain Appeal’s Innovation Fund, to investigate the harmful effects of global heating on people with neurological conditions.
He continued: “We need to gather the fundamental data on how temperature affects the workings of the brain. Currently there is very little out there.
“The world’s climate is changing now. Global heating and its consequences will greatly affect our lives and work in the years ahead. For people with neurological diseases, and for research into those diseases, climate change is likely to pose significant challenges. We will do what we can to meet these challenges, to reduce our contributions to climate change, and to promote sustainability.”
He continued: “As clinicians and researchers, we need to be more thoughtful about travel. It’s about asking if every meeting we want to go to is useful, or if the learning we get from it could be done remotely.” With our patients, we can learn from what we had to do in the pandemic and – where it is appropriate – make more of our consultations remote.”