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Abstract
Background The NHS’ impact on the environment is significant, accounting for 5.9% of the national carbon footprint of the UK and 20 million tonnes of carbon dioxide equivalent (Mt CO2e) emissions a year.
The procurement of goods and services is responsible for 72% of the NHS carbon footprint—equivalent to 15.2Mt CO2e. Procurement is, therefore, a priority focus area to consider, if carbon reductions are to be made. The impact of procurement decisions extends over the ‘whole life’—from identification of the need for a product or service through to the provision of the product or service and including the product’s ‘end of life’ process (disposal).
From April this year, any new procurement needs to have a 10% net zero and social value weighting. From April 2023 onward, any new procurement two times per day should incorporate carbon footprint and environmental impact.
This paper aims to introduce clinicians to the concept of green procurement and illustrate the potential greenhouse gases savings possible if procurement decisions were informed by the sustainability credentials such as the carbon footprint of a product or the corporate social responsibility programme of the supplier.
Methods While seconded at the Department of Health and Social Care, the senior author on this paper collaborated with the NHS Supply Chain to pilot carbon footprinting of one clinical item. We chose to focus on the 20-gauge ‘pink’ cannula as a high-volume familiar article; 25 million cannulas are purchased via the NHS Supply Chain each year, of which the most commonly used size is the 20 gauge.
Results Of the seven companies approached, five sent us their CSR strategies. Four companies provided product primary data, and of these four, one provided sufficient data to carry out a carbon footprint analysis. The one set of detailed data provided was for two 20-gauge cannulas, 1 with wings and 1 without. The total carbon footprint for Cannula 1 is 33.92 g CO2e. The total carbon footprint for Cannula 2 is 35.45 g CO2e. This amounts to a 1.54 g CO2e difference between the 2 cannulas.
Conclusion It is both necessary and possible for the NHS to demonstrate leadership in reducing the carbon footprint of healthcare.We have provided an overview of NHS procurement to empower clinicians to get involved with local and national decision-making. We have demonstrated the potential carbon savings that could be made through careful choice of products. We have also highlighted the risks if clinicians do not engage with green procurement.
- sustainability
- health policy
- clinical leadership
- productivity
Data availability statement
Data may be obtained from a third party and are not publicly available. No applicable.
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WHAT IS ALREADY KNOWN ON THIS TOPIC
There is very limited literature on procurement and clinical leadership.
This is the first published paper of the carbon footprint of a cannula.
WHAT THIS STUDY ADDS
This study explains the impact of procurement on the carbon footprint of the NHS and demonstrates the difference in choosing one cannula over another as an example of how procurement decisions can lead to a greener NHS. It also highlights the benefits of clinicians asking suppliers about their science-based targets, engaging with the NHS Supply Chain and signalling to the leadership that green procurement is possible and necessary.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
This study might enable clinicians to understand enough about policy and procurement to enable them to engage with management and procurement personnel effectively. We hope this paper demonstrates clinical leadership in local and national policy-making can lead to greener procurement and, therefore, a greener NHS.
Introduction
Although the mission of the health sector is to protect and promote health, the impact of the NHS on the environment is significant, accounting for 5.9% of the national carbon footprint of the UK,1 and 20 million tonnes of carbon dioxide equivalent (Mt CO2e) emissions a year. CO2e is a metric measure, used to compare the emissions from various greenhouse gases (GHGs) on the basis of their global warming potential by converting amounts of other gases to the equivalent amount of carbon dioxide with the same global warming potential.2
It is proven that global heating, largely driven by increasing levels of GHGs such as atmospheric carbon dioxide, is having a persistent and devastating effect on the health and well-being of individuals and societies.3 Studies have revealed associations between extreme heat and increasing antibiotic resistance,4 worsening mental health5 and impaired cognitive function.6 Worldwide, climate-sensitive infections are on the rise due to spread of vectors such as mosquitoes beyond their original geographic habitat.5 Extreme weather events may in the short term involve hundreds of casualties and possible fatalities, in the longer term mass migration.7
These are not abstract threats—they are all public health concerns developing at speed that health systems will be expected to help manage. In the light of this knowledge, we should be doing everything we can to minimise the carbon footprint of the NHS—and indeed, there have been commitments within the NHS long term plan8 and the delivering a net zero national health service.9
A lifecycle analysis of the industry of healthcare demonstrates significant demands on the natural environment, generating GHG emissions (GHGEs) through extraction of raw materials, distribution of electricity, gas and heating or cooling, healthcare facilities operational emissions, research and development of drugs and medical devices, manufacturing, packaging, transport and disposal of equipment, clinical supplies and pharmaceuticals both within the supply chain and to the end user.10 The procurement of goods and services is responsible for 72% of the NHS carbon footprint—equivalent to 15.2 Mt CO2e.11
Procurement is, therefore, a priority focus area to consider, if carbon reductions are to be made.
Procurement is the process of purchasing goods and services by organisations (eg, NHS trusts or the NHS Supply Chain) from third-party organisations (eg, medical equipment manufacturers). The impact of procurement decisions extends over the ‘whole life’—from identification of the need for a product or service, through to the provision of the product or service and, including, the product’s ‘end of life’ process (disposal).12
From April this year, any new procurement needs to have a 10% net zero and social value weighting.13 From April 2023 onward, any new procurement two times per day should incorporate carbon footprint and environmental impact.13
Currently, 40% of NHS trusts purchase through the NHS Supply Chain, which offers a range of Nationally Contracted Products (NCP), with prices negotiated centrally and savings passed on to Trusts—essentially leveraging the considerable purchasing power of the NHS and the billions it spends per year on clinical items and medical equipment.
The Sustainable Development Unit (SDU), set up in 2008, identified a priority list of procured items which contribute the greatest portion of the overall NHS carbon footprint.14 These items include syringes, cannulas and gauze, with more detail found in online supplemental appendix 1. This work is now being carried out by Greener NHS.15 Clinical leadership has already been demonstrated in numerous case exemplars of sustainable healthcare from around the country.16–18
Supplemental material
Aim
The aim of this paper is to introduce clinicians to the concept of green procurement19 and illustrate the potential GHGs savings possible, if procurement decisions were informed by the sustainability credentials such as the carbon footprint of a product or the corporate social responsibility (CSR) programme of the supplier. While seconded at the Department of Health and Social Care (DHSC), the senior author on this paper collaborated with the NHS Supply Chain to pilot carbon footprinting of one clinical item. We chose to focus on the 20-gauge ‘pink’ cannula as a high-volume familiar article; 25 million cannulas are purchased via the NHS Supply Chain each year, of which the most commonly used size is the 20 gauge.
Methods
With prior approval from the SDU, NHS Supply Chain and the chief scientific advisor, a request for technical information was sent out to seven companies, which supply cannulas to the NHS Supply Chain. This work was carried out over 12 months on a 50% full time equivalence.
The following information was requested.
Primary data relating to the product (to enable carbon footprint calculation):
A detailed bill of materials, including the packaging (each individual component’s weight and material composition).
Percentage of recycled content.
Manufacture location, assembly location and transportation hubs locations.
Method of transportation between each point.
Existing environmental information from the supplier:
Existing carbon footprint calculation of stipulated product.
Climate change risks and opportunities.
Company’s emissions and reduction targets.
Company’s CSR proposals.
This information was confidentially shared with an environmental sustainability firm, 3Keel,(https://www.3keel.com) and carbon footprints were calculated with methodology in keeping with GHG protocol for medical supplies.20 The analysis was carried out by 3Keel pro bono, with a total effort of 25 hours for planning and complete analysis. Carbon footprinting would usually cost between £2000 and £50 000 per medical device depending on the item and depth of analysis. The cost of the senior author’s time, as a clinical consultant seconded in the civil service, was approximately £28 000.
The details of the supply companies and cannula product specifics have been kept confidential as this is commercially sensitive information.
Results
Of the seven companies approached, five sent us their CSR strategies. Four companies provided product primary data, and of these four, one provided sufficient data to carry out a carbon footprint analysis. The one set of detailed data provided was for two 20-gauge cannulas, 1 with wings and 1 without. These are henceforth analysed, and described as Cannula 1 and Cannula 2. The total carbon footprint for Cannula 1 is 33.92 g CO2e. The total carbon footprint for Cannula 2 is 35.45 g CO2e. This amounts to a 1.54 g CO2e difference between the 2 cannulas.
As both cannulas were produced by the same company within the same supply chain, the analysis of cannula manufacture location, method of transportation and logistics demonstrated very little difference between the two cannulas. It was predominantly based on the weight of each component part—given the supply chain data were equal.
Therefore, the difference in carbon footprint between the two cannulas was due to the design of the cannulas and the weight of the raw materials to make each component of the cannula. Each cannula was broken down into 21 component parts (figure 1). The carbon footprint of the component parts was calculated for each cannula.
Twenty-one component parts in a cannula.
Figure 2 outlines the difference in weight of raw material between Cannula 1 and Cannula 2.
Graph of weights of raw materials for component parts of Cannulas 1 and 2 and contribution to GWP. GWPs are relative to the impact of carbon dioxide. GWPs are an index for estimating the relative global warming contribution due to the atmospheric emission of a kilogramme of a particular GHG compared to the emission of a kilogramme of carbon dioxide.22 CO2e, carbon dioxide equivalent; GHG, greenhouse gas; GWP, global warming potential (kg CO2e); X axis, component part; Y axis, weight of component part in grammes.
The GHGEs breakdown were broken down by component (see figure 3). There is a total difference of 1.5 g CO2e between the two cannulas. Of the 21 different component parts analysed, the carbon footprint is nearly identical between the two cannulas for most parts, except for the protector. This is the main component that contributes to this difference in CO2e. The protector is the protective sheath which is disposed of before the cannula is used. This is ultimately due to the amount of plastic used to make the protectors. Cannula 2’s protector weighs 0.1 g more than cannula 1’s. This is the first published example of a direct comparison of the carbon footprint associated with two different cannulas, and shows a significant carbon saving potential based on choosing one product over another. The NHS Supply Chain (used by approximately 40% of NHS trusts) purchases 25 million cannulas per year21—therefore, a rough estimate of the total number of cannulas used across the UK is 62.5 million. Based on our analysis of two types of cannula, if the lower carbon footprint cannula was used throughout the NHS, there would be a potential saving of up to 60 tonnes of CO2e over a year. This potential carbon saving is based on only one type of product; if every product purchased within the NHS went through a similar carbon footprint analysis, and lower carbon options were routinely selected (while still maintaining the best clinical standards), substantial carbon reductions could be achieved.
GHGEs breakdown by component. This histogram explains which component part contributes to the difference in CO2e for each between the two cannulas.22 CO2e, carbon dioxide equivalent; GHGEs, greenhouse gas emissions; X axis, component part; Y axis, greenhouse gas emission in g CO2e.
Discussion
It is both necessary and possible for the NHS to demonstrate leadership in reducing the carbon footprint of healthcare. It has set high ambitions—to be the first net zero national healthcare service in the world. As an anchor organisation and an internationally recognised brand, this commitment to tackle climate change may influence other public and private sector organisations.
Public sector spend in the UK on goods, services, works and utilities is a significant proportion of Gross Domestic Product (GDP) (13%); therefore, shifting procurement in the public sector has the potential to stimulate the market to increase availability of sustainable goods and services.9 Second, by demonstrating leadership on this issue, that is, by embedding sustainability considerations into procurement decisions, the government can influence the consumption patterns of business and consumers toward more sustainable options.22 While carrying out this work, four of the seven medical devices companies were relieved that the DHSC was asking for this data as it would require them to review their CSR and green credentials.
The current context provides an ideal opportunity to progress sustainable procurement in the NHS.23 Since October 2019, the NHS no longer requires unit cost-based finance models.24 This is a financial model based on the purchase price per unit and does not take into consideration the life cycle of the product. There is now focus on ‘value-based procurement’, where there is a shift in emphasis from reduction in product costs (which typically account for between 10% and 15% of procedure costs) to working with industry to consider technologies that can influence a reduction in total costs within the patient pathway.25 This means procurement decision-making can be based on cost over the entire life of the product rather than its up-front cost. NHS Trusts are also able to demonstrate financial budgets for NHS Supply Chain procurement on longer than a yearly basis.26
In the case of the cannulas that we analysed, the protective sheath (which is disposed of) was the main reason for variation in carbon footprint between the two products. It has not been proven that the clinical efficacy of the product is dependent on the sheath weight. Product design can be optimised to reduce the carbon footprint, and this is something that, with the purchasing power of NHS Trusts and the NHS Supply Chain, companies could be incentivised to address. However, leveraging this purchasing power would require leadership from the NHS Supply Chain and frontline clinical staff to catalyse these changes.
How could procurement for carbon reduction be introduced?
Products in the NHS Supply Chain catalogue are currently chosen for their quality, safety and value. Environmental impact and social weighting will be added as another criterion by which products are assessed for inclusion in the catalogue. Procurement decisions are ultimately set by clinical decision-making and, therefore, clinical leadership is essential for the NHS to reduce waste and carbon emissions by greening the procurement process.
Clinicians interact and work with medical equipment from initiation of procedure to disposal, and, therefore, are best placed to identify which format variations are wasteful and could be optimised. In this carbon footprint, it is evident that the unnecessarily heavy-duty plastic protective sheath leads to a greater carbon footprint of the product and does not add to quality or clinical efficacy. Standardised carbon footprints, conducted in line with assessment protocols, are being published to allow purchasing decisions to be made with carbon impact in mind.
Ways to embed green procurement into the NHS is to work with:
Suppliers: invite suppliers to a roundtable to identify climate opportunities and risks:
At a corporate level: suppliers should have a scope 3 ‘Science Based Target’ (SBT). This is a corporate GHG decarbonisation target—which has been approved by the SBT initiative (SBTI).27 The GHG Protocol Corporate Standard classifies a company’s GHG emissions into three ‘scopes’. Scope 1 emissions are direct emissions from owned or controlled sources. Scope 2 emissions are indirect emissions from the generation of purchased energy. Scope 3 emissions are all indirect emissions (not included in scope 2) that occur in the value chain of the reporting company, including both upstream and downstream emissions. This gets around the devilish complexity of single footprints but still demands companies take their GHG emissions seriously for their entire business and will drive GHG emissions down.28
At a product level: suppliers need to provide a detailed carbon footprint in line with a recognised assessment standard which should be submitted as part of the procurement process.
Design products with green procurement in mind with frontline clinical staff.
NHS Supply Chain: to offer side by side standardised carbon footprints on the NCP catalogue, conducted by the supplier or a third party in line with the international standard carbon accounting protocol,29 with results verified by a recognised verification provider. This would be part of the terms of the products being included in the NHS NCP catalogue. This would be complex and expensive. The quoted cost of a sustainability company to carbon footprint 1 item is between £2000 and £50 000. These costs may be reduced if done in house at the drug companies but may lead to price rises and withdrawal of products.
Clinical staff to work with Greener NHS, the NHS Supply Chain and manufacturers to highlight areas of inefficiency both in product design and clinical processes, and unnecessary GHG expenditure.
In this article, we have demonstrated the theory that significant carbon reductions could be achieved if NHS procurement decisions took product carbon footprints into account. Due to the 2012 Health and Social Care Act,30 it is not possible to make central purchasing through the NHS Supply Chain mandatory. However, if carbon footprint analysis was incorporated into the selection of Nationally Procured Products and the carbon reduction benefits of purchasing through the Supply Chain were made clear, it could convince more NHS Trusts to purchase through the Supply Chain in order to meet their own carbon reduction targets. This ‘gold standard’—product level comparable carbon footprinting across all procurement within the NHS—would have a huge impact on green procurement given the scalability potential across the supply chain. However, as has been demonstrated in the food and cosmetics industries,31 carbon footprinting individual products is challenging to implement in practical terms—it can be costly, and there is more than one model of carbon footprinting meaning that direct comparison can be difficult to achieve. Furthermore, if individuals responsible for procurement were to significantly change purchasing decisions without clinician input, this could lead to unintended consequences and reluctance from clinicians to use a new type of product they did not have prior experience of (even if that change seems minor, such as a change in brand of cannula).
For environmentally sustainable procurement to be embedded successfully, end users and purchasers must work closely together. The ‘frontline’ must be involved in procurement decisions as there is no use (and in fact, more waste would be generated) in procuring an ‘environmentally preferable’ product, which clinicians find unusable. As many clinicians are increasingly aware of the climate crisis,32 and given the positive impact green procurement would have on the overall carbon footprint of the NHS, many would see the advantages of using an equally safe, reliable and effective piece of equipment with a significant carbon reduction to be made.
A more pragmatic and immediately feasible step for clinical leaders in procurement to take would be to demand all companies that supply products to the NHS have set scope 3SBT independently verified against a set of criteria developed by the SBTI.27 Suppliers who have set scope 3 SBT (the most ambitious target) must prove that they have a plan to decarbonise their GHGEs—including all indirect emissions that occur in the value chain of the reporting company, and including both upstream and downstream emissions.
The benefit of using scope 3 SBT over individual carbon footprinting of products is that scope 3 SBT is already a well-recognised industry standard, while individual carbon footprinting is expensive and difficult to standardise across an industry. During this process, we spoke to 39 suppliers over 9 months. Many were relieved that the NHS was finally asking for this information and nudging them to think about sustainability. Many suppliers had already taken steps to reduce carbon emissions at a corporate level and were beginning to target products. By asking suppliers to voluntarily disclose their climate change risks and opportunities, together with their emissions and reduction targets is known to lead to carbon reduction; it signals that the NHS is taking procurement for carbon reduction seriously and is working to drive emissions down, across whole product groups and markets.
It is vital that clinicians engage in decarbonising the NHS and demonstrate clinical leadership. Clinical leadership in green procurement is essential. The paper hopes to aid clinicians to understand the fundamentals of green procurement in the NHS.
Limitations of this study
This was a feasibility study to identify cost and work required to carbon footprint individual medical devices. Out of the seven companies supplying the NHS Supply Chain with cannulas, four supplied information, and only one responded with sufficient information about two different types of cannulas to allow the carbon footprints to be calculated. However, the NHS England Public Board has approved a roadmap to help suppliers align with our net zero ambition between now and 2030. This approach builds on UK Government procurement policy (PPN 06/20 and PPN 06/21). Therefore, we would expect more industrial partners to publish the carbon footprint of their products.
In our study, we were in line with the Product Lifecycle Accounting and Reporting Standard from the GHG protocol and this is an openly available standard.33 This is not proprietary to 3Keel. There are other methodologies. For example, there is the Extended Input–Output analysis—this is a methodology which uses financial expenditure to estimate the carbon intensity based on the value of goods and services procured. It is generally recognised to be less accurate than product lifecycle accounting and reporting standard as used in our approach.
It is possible that these companies could not supply the granular level of product detail requested because they do not measure or record it. Naturally some companies were concerned how carbon footprints would impact business development, whether data would be open and accessible, and skew rationalisation. Skew rationalisation of products could result in fewer variants of a certain product and reduce clinical equipment availability. This is already happening with reduced arthroplasty implants available in the UK because of costs of the aligning to the new Medical Device Regulation (MDR). The MDR entered into force on 25 May 2017, marking the start of the transition period for manufacturers selling medical devices into Europe.34 Therefore, it is essential clinicians advocate for their patients and ensure that clinically focused green procurement decisions are made on a national and local level.
Conclusion
We have provided an overview of NHS procurement to empower clinicians to get involved with local and national decision-making. We have demonstrated the potential carbon savings that could be made through careful choice of products. We have also highlighted the risks if clinicians do not engage with green procurement.
In the wake of the COVID-19 pandemic, European leaders have committed to making the European Green Deal ‘central to a resilient recovery after COVID-19’ with ‘sustainable growth, integrating the green transition and the digital transformation, and drawing all lessons from the crisis’. The NHS is doing the same, and transforming procurement processes with clinical leadership is key.
Data availability statement
Data may be obtained from a third party and are not publicly available. No applicable.
Ethics statements
Patient consent for publication
Ethics approval
Not applicable.
Acknowledgments
We would like to thank the following people and organisations for their support in this work: Sonia Roschnik and Eleni Pasdeki-clewer of the Sustainable Development Unit, NHS England Jin Sahota, Alan Wain and all the procurement tower teams in the NHS Supply Chain for support in this work. Strategy Unit, Department of Health and Social Care for support; Prof Chris Whitty, Chief Medical Officer for his guidance and insights. 3Keel for supporting the analysis work pro bono.
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Contributors NA-H: conceived and developed the paper and liaised with all the pharmaceutical companies, NHS Supply Chain and Department of Health and Social Care. KK, AG and MVH: conceived and co-wrote the paper. XVG: did the carbon footprint calculations. NA-H, Guarantor.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests NA-H is married to Simon Miller, the Managing Partner of 3Keel, Sustainability Consultancy Firm, who carried out the carbon footprint work pro bono.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.