Circular thinking – a miracle cure for NHS waste management?

Driving NHS waste prevention has become a priority, given the increasing costs of clinical waste management. According to a 2013 Defra report – Prevention is better than cure – in 2011-12 the NHS spent a total of £90m on waste management – trusts are now being encouraged to reduce this expenditure, not just through adoption of better recycling practices, but through smarter asset sharing and procurement strategies.

Reuse represents a huge opportunity here. Earlier this year NHS Scotland signed up to a ground-breaking deal by contractually committing to reuse furniture and equipment across all of its 2,000 facilities. The scheme, facilitated by Warp It, is expected to generate savings of more than £300,000 in the first year.

NHS Tayside was an early adopter – for the past two years, it has been part of the Warp It asset sharing network, Tayside Opportunities for Procurement in Collaboration (TOPIC). Through TOPIC, the trust has been sharing surplus items with three councils in the region (Dundee City, Angus, Perth & Kinross) and the University of Dundee.  

“Waste is a big issue for us, we could see this scheme would solve a problem for us,” says Andy Hay, procurement planning manager for NHS Tayside. According to Hay, being part of a larger network is beneficial as it releases more assets – the University’s participation in particular has been valuable for securing good quality IT equipment.

Return on investment

The scheme took a year to bed in at NHS Tayside. Collaboration between procurement and facilities management was critical to make it work. “In our business, it’s really hard to get people to change. This type of scheme needs a bottom-up approach, people need to be brought into it. The perception is that it needs dedicated resources, but that’s not true,” says Hay.

To date, the trust has achieved over £75,000 in total cost savings through TOPIC – internal reuse (£58,500), external reuse (£4,800), admin costs (£10,250) and waste disposal (£1,450). In total, 10,895kg of waste has been avoided.

Hay says he’s had interest from other trusts wanting to learn from Tayside’s experience and going forward, he’s keen to see if the platform can be built on to enable loaning of idle assets. This could see greater mobilisation of medical equipment between different healthcare departments and facilities – something the Cohealo cloud-based platform is looking to exploit out in the US.

“I see a lot of value in sharing equipment and other big ticket items, making resources more movable and flexible.” However, Hay admits this prospect is some way off yet given the challenges of logistics and infection control. “It would take many years to implement.”

New business models

In London, Guy’s and St Thomas’ NHS Foundation Trust runs its own in-house programme for furniture refurbishment and reuse. The trust’s associate director for sustainability, Alexandra Hammond, says the scheme is saving the organisation around £150,000 a year in waste disposal costs and avoided procurement costs.

The trust is now looking at other opportunities such as leasing. “We are undertaking a huge investment programme with all of our desktop computers and workspace IT … we’re doing a lease model on that so we don’t own the asset, so they can be taken back for refurbishment and reuse,” Hammond says.

The trust is also concentrating its efforts on data measurement. By monitoring waste streams and arisings, the trust will be able to build up a more detailed picture of waste flows and compliance across its entire estate.

“The longer term plan is for departments to have a very clear understanding of what it costs to run those departments – not just waste and materials, but other operational costs such as energy and water. We want to be able to give departments specific information and we are looking at rewarding departments for producing less waste – to incentivise this,” Hammond says.

She adds that the trust has discussed the prospect of passing fines for non-compliance back to the department responsible. “When you put a syringe in a recycling bin, that potentially costs us a huge amount of money, so it’s definitely an option we are considering.”

Re-use challenge

On the Isle of Man, Nobles Hospital has been running a washable nappies scheme within its maternity unit for the past ten years. The initiative was initially introduced by a former midwife there and now forms part of the Isle of Man Real Nappy Campaign.

According to reports, since introducing washable nappies the maternity unit has reduced its disposable nappy waste for incineration to nearly zero (99.9%) and is achieving cost savings of £14,000 a year. The nappies are washed on-site, in a laundry that has a heat recovery system to reduce energy consumption. The hospital also encourages new mothers to consider using reusable nappies in their home.

The scheme has been picked up by the London Community Resource Network (LCRN) who is  promoting the concept to London birthing centres. LCRN’s Hilary Vick says it’s proving difficult. “There are a lot of challenges in the NHS at the moment, especially within midwifery, which means the energy isn’t there to do new things,” she says.

Vick says mindsets around reusable nappies also need to be changed. “The NHS [tend to say] bring in your disposable nappies when you come to the labour wards to have your baby. It immediately establishes disposables as the norm.”

More recently, Cambridge University Hospitals NHS Foundation Trust has been exploring alternative procurement approaches for its pressure therapy mattresses. The trust is working with consultancy Ricardo-AEA to assess the cost benefits of three options – leasing, managed service contract and a hybrid mattress contract.

According to Ricardo-AEA’s client manager for the NHS, Jessica Twemlow, pressure ulcers are regarded as the most expensive chronic wound in the healthcare system. “It is estimated that wound care accounts for 3% of the annual NHS expenditure,” she says. “As demand for pressure therapy systems is increasing, managing the supply of beds and mattresses through direct purchases is becoming more costly and resource intensive.”

Hybrid systems

While leasing and managed services can provide a more circular approach over direct purchase of these mattresses, the study found that greater opportunities exist in switching to a hybrid mattress agreement. Generally, trusts procure two types of mattresses – a standard form-filled one for all hospital beds, and a set number of pressure therapy ones.

With a hybrid system, trusts only need to procure one mattress type, which can be used in static or dynamic mode. This eliminates the need to move the patient in and out of bed and swap mattresses as their condition changes, saving on both nursing time and mattress handling/storage requirements.

“The cost savings associated with moving to a hybrid mattress arrangement were estimated at £202,800 over the lifetime of the four-year contract,” says Twemlow. These figures are based on avoided cost savings of purchasing 309 dynamic pressure therapy mattresses (based on Cambridge’s current contract) and 1,200 foam mattresses (based on the total number of beds), and leasing the hybrid mattresses instead.

According to Twemlow, hybrid mattresses have only been available in the UK since 2012. One of the first trusts to use them, Medway NHS Foundation Trust, estimated that the system overall saved the time of 2.5 full time equivalent nurses a year.

“The concept of a circular economy does not resonate within the heathcare sector, in the same way that it does for industry,” Twemlow maintains. “The NHS needs far greater evidence of the cost benefits before they might be persuaded to be more innovative in their procurement approach.”

Maxine Perella