Counting the carbon cost of care

Andy Connor's picture

The NHS Carbon Reduction Strategy has set targets for the reduction of GHG emissions within the NHS. Taking 2007 levels as the baseline, the strategy requires an 80% reduction before 2050 and a 34% reduction as early as 2020. If we are to meet these challenging targets, our health economists will have to become as familiar with the rationing of healthcare of the basis of carbon as they presently are with financial resources. A scary thought? Well, no. This shouldn’t frighten clinicians at least - the sustainability, financial and clinical agendas can often be aligned. In fact, sustainability offers a further lever to achieve the financial and clinical targets required. Within nephrology for example, transplantation (surely the ultimate in recycling) will likely prove to have a lower environmental impact than dialysis, and pre-emptive living donor programmes will reduce emissions further.

But this is part of the (our) problem. We don’t know for sure if transplantation is greener than dialysis. In fact, we don’t know much about the carbon cost of the individual components of the healthcare we provide. So, effective carbon rationing within healthcare is going to require advances in our understanding of the carbon footprints of the different treatments and services provided. Renal medicine (and the Green Nephrology Programme) has been doing its bit to lead on this front, providing carbon footprints of treatments (HD) and services. We’ve done this by importing the carbon footprinting methodologies and standards accepted within other sectors (commerce, agriculture etc – everyone’s been doing it apart from us, it seems!) into the healthcare setting. But there remains a distinct need for further research to develop and refine the healthcare-specific emissions factors that are required to improve the accuracy and ease of use of these techniques.

Many of us would agree that it is regrettably difficult to envisage carbon rationing shaping the delivery of renal services in the immediate future. Instead, consideration must be given to other means of incentivising the delivery of sustainable healthcare and, until such measures are in place, those of us wishing to implement more sustainable models of care must remain vigilant for the sustainability opportunities that arise from the need for service reconfiguration driven by other influences (such as patient safety or cost-cuttting, for example). However, in order that such opportunities may be taken, tools must be developed to allow us to evaluate the environmental impacts of different treatments and pathways of care in a timely manner – from experience, the undertaking of detailed carbon footprinting studies in this setting is frankly not feasible. The development of a library of indicative carbon burdens covering standard episodes of patient care, such as those already determined for inpatient admissions and outpatient appointments, might allow approximate – but adequate – analyses to be built up in the double-quick time required to include them in business plans. With time, this library could be extended to include individual practical aspects of care such as catheterisation, endoscopy or renal biopsy. Some of the information is already out there: an Australian group have compared the life-cycles of disposable and re-usable central line insertion packs (McGain et al, 2012).

But who will do this research? The incorporation of sustainability into healthcare offers opportunities for the development of partnerships across the healthcare community that are mutually beneficial to healthcare providers, industry and the public. For example, although no such project exists at present, the development of an open-access database – to which companies might submit environmental data pertaining to their products (including, for example, the products’ carbon footprints or information about their recycling possibilities) – would be a valuable venture. Not only would this allow industry organisations to showcase good environmental practice, the information provided would be of benefit to a diverse group: commissioners seeking to implement sustainability criteria into procurement contracts; individual renal services wishing to improve local waste management strategies; and, healthcare providers hoping to compare the environmental impacts of different models of care (such a database would overlap usefully with the aforementioned library of indicative carbon burdens for healthcare episodes).

Enough parts of the delivery of healthcare have now been footprinted to ‘show that it can be done’. What we really need now is to join the dots. Collaboration between the pharmaceutical and medical equipment industries and those delivering the healthcare is required to make this effective. Why not start asking companies for the footprints of the items you’re purchasing…



Chris Pearson's picture

Interestingly we used to practise dialyser re-use in the UK until lobbying by the manufacturers resulted in it being banned about 6 years ago despite absolutely no evidence of any patient related incidents ever being reported to the MHRA.

Perhaps somebody should be looking at this again given the amount of dialysers being discarded and incinerated i.e. 1.4 million kgs annually which could be reduced by a factor of 12.


Other Countries not so gullible

William Beale's picture

With our travel on holiday dialysis we have been to units in The Netherlands and Denmark.  When we explained in the UK our "Health and Safety" and "Infection Control" police have prohibited reuse of acid they fell about laughing.

It was explained to us that a primary school child in science study is taught that bacteria does not grow in acid so is completely safe to reuse providing no external contaminents.  

I have no idea if it is safe or not to reuse acid but it looks worthy of further study.



Chris Pearson's picture

They perhaps wouldn't fall about laughing if their children were cross infected by a virus carried on the outside of the can from blood splatter during the previous treatment of an infected patient .

They perhaps also wouldn't find it amusing if an untrained worker poured the remainder of 1 formulation into another can of a different formulation and hence given the wrong mixed formulation resulting.

The law is exactly the same elsewhere in the EU in terms of the definition of Clinical Waste which is very specific and covers anything which may have been contaminated during use.


some good points

William Beale's picture

Hi Chris

You raise some good points but please help my understanding.

I have seen blood splatters and contamination on new unused cans.  Sometimes a previous patient starts bleeding again and this splattered blood seems to go everywhere.  Normal nursing procedeures must apply to both methods. I dont understand why you think unused cans are exempt from splatter.  In a busy unit with pressure to not keep patients waiting unnecessairily long pack are often prepared in advance and in reach of blood splatter.  

I have seen trained nurses making mistakes and using the wrong acid.  I would have thought the same management controls and checking would apply.  It would be nice to think that trained staff never made mistakes and all mistakes are generated from untrained staff and so avoidable.

If a law is wrong then it must be changed.  In an ideal world with unlimited budgets perhaps it is safer not to reuse acid.  Some of us would have seen that the law on not reusing nailclippers between patients because of a theriotical comptamination of Cjd is good but there have been more documented deaths because of using the lower quality of disposable clippers than reusable ones.  Perhaps you need to declare that you supply medical consumables so may be biased.

Nothing in this world is ideal, we know that as patients and carers we have a high carbon footprint.  We also know that by 2050 there will not be the resources to treat more than 1 in 5 patients.  Calculated risks are necessairy.  Sometimes the "cure" is worse than the problem.

Medical treatment is a serious metter but it is laughable to think that mistakes do not happen with whatever modality adopted and using only the most expensive option (as in disposable clippers) is always best.  It may be best commercially for the suppliers but not necessairily for the patients. 


Hi William,I'm not sure that

Chris Pearson's picture

Hi William,

I'm not sure that I did say unused cans were exempt from splatter?

Are you saying you set up the machine with a new can and other sterile disposables before the patient being taken off had gone and everything cleaned and disiinfected,surely not?

I have seen and heard of numerous issues with incorrect concentrates being used and also the wrong chemicals being put in the wrong cans and then connected up so my point was if it can happen it will whatever procedures are put in place accidents happen and we should all be taking steps to reduce this given the exponential rise in compensation payments being made by the NHS Litigation Authority.

Bit of a low blow to try and accuse me of being biased,not sure why that is called for,just putting over my personal opinion with 39 years of experience in Renal Care both NHS and commercial.

Unfortunately whether we agree with the current law or not unless it's changed we all have to comply and when we don't and patients are harmed as a result due to shortcuts being made thats why as above compensation payments are rocketing.

I really don't agree that suppliers such as myself are driving this it's EU law and all the private dialysis facilities are regularly checked with compliance which as far as I am aware isn't being done in the NHS units.

Bottom line on this to me is that anything which has been on the front of a machine during a treatment MAY be contaminated and therefore should be yellow bagged and incinerated.

If you do want to recycle the plastics such as the Bicart's and cans then they should be sterilised before exposing the refuse collectors and recyclers to prosecution and infection.


Wow this seems to have

Ben Wilson's picture

Wow this seems to have sparked some heated debate!

I agree that infection control and health and safety can sometimes cause us to put in systems and processes to fix problems that only they can see but not everything that they ask us to do/ not to do is pointless. From my perspective the most important thing is that the patients I take care of are looked after as safely as possible and have the best possible quality of treatment we can offer. The only 'green' practices and changes we are trying to implement on our unit either have no effect or a positive effect on the standards of care we give.

I'm all in favour of trying to make our renal care as green as possible but I would have real reservations about going back to the days of re-using dialysers. I would imagine that the potential for infection or cross contamination would rocket (though I have no reason to doubt the evidence to the contrary quoted earlier by Chris). There would also surely be the issue of dialyser efficiency reducing as it is re-used. Assuming the dialyser became less efficient with each subsequent treatment we would then need to increase the hours that the patients dialyse for to achieve the target Kt/V and as a result the extra running time would result in extra costs. These costs would be both both environmental and financial (before you even touch on the potential physiological and psychological impact on the patients from spending extra time on dialysis). It would require extra bicarb, concentrate acid, electricity, anticoagulation, nursing hours etc... to cover the extra time spent on the machine. Surely there would also be the potential to re-use the kidney on the wrong patient and cause serious harm/death. For me the environmental and financial cost of single use equipment for each session is well worth the expense. There are other areas where we can make significant changes which will not put the patients at risk of harm


Its good to see that its got people so passionate though!!



William Beale's picture

I think it is fair to say that the current way of doing things is not sustainable either in environmental or financial terms.


I agree that not reusing acid is ideal but I fear within a short time (in historical terms) there will be a stark choice of being more efficient or ration treatment.


If any of you have the courage to tell a patient that there are no resources to treat them because we chose to be inefficient with acid for decades you are you are much braver than me.  The sad choice is that when the crunch comes whover makes the financial decision not to treat because of financial resources probabily does not have the courage to face the patient and justify what many consider as unjustifiable.


Can any of you face your family and say that you are doing everything possible to ensure future generations have sustainable treatment?  All good ideas start with a minority of one just because standard knowledge says we must do things in certain ways.  In historical terms blood letting was a cure all for many ailments including anaemia, think of the resistance someone had for suggesting that the prevailing wisdom of the wime was wrong and unsustainable?





I agree that we should be

Ben Wilson's picture

I agree that we should be looking at every possible way of cutting our carbon and financial costs and us as nurses and doctors along with you guys as patients should be looking to challenge conventional thoughts and look at innovative ways of making these savings I'm just a little uncomfortable with the issues of sharing acids as there is the potential of cross contamination. The ideal solution to this issue is to have central concentrate vats where the risk of contamination is not an issue and wastage is also virtually eradicated as there are no half empty containers poured down the sink.



Mary Thomson's picture

Everything we do within the NHS these days is all about
money, there is no way around this. As a renal nurse and a member of the public
who may need to use the NHS at anytime I want to know what the NHS is doing to
ensure that this great service is sustainable. As Ben said, as Nurses and
Doctors we have a duty to make more efficient use of the products we use and
without a doubt reduce the amount of waste we produce! It's common sense, all
our patients are screened so we know who is at risk and who isn't, bbags and
canisters can be recycled with no issues, wipe them down with a detergent wipe
and recycle them. I disagree with the reuse of acid, blood may have
contaminated it, and a CDS is the way to go. Let's talk to the companies, do we
need 5/6 litre canisters of acid, can't we have any size. Let's get a sensible,
practical and sustainable head on our shoulders - burning our money or pouring
it down the drain is not right, whatever way you dress it up....


acid reuse

Fraser Gilmour's picture

CDS should be standard in all new builds but due to cost and space issues it's not a solution for all existing units. Even when possible it will not stop waste completely as typical systems only use one acid formulation leaving maybe 30%-40% of patients still using canisters with the potential for waste. The risk of acid canisters potentially being contaminated is there and could be happening right now, most machines use a simple pick up rod in the top of can which sits open to anything being dropped inside during a treatment. Cross infection is unlikely by this route due to the ph of the solution and the fact that most machines use or can be fitted with point of use ultrafiltration. Fixed volume acid cans are likely to be with us for a long time to come. It should be possible to protect them from accidental contamination which would allow leftover acid to be used for subsequent patients. I may be cynical but this probably isn't a priority for acid manufacturers as it would significantly reduce the amount of acid they sell, who knows it may be worth lobbying them. I'm looking at can covers to stop contamination occurring and allow use of the leftover acid as part of an options paper to reduce waste in our units.


Cross contamination

Chris Pearson's picture

One of the points I would like clarifying is the topic of conversation?

I was under the impression that we were discussing green issues but it seems to be centered on the moral issues in relation to coping with inadequate budgets.

My point in relation to cross contamination issues with concentrate cans wasn't in relation to blood in the actual acid but with how the empty or almost empty cans are handled post dialysis and any blood splattering on them dealt with.

The reason I'm interested in this because we were recently asked by a customer if we could recycle concentrate cans and I came to the conclusion havong talked to several people and read several articles and studies (2&3) that this wasn't something that we should even consider.

In relation to decanting small residual amounts of acid into another can to prevent waste my concern was with errors in mixing 2 different formulations rather than blood contamination.

There is little doubt in my mind that anything which has been on the front of a machine during a treatment MAY be contaminated and therefore classed as Clinical Waste and a quick wipe down with a wet wipe doesn't in my opinion alter this,they would need to be sterilised before recycling.

I understand that known infectious patients may be isolated but clearly from the recent documented outbreak at Heartland Hospital (1) this isn't foolproof and we should be using Universal Precautions and again therefore in my opinion it should all be considered infectious and incinerated rather than the risk of leeching residues from landfill into waterways.

I don't think there is any doubt that the best solution to waste of concentrate is for central delivery wherever possible and where not to contract with the manufacturer for smaller amounts of concentrate in each can which not only saves money and waste but is far better from a lifting and handling perspective.


REF1:Journal of Clinical Virology 45 (2009)296-299

Holiday haemodialysis and imported hepatitis C virus infection:A series of sixteen cases in two large haemodialysis units.

Ref2:Journal of Environmental Health January-February 1999

Assessment of blood splash exposures of medical waste treatment workers.

How to comply with your environmental permit

Additional guidance for:

Clinical waste (EPR 5.07)


Acid cans can be recycled!

James Dixon's picture

Chris I'm very surprised with your stance on the classification of ALL dialysis acid cans as infectious and needing incineration. This goes completely against the DoH guidance in the Safe Management of Healthcare Waste document. The only infectious clinical waste that is sent for incineration in the UK is Category A (i.e. vCJD) patient waste. Category B infectious waste (includding HIV and Hepatitis) can be sent for heat treatment and should not be sent for incineration.

We recycle our clean rinsed dialysis cans on our unit and were commended for doing so by this Green Nephrology network. We have had no incidents to suggest this practice is doing anything but good. Our Microbiology, IPC and H&S teams fully support this work. What you are suggesting would put the NHS back about 10 years in environmentally sustainabillity terms.


recycling cans

Chris Pearson's picture

Just my own personal viewpoint that it makes more sense from a cross infection viewpoint and in real terms a green viewpoint to incinerate all the clinical waste i.e. anything that has been on the front of a dialysis machine during a treatment which MAY therefore be contaminated with blood.

Not sure why this would be considered a retrograde step as we have incinerators running below contracted capacity which generate heat for local social housing and in my personal opinion better than any risk of contamination into groundwater from landfill which in my opinion is a timebomb.


reducing contamination by design

Frances Mortimer's picture

Are there any manufacturers of dialysis machines who are looking at design features which would minimise contamination of consumables?  

Seems to me that there is no reason why acid or bicarbonate bottles need to be exposed to risk of blood splashes - they could be positioned at the back of the machine or placed behind a protective screen.


cross contamination risk

Chris Pearson's picture


That would help but during stripdown at the end of treatment there would still be a risk however slight that cross contamination could occur from residual blood on gloves picked up from the bloodlines,needles or dialyser and tranferred onto the can or cartridge.

It would be interesting to hear from a member of the team at Heartlands if they ever came to a conclusion as to how the virus was transmitted from patient to patient.

We worked closely with them at the time on dialysis chairs and as a direct result completely redesigned our upholstery to make it easier to clean and disinfect by removing all cosmetic stitching and seams.


contamination of consumables

Fraser Gilmour's picture

There are two elements to this, protecting the acid and bibarb from contamination so they can be used for subsequent treatments, and protecting the plastic containers these come in in order to recycle them.My concern at the moment is the former, which I think is entirely possible. Recycling plastics which are deliberatley exposed to biological contaminants is a tricky issue for the reasons Chris has given. I'm not sure how companies or authorities who actually carry out the recycling manage this risk. Surely they should treat everything as potentially "contaminated" even household recycling? and take appropriate precautions.


Clinical incinerators

James Dixon's picture

I can't comment on the clinical waste incinerators in other areas, but the one that treats clinical waste from Trusts in Yorkshire and the Northeast (and imported clinical waste for incineration from Ireland) does not generate heat for social housing. It simply burns clinical waste at 1000degC (or higher for cytotoxic/static waste) with no heat recovery. It doesn't even use the waste heat to contribute to the space heating of the facility offices.

From this point of view, it is very poor environmental option. SRCL (who run the facility) suggest that for every tonne of waste incinerated they produce 2.2t of CO2e. This also takes into account the lime and other chemicals used to clean and scrub the stacks to keep them WID compliant.

Compare this directly to a tonne of infectious clinical waste sent to a local Heat Treatment facility in the Northeast (where all our "orange" waste goes) which only generates 427kg (0.43t) of CO2e. This is because the waste is shredded, heat treated then the inert flock is used as RDF in a local cement works to fuel their kiln. Before July 2012 this heat treatment facility used to send the inert flock to deep landfill, where it was isolated into a separate lined cell and then capped immediately after tipping. Even treating the waste then landfilling it this way only resulted in 1.07t of CO2e per tonne of waste (less than half the environmental impact of incinerating it).

I must confess that these figures were provided by SRCL and are loosely based on average DEFRA GHG conversion rates for their facility energy use, transport and disposal routes. They have not been externally verified but I'm happy enough to use them when carryingg out rough calculations of the carbon footprint of our Trust's waste disposal activities. If your clinical waste incinerators are tied in with heat recovery and domestic hot water provision for social housing then they may perform much better than this from a CO2e point of view.

However, I will still return to the fact that the only clinical waste in the UK that should be sent for incineration is Category A Infectious (i.e. vCJD), Anatomical Waste, Sharps, Hazardous Medicines (cyto) and Non-Hazardous Medicines. Category B Infectious (the vast majority of infectious/potentially infectious waste in the NHS) should not be incinerated but should be sent for Heat Treatment.



James,I'm not saying you are

Chris Pearson's picture


I'm not saying you are wrong or saying that it MUST go to incineration just saying IMHO it would be better incinerated and the heat used for social housing such as in Sheffield rather than it all being hidden away in landfill for future generations to deal with,there is only a finite amount of land we can use and its gradually being used up.

I understand the new plant at Allerton has been given the go ahead and this will produce electricity and reduce landfill volumes,what's the drawback?


Clinical incinerators

Jerome Baddley CEnv FIEMA's picture

Interesting discussion.

Our analysis at NEP of incineration emissions has shown that the CO2 emissions are highly dependent on the mix of wastes burnt. Burning plastics may result in 2.2tCO2e per 1t of waste. Biomass however, is more or less zero. Typically municipal waste is assumed to be 10% plastics so the energy from EfW is usually attributed carbon with this in mind.

On that basis knowing the % mix of biomass and fossil waste in offensive waste is essential to determining whether incineration or landfill is best.

We analysed the composition of care home offensive wastes (which incidentally make up 50% of the total UK offensive wastes arrisings) to this end and determined that is was significantly better to dispose of this waste stream by incineration than landfill. 66% of the composition of continence products is biomass and the full weight of the excreta is of course biomass pgs 36 and 37

Almost all new incinerators will be build with at least power generation attached. As a rule of thumb I would say that plastics heavy offensive waste would be better landfilled, but biomass heavy wastes should be incinerated for energy recovery.

I have written extensivley on this issue over the last couple of years, feel free to have a read

Kind regards



An Australian perspective

Anthony Perkins's picture

Hi guys, 

We have been recycling the acid bottles used in dialysis for about 10 years now, our infection control committee is happy with the recycling of the platic bottles, on the provision that the waste disposal company is informed that these recepticles are not used for personal/social use.  5 litre plastic bottles might seem like a nice vessle for storing water for camping etc., so we inform them that these container have been used in a process where contamination is possible.  As the plastic is bagged and standard protective equipment is used, ie gloves, then the risk of cross infection from object to person is decreased significantly.  Once the manual handling has been taken care of the plastic is heat cleaned and separated, again leaving minimal risk of infection.  In the 10 years we have been doing this, we have not had one report of infection from handling spent dialysate containers.

Not in any case have we ever considered re-using acid or bicarbonate.

I am however, unsure of the bureaucracy in the UK which I expect is standing in the way of universal recycling of acid botles, which should be a relatively easy recycling project.



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