Skip to content

Q logo

The challenge

 Sustainability should be considered a domain of quality in healthcare. Sustainable value considers patient and population outcomes against environmental, social and economic costs.(1) Sustainable value may be maximized by applying the principles of sustainable clinical practice: prevention, patient empowerment and self-care, lean service delivery and use of low carbon alternatives.


Anthropogenic climate change is the ‘greatest threat to global health in the 21st century’.(3) The NHS contributes a quarter of all UK public sector carbon dioxide emissions(4), amounting to 22.8 million tonnes per year.(5) Medical instruments alone account for 10% of this.(6) Around a third of all NHS hospital admissions are for surgical care, resulting in over 10 million procedures per annum.(7) Operating theatres are six times more energy-intense than the wider hospital(8) and responsible for 21-30% of total hospital waste.(9) 


The NHS is currently facing a deficit of £800 million, with a £20 billion funding gap predicted over the next five years.(9) Surgery accounts for £4.5 billion/year of NHS spend(10) with running costs for an operating theatre estimated at £1200/hour.(11)


Previous literature examining the sustainability of surgery has been done in very specific areas, focusing on individual operations or instruments, rather than tackling surgery on a broad scale. Studies have frequently focused on financial rather than environmental or social impacts. Studies have found:


•           13% of disposable items opened for neurosurgical procedures were discarded without use(12)

•           90% of pre-operative set-up waste in otolaryngology procedures was recyclable(8) 

•           Optimisation can eliminate an average of 60% of instruments per surgical tray(13)



This project will partner with the UK Centre for Sustainable Healthcare (CSH). This grant application is for research conducted by the first UK Surgical Sustainability Fellow (CR).


Our research will:

a)         Quantify the carbon, financial and social costs of surgical services

b)         Identify opportunities for improving the sustainable value of surgical services 

c)         Assess potential drivers and perceived barriers for adoption of sustainable practice within surgery


We will evaluate the environmental sustainability of national surgical services in England using a hybrid approach, combining ‘top down’ environmental input-output modelling with ‘bottom up’ life cycle assessment.(14) This will be used to identify carbon hotspots and areas of greatest carbon consumption within surgery. We will evaluate social sustainability through considering the impact of surgery on the quality of life of patients, staff, carers and communities involved in the surgical supply chain. The latter will include an evaluation of the risk of labour rights abuses. 


The national study will be used to inform a granular study focusing on carbon hotspots identified and conducted across 2 hospital sites (Brighton and Worthing). Lean service delivery is a principle of sustainable clinical practice (2) and lean management principles will be applied to tackle hotspots. We anticipate these will be studied within the context of the most common elective hospital operations in the NHS:(1)

•           Hip arthroplasty

•           Knee arthroplasty

•           Cholecystectomy

•           Surgery for Dupuytren’s contracture

•           Tonsillectomy


The granular study will again use hybrid carbon footprinting methodology, here integrating value stream mapping. This involves documentation and analysis of the stages of an operation from start-to-end and the products used in that process, including gowns, drapes, sutures, and surgical instruments alongside consumables. The frequency of use of individual surgical instruments can be mapped with a Pareto chart. We will consider the environmental, financial and social impact of leaning surgical services.


Our recommendations will be informed by the above analysis alongside a systematic review of published literature. This will identify potential areas for change, including opportunities to minimise use of consumable products, reduce waste and recycle. For example this may include:

•           Use of reusable, fair trade surgical devices, gowns and drapes, or reprocessing of single use devices

•           Streamlining instrument trays 


Surgeons have a unique position of influence within the operating theatre. The final stage of our research will include semi-structured questionnaires and interviews with key surgical opinion makers. This will identify personal and contextual factors surrounding adoption of sustainable surgery, including potential drivers (environmental, social or financial factors) and perceived barriers. 


What is the benefit

•      Patients will benefit from sustainable leaning of surgical care, designed to optimise use of limited resources to deliver patient outcomes (sustainable value).

•      The NHS will benefit from the reduction in wasteful activity and meeting carbon and financial commitments.

•      Healthcare staff will benefit from engaging in service improvement and resource stewardship.


Benefits for the Q community

•      This project offers to showcase Q’s commitment to healthcare sustainability. 

•      We seek to engage with Q members to increase awareness of sustainability challenges within the NHS and the relationship of quality, value and sustainability.

•     We will actively engage with Q members and enable them to become involved in improving sustainability within their local trusts, including through Special Interest Groups and Randomised Coffee Trials.
















14)ISBN 9781846688911


How you can contribute

  • • We would love to hear what is being done in your local area to improve sustainability in operating theatres?
  • • What are your own thoughts and attitudes towards sustainability within a healthcare setting?
  • • Who do you think should be responsible for ensuring the financial and ecological sustainability of NHS operating theatres?
  • • What is the best way to disseminate the findings of this study, to optimise the spread and scale of sustainability recommendations?

Further information

Q poster (PDF, 11MB)

Reviewer feedback

This is a great project because…

The team have presented detailed and compelling evidence of the opportunity for change. We like the focus on environmental and financial costs and how lean could be applied in this context. There is strong academic input which should help with the evaluation but also a good practice focus.

By the time of the event we encourage the project team to think more about…

Although the research focus is a strength of the project we would like to see further engagement with evidence and experience of implementing lean projects.


  1. Want to learn more about what Coproduction is - and isn't? Want help and advice with your own improvement project's co-production challenges?

    Do join next month's zoom video call with Q's Coproduction SIG and Coproduction expert Carol Munt.

    To register go here:

    Bring your challenges!

    Chantelle, I've had a couple of ideas that may help your project. First are you familiar with the 'Releasing Time to Care' series? The most well known of this series was 'The Productive Ward' box set. Another box set in the series was The Productive Operating Theatre. I've not been able to get hold of a copy of this box set but I'm sure that it will be as good as The Productive Ward. I'm sure it will provide some very worthwhile ideas for your project. An evaluation of The Productive Operating Theatre can be found here:
    Second have you had a look at my process visualization of the NatSSIPs? It can be found here:
    If you click on any box the tasks for that part of the flowchart will be displayed. Additional links could be included in the visualization to add detail relating to waste minimization strategies showing exactly the point in the process where waste occurs.
    If you have LocSSIPs for the 5 most common elective hospital operations in the NHS, process visualizations could be designed from these standards and the different waste footprints for each operation type analysed. Please let me know if you want any additional information. Regards Tom

    1. Thank you Tom- our work focuses specifically on sustainability but draws on the principles of productive operating theatre in terms of improving resource efficiency. Thank you for sending the link to your own work. This current surgical sustainability research is part of my PhD which I have just started, but I recently completed a masters using lean management techniques to streamline the unilateral tinnitus patient pathway. In this I used value process mapping so have had experience in process visualisation (including mapping variation in care) over the last few years. I look forward to discussing my VPM approach in September at the Q event



  3. Hi Chantelle - looks like a great project. Look forward to hearing how it progresses. Best wishes, Stephanie

  4. Great.  Yes, I have read that review.  I do think if we waited for a system to be ready we would never change anything, we need to continuously re-shape the current context.  Paul Bate's work on context is an excellent read.  I'll be interested in your findings.  I suppose there are different methods/approaches depending on whether you want to establish the most efficient approach (research) or implement the new approach (improvement).  Of course, in the end, we usually want to do both.

  5. Thanks for sharing your idea Chantelle.  I think it’s a brilliant idea that has the potential for financial and environmental benefit across healthcare.  I have not used Lean in this context but I have used the tools to re-design a service with Drug and Alcohol Recovery teams.  I’ve got a couple of suggestions/comments that I hope will be of some help.  Apologies if you have thought these through, but are not apparent in your pitch.  Your pitch seems to focus on the ‘technical’ elements of improvement as opposed to the psychosocial.  I think both are needed for improvements to 'stick.'  For example, who and how will the value stream map be created?  How will you get surgeons and others to agree it is an accurate reflection of the process (at least 80% of the time)?  Would process flow mapping help as a first step? Could teams come up with the re-use, reduce and remove actions and design a future value stream map?  I think engagement from the start is essential for future buy in and future dissemination. Finding out the potential cost savings and reducing carbon are important but only useful if clinicians will implement the change.  If you are going to really engage teams in the process then I would consider reducing the operations you are including to one or two as engagement will be time consuming in a 30K budget.  I’m very interested in your environmental input-output macroeconomic modelling and wondering if it would be useful for our proposal as we are considering estimating the carbon emission reduction from reduced travel for our alternative telehealth  ‘home’ appointments.  I'm looking forward to reading more about your project.

    1. Thanks Michelle... A systematic review identified that many healthcare studies reporting potential lean processes fail to consider contextual factors that may impact upon adoption. This may relate to the nature of the innovation, adoption by individuals, assimilation by the system, pathways for diffusion and dissemination, alongside system readiness.

      The final stage of the research will therefore be a qualitative narrative interview case study to identify personal and contextual factors surrounding adoption of lean principles in surgery, including potential drivers (green or financial factors) and the perceived barriers to adoption. The interview topic guide will be informed by both the systematic review, semi-structured questionnaires and interviews with key opinion makers in the operating theatre. The study participants will be surgeons from the surgical subspecialties we are engaged with (orthopaedics, upper GI surgery, plastic surgery, and ENT surgery), operating department practitioners and those responsible for procurement of goods for theatres
      In summary we will be engaging with our key stakeholders from the start, identifying the barriers and enablers to the changes we propose. In addition, 2 of the researchers are insider researchers (with an 'emic' perspective). We have therefore discussed the research heavily with other surgeon colleagues.

      We will be conducting the macroeconomic modelling in collaboration with the Centre for Sustainable Healthcare who are experts in this field... it may be worth getting in touch with them?

  6. Hi Chantelle How does this proposal fit with the NHS GIRFT programme that is also driving efficiencies and reduced variation in surgery? Is there a link up? Or any learning from the GIFRT work to date?

    1. Hi Elizabeth- our trust has been chosen as one of the GIRFT centres for ENT, so we will be linking in with them directly. Certainly lessons to be learnt from their orthopaedic & gen surg work so far.

  7. Chantelle, Good project. I'm sure that some process mapping (visualization) would help to identify at which point waste is being generated. I would be happy to undertake that task for your project if asked. Regards Tom

    1. Chantelle, It would be great for our SIG to get stuck into some real process mapping. I look forward to being involved. Regards Tom

    2. Hi Thomas,

      Thank you for your kind offer. I have used process mapping during my Masters of Research dissertation previously and intend to use it again in this research. It would be great to discuss at some point within our SIG.

      Many thanks,


Leave a comment

If you have a Q account please log in before posting your comment.

Read our comments policy before posting your comment.

* required fields

This will not be publicly visible

Please note that you won't be able to edit or delete comments once posted.