Hampshire Hospitals NHS Foundation Trust Green Team Competition 2024
In May of this year, Hampshire Hospitals NHS Foundation Trust (HHFT) commenced a Green Team Competition in partnership with the Centre for Sustainable Healthcare. The competition has brought anticipated annual savings to the Trust of £365,991 and 108,212 kgCO2e. This is the carbon footprint equivalent of driving 318,842 miles in an average car (or 385 return trips between Hampshire and Glasgow).
Through the Green Team Competition, six teams from HHFT were selected to engage in our award-winning programme in sustainability in quality improvement (SusQI) that transforms expert knowledge into action. Each team received mentoring from CSH facilitators to drive healthcare transformation by developing, implementing and measuring the impact of projects through the lens of the sustainable value equation.
Through the Green Team Competition, six teams from Hampshire Hospitals NHS Foundation Trust were selected to engage in our award-winning programme in sustainability in quality improvement (SusQI) that transforms expert knowledge into action. Each team received mentoring from CSH facilitators to drive healthcare transformation by developing, implementing, and measuring the impact of projects through the lens of the sustainable value equation.
At the November 26th Showcase and Awards Ceremony, the teams presented their projects, including the anticipated savings and opportunities to scale and spread, to an audience from the Trust and the judging panel including:
Alex Whitfield, CEO, HHFT
Carl Brookes, Clinical Sustainability Lead, HHFT
Julie Dawes, Chief Nurse, HHFT
Sue Garvan, Patient Representative, HHFT
Cath Richards, SusQI Programme Lead, CSH
“The Green Team Competition has been an incredibly valuable initiative, providing a unique platform to showcase and drive forward sustainability efforts across the Trust.“
Miranda Chubb, Sustainability Officer, HHFT
Miranda Chubb, Sustainability Officer at Hampshire Hospitals NHS Foundation Trust expressed her enthusiasm for the Green Team Competition, emphasising its significant impact on sustainability efforts across the Trust. Chubb highlighted how the competition served as a unique platform to showcase and advance innovative initiatives that not only reduced the organisation’s environmental footprint but also brought about meaningful changes in practices, directly enhancing patient care. She praised the dedication of the teams involved, noting their success in implementing projects that improve care quality and generate cost savings while aligning with the Trust’s Green Plan and the NHS’s broader net zero commitments.
Winners: Nightingale Theatres
Congratulations to the winning team, the Nightingale Theatres, led by Laura Vale – Senior Operating Department Practitioner, Krithea Baker – Recovery Nurse Practitioner and Dr Jaco DeBeurs – Specialist Doctor Anaesthetics, with special thanks to Oliver Grassby (CT2 Anaesthetics), Jessica Lynch (CT1 Anaesthetics), Alhan Al-Sammak (Speciality Doctor) & Ellie Watson.
“It has been a great experience taking part in the green team competition and working with the CSH team. We have learnt lots about sustainable QI and carbon footprinting, we are looking forward to implementing the skills we have learnt in future sustainable projects.“
Krithea Baker, Recovery Nurse Practitioner and Laura Vale – Senior Operating Department Practitioner, HHFT
The team undertook six separate projects aiming to improve sustainable value in a variety of ways in the department. The team were praised by the judging panel for their engagement with a wide variety of stakeholders which was essential for driving progress, for persisting and taking on learning when one change could not progress, and for their efforts to shift practice culture among the multidisciplinary team.
The Centre for Sustainable Healthcare would like to thank and congratulate all teams that took part in the competition. The competition’s outcomes serve as proof of the teams’ commitment and efforts to improve the sustainability of our healthcare systems.
Green Team Competition Projects
Read the full Impact Report here or view the project summaries below.
Arthroplasty procedures present significant opportunities for carbon reduction given their high use of single-use consumables and energy-intensive equipment. A knee arthroplasty has a carbon footprint of 85 kgCO2e.
HHFT performed 991 arthroplasty procedures in 2023-2024, and this number is expected to grow with the establishment of a new elective arthroplasty centre. Given the volume of such surgeries and their reliance on disposable products, targeted improvements could meaningfully reduce emissions.
The team identified six changes that could be made to improve sustainability of arthroplasty procedures.
Intervention and outcomes
Switch from Ethyl Chloride Spray to The CoolStick®: This involved replacing a disposable anaesthetic cooling spray with a reusable, non-inferior alternative.
Outcomes:
Clinicalsustainability: Non-inferior in terms of patient anaesthetic experience.
Reduce energy consumption by switching off Heating, Ventilation, and Air Conditioning (HVAC) systems and Anaesthetic Gas Scavenging Systems (AGSS) when theatres are unoccupied (Not yet implemented).
Outcomes:
Clinicalsustainability: No anticipated impact on patient outcomes.
Environmentalsustainability: Estimated savings of 58,658 kgCO2e.
Financial sustainability: Estimated annual savings of £34,203.
Socialsustainability: Aimed to improve staff burden with energy-saving automation.
Ecopulse Device Implementation: Proposal to replace disposable, battery-powered pulse lavage devices with a lower-carbon alternative. This has not been implemented due to additional costs (therefore potential impacts have been excluded from total savings).
Outcomes:
Clinicalsustainability: No impact on patient outcomes.
Environmentalsustainability: Expected reduction of 2,789.64 kgCO2e.
Financialsustainability: Annual cost increase of £7,601.04.
Socialsustainability: Anticipated noise reduction benefits for theatre staff.
The first 5 projects combined have potential annual savings of £67,968 and 66,051 kgCO2e, equivalent to driving 195,071 miles.
Key learning points
The initiative demonstrated that even small, targeted changes could lead to substantial carbon reductions and cost savings when embedded across a department. To enable change to happen in a complex environment like the operating theatres involves many stakeholders. It is important that these stakeholders are engaged early in the project as some of the processes of engagement can be lengthy. A good relationship with stakeholders was a key element that contributed to the success of this project.
Going forward, the team aims to ensure that these initiatives become embedded into daily practice, through review and audit of our processes. The aspects of their project that are yet to be implemented will be prioritised, and data collection ongoing to measure the impacts across the triple bottom line and improve sustainable value in their department.
This project highlighted that, even when problems or barriers occurred during the implementation stage or the results were not as expected, there was still key learning and knowledge to gain. Not all projects will achieve the triple bottom line but the QI practice that is involved in the process of completing a project provides good learning and experience.
To ensure lasting change, they plan to continue to engage with their department, providing updates on projects at clinical governance and also present their findings at relevant events across the trust. The team will also continue to seek opportunities to align with national recommendations as outlined in the Green Surgery Report (2023) and work towards a net zero NHS.
Team members: Dr Daniel Lopez Baez – Emergency Medicine Trainee ST1, Dr Rachel Harrison – Paediatric Emergency Department (ED) Consultant, Dr Nitya Mandeda – Clinical Fellow in Emergency Medicine.
Setting / patient group: Paediatric Emergency Department
Issue
Children are disproportionately highly represented amongst an overall increase in Emergency Department (ED) attendances. The most common cause of these attendances are injuries, among which the most common are buckle fractures. The Forearm Fracture Recovery in Children Evaluation (FORCE) suggests that less is more, and that there is no significant difference between managing such injuries with a bandage and a splint and cast. The ‘FORCE’ protocol, though, has low uptake, with a local audit finding 0% of buckle fractures were managed with a bandage.
The same investigation also found that many other upper limb injuries did not require interventions and so could have been managed from home. A survey of caregivers found that most believe an online resource could have removed the need for an ED attendance, but there was low awareness of such resources, even where they already existed.
Intervention
An initial survey of doctors, emergency medicine nurses, and physician associates showed awareness of the FORCE protocol was only 20%, and in no cases were bandages used ahead of splints or casts and reattendance. The team decided to intervene through a campaign to increase awareness of the force protocol through infographics, reminder communications, and education for clinicians. The initial survey itself also served as a mechanism for raising awareness, as did engagement with senior leadership.
To increase awareness of a local online information resource for managing injuries at home (Wessex Healthier Together), the team engaged with patients and caregivers through infographics in paediatric ED waiting areas and encouraging clinical staff to explain the resource to their patients.
In a first month of measurement there were 120 buckle fractures and 57% were treated with a bandage, up from a 0% prior to the intervention. This led to savings through using a lower carbon footprint alternative (bandages produce 0.1852kg CO2e compared to 0.3535kg CO2e for a splint), and a reduction in ED attendances (13.8kg CO2e).
Outcomes
Clinical sustainability:
Faster return to normality and reduced muscle atrophy when FORCE protocol applied.
Increased standardisation of care.
Environmentalsustainability:
11.5kgCO2e per month; projected to 138kgCO2e a year.
Projected reduction of 125 unnecessary reattendances, equivalent to 20,700kg CO2e across a year.
Financial sustainability:
Monthly saving of £857.17, projected to £10,286 over a year.
Increasing at home management of injuries could reduce unnecessary attendances worth £141,000 a year.
Social sustainability:
Improved confidence for staff managing fractures more sustainably.
Increased confidence for caregivers managing injuries at home.
Key learning point
Increasing awareness of the FORCE protocol has increased the standardisation of care for paediatric buckle fractures and reduced the carbon and financial cost of that care. In bringing about the change in practice, it was particularly valuable to ensure that key decision makers were onboard, and foster word of mouth and ‘shopfloor conversations’ through ongoing education and awareness raising.
The work to increase at home management of injuries revealed that caregivers believe an online resource could reduce the need for reattendance at ED. This highlights the need to focus on patient education to reduce attendances. Further work should be done to promote such resources not only to patients who have presented to ED, but also the wider population.
Team members: Helen Murphy – Trust Waste Facilities compliance manager, Rachael Aitken – Lead nurse for patient support services.
Setting / patient group: Hampshire Hospitals NHS Foundation Trust (HHFT) – all staff and visitors.
Issue
Effective waste management and disposal is crucial to avoid contamination, protect public health, and ensure proper disposal. Healthcare waste must be segregated in accordance with HMT07-01 The Safe and Sustainable Management of Healthcare Waste. This splits waste into specific bags which are then disposed of appropriately. Where an audit of this process is failed, all bagged waste must be incinerated.
After failing such an audit in November 2022, Royal Hampshire County Hospital (RHCH) and Andover War Memorial Hospital (AWMH), incurred penalties accumulatively costing the trust HHNFT an additional £123,763.50 to date.
The aims of the team in response to this issue was to identify why staff are incorrectly streaming waste and educate staff to do so correctly. Doing so would align with trust with waste legislation, reduce additional financial costs, and improve the carbon footprint. The team targeted their intervention on pharmaceutical waste as this was the area with the largest impact and potential gain, but the project likely also reached non-pharmaceutical waste.
Intervention
An initial staff survey revealed staff are confident they can follow the waste management process, and happy that explanatory resources were sufficient. However, most staff answered incorrectly when asked how to dispose of both IV paracetamol bags (63.3% incorrect) and blister packs (60.4% incorrect). The survey was paired with ward walk around conversations that revealed that staff felt waste training was uninteresting, would benefit from in person delivery, and that more signs, posters, and labels, would also be beneficial.
The team developed an interactive game, ‘Bin-Go’, that they toured around the trust’s sites. The game encourages staff to test their knowledge on disposal processes with their teams. Playing along with their colleagues was popular amongst staff, and the campaign was further circulated on social media and through word of mouth. Posters and labels were also designed with bright colours to stand out on busy clinical area walls.
A future initiative is in place to use colour-coded cable ties to identify the clinical area that waste comes from to provide accountability and targeted training in the result of future failed audits.
Outcomes
Clinical sustainability: No impact on patient outcomes.
Environmental sustainability:
A total saving of 196 tonnes of co2e per year through proper disposal and reduced incineration – the equivalent to 41,457 miles driven.
Further reductions are possible by reducing the distance travelled by waste through local Energy Recovery.
Financial sustainability:
Reduction in fines saving an initial £100,800 per year.
Energy Recovery can save a further £58,000 in future.
Social sustainability:
Strong staff engagement through the game, and enthusiasm with more bins being requested.
Increased confidence about waste streaming.
Address patient and public concerns about NHS waste.
Key learning point
The project identified the main barriers staff faced to not streaming waste properly. These included misunderstanding due to lack of engagement with online training, confusion regarding the waste streams available, and the process of identifying the purpose of each bin. It was particularly valuable to bring the training to staff on the wards and encourage learning through a more relaxed game, rather than through a formal online training module.
Maternity care currently uses a high volume of single-use instruments. Such instruments are the largest contributor to carbon emissions for the NHS, with a large carbon footprint across their lifecycle. Single-use instruments were initially preferred due to infection prevention and cost factors.
While the initial upfront cost of reusable instruments appears greater than single use, in the long-term reusable options also bring significant savings. Single-use instruments have also been reported to be inferior to reusables, with items sometimes missing or of poor quality. This provides challenges to staff experiences and can negatively impact patient outcomes, particularly where such kits are required to facilitate emergency births.
Intervention
The team conducted a staff survey of all registrants involved in the facilitation of vaginal births and suturing, including maternity support workers and theatre nurses. The survey aimed to gather perceptions of single use tools, assess staff opinion on a switch to reusable items, and identify the single-use tools that are used the least often. The survey reported consistent issues with a number of single-use instruments, including Episiotomy scissors and Spencer Wells forceps. The Episiotomy scissors were also the least commonly used item in the kit.
Following a meeting with an external supplier, the team consulted the Theatre Sterile Supply Unit (TSSU). Meeting with the TSSU was important to confirm that they could meet the demand of sterilising instruments within a 4-hour window. Once this was confirmed, the team decided to move forward with a business case to support the purchase of new reusable item packs for suture packs, birth packs, and two individual items (Episiotomy scissors and sponge holding forceps).
Outcomes
Clinical sustainability: Can improve care outcomes as staff are using better quality instruments.
Environmental sustainability: Reducing reliance on single-use instruments cuts emissions by 2,869 kgCO2e annually, equivalent to eliminating the carbon footprint of driving 8,453 miles.
Financial sustainability:
Per year this change will save the service £27,692, which can be used to purchase further reusable equipment or hire more staff.
A further £372 will be saved from reduced disposal costs.
Social Sustainability:
Addresses the staff concerns around single use equipment quality.
Meets staff preferences to use more reusable instruments, as 80% of staff are worried about the environmental impact of their work.
Key learning point
Moving toward more sustainable equipment in maternity has significant benefits both for environmental impact and staff satisfaction. Implementing the change relied on strong staff engagement, as was ensuring that equipment can be effectively and efficiently sterilised by the TSSU.
Team members: Melanie Broach – MSK Therapy Team Lead RHCH, Kathryn Cartwright – MSK Therapy Team Lead BNHH.
Setting / patient group: Staff issuing / patient receiving mobility aids across all sites.
Issue
Walking aids have historically been treated as single use items, and after their use a patient was not required to return the devices (e.g. elbow crutches, frames, and sticks) to trusts. In NHS England’s 2020 report committing to ‘Delivering a ‘Net Zero’ National Health Service’, walking aid refurbishment schemes were specifically mentioned. Successfully refurbishing a walking aid produces 87% less carbon emissions than purchasing a new one.
Reuse and recycling of these devices has been in place at HHFT for a few years. However, it is evident that staff and patients are often unaware that returning mobility aids is an option.
Staff in therapy departments (the largest purchaser of mobility aids) are best placed to drive the return, reuse, and recycling of these devices to improve HHFT’s carbon footprint and align with the trust’s sustainability plan. The team hoped to increase refurbishment by 40% in line with NHS England’s stated goal.
Intervention
The team started by issuing a survey to staff to assess their understanding of the returns process, including whether they were even aware that returning devices was possible. The survey revealed a set of barriers to returning devices consistently, including the absence of a clear process, varied advice being given to patients, and a lack of a set assurance process for the quality and safety of returned devices. It was also raised that a designated, accessible, returns location would be beneficial, along with a standardised process for logging issue and returns of devices.
A baseline for assessing impact was developed based on the Basingstoke sites log of returned devices, as this was the only site with a standardised recording process. Further data was gathered from trust procurement to measure annual spend on mobility aids.
A process map was developed which identified the necessary interventions: creation of a log for issued and returned aids; information sheets provided via QR code on how to return devices; a designated returns location at the entrance to each site; and, rolling out training on the cleaning of devices for relevant staff.
Outcomes
Clinical sustainability:
Increased availability of aids preventing delays in providing patients with suitable aids.
A consistent process minimising risk.
Further equipment can be purchased with saved budget.
Environmental sustainability: It is estimated that this project would save 107 kgCO2e per year, the equivalent to driving 315 miles.
Financial sustainability: A 10% reduction in the procurement of aids through increased returns is projected to save £6,844.88 annually.
Social sustainability: Staff and patient satisfaction increase due to positive impact of contributing towards sustainable outcomes.
Key learning point
Communicating with stakeholders was key to the success of this project, ensuring that any changes are suitable for all to have longer term effects. Ensuring the return points were well signposted and located in an accessible area was also important.
Team members: Dr James Kinchen – Consultant Gastroenterologist, Resmi Rajesh, Charge Nurse – Endoscopy Unit, Edit Szabone Kalmar – cellular pathology operational manager.
Setting / patient group: Basingstoke and North Hampshire Hospital Endoscopy Unit.
Issue
Where biopsies are taken during an endoscopy (> 50% of cases), the samples are currently placed in an individual pot containing a preservative solution, formalin. Each sample, including where multiple are taken from an individual patient, requires its own pot. These are then transported to a histopathology lab, where each is then put in a paraffin block that before processing for analysis.
‘Multiwell’ cassettes are also available, that allow for multiple samples to be stored in a single container. This reduces the use of plastic and resources both up and down stream. Less plastic storage is required during the endoscopy and biopsy, and fewer paraffin blocks and glass slides are required in histopathology. These benefits reduce environmental impact, financial cost, and reduce staff exposure to chemicals (fewer formalin pots required), and potentially reduce reporting time by increasing processing efficiency in the histopathology labs.
Intervention
A Standard Operating Procedure (SOP) was developed from a previously trial using multiwell sample cassettes at Winchester Hospital. The team then engaged with cellular pathology and the wider endoscopy team to foster multidisciplinary working. This group collaborated to identify benefits and address challenges arising from changes to the biopsy protocol. For example, it was agreed to exclude cancer patients due to increased risk around sample contamination. Once the new protocol, including the use and consistent labelling of “Multiwell” cassettes, has been finalised, it will be presented for clinical governance sign off, and it will be disseminated to staff, along with the new cassettes.
Outcomes
Clinical sustainability: Reduced reporting times reducing both patient anxiety and quickening a patients introduction to an appropriate treatment pathway.
Environmental sustainability: Reducing use of single sample pots reduces emissions by 4277kg CO2, the equivalent to driving 12,602.
Financial sustainability: The new protocol will save £2.50 per patient, saving £11,400 per year for the Basingstoke Site.
Social sustainability:
Improved efficiency and productivity for pathology teams.
Reduced anxiety for patients as they will have a shorter wait time for biopsy results.
Reduced staff exposure and risk of chemical spills.
Key learning point
The success of this project hinged on the formation of a multidisciplinary team comprising consultants, nursing staff, and laboratory personnel. Equally crucial was the development of a clear standard operating procedure (SOP) and effective communication of the changes to all staff members.
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