What Does a Sustainable Medical Device Look Like? It Looks Like the Future

The word sustainable seems to be everywhere at the moment. Every international conference wants it in its title, and it is frequently found alongside another favourite, innovation.

However, the word sustainability is often used without regard to its full meaning. It is regularly used in reference to financial sustainability. But it is questionable whether anything can be truly financially sustainable if it is not socially and environmentally sustainable, as well.

Many medical device manufacturers recognise the importance of environmental sustainability. Perhaps less obvious is the increasing recognition of its importance on the demand side among healthcare purchasers, providers and regulators.

Drawn up by the NHS Sustainable Development Unit, the Route Map for Sustainable Health is divided into three domains: behaviours, standards and innovation.

This article describes the work of the National Health Service Sustainable Development Unit [5] (NHS SDU [5]) in England and considers what the future might look like as we move to a more environmentally sustainable healthcare system in England and globally. The article goes on to outline the potential benefits of industry/healthcare provider collaboration in developing more sustainable medical devices and healthcare.

Low-carbon healthcare
At the NHS SDU, our aim is to help the NHS in England fulfil its potential as a leading sustainable and low-carbon healthcare service. We do this by the collaborative development of organisations, tools, policy and research that will enable the NHS to promote sustainable development and mitigate climate change.

We have been predominantly focused on the challenge of climate change and carbon reduction while recognising the importance of other environmental, social and financial aspects of sustainability.

In 2011, we published a Route Map for Sustainable Health [6]. This report was developed after dialogue and engagement across the whole healthcare system. It laid out a vision for a future sustainable health system.

Many transitions were identified as important. These included a shift to integrated decision making that accounts for the impact of decisions on society and nature now and in the future. The “Route Map” was divided into three domains: behaviours, standards and innovation.

Of particular relevance to the medical device industry was the recognition that investment in sustainable technology is needed and that the system would need to value environmental impacts and take these into account during the decision-making process.

Earlier this year, we published an updated NHS England carbon footprint— “Sustainability in the NHS: Health Check 2012 [7]”—as part of the report. Overall procurement is thought to be responsible for 65% of the NHS footprint. Only the pharmaceutical industry and business services sectors are thought to contribute more than medical devices to the procurement footprint. It is estimated that medical devices and equipment used in the NHS have an annual footprint of 1.6 million tonnes. This is why reducing the environmental impact of medical devices and pharmaceuticals is a priority for the NHS.

Key metrics
What does a sustainable medical device look like? we ask in the headline of this article. Well, there is no easy answer to this. Most would agree that environmental and social harms related to the product would have been minimised. There is no right answer to what dimensions of sustainability should be considered. At the NHS SDU in England, we have started with carbon footprinting as the key measure. However, we do recognise that there are many other important aspects such as water usage or pollution, and social measures such as the effect of industrial working conditions on local communities. Elsewhere the focus has been more on these other measures.

From the perspective of a consumer wishing to take responsibility for the impact of his or her choices, it is necessary to have a transparent lifecycle assessment of a product. One important consequence of taking a lifecycle perspective is that it puts an onus on the user organisation to participate in determining the impacts, as the assessment includes in-use and disposal phases. We recognise that this is not currently well measured and reported in the NHS. The use phase of some products may already be well characterised for health and financial impacts. For example, in the United Kingdom this informs economic modelling in health technology appraisal by the National Institute for Health and Clinical Excellence (NICE). In the future, this modelling could be expanded to develop an understanding of in-use environmental effects.

SDU and the medical device industry
The NHS SDU has been building a collaboration that brings together leading companies in the pharmaceutical and medical device industry with leading public sector organisations to agree on the most important steps in moving to a more sustainable healthcare system.

An early priority identified by both manufacturers and NHS/public sector parties is the need to have a standard method for describing the environmental impact of products. This will better inform efforts to reduce the environmental footprint within industry and during the use and disposal phases. This also will have the potential to allow consumers—purchasers, clinicians and patients—to understand the effects of their choices. So a project is in development to turn existing nonspecific global carbon footprinting protocols into sector-specific guidance for pharmaceuticals and medical devices.

There are several other lines of work, which the SDU has not developed yet, that could be explored in the future. One could focus on the disposal phase of devices to better understand the role of reprocessing and the value this could bring if better facilitated. Another could focus on understanding how environmental footprinting information could be used by consumers of medical devices. Substantial dialogue is needed across the health system with clinicians, patients, policy makers and regulators as well as industry to agree on this. This is a conversation that is increasingly occurring across the NHS. Nonetheless, a clear necessary first step is the development of sector-specific guidance and product rules for carbon footprinting drugs and medical devices. So this is where we have started.

The role of the manufacturer
Manufacturers already know the reputational and economic arguments for becoming more environmentally sustainable. Perhaps less well recognised are the benefits that will come from the greater collaboration upon which future sustainability depends. Medical device manufacturers are central to efforts to reduce the environmental impact of the NHS. Mutual understanding and dialogue between manufacturers and medical device purchasers, users and regulators are needed if our sustainability goals are to be achieved.

There are three potential benefits to greater collaborative working that we have learnt from our discussions to date:

• At the NHS SDU, we encourage engagement in collaboration to establish a global sector-wide agreement on how to measure the carbon footprint of devices in a standard way. This must meet the needs of the manufacturer and the purchasers. The outputs of this process not only will help consumers understand the impact of their choices but, as importantly, will help manufacturers to better understand their products quickly and cost efficiently.
• Understanding the lifecycle footprint of products will necessitate closer relationships with healthcare providers to understand the in-use impact of products. Greater understanding of the use phase should help manufacturers develop better products for patients.
• Through cross-system collaborative working, medical device companies can better understand the potential for reshaping their business models for the sustainable 21st century healthcare system. In some cases shifting to a service rather than product-based approach may be beneficial both for manufacturers and the quality of patient care. This is particularly the case for products where there would be value in manufacturers operating a cradle-to-cradle service that allows efficient reprocessing and reuse of materials.

So, what next?
The issue of sustainability may well be the defining issue for both healthcare and industry in the 21st century. The challenges of climate change are substantial. But this is also a great opportunity for us to redefine how we work together to create a sustainable healthcare system.

Creating sustainable medical devices does not just depend on manufacturers changing their processes. It depends on the whole health system re-examining how it describes products, how it uses and disposes of products and how the various elements work together. 

At the SDU we have worked hard with manufacturers and healthcare organisations to identify where greater collaboration will be helpful. We will keep doing this. If we are to create a sustainable healthcare system, collaboration will be a key part of this transition.

James Smith, MRCGP (UK),
is Public Health Registrar, NHS Sustainable Development Unit, Victoria House, Capital Park, Fulbourn, Cambridge CB21 5XB, UK
tel. +44 1223 597 614
e-mail: karl.heidel@sdu.nhs.uk [8] (Communications Manager)
www.sdu.nhs.uk [9]