Healthcare and Clinical Waste – The NHS in Focus

Wednesday, October 8, 2014

Following on from CIWM’s and Cloud Sustainability’s recent articles on healthcare waste, our CEO Dan Botterill, undertook some research with NHS Trusts and their healthcare waste contractors to gain some insight into the key issues they face.

Below is an article on the findings of this research, which was printed in full in the CIWM Journal Magazine October 2014 edition.

Of all the sectors and industries that are scrutinised over ‘waste’, the NHS in particular is one that can’t help but grab the headlines.  This is hardly surprising given the scale of the organisation and the public and media scrutiny it constantly attracts.

The statistics are quite staggering when you examine the enormity of the organisation.  The NHS employs over 700,000 people, deal with over one million patients every 36 hours and is projected to spend more than £100 billion in 2014.  In sustainability management terms, it’s a beast like no other.

The management of healthcare waste is also a hot topics, and there was an excellent article in last’s months CIWM Journal (September 2014) discussing compliance and categorisation of healthcare waste, with the management of ‘offensive waste’ being the most prominent and potentially divisive issue between the waste producer and the waste contractor.

Following this, I was interested in taking a look at the NHS in broader terms, and examining how ‘waste’ was viewed in sustainability, compliance and operational terms.  We have a number of customers operating in this sector, both NHS Trusts and contractors, and it’s an interesting relationship between the two to comment upon.

We spoke with 20 NHS Trusts and a few of the large waste contractors who service the industry.  We also spoke with the NHS Sustainable Development Unit (SDU) to get its perspective on waste management in the sector, as well as the Department of Health.  This article is designed to provide some insight into some of the key sector issues, rather than communicate the results of a comprehensive analytical survey.

Waste Producer Perspective: NHS Trusts

Our questions focused on four core areas: policy and strategy, performance reporting (waste data and financial), training and compliance.

Policy and Strategy

Of the NHS Trusts we spoke to, more than 75% saw waste as a key sustainability priority.  Once Trust went as far as saying that “waste management is very important correct segregation is our highest priority outside of patient care”.  Other answers vary in significance, with a number also saying that “waste is not taken seriously by the Trust”.

The 75% figure is clearly encouraging, however, in reality many Trusts do feel they have bigger fish to fry, particularly in terms of energy management, which often accounts for more than 15 times the waste management bill (direct waste costs).  The Trusts that prioritise waste generally do so for compliance reasons, although the most common drivers were linked to minimising spend on waste treatment and disposal.

We also asked the Trusts whether they had formal waste policies and strategies in place, with appropriate senior level or board sign-off.  This varied dramatically and, although most of the Trusts reported to have some form of strategy, less than 25% were signed off at board level.

The NHS Premises Assurance Model (RAM) recognises that having a waste management strategy in place is an important factor in the safe and efficient running on an NHS Trust.  Most of the Trusts have waste targets in place that vary quite significantly in terms of their formal or binding nature.  There is predominant focus on diversion of waste from landfill and financial targets, rather than boarding waste hierarchy targets, such as was prevention.

Performance Reporting (waste and financial)

Every year NHS Trusts make annual returns (estates Return Information Collection, or ERIC) to the Department of Health on a range of performance areas; waste is included as one of these headline indicators.

This return is no mandatory for all NHS provider organisations, including established Foundation Trusts.  Based on 2012/13 ERIC returns and the information provided by 281 Trusts within the return summaries, 370,000 tonnes of waste was produced by NHS provider organisations, and the sector spent £86 million on waste treatment and disposal.

It should be noted that the ERIC return summary for 2012/13 is far from easy to navigate, with questionable data collection categories used as headlines, so these figures should therefore be taken with a pinch of salt.  I’d like to present some performance data for the sector based on this return (i.e. recycling and recovery rates) but I wouldn’t be confident in the accuracy, particularly when it comes to ‘energy recovery’.  It is also easy to see how double counting could be prevalent, based on the data fields the organisations are asked to complete.

My conclusion on data is, therefore, that it is near impossible to tell what is actually going on in the sector from analysing the ERIC return! From an organisation perspective, I see how challenging this could be, especially given there is quite a lot at stake in benchmarking terms.  We are informed by the NHS SDU that the 2013/14 categories are much easier to work with, aligning much closer with the waste hierarchy categories (preparing for re-use, recycling, other recovery).  We were also able to speak to the Department of Health NHS Estates and Facilities Policy Division, who informed us that an extensive review of the ERIC questions and reporting mechanism are about to be conducted.  So, if you are an NHS organisation, now’s your time to speak up!


Most of the Trusts reported on compliance being a core issue, but less than 50% said they had systems in place that they would describe as being ‘robust and audited’.  This is an area we didn’t want to delve into too much, as it’s very difficult to comment on compliance without auditing or seeing the information first hand.

The majority of Trusts we spoke to didn’t subscribe to any compliance update services, but generally relied upon information from their contractors, or the likes of CIWM or the NHS National Performance Advisory Group (NPAG), to keep them suitably informed on waste legislation.

It was apparent from our conversations that those Trusts that had staff in more formalised waste management roles were the most confident when it came to determining their compliance position.


Training was raised as a key issue by all of the organisations we spoke to.  All of the Trusts rely on ‘face-to-face’ training with varying levels of success.  Only 10% of the Trusts have made use of other forms of training, such as online tools.  One Trust stated that the “NHS is desperate for consistent waste management training”.

Due to the number of staff within a Trust, it can be very difficult to access them all and dedicate a suitable amount of time to the subject.  Many of the Trusts relied on waste management training to be included as part of their induction or mandatory infection control training programmes.

The Waste Contractor Perspective

Waste Contractors have needed to react to some significant healthcare sector changes in relation to waste management practices in recent years, mainly due to the introduction of waste pre-acceptance audits and more of their clients looking to segregate offensive waste streams.

Pre-acceptance audits and more detailed guidance has generally resulted in an overall improvement in waste management practices and, indeed, better levels of waste segregation.  However, to counter this trend the waste contractors have had to deal with a number of issues regarding the poor implementation of offensive waste management procedures in the Trusts.

Financial savings are a key drive for many, and segregating offensive waste from clinical waste is an area that creates significant opportunity.  Some Trusts don’t always appreciate, however, that there isn’t always a convenient site nearby that can accept offensive waste and that transport and logistics are a major financial consideration that need to be accounted for.

Where energy recovery is possible for an offensive waste, contractors also feel that their clients should consider the waste hierarchy with energy recovery being preferable to landfill disposal.

In some cases NHS Trusts have looked to segregate offensive wastes without first conducting appropriate risk assessments and training.  This can have disastrous consequences resulting in contaminated loads and associated environmental, compliance and health and safety risks.  It can also lead to a much greater financial cost to the Trust itself.


When looking at the sector from a waste perspective, once thing becomes very clear.  The management of waste is not about being green or about corporate responsibility drivers, it’s about cost rationalisation ad saving money.  I don’t think the NHS is unique in this way; this a common position across the country.  I do, however, feel this is dramatically emphasised in the NHS.

What’s missing for me here is that waste management is essentially viewed as a fire fighting exercise.  It is accepted that waste will be produced, and therefore all effort is focused on making this waste ‘disappear’ at the mots minimal cost to the organisation.

‘Waste’ can be viewed in a variety of ways but little, if no thought appears to be going into understanding what this waste is, why it exists and what can be done to minimise its production.  It’s easy to sprout the common lines about waste being a valuable resource, but this is plain lazy as far as rationalisations go.

Although the NHS SDU conceded that reducing waste to landfill is the core high level message being promoted, it also recognises that waste is more ethereal and ca be described as something that does not fulfil its full potential value. 

I’d personally like to see that last sentence as the basis for a sector strategy.  It’s far more meaningful, ambitious and will deliver considerably greater savings than current focus, which is at the bottom of the waste hierarchy.

The NHS is keen to save money.  We understand that.  We would, however, urge a longer term view here; to view waste as a procurement and efficiency and invest to save.

Original Article from CIWM Journal Magazine, October 2014 edition. 

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