Environmental sustainability projects in radiotherapy in the UK

Centre

University Hospitals Birmingham, Birmingham

The issue(s)

1) Production of paper for plan approval purposes.

2) Limited access to planning systems (no remote access).

The Solution(s)

1) Moving towards a paperless solution.

2) Providing Citrix / Remote access to systems.

The Impact(s)

1) >£1,000 per 3 months cost of cartridges for printing.

2) Time / cost savings from working at home for planning related work.

What next

Consent forms to be moved to electronic form (so patients can sign electronically) - trust wide project.

Centre

Mount Vernon Cancer Centre, Northwood

The issue(s)

We don't know the carbon footprint of brachytherapy

The Solution(s)

Two posters presented on carbon footprint of brachytherapy in local department (UK Prostate Brachy user group, and STEF) which resulted in UK-wide audit group forming to audit and report back on brachy footprint and waste generation for UK Prostate Brachy user group 2024 meeting.

The Impact(s)

Still in progress but aim is to find the hotspots of brachytherapy treatments so we can hope to focus efforts to reduce them.

What next

Need to analyse data, and work on reducing the carbon hotspots. Likely areas where progress can be made include theatres and waste streams from brachy; possibly also engaging source manufacturers.

Centre

Clatterbridge Cancer Centre 

The issue(s)

We don't know the carbon footprint of brachytherapy.

The Solution(s)

We have submitted data to the Mount Vernon Cancer Centre brachy footprint audit which also serves us as baseline data for Cervix, Prostate and Vaginal Vault Brachy.

The Impact(s)

Collaboration with others on nationally driven projects.

What next

Base line data acquired. Some small scale improvements already completed and plans to address other issues highlighted. Combine with other CO2e studies in RT at our centre to provide a carbon footprint of the whole radiotherapy service.

Centre

The Christie NHS FT, Manchester

The issue(s)

We need to know the carbon footprint of external beam radiotherapy to enable us to find the hotspots and start trying to reduce them. 

The Solution(s)

Were awarded nearly £10,000 by the North West Greener NHS Innovation Fund to estimate the carbon footprint of the radiotherapy pathway. We then joined up with 3 other centres to start to estimate the variation across centres too.

The Impact(s)

The results have now been published here:  https://doi.org/10.1016/j.ejmp.2023.102652

What next

Focus on increasing the use of hypofractionation.

Centre

CCC

The issue(s)

We don't know the carbon footprint of our external beam radiotherapy service and how that compares to other radiotherapy services across Europe.

The Solution(s)

We are contributing to the international ESTRO carbon footprinting of external beam radiotherapy project, and will use this data as baselining and for hotspot analysis to identify where significant carbon reductions can be made.

The Impact(s)

Highlight the carbon footprint of the service and identify areas for the largest reductions in CO2 emissions. Provide baseline data and contribute to the first Europe wide study of CO2 emissions in radiotherapy.

What next

Collect data and submit to ESTRO project team. Use results as a baseline to benchmark against published UK data and for future work. Combine with other CO2e studies in RT at our centre to provide a carbon footprint of the whole radiotherapy service. Implement identified ways of reducing CO2 emissions.

Centre

The Christie NHS FT, Manchester & Clatterbridge Cancer Centre

The issue(s)

We need to know the carbon footprint of proton beam therapy (PBT) to enable us to find the hotspots and start trying to reduce them.  

The Solution(s)

A carbon footprint project is underway comparing the carbon footprint of low-energy PBT for ocular tumours at the Clatterbridge Cancer Centre with that of the high-energy PBT centre at The Christie.

The Impact(s)

Project on-going

What next

On-going.

Centre

Mount Vernon Cancer Centre, Northwood

The issue(s)

No funded staff time provided from Trust to look into sustainability of centre.

The Solution(s)

Attracted charity funding to employ one person 1d/w for 1 year as a Centre for Sustainable Healthcare (CSH) "Sustainability Scholar" to work specifically on perceived sustainability issues within the centre.

The Impact(s)

Funding in place, appointment made; start date should be end 2023

What next

Dedicated person to focus on sustainability issues with the centre.

Centre

Mount Vernon Cancer Centre, Northwood

The issue(s)

Widespread leaving of equipment and air con turned on over weekends and overnight.

The Solution(s)

Staff awareness increased; portable power meter used to identify equipment taking most unnecessary power.

The Impact(s)

Measurements showed that screens rather than PCs are worst offenders - some old ones up to 80W per screen without sleeping when blanked. Not quantitative (wish I had done that!) but noticeable that fewer screens now left on overnight.

What next

Planning to roll this out as Trust-wide initiative.

Centre

Mount Vernon Cancer Centre, Northwood

The issue(s)

Volume of Personal Protective Equipment (PPE) used

The Solution(s)

Initiated large (rapidly became Trust-wide) project to attempt to minimise single-use PPE, along with colleagues from Theatres. Suggesting both minimisation of unnecessary PPE use (see the GOSH "Gloves Off" initiative) and potential business case for introduction of re-useable PPE.

The Impact(s)

Very long project, still at planning stage. Re-useable PPE may be possible, but introducing it involves infection, prevention and control (IPC), Procurement, and Estates, and is a long process. So far we have established support in principle from all parties. Working on business case now. Also just realising that with the relaxation of IPC rules from COVID, there is a lot of "habit"-based excessive use of PPE, contemplating how we would frame communications to make staff more mindful of the need not to create excessive waste.

What next

Business case, communications, lots of meetings and emails but we have support from all parties. Limiting factor is that there's no funded time for this project.

Centre

Mount Vernon Cancer Centre, Northwood

The issue(s)

We are lucky to have large areas of green space outside our buildings, but these were rarely used by staff or patients.

The Solution(s)

Appointed "Nature Recovery Ranger" through Centre for Sustainable Healthcare (CSH) with specific mandate to make greenspaces accessible to staff and patients for wellbeing, as well as increase biodiversity on site and preserve greenspaces themselves.

The Impact(s)

Large recognition from staff community as to value of greenspaces. Many staff take lunch or other breaks outside now that access has been improved. Staff have become involved in caring for green spaces. See talks given by Karen MacKelvie to NHS Forest conferences.

What next

Post extended twice. More of the same this year; probably also would like to encourage more patient use of greenspaces (in addition to staff).

Centre

Mount Vernon Cancer Centre, Northwood

The issue(s)

Low awareness of Greener NHS and net zero targets among staff; also low awareness of what each of us can do to help.

The Solution(s)

Talks given at all-staff meetings; training package written for Trust learning hub; time has been allocated at staff induction meetings; posters displayed by canteen for a while.

The Impact(s)

Probably more awareness and discussion now; a new staff survey currently being designed which will quantify this.

What next

Planning specific talks to be given at radiographer staff meetings.

Centre

Cambridge University Hospitals NHS Foundation Trust (Addenbrookes Hospital)

The issue(s)

We have 3 different linac manufacturers represented within our vendor neutral department and we wanted to know which linacs used the most energy. We also wanted to know if it was cooling, or the actual linac which consumed the majority of the energy.

The Solution(s)

Energy readings were taken at the same time of day on all linacs over a couple of months. While the type of patient treated on each unit varies it can be seen where the energy is being consumed on each unit.

The Impact(s)

Energy measurements taken.

What next

Once the older units are replaced the process will be repeated with the newer units, to compare. The hope will be that this will help inform choice of machine purchase in the future if there is a choice between units which perform equally, but one is more energy efficient. It is hard to know where the project will go next, but without baseline data nothing can change.

Centre

Cambridge University Hospitals NHS Foundation Trust (Addenbrookes Hospital)

The issue(s)

We are looking at the sustainability of returning lead pots to the supplier vs smelting e.g. what is the carbon footprint of returning lead to the supplier in the US for reuse vs. smelting locally.

The Solution(s)

The physicist in charge is contacting the supplier to work out the carbon footprint, and contacting the local company that is used for recycling here.

The Impact(s)

The project is on-going

What next

We will change our process dependent on the outcome of this project.

Centre

Royal Marsden NHS Foundation Trust, Sutton

The issue(s)

Single use plastic cups used by patients to fill their bladder for radiotherapy sessions. Estimated about 60,000 annually.

The Solution(s)

Re-usable drinking bottles that can be used at every treatment session and recycled in the patients' home curb-side recycling when no longer required.

The Impact(s)

Reduction in the use of single use plastic cups in the department. Published results can be found here: https://doi.org/10.1016/j.tipsro.2021.04.001

What next

There were additional benefits to the patients and radiotherapy service in an improvement in patient compliance with bladder filling. The percentage of optimally filled bladders increased compared with before the implementation of the project.

Centre

The Christie NHS Foundation Trust, Manchester

The issue(s)

Staff travel from home to site

Staff travel to district general hospitals

Patient travel to hospitals

The Solution(s)

Online MDT arrangements.

Remote radiotherapy contouring, and radiotherapy bookings and approvals.

Telephone consultations, video based consultations.

Postal medication delivery option to coincide with remote consultations.

Patients offered blood test closer to home options

Car share arrangements and not driving options encouraged amongst staff regularly

The Impact(s)

Reduced travel.

What next

Expand patients treatment closer to home by expanding slots in satellite radiotherapy (https://doi.org/10.1016/j.ipemt.2023.100021 ) and chemotherapy centres

Centre

Weston Park Cancer Centre, Sheffield

The issue(s)

Patient journeys for radiotherapy are a huge part of the carbon footprint for radiotherapy services.

The Solution(s)

In Sheffield, our cancer charity provides daily minibuses from three locations around our catchment area.  https://www.westonpark.org.uk/transport-service

The Impact(s)

I'm looking in to whether we can put some figures on how much carbon is being saved.

What next

Investigating working with the charity to get some data on how much difference this has made.  Hopefully this will incentivise our organisation and others to follow a similar route.

Centre

Royal Cornwall Hospital, Truro

The issue(s)

High usage of face masks during the pandemic

The Solution(s)

RCHT was the first Trust in the UK to start recycling face masks.

The Impact(s)

Recycling essential PPE

What next

Any projects considered to improve the situation. 

Centre

Cambridge University Hospitals NHS Foundation Trust

The issue(s)

Use of plastic cups in water dispensers

The Solution(s)

Move to paper based material

The Impact(s)

Too early to say as only just changed

What next

None planned at the moment

Centre

University Hospitals of North Midlands, Stoke-on-Trent

The issue(s)

Paperwork in the department

The Solution(s)

We have gone paperless

The Impact(s)

Less paper around the department.

What next

None planned at the moment

Centre

Queens Center, Hull University Teaching Hospitals NHS Trust

The issue(s)

1. High energy usage

2. High use of paper & printing

3. Plastic cups

4. Plastic single use jugs

5. High pharmacy bills

6. Polyroll (paper towel) high usage

7. Printing of leaflets

The Solution(s)

1. Implementation of Halcyon machines

2. Paperless department

3. Reusable water bottles for bladder fillers

4. 'Pulp' jugs

5. Moisturizer only given to high risk patients and repeat upon request

6. Upper body modesty gowns

7. QR codes are available for patients and carers to scan & tv screens display relevant information

The Impact(s)

Reduction in costs

What next

None planned at the moment

Centre

Royal Marsden NHS Foundation Trust - Sutton and Chelsea

The issue(s)

1. Treatment cards, paper referrals and associated paper forms were in use for each patient creating a large amount of paper usage and storage requirements with the risk that it could go missing by being misfiled etc.

2. Plastic cups used for bladder filling prior to planning CT scan and treatment - if patients needed 2 or 3 cups of water they would often use 2 or 3 cups.

3. For male sarcoma patients there is a requirement to often dress their genitalia away from the treatment field which can require the use of paper/bandages/tape, generally used as single use.

4. The amount of paper towel that is used to cover the CT/treatment couches for each individual patient.

5. The number of pieces of equipment, including computers and monitors, left on overnight. This in part can be caused by hot desking and people not knowing if they are the last one out type of situation.

6. Not recycling all items that could be recycled due to lack of provision for recycling.

7. Single use takeaway cups and containers used in the canteen.

8. Single use plastic cups available for patients and staff to use at water fountains, the plastic cups were not recyclable.

9. Being a Trust on multiple sites and also with the radiotherapy department across two sites there was a lot of inter-site travel.

10. More than one cannula/butterfly used for a patient with multiple appointments on the same day.

11. A lot of cardboard and other packaging which is waste.

12. Broken equipment such as chairs need replacing.

13. Washing up liquid being bought, used and then the empty bottles being either put in for recycling or worse the normal rubbish from the Radiotherapy staff room/drinks making areas.

The Solution(s)

1. From March 2023 the department is now virtually paperless utilising appropriate digital solutions.

2. Reusable plastic bottles are provided to each patient required to complete bladder filling. The bottles have the number of cups marked on them as a scale and the patients can keep and use the refillable bottles after their treatment has completed.

3. A study is being undertaken on the use of the ‘Ting-Sling’ which is a reusable pouch to dress the genitalia away from the treatment field.

4. Currently only in Cyberknife, when patients are fully clothed they no longer use paper towel on the couch.

5. Main items of equipment do get turned off overnight and people are encouraged to turn off computers and monitors.

6. Recycling bins are provided by the Trust in communal areas and one radiographer has recently started providing a collection point in Radiotherapy staffroom/drink making facility areas to collect packaging, such as crisp packets, that have to be taken to a supermarket for recycling.

7. This is a Trust wide solution with the gifting to staff recently of Marsden Charity reusable cups during a recent well-being/thank you week. This with the already in place price discount for using a reusable cup for drinks and reusable container for food to be taken away from the canteen has encouraged the use of reusable items.

8. The Trust carried out some research into alternatives to the plastic cups and originally introduces paper cones that could be recycled but these could not be stood down and those with mobility issues found them difficult to use, a compostable cup has now been introduced.

9. The use of electronic meeting facilities via Teams has allowed the use of e-meetings.

10. Ensure that any other appointments are known about and reviewed for a patient who is to have contrast at CT to ensure that maximum use is made of any cannulation equipment e.g. for blood tests, other appointments needing IV access e.g. contrast enhanced MRI.

11. Several people in the department will take cardboard and other packaging material, including cardboard tubes from paper towel, to use for craft work with children’s groups/schools.

12. Waste Management run a Trust wide furniture reuse store which has recently been made official although prior to this if you needed something such as replacement desk chairs you could put in a request and if the item was not urgent and not too specific in design, they would let you know when they had some that had been sent to them for disposal. Radiotherapy have in the past managed to obtain six desk chairs for the clinicians outlining room which were destined for disposal, the chairs are still in use a couple of years later. 

13. Bottles labelled ‘not to be thrown away’ and one radiographer refills them with washing up liquid when required. The washing up liquid is obtained from a local distributor who, with their suppliers, operate a closed loop system meaning all containers are reused.

The Impact(s)

1. A very large amount of paper and card are saved from having to be physically stored and then when legally appropriate being confidentially destroyed. Added benefit that important documents can no longer really go missing. Also provided more efficient use of time for members of staff who no longer have to move the paper versions from area to area.

2. A number of individual disposal cups are no longer used by patients required to fill their bladders prior to treatment although they sometimes forget their bottle.

3. The ‘Ting-Sling’ is a reusable pouch and although mainly being instigated for patient experience it has the added benefit of being reusable and therefore reducing the use of single use items such as paper towel, bandage and tape.

4. Less use of paper towel.

5. Energy saving if equipment is turned off overnight as this is often a longer period of time than the time they are actually used during the working day. Even in a powered down state their will be some underlying resource usage.

6. Items are recycled both those that the Trust will recycle and also those not currently recycled by the Trust such as crisp packets. Less material going to landfill.

7. Less takeaway single use disposable cups and food containers are used and going to landfill which also reduces the amount and cost to the Trust.

8. Single use cups can now be composted.

9. Less travel by staff members so better environmentally. Improved communication as even short catch-up meetings/discussions can be held including the ability to share screens etc. Staff can set up their own Teams meetings where as previously conferencing facilities were only available in a few rooms and booking was difficult and then quality of sound etc was minimal.

10. Main reason for doing this is for patient experience but it has the added benefit of reducing resources used and thereby clinical waste created.

11. Reusing cardboard and other packaging keeps it out of the waste stream and allows reuse/repurposing, saving money on waste disposal for the Trust.

12. Equipment that was in working order and still has life can be reused to reduce waste and also cost. The Trust also donates equipment it cannot reuse to appropriate charities.

13. Many plastic bottles have been saved from having to be purchased which means they have not been added to the waste stream. This has also supported a local business.

The new NHS national uniform if introduced has potential to be a large contributor to waste and impact of the production of new uniforms on the environment depending on whether it is a complete change for a department in one go or as people need new uniforms. This is without considering the impact of the cost of any such change. Current uniforms also come individually wrapped in plastic so perhaps there needs to be work carried out with suppliers to reduce the amount of unnecessary packaging, I would think most people wash new uniforms before wearing them.

What next

1. Final few pieces of information for patients which are currently not available electronically need to be made electronic versions so that where patients can receive electronic documents and they wish to do so then these can be provided in a paperless format.

2. Nothing planned but it would be good to know if there is a better solution than the plastic bottle as although it has reduced plastic cup usage, and can be used after treatment in day-to-day life, it is still plastic. The graduation of cups on it is an important feature as some patients do their preparation prior to arrival in the department.

3. Study is on-going.

4. Work to be carried out looking at potential for using less paper towel, need department agreement to a standard for use and maybe also approval from Infection Control, might also need to check on how patients view an uncovered couch depending on area being treated/what area of the body is unclothed etc. Currently couches not only have the paper towel but are wiped down between each patient. Be interested to know what the policy is in other departments for both couch cleaning between patients and use of paper towel.

5. Need more of a campaign to remind people to turn of computers, monitors and smaller items of equipment. Find solution, if possible, for some items that are currently not switched off overnight due to either request of manufacturer or to solve problems that have experienced. Encourage people to not only turn off their own computer/monitor but to see what else might have been left on in the room, people can be good at the former but not on the latter.

6. There is a need to check the location of recycling bins is appropriate and that there are enough of them as if it is difficult to do then people will just use the nearest rubbish bin. May need to provide recycling bins in control areas or perhaps move normal waste bins so they are no more convenient than recycling bins in location. Number of bins needs to be considered with time to empty them for the cleaning contractor. Food waste is not currently recycled anywhere outside of catering and could be looked at within department staff room/drink making areas but would need wider Trust involvement/input into a solution. Need to ensure everyone knows what can be recycled via the Trust recycling as this is not always very clear.

7. Continue to promote and encourage the use of reusable containers with staff and also find a method of encouraging patients to do the same and letting them know of discounts if they do.

8. If patients and staff can be encouraged to bring a reusable cup then less cups of any type of single use will be the result.

9. No further work/development planned.

10. No further work/development planned.

11. Always seeking ideas of what different packaging and other clean waste materials can be used for.

12. Reminding people in Radiotherapy that before ordering new items of furniture, such as chairs, a check should be made with waste management and their furniture store.

13. Continue the provision of refilled washing up liquid bottles and potentially include some areas outside of the Radiotherapy department.

Many are keen to look at the use of gowns as the current practice is to give each patient that needs to change a clean gown each time. There needs to be some work carried out on this as Infection Control would need to approve of any changes, we need to be able to cover patients during scanning and treatment and we need to be sure of no metal for MRLinac (MRL) treatments which makes using patients own provisions more challenging. We need to look at whether a patient being provided with a hospital gown at pre-treatment, keeping the gown for each appointment and then returning it would be acceptable to the Trust Infection Control team. May need to consider the cost of washing daily gowns versus the cost/risk of losing a few that patients may forget to bring back and whether the Trust accepts this.

Centre

CCC

The issue(s)

1. High use of paper, printing and scanning of documents

2. Plastic cups used for bladder filling for planning CT and treatment (3 cups each time)

3. Single use plastic cups available for patients and staff to use at water fountains, no recycling bins for the cups

4. Intersite travel

5. Service is provided over 3 geographical sites

6. Plastic covers on chin straps/mouthbites

7. Printing of leaflets

The Solution(s)

1. Paperless department including consent, NEWS2

2. Trial of refillable water bottle for RT prep

3. Notices to advise to reuse the same plastic cups/ paper cups will hopefully be available at one site

4. Remote working for staff where possible, some staff groups have hybrid working.

5. Staff assigned to 2 nearest geographical sites to reduce travel

6. Removal of these

7. All leaflets available on CCC internet

The Impact(s)

What next

Better options for recycling, review PPE