The next green pathways: where to apply the ELLA methodology within urology to improve environmental sustainability

Abstract

Introduction:

The National Health Service (NHS) accounts for 4%–5% of the UK’s greenhouse gas (GHG) emissions, approximately 20–25 million tonnes of carbon dioxide equivalent (CO2e) annually. Recognising the increasingly harmful effects of climate change on human health, the NHS aims to achieve net zero GHG emissions by 2045. The Environmental Lessons Learned and Applied (ELLA) methodology, developed and tested by the Getting It Right First Time (GIRFT) programme in the NHS in England, sets out a stepwise process for redesigning a clinical care pathway to reduce carbon emissions while maintaining or improving clinical standards.

Methods:

We reviewed peer-reviewed and grey literature to identify clinical pathways within urology with probable large decarbonisation potential if the ELLA methodology was applied.

Results and discussion:

Opportunities lie in applying the ELLA methodology to uro-oncology, UTIS and outpatient care, catheter care and elective surgery. Suspected cancer pathways and outpatients are some of the highest volume pathways. The highest intensity modifiable hotspots at a per-patient level likely include surgery, particularly robot-assisted. The ELLA methodology guides identification of sustainable interventions through care pathway mapping, rather than focusing on individual procedures. This allows a wide range of potential sustainable improvements to be considered and prioritised. This approach can potentially drive greater reductions in the GHG emissions of urological care and avoid the pitfall of single-action bias.

Conclusion:

We have applied the first steps of the ELLA framework to consider where future opportunities for decarbonisation of UK urology might lie. We have identified several pathways that have either very high levels of activity and/or very carbon-intensive processes. Full application of the ELLA framework to urological pathways can develop pragmatic strategies for decarbonising UK urology practice. We encourage multidisciplinary efforts to advance and build on the ideas raised and form action plans for the ongoing decarbonisation of urological care.

Level of evidence:

Keywords

basic science other oncology core urology endourology

Introduction

The National Health Service (NHS) accounts for 4% to 5% of the UK’s greenhouse gas (GHG) emissions, approximately 20–25 million tonnes of carbon dioxide equivalent (CO₂e) annually. Recognising the increasingly harmful effects of climate change on human health, the NHS aims to achieve net zero GHG emissions by 2045.¹ Surgical care has a very large carbon footprint, and operating theatres account for 28% of hospital waste.^2–6 Inpatient and outpatient urology care in England accounted for an estimated 40 (kilotonnes CO₂e) and 43 (kilotonnes CO₂e) in 2022/2023.³ The Greener NHS programme has supported positive change towards net zero, for example through the reduction in use of hydrofluorocarbon propellant inhalers and anaesthetic gases (36% since 2019), reduced energy consumption (11% since 2019).⁷ However, there is much left to do across broader areas of health care, both in patient-facing care and supporting NHS functions.^7,8

The Environmental Lessons Learned and Applied (ELLA) methodology, developed and tested by the Getting It Right First Time (GIRFT) programme in the NHS in England, sets out a stepwise process for redesigning a clinical care pathway to reduce carbon emissions while maintaining or improving clinical standards.^8,9 The aim is to identify and focus on large modifiable GHG emission hotspots. It involves pathway mapping, evidence review, GHG emissions modelling and engaging an expert interdisciplinary working group with clinical and academic knowledge, as well as patients, to co-design recommendations that can be implemented safely (Figure 1). The GIRFT Greener Pathways guide for bladder cancer identified 12 priority recommendations to decarbonise care across England.⁷

The first step in the ELLA methodology is to select a suitable care pathway, ideally one with large, modifiable GHG emissions hotspots.⁸ The aim of this mini-review is to narratively explore which care pathways within contemporary UK urology practice might offer substantial opportunities for improvements in environmental sustainability if the ELLA methodology was fully applied.

Methods

We reviewed peer-reviewed and grey literature to identify clinical pathways within urology with probable large decarbonisation potential if the ELLA methodology was applied. This involved two connected steps:

Reviewing literature on environmental sustainability to understand where there is pre-existing specific evidence relating to clinical activities in urology pathways.

Reviewing data about the frequency of different clinical activities across urology care in England to understand where the application of generic principles (i.e. the 9 R’s) or specific sustainability evidence could be scaled to achieve substantial decarbonisation.¹⁰

The literature review was conducted using PubMed, Google Scholar and healthcare LCA databases, as well as published NHS statistics, including using the NHS model hospital to identify high-volume clinical pathways.^11,12

Results

UK Urological services assess, diagnose and treat hundreds of thousands of patients each year. Care is delivered in the community, outpatient clinics and through emergency and elective hospital pathways. There are many urological pathways with major opportunities to improve environmental sustainability. The greatest decarbonisation opportunities are likely to be areas where the volume of clinical activity is particularly high (e.g. prostate magnetic resonance imaging (MRI) and biopsy), or where unit activities are particularly “carbon-intensive” (e.g. robot-assisted surgery).

Cross-cutting service configuration

Innovations in care delivery offer to optimise patient care while supporting decarbonisation. Most common urgent and emergency presentations can be managed on ambulatory pathways.¹² Avoidable hospital admissions are currently common. Dedicated same-day emergency care (SDEC) facilitates same-day specialist urology reviews, and emergency “hot lists” can be utilised to provide definitive early primary treatments.^12–14

Outpatients

In the financial year 2023–2024, almost 3 million patients were assessed in urology outpatients.¹⁵ Urology is now predominantly an outpatient specialty, and we only list 1 in 10 patients for surgery. With such a high volume of patients, any scalable decarbonisation opportunities would have a large impact. The use of remote or telephone clinics can improve sustainability by reducing patient travel.¹⁶

Outpatient clinics offer opportunities to optimise conservative and medical management of urological conditions and, when surgery is necessary, set expectations around day-case pathways.¹⁷ Early identification and modification of risk factors can also support improved post-operative recovery time and reduced complication rates. Remote and patient-initiated follow-up offers to reduce “low-value” appointments and travel if implemented effectively.¹⁸

Uro-oncology

Kidney cancer

Approximately 14,000 new cases of kidney cancer are diagnosed each year in the United Kingdom, many in patients >75 years (35%).¹⁹ Most cases are identified incidentally on cross-sectional imaging.²⁰ This can present a clinical challenge, particularly in relation to small indeterminate lesions. Understanding how to safely avoid over-investigation and treatment of renal masses could benefit patients and have a lower environmental impact.

Depending on size, appearance and patient factors, patients with a new localised kidney cancer might undergo surveillance, a biopsy, or proceed straight to radical or partial nephrectomy. These procedures are performed laparoscopically or increasingly robotically, and an increasingly salient current question is whether radical nephrectomy should be performed using robot-assistance instead of laparoscopically, given the extra cost and resources involved. Ablative therapies are increasingly used for small renal masses.^21–23 These offer good oncological outcomes and are likely to have a lower carbon footprint than partial nephrectomy, albeit they do still require general anaesthesia.

Prostate cancer

Nearly 200,000 patients are referred with suspected prostate cancer each year in England. Many proceed to MRI, and ~100,000 undergo biopsy.^24,25 Around 64,000 new diagnoses are made across the United Kingdom annually.^1,26 The prostate cancer pathway can be modified to improve efficiency: avoiding referral of frail patients who will not benefit from investigation and treatment, reducing duplication (i.e. repeat prostate specific antigen (PSA) tests or unnecessary clinic appointments) and straight-to-test referral pathways for those fit for radical treatment.²⁶ Future opportunities include the use of biparametric MRI and performing biopsies under local anaesthetic in an outpatient setting.^26,27

Robot-assisted radical prostatectomy is now ubiquitous across UK urology. It involves substantial resource use and has a very large carbon footprint; however, inpatient length of stay is reduced when compared to open surgery, especially when an enhanced recovery after surgery protocol (ERAS) programme is used.^15,28–31 Single-use equipment and equipment with planned obsolescence are major issues and should be addressed by manufacturers.¹² However, as yet, no comprehensive investigation has been undertaken into how clinical teams can maximally mitigate GHG emissions for robotic urological operations, including prostatectomy.³² Expert working groups could generate carbon reduction action sets to reduce GHG emissions for RAS as much as possible, similar to those developed in the Greener GIRFT bladder cancer pathway guide.⁷

Radiotherapy for prostate cancer requires frequent patient travel, and evidence supporting hypofractionation is increasing.³³ This reduces hospital travel and increases radiation therapy service capacity, maximising the utility of the resources used. The PACE-B trial showed five-fraction SBRT to be clinically non-inferior when given without adjuvant hormones for low- and intermediate-risk localised prostate cancer.³⁴ When considering net environmental impact, however, the higher rate of genitourinary complications observed with some hypofractionated regimens should be considered.

Urinary stone disease

Across the general population, the incidence of urinary stones is 1–2 per 1000 people/year, with 10% of people forming one or more stones in their lifetime. This results in 60,000–100,000 attendances to the emergency department in the United Kingdom per year.³⁵ Of these, approximately 30,000 are admitted to the hospital, accounting for up to 25% of emergency urology admissions.¹⁰ Urinary tract stone rates are increasing with extreme heat events caused by climate change, and stone incidence increases with frailty. This makes stones a particularly salient issue for UK urology services, due to climate and demographic shifts.^36–41

Evidence indicates that stone recurrence might be decreased by more than 50% by improving fluid intake, although there is limited evidence delineating how best to support patients in succeeding in this aim.^42,43 Given the high recurrence rate of stones, however, any fractional improvements in prevention could offer a substantial decarbonisation opportunity. Given the high incidental detection rate of stones on cross-sectional imaging (2.8% of abdominopelvic computed tomography (CT) scans), means of remotely advising and reviewing patients should also be prioritised, enabling efficient care that avoids travel and over-investigation.⁴⁴

A lower carbon acute colic pathway could include inpatient admission avoidance with the use of ambulatory SDEC pathways, offering same day CT kidneys, ureter and bladder and urology review.¹³ Hospital admission in England is estimated to incur in the region of 20–40 kg CO₂e daily, so avoiding this for many of the 74% of patients likely to spontaneously pass their ureteric stone offers substantial benefit.⁴⁵

Access to early (<48 hours) primary treatment of ureteric colic for those likely to require intervention can help to reduce complications, treatment escalation and repeat attendances.⁴⁶ Case selection will be important to avoid unnecessarily treating stones likely to spontaneously pass safely, and local or national data can support informed shared decision-making in relation to this.^45,47 In relation to treatment choice, extracorporeal shockwave lithotripsy (ESWL) has been shown to be non-inferior in comparison with ureterorenoscopy (URS) from a patient perspective for treating both ureteric and renal stones.^48,49 While ESWL requires more treatments on average per stone, it avoids carbon-intensive operating theatres, required for URS. ESWL is, therefore, likely to provide more environmentally sustainable treatment for most patients. The British Association of Urological Surgeons (BAUS) renal colic audit demonstrated higher rates of temporising stent (13%) than those typically present with infection (2%), implying an opportunity to increase uptake of primary definitive treatment and entirely avoid temporising stent insertion in operating theatres.^50,51

Optimisation of intraoperative consumables and theatre efficiency can also support decarbonisation.^52–54 Stone surgery is a rapidly evolving field with ever-growing availability of new surgical devices, particularly single-use products. The environmental impact of such products should be evaluated alongside whether they introduce improvements in surgical outcomes.^55–57

Urinary tract infections

Urinary tract infections (UTIs) account for almost 200,000 hospital admissions per year in the United Kingdom and 1.2 million inpatient days.⁵⁸ The burden of disease is considerable, and disproportionately affects women and older people, with considerable impact on other health issues such as delirium and the ability to live independently. Optimisations in the prevention, detection and treatment of UTIs, therefore, could improve outcomes and reduce net healthcare resource use. Examples include better use of culture-guided treatment, evidence-based treatment selection and duration, and improved uptake of preventive and prophylactic measures across patients managed by urology, general medicine and primary care.^59–61 For patients undergoing urological surgery, proactive and pragmatic testing and decision-making in relation to preoperative asymptomatic bacteriuria and UTI could help to reduce on-the-day cancellations, enabling better utilisation of operating theatres.⁶²

Catheters and incontinence

Approximately 100,000 people live with a long-term catheter in the United Kingdom. Catheter issues account for 150,000 emergency attendances, with more than 1 million community contacts. Patients who attend the emergency department with catheter issues are very likely to re-attend within a month (15%).^13,14,16 The provision of training and secondary care advice and guidance for those managing catheters in the community, such as district and practice nurses, could enable improved troubleshooting and fewer emergency hospital referrals. Equipment used to perform catheterisation, including that found within pre-made catheter packs, is highly variable and often incurs avoidable waste. Development of a consensus “carbon reduction action set” for lean yet safe catheter insertion could reduce carbon emissions.

Many patients will have a short-term catheter placed post-procedure. This does not require them to remain in hospital, as they can be considered for self-removal of the catheter where a pathway is in place, and the patient is deemed appropriate.⁶³ Evidence suggests that the use of multiple in-out single-use catheters over a long-term catheter may not reduce urinary tract infection risk and has a large environmental impact, and that mixed-use catheter management, including an evidence-based cleaning method for the multi-use catheters, was not inferior with regard to UTIs.⁶⁴

BAUS estimates 3 million people in the United Kingdom have urinary incontinence.⁶⁵ Many of these patients do not seek medical support (>60%), and simple lifestyle measures and pharmacological treatment can often successfully manage symptoms in primary care.⁶⁵ One million incontinence pads are used daily in the United Kingdom, and the NHS supports 160,000 of these patients each year with containment products, which are predominantly single-use.^66,67 With an estimated carbon footprint of 0.11 kg CO₂e per pad, that is an approximate annual footprint of 40 kilotonnes CO₂e. Greater public and healthcare professional awareness about the medical and conservative management options for urinary incontinence, as well as the potential surgical management, could improve patient outcomes. This could in turn lead to a reduction in the carbon footprint of the patient’s incontinence management over long time horizons by reducing reliance on disposable pads.

Bladder outflow obstruction

In total, 3.4 million men in the United Kingdom are living with moderate or severe urinary symptoms due to BOO.¹⁹ The GIRFT BOO pathway suggests streamlining of referrals with suggestions for initial general practitioner-led medical management, one-stop initial assessment clinic with access to assessment of flows, post-void residual volumes and flexible cystoscopy.^19,66 This facilitates efficient early decision-making and definitive management. Elective bladder outflow obstruction (BOO) surgery is common and should be performed as a day-case as a default; however, currently, the average rate of day-case BOO surgery is only 25.6%.⁶⁶ A wide range of different surgical treatments exists for male BOO, and while the environmental sustainability of a number of these has been estimated, this evaluation focussed on the devices themselves and did not consider the broader patient pathway and long-term treatment durability.^67,68 Wider pathway evaluation could help to inform patients and urologists about the respective environmental performance of these different modalities, with the information incorporated into patient decision aids.⁶⁸

Penoscrotal surgery

In the United Kingdom, approximately 30,000 patients undergo penoscrotal surgery (circumcision, hydrocoele repair, epididymal cyst excision) each year.¹⁰ Hydrocoeles and circumcisions are routinely performed under local anaesthetic abroad, and high-volume local anaesthetic lists could be adopted widely within the United Kingdom, avoiding carbon-intensive general anaesthesia.

Discussion

This review has identified potential opportunities for decarbonising UK urology practice by applying the first steps of the ELLA methodology.⁵ Meaningful carbon emission reductions can be achieved across urological subspecialities, from prevention and community assessment to outpatients, theatre and follow-up. Suspected cancer pathways and outpatients are some of the highest volume pathways. The highest intensity modifiable hotspots at a per-patient level likely include surgery, particularly robot-assisted.^28,53,69 The ELLA methodology guides identification of sustainable interventions through care pathway mapping, rather than focusing on individual procedures. This allows a wide range of potential sustainable improvements to be considered and prioritised. This approach can potentially drive greater reductions in the GHG emissions of urological care and avoid the pitfall of single-action bias ⁷⁰

Successful implementation of hotspot mitigation strategies requires collaboration and buy-in across the profession. Engagement with patient and clinical reference groups, including input from specialist associations such as BAUS, BAUN and the Royal Colleges, can help achieve clinical consensus, maintain standards and promote patient experience. Multidisciplinary clinical reference groups can ensure that proposed interventions are pragmatic and that they can be sustained. Close collaboration with BAUS has broadened the reach of pre-existing initiatives by hosting national audit against the Greener GIRFT bladder cancer recommendations and by prioritising sustainability through the BAUS sustainability 10-point plan.^8,71 Ongoing support from the association will be crucial in realising the benefits of further guidance development using the ELLA methodology. Recognising and communicating the potential patient (i.e. experience and outcomes) and health-service (i.e. cost and efficiency) co-benefits often afforded by action to mitigate healthcare’s GHG emissions could increase support for these initiatives across the profession.

There is a need for high-quality data to support effective decision-making on a local, regional and national level. Use of model hospital data can be used to “benchmark” local services against national standards and inform change. More studies reliably evaluating the environmental impact of urological management, equipment and emerging technologies would support increasingly comprehensive evidence-based action using the ELLA approach. A demonstration that clinical teams and patients are willing to make treatment decisions based on environmental sustainability should complement the supply chain initiatives undertaken by the Greener NHS and encourage suppliers to measure and improve the sustainability of their products.⁷² Sustainability is an important ground for supplier innovation.

While highlighting pathways likely to be amenable to environmentally sustainable improvement in UK urology, this mini-review is inexhaustive. Future work to apply the ELLA framework more broadly is needed, with national programmes such as GIRFT well placed to support the methodological steps required, along with a broad base of collaborators.

Conclusion

We have applied the first steps of the ELLA framework to consider where future opportunities for decarbonisation of UK urology might lie. We have identified several pathways that have either very high levels of activity and/or very carbon-intensive processes. Full application of the ELLA framework to urological pathways can develop pragmatic strategies for decarbonising UK urology practice. We encourage multidisciplinary collaborative efforts to advance and build on the ideas raised and form action plans for the ongoing decarbonisation of urological care.

Footnotes

Acknowledgements

No acknowledgements.

ORCID iDs

Harriet Louden

William K. Gray

Ethical considerations

There was no requirement for ethical approval of this literature review.

Consent to participate

Ethics approval and consent was not required for this literature review.

Consent for publication

Ethics approval and consent was not required for this literature review.

Author contributions

Conception and implementation by J.J., T.N. and H.L. Data analysis and manuscript drafting by H.L. All authors reviewed the manuscript and approved the final version of the manuscript.

Funding

The authors received no financial support for the research, authorship and/or publication of this article.

Declaration of conflicting interests

The authors declare that there is no conflict of interest.

Data availability statement

Data available through sited resources.

Informed consent

No patient consent was required for this literature review.

Guarantor

J.B.J.

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