Sustainability is a major challenge for the NHS, which must decarbonise while also maintaining patient safety, a balance few organisations of its size and complexity face. A large proportion of the organisation’s emissions come from heating water to high temperatures as a safeguard against infection. Water, waste, and building energy contribute 15% towards the total carbon footprint and reducing these emissions without compromising infection control or patient safety is a complex task requiring collaboration and innovative thinking.
This was the challenge presented to experts from across the healthcare sector that Armitage Shanks brought together for the 2024 Water Safety Forum, hosted at the manufacturer’s London Design and Specification Centre in Clerkenwell. Chaired by Elise Maynard, a director of the Water Management Society and an independent microbiologist, the discussion was led by the question: How can the drive to net zero in the NHS be compatible with safe water delivery?
The following experts attended the forum:
- Elise Maynard (Chair): A director of the Water Management Society and an independent microbiologist
- Professor Elaine Cloutman-Green, Consultant Clinical Scientist, Infection Control Doctor and Deputy DIPC at Great Ormond Street Hospital, Honorary Professor at UCL, and Chair of the Environment Network
- Greg Markham, Estates and Assets Director at Serco Health, Chartered Engineer and Estates professional, past president of IHEEM
- Terry Moss, New Product Development Leader for Non-Residential Fittings at Ideal Standard
- Peter Orendecki, Contract and Support Manager and Water Responsible Person at University Hospital Southampton
- Steven van de Peer, Head of Authorised Engineer Services at Tetra Consulting and Lead Author of CIBSE KS21 rewrite
- Alyson Prince, Nurse Consultant IPC in the Built Environment
- Steve Vaughan, Technical Director of Public Health Engineering and Fire Protection at AECOM and past chair of CIBSE SoPHE
- Richard Wainwright, Programme Manager and Senior Authorised Person at CBRE
Understanding the challenge
One of the key challenges for water safety and sustainability teams is collecting the data needed to identify where water and heat are being wasted. The Forum heard that hot and cold water usage currently isn’t measured consistently across the NHS, with different trusts and sites using different monitoring systems and technologies. This makes good practice hard to benchmark and limits what trusts can learn from one another when it comes to improving water efficiency and safety together.
Participants raised the comparison between water and sustainability data and clinical data, which is more readily available and more heavily scrutinised. The manner in which clinical data is collected and analysed provides a great example model of what needs to be followed with water data to find opportunities for marginal gains in efficiency. It's not just the lack of data that’s hindering sustainability efforts; many water safety teams are working with outdated data feeds, and without an accepted baseline, each trust ends up starting from scratch. This is further exacerbated by a lack of standardised collection and analysis procedures, against which progress can then be measured.
The panel also highlighted a drawn-out process of turning insights from data into new design guidance – if annual data is published for the previous year, and guidance takes a year to be drafted, the source data is two years out of date by the time insights are put into practice on projects. In a fast-moving sector where new solutions are coming to market regularly, this delay means new projects are consistently behind the curve.
Real-term design
Water safety teams are no strangers to the questions of human psychology and behaviour that come with the design of healthcare facilities, and these questions are just as important when it comes to designing for water economy, led by one key question: How will people actually use these facilities? To get the full picture, all those utilising the facilities should be consulted, bringing the expertise of multi-disciplinary teams to the forefront of the design process, including water safety and construction professionals, cleaners, maintenance teams, and of course clinicians.
Without this broad input, efforts to increase water efficiency could come into conflict with water safety. One example raised at the Water Safety Forum was removing basins in patient bedrooms where there is already one in the bathroom. While this would save on water and maintenance costs, it could also introduce severe clinical risks, encouraging clinicians, patients, and visitors to wash their hands in basins where patients brush their teeth. This is an example of how human behaviour often isn’t factored into the design of facilities.
It raises the issue of collaboration, but also sheds light on the necessity of broad, deep competence from everyone on the team, on both sustainability and water safety and the importance this collaboration can have in creating better guidance. This means team members and contractors need to understand the issues of water safety and sustainability, but also how their role relates specifically to these larger issues.
With more people potentially involved in the process, the panel raised the question of accountability – something particularly relevant with the introduction of the new Building Safety Act.
The implementation of the Building Safety Act needs to be considered alongside the importance of water safety throughout the construction and operation of a facility. Maintaining water safety depends on clear accountability, raising two key questions: who is the Accountable Person, and do they have the skills and knowledge needed to do the job properly?
The implementation of the Building Safety Act needs to be considered alongside the importance of water safety throughout the construction
For clinicians, this level of accountability is nothing new – they’re responsible for every decision they make regarding patient safety. In contrast, the implications of the Building Safety Act may not yet be fully understood by those outside clinical roles, especially as roles and responsibilities for the Accountable Person are still being explored. There’s a risk that individuals without proper training, such as general builders who aren’t specially trained, could take on the Accountable Person role to secure extra work or contracts. Given the systems already in place to maintain and assess clinical competence, establishing similar safeguards for those responsible under the Building Safety Act would ensure safety and compliance.
Sustainable solutions
In order to improve sustainability, one key challenge is reducing water temperatures. However, organisational and structural steps need to be taken before alternative solutions to high temperatures can be embraced as the gold standard against infection prevention. Filtration is one such alternate solution that has already been implemented at some NHS sites. Filtration doesn’t just target the bacteria in water systems, but also the nutrients that bacteria feed on preventing any newly introduced bacteria from surviving. The technology is not without issues however, one example being that the efficacy of point of use filtration depends on local factors, such as where water is drawn in from, making each implementation case unique.
Biocides offer another potential solution, or at least part of the puzzle in reducing reliance on thermal control. However, the panel raised the issue of biocides needing to be tailored to the specific risk profile of the system. This comes with its own set of problems, with the system needing to be up and running to determine where the risks are and how best to combat them.
Regional differences and changing microbial risks over time can create further challenges
Regional differences and changing microbial risks over time can create further challenges too making implementation difficult en masse. Meanwhile functioning biocide systems can hide problems like broken filters, and if not handled properly, increase the risks to patients or staff.
Again, competency was at the heart of the discussion, in this case specifically calculating the right dose that will provide effective protection against bacteria without introducing adverse effects for patients or staff.
Despite these issues, biocides and filtration may well have a role to play in creating a more sustainable NHS, helping to reduce reliance on carbon-intensive thermal control. However, scaling these solutions effectively will require significant effort to develop the necessary processes, skills, and infrastructure to make them work reliably on a larger scale.
No easy answers
There is no one-size-fits-all solution that will allow the NHS to easily balance water safety and sustainability. It’s a significant challenge and the Water Safety Forum provides a snapshot of the potential solutions, as well as the skills and systems that need to be established to ensure these solutions are implemented correctly and effectively.
Discussions like these are a vital starting point and a crucial example of the multi-disciplinary approach that needs to lead the way.
To find out more about the discussion at this year’s Armitage Shank’s Water Safety Forum, sign up for the Forum’s official journal.