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Cutting emissions from anaesthetic gases in England – ending the use of desflurane

The National Health Service (NHS) in England provides publicly funded health services – including hospital, ambulance, community, mental health and primary care – and is Europe’s largest employer. NHS England provides national leadership for the NHS. In 2020, the NHS became the world’s first health system to commit to reaching net zero carbon emissions, with two targets: to be net zero by 2040 for the emissions it controls directly and to reach net zero by 2045 for the emissions it influences, including the emissions embedded in the goods and services it buys. 

Work is underway to meet the target, and in January 2023, NHS England, with the support of the Royal College of Anaesthetists and the Association of Anaesthetists, announced the decommissioning of desflurane – an anaesthetic gas with high global warming potential - by early 2024.

 

Background

Thanks to the actions of its workforce, the NHS has already reduced its emissions by 30% since 2010, ahead of the UK Climate Change Act target.  All NHS trusts and integrated care systems in England – including more than 1,000 hospitals and healthcare facilities – now have a ‘green plan’ in place which sets out how their organisation will reduce emissions in line with the national target. Together, the green plans are expected to cut more than 1m tonnes of carbon emissions in the next three years, which is the equivalent of taking 520,000 cars off the road. Work is underway across the health service in England to put these plans into action.

The challenge:

Medicines account for 25% of the total NHS carbon footprint, with anaesthetic and medical gases responsible for 2% alone. Desflurane, an anaesthetic gas routinely used in surgery, is more than 2500 times more potent as a greenhouse gas than carbon dioxide.

One hour of anaesthetic using the gas will warm the atmosphere by the equivalent of between approximately 30 and 60kg of CO2. That’s the equivalent of driving between 200 and 400 kilometres. This is compared to driving between five to ten kilometres for sevoflurane, a lower carbon alternative.

The solution

Safe and appropriate alternatives with a significantly lower global warming potential exist, such as sevoflurane and total intravenous anaesthesia. Modern anaesthetic machines and advances in equipment allow anaesthetists to safely use smaller amounts of anaesthetic gas or only intravenous medication, which are both equally clinically effective for patients. Alternatively, local anaesthetic can be used to numb the part of the body required – with a spinal injection, epidural or nerve block – which may be clinically appropriate or preferable for some patients and procedures.

Alert to its environmental impact, clinicians in England have begun a sustained move away from desflurane and have been opting to use clinically appropriate and safe alternatives.

“We presented the science behind the harm desflurane causes, a plan to stop using it and communication of these with anaesthetists and theatre staff, which enabled a smooth switch from desflurane to alternatives such as lower-carbon volatile agents or total intravenous anaesthesia (TIVA).

“Initially it was still available for emergency theatres and paediatrics. However, over time it wasn’t requested by clinicians and the vaporisers have been gradually returned to the manufacturer.” Amy Greengrass, consultant paediatric anaesthetist, Norfolk and Norwich University Hospitals NHS Foundation Trust.

“Following discussions with our anaesthetists, we removed desflurane from the anaesthetic machines we use at Torbay Hospital in February 2019.

“To support colleagues, we still had it available to use it on a patient-by-patient basis. With continued education and auditing of desflurane use, we finally agreed to remove desflurane completely from Torbay Hospital in July 2022.” 

Dr Louise Webster, associate specialist anaesthesia and sustainability lead for theatres, Torbay and South Devon NHS Foundation Trust.

More than 40 NHS trusts in England have already stopped using desflurane altogether – with NHS trusts like Norfolk and Norwich, Bristol and Weston, and Torbay and South Devon leading the way. The use of desflurane across the NHS in England has fallen from 20% of all anaesthetic gases used, to just 3%, over the last 4-5 years.

In January 2023, NHS England, with the support of the Royal College of Anaesthetists and the Association of Anaesthetists announced the decommissioning of desflurane by early 2024. Stopping the use of desflurane across the NHS completely, with use allowed only in exceptional clinical circumstances, will reduce harmful emissions by around 40 kilotonnes of carbon a year – the same as powering 11,000 homes every year.

“If we are serious about combatting the catastrophic effects of climate change, we must reduce those emissions associated with medical gases when we have clinically suitable alternatives already available.

This is a hugely significant achievement which would not have been possible without the support of our members who are working incredibly hard to deliver a greener health service by moving away from the routine use of desflurane.”

Dr Matthew Davies, President of the Association of Anaesthetists

“The Royal College of Anaesthetists are proud to partner with NHS England on the commitment to stop using desflurane in routine practice by early 2024.

Anaesthetists are in the privileged position to be able to influence greatly the NHS’s carbon footprint. This is a significant step in the right direction, but there is a lot more to do, and we are determined to do what we can to reach net zero,and reduce the potentially catastrophic impact of climate change.”

Dr Helgi Johannsson, Vice President of the Royal College of Anaesthetists.

Lessons learned

  • Clinically driven change. As awareness of the impact of desflurane on the environment has grown and change has been driven by the clinical community itself. Recognising the profound threat to health posed by climate change, those in the specialty of anaesthetics have taken decisive steps to embed change at a hospital and ward level.
  • Leadership from professional associations. The support and partnership with the Royal College of Anaesthetists and the Association of Anaesthetists has been critical to success - achieving widespread recognition of the issue and accelerating action. Read the joint statement from NHS England, the Royal College of Anaesthetists and the Association of Anaesthetists on the decommissioning of desflurane by early 2024.
  • Multidisciplinary engagement. The switch away from desflurane has required the support of not only anaesthetists, but also theatre staff, procurement specialists and pharmacists. Sufficient stock of alternatives, such as sevoflurane, are essential to help ensure change is possible on a practical level.

Next steps

Further action is underway to tackle the emissions associated with medicines, including improving outcomes for respiratory patients while reducing emissions from inhalers. The NHS in England is also undertaking work with suppliers and clinicians to tackle over prescribing and polypharmacy and reduce medicines waste.

These actions will make patient care better, support the NHS and reduce carbon emissions.

More information

For more information please contact the Greener NHS team on greener.nhs@nhs.net

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