The research, led by Carrie Llewellyn and Mahood Bhutta of Brighton and Sussex Medical School together with colleagues at the Centre for Sustainable Healthcare, set out to answer a deceptively simple question: how prepared are large public healthcare organisations in England and Wales to switch to high-priority reusable medical products? The team conducted semi-structured interviews with thirteen stakeholders drawn from ten NHS Trusts and Health Boards, spanning clinical leads, procurement managers, sustainability programme managers and infection prevention specialists. Rather than relying on intuition, the researchers anchored their interview schedule in the Theoretical Domains Framework, a validated model of behaviour change covering fourteen domains from knowledge and skills to environmental context and social professional roles, supplemented with elements of the NASSS-CAT toolkit, which examines why health technologies are adopted, abandoned or fail to scale. Data were analysed using Framework Analysis, a matrix-based thematic method, and reported according to the COREQ guidelines for qualitative research.

The organisations studied were not starting from zero. Most had already implemented what participants called the low-hanging fruit: reusable surgical hats, gowns, drapes and tourniquets, items that slot into existing workflows with minimal disruption. One clinical lead for net zero noted that staff often did not notice the difference at all. Organisations further along the implementation pathway had begun adopting more complex technologies, including laparoscopic instruments and suture kits, marking a progression from peripheral products towards the core of surgical practice. Approval processes across organisations followed a recognisable structure, typically requiring clinical protocols, formal risk assessments, sign-off from infection prevention and control teams, and ultimately the endorsement of senior leadership. Procurement teams, clinical leads, infection prevention specialists and decontamination services formed a common multidisciplinary implementation core.

Yet the study’s most striking finding is what researchers call the knowledge-action gap. Awareness of sustainability was widespread among staff, but awareness alone rarely translated into changed practice. One sustainability clinical and innovation lead put it bluntly: there is a big gap between knowing and doing. Participants described time constraints, cognitive overload and the sheer difficulty of evaluating alternatives while delivering frontline care. Misinformation and inconsistent communication about the efficacy and safety of reusable products compounded the problem, with clinicians, trained to demand robust evidence, expressing scepticism about products for which reliable comparative data remain scarce. As one clinical procurement participant observed, there is not enough evidence out there yet for some of these products, a serious obstacle in a profession that is, quite rightly, evidence-based by default.

History partly explains this caution. The shift to single-use devices accelerated in the 1990s following the emergence of variant Creutzfeldt-Jakob disease, which raised fears of transmission via surgical instruments. However, the study’s authors point to recent evidence that properly sterilised reusable items do not increase the risk of surgical site infections, and that no cases of patient-to-patient spread of vCJD have ever been reported. World Health Organization guidelines and UK regulatory frameworks support safe reuse under strict sterilisation protocols. Despite this, risk perceptions within infection prevention and control teams varied widely between organisations, and that inconsistency proved consequential: where IPC teams were confident, implementation advanced; where they were hesitant, projects stalled. The study found that even one or two dissenting voices could halt an entire initiative, underscoring how fragile consensus around change can be in high-stakes clinical environments.

Financial structures emerged as another formidable barrier. The NHS annual finance cycle rewards savings declared within a single twelve-month period, making it difficult to justify investments whose payback spans years. Whole-life costing, which accounts for the total cost of a product across its lifetime, is simply not built into procurement decisions, participants reported. Although economic analyses suggest reusable personal protective equipment and surgical instruments can achieve savings of up to fifty percent per item when managed at scale, upfront capital costs, reprocessing expenses and the need for sterilisation infrastructure deter budget holders focused on immediate financial periods. Staff turnover added a further layer of instability: successful pilots frequently failed to become permanent practice because the champions who drove them moved on, governance arrangements were unclear, and institutional memory evaporated with each departure.

Procurement systems themselves conspire against reuse. Participants described fragmented purchasing arrangements, particularly in large trusts with regional procurement functions, and a catalogue system in which reusable products are effectively invisible. If the word reusable does not appear in a product descriptor, one sustainability programme manager explained, you will not find them. Some staff also perceived sustainability as someone else’s problem, a disconnect between clinical practice and procurement accountability that the authors identify as culturally corrosive. Operational realities add complexity: hospitals often must run disposable and reusable systems in parallel during transitions, straining storage, logistics and sterilisation capacity. In some cases, staff were asked to launder reusable theatre hats at home because on-site facilities were inadequate, a request that generated understandable resistance. Interestingly, one participant challenged the common assumption that reusables demand more space, arguing that fewer reusable items are needed to replace their disposable counterparts, suggesting that misconceptions about logistics may themselves be impeding adoption.

Against these barriers, the study documents a remarkable cadre of sustainability champions who act as enablers, bridging clinical and managerial worlds, securing external consultants, coordinating with quality improvement teams and building momentum by recruiting motivated colleagues. Their work carries an emotional cost, with participants describing frustration and disillusionment at slow progress and lamenting that senior leaders are not dictating more. Where projects had dedicated leadership and protected time, they advanced; where leadership roles were ambiguous, they stagnated. Training remains fragmented and voluntary, with no standardised curriculum across trusts, leaving newly qualified clinicians trained exclusively on single-use devices. Participants proposed mandatory training modules within the NHS Electronic Staff Record and structured communities of practice as ways to institutionalise learning rather than depending on individual enthusiasm.

The authors conclude that the NHS transition to reusable medical products must move from isolated local initiatives powered by passionate individuals to coordinated system-level improvement under strategic national leadership. They call for central guidance on policy, governance and infection risk, a flexible but standardised implementation framework aligned with existing NHS quality improvement structures, and mandatory public reporting of both successful and unsuccessful attempts, potentially through the Greener NHS Dashboard. Tools such as the Evergreen supplier sustainability assessment offer promise for aligning procurement with environmental goals but require far broader uptake. The researchers also flag a striking blind spot: the role of patients and the public in driving this transition remains almost entirely unexplored. With reusable gowns described by participants as superior products in almost all metrics, and small touches such as named surgical hats improving patient experience, the clinical case for reuse appears sound. What remains is the harder task of rewiring the governance, finance and culture of one of the world’s largest health systems, a task that, this study makes clear, no single enthusiastic individual can accomplish alone.

Subject of Research: Barriers and enablers to adopting reusable medical products in NHS hospitals in England and Wales

Article Title: The transition to reusable medical products in NHS hospitals in England and Wales: A theoretical domains framework informed qualitative study

Article References: The transition to reusable medical products in NHS hospitals in England and Wales: A theoretical domains framework informed qualitative study. (n.d.). https://doi.org/10.1371/journal.pstr.0000283

Image Credits: AI Generated

DOI: 10.1371/journal.pstr.0000283

Keywords: NHS, reusable medical devices, single-use plastics, sustainable healthcare, net zero, procurement, infection prevention, implementation science, Theoretical Domains Framework, carbon emissions, qualitative research, healthcare sustainability