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

The study, published in the Journal of Industrial Ecology, used a research-through-design approach to develop four alternative concepts for a single-use powered linear laparoscopic stapler: a fully recyclable device, a partially reusable device, a multifunctional device with interchangeable modules, and a manual device stripped of its electronics. Each concept was evaluated with fast-track life cycle assessments and scrutinized by both Medtech industry experts and a broader group of ten stakeholders spanning clinical, sustainability, technical, and business perspectives. The goal was not to produce a final product but to systematically map where circular design collides with the non-negotiable demands of healthcare: patient safety, clinical performance, usability, regulatory compliance, and financial viability.

The environmental case for redesign is compelling. Previous research has shown that switching from single-use to multi-use surgical staplers can reduce waste by 40 percent and material requirements by 92 percent in laparoscopic sleeve gastrectomy. Hybrid laparoscopic instruments that combine reusable and disposable parts have been shown to carry a carbon footprint of roughly 1,756 grams of CO2-equivalent per operation, compared with 7,194 grams for single-use equivalents, a 75 percent reduction. Yet powered staplers are far more technically complex than those instruments, embedding printed circuit boards and batteries that dominate their manufacturing footprint. The new study’s baseline life cycle assessment confirmed that manufacturing impacts, particularly the production of electronics, were the largest contributors, with transport impacts close behind because assembly, sterilization, and use occur in different countries, including assumed air freight from a United States distribution center to hospitals in Belgium.

The life cycle modeling, performed in SimaPro using Ecoinvent v3.9.1 data and the Environmental Footprint 3.0 impact method, compared each concept against the baseline over 50 use cycles, the maximum reuse figure specified by manufacturers for reusable laparoscopic instruments. The results were striking. The multifunctional and manual designs could theoretically reduce environmental impacts by 80 to 90 percent, either by eliminating electronic components altogether or by consolidating multiple functions into a single reusable electronics module paired with separate metal actuator modules. The partially reusable device, which extends the life of the electronics while keeping the housing disposable, offered a moderate improvement. The fully recyclable single-use device, despite being engineered for disassembly and material recovery, delivered almost no carbon benefit, because the dominant manufacturing impacts of the electronics remained untouched.

Perhaps the most provocative finding concerns the gap between environmental performance and stakeholder preference. The Medtech experts rated the recyclable device as their overall favorite, precisely because it resembled existing products and could slot into familiar clinical workflows and regulatory pathways, even though it offered the least carbon reduction. Broader stakeholders, by contrast, rejected it for exactly that reason, warning that plastic recycling remains economically limited when virgin materials are cheap and that reliance on virgin feedstocks carries significant transport and material costs. Meanwhile, the multifunctional device, with one of the lowest estimated footprints, was judged technically infeasible by industry experts due to differences in circuitry and actuation, and stakeholders flagged logistical complexity, inventory tracking difficulties, and regulatory hurdles around reprocessing components. Yet the surgeon participating in the study named the multifunctional concept his preferred option, citing its usability and practicality, a direct contradiction of assumptions voiced by other participants about what surgeons would accept.

The partially reusable device emerged as a pragmatic middle ground. Half of the surveyed stakeholders named it their favorite, praising its ability to cut electronic waste while leaving design and logistics largely unchanged. Comments included observations that staff would only need to charge a battery as an extra step and that a single-use housing would likely still comply with existing frameworks. Industry experts, however, cautioned that charging and reassembly steps could introduce risks around maintenance, reliability, and aseptic transfer, the process of moving materials without contamination, and warned that perceived risks of reusing contaminated components could trigger user resistance, even though in practice the electronics module never contacts bodily fluids. This tension between perceived and actual risk recurred throughout the study and echoes earlier findings that barriers to sustainable medical device design are often more perceptual than factual.

The manual device presented a different kind of dilemma. Removing electronics entirely yields the lowest theoretical carbon footprint and, according to stakeholders, simpler logistics with no complex waste management required, no battery charging, and potential alignment with emerging sustainability regulations. Some even suggested it could enable pay-per-use business models in which hospitals or manufacturers capture value through per-surgery pricing. But Medtech experts were blunt: powered staplers exist for ergonomic and performance reasons, and achieving comparable precision and consistency through mechanical means would be highly challenging. They also noted that any increase in surgical complications could raise the total cost and carbon footprint of the entire patient journey, since treating complications is part of care delivery. The lesson, the researchers argue, is not that manual designs are off the table, but that any such redesign must identify which electronic functions are essential and find smart mechanical alternatives that preserve performance.

Beyond the concept comparisons, the study cataloged recurring trade-offs organized by the underlying circular intervention, whether enabling reuse, reducing electronics, multifunctional design, or improving traceability. Common drawbacks included increased sterilization burden, altered surgical workflow, reduced user familiarity, and regulatory complexity around reprocessing. But the researchers also documented a set of genuine synergies in which circular strategies improved environmental and operational outcomes simultaneously. Reuse can lower material and logistics costs by extending the life of high-value components, improve alignment with emerging regulations, and generate long-term savings despite higher upfront investment. Eliminating or reducing electronics can simplify production, reduce failure risks in the operating room, enhance sterilization compatibility, and make devices more intuitive for staff. Circular design, the study concludes, does not always involve sacrifice.

The authors are careful to acknowledge the limits of their work. The analysis examined a single device type, relied on conceptual designs rather than physical prototypes, and used fast-track life cycle assessments whose assumptions about reuse cycles, sterilization intensity, and maintenance requirements are key uncertainty drivers. The stakeholder sample of ten was purposive rather than statistically representative, and the differing scoring scales used for experts and survey participants constrained direct comparison. The life cycle results should be read as a comparative assessment of the relative potential of circular strategies, not precise predictions. Future research, the team suggests, should include prototyping, user testing, sensitivity analyses, and the development of a circular design guide for medical devices that embeds trade-off mapping at each stage of product development, alongside exploration of take-back models, product-as-a-service approaches, and service-based sterilization arrangements.

The broader significance of the study lies less in the four stapler concepts themselves than in the decision-making process it demonstrates. By pairing quantitative life cycle modeling with structured stakeholder evaluation, the researchers showed that sustainability, technical feasibility, clinical usability, and regulatory compliance act as separate filters on design ideas, and the best overall design rarely maximizes any single criterion. They argue that companies should model the environmental consequences of their choices just as they already model financial and clinical ones, and that even when the most sustainable option is not chosen, it can point the way from today’s incremental strategies toward more transformative circular redesigns. Regulatory frameworks such as the European Medical Device Regulation and the Waste Electrical and Electronic Equipment Directive will shape what is possible, and procurement policies that consider lifecycle value rather than upfront cost could accelerate adoption. For a sector under growing pressure to shrink its climate footprint while safeguarding patients, the message is clear: the path to circular medical devices runs not through engineering alone, but through a systems-level alignment of design, regulation, clinical practice, and business incentives.

Subject of Research: Circular design trade-offs and carbon footprint reduction in single-use powered laparoscopic surgical staplers

Article Title: Balancing trade-offs in circular medical device design: a case study on laparoscopic devices

Article References: Hoveling, T., Muindi, N., Faludi, J., & Bakker, C. (2026). Balancing trade-offs in circular medical device design: a case study on laparoscopic devices. Journal of Industrial Ecology. https://doi.org/10.1007/s44498-026-00189-8

Image Credits: AI Generated

DOI: 10.1007/s44498-026-00189-8

Keywords: circular economy, medical devices, laparoscopic surgery, life cycle assessment, sustainable healthcare, surgical staplers, e-waste, research through design, carbon footprint, regulatory compliance, medical device design, reuse and recycling