Ensuring water safety in the drive to Net Zero

Decarbonising the NHS is a huge and complex challenge, not just because of the size and complexity of the organisation, but also due to the task of reducing emissions without introducing risks to patient safety. The solution will need to bring together professionals from across the healthcare sector alongside contractors and suppliers from the private sector, and will likely come in the form of both technological and procedural progress. Water is at the heart of the challenge, with the NHS required to heat a huge amount of water, and using a huge amount of energy to do so. Water, waste, and building energy contribute 15% towards the total carbon footprint of the service, meaning water has to be a central pillar of carbon reduction efforts.

Forum brought together experts

To address these issues and foster multidisciplinary collaboration, Armitage Shanks brought together experts from across the healthcare sector for its 2024 Water Safety Forum hosted at its London Design and Specification Centre in Clerkenwell. The 2024 Forum was chaired by Elise Maynard, director of the Water Management Society, and an independent microbiologist. The wide-ranging discussion explored the question: ‘How can the drive to Net Zero in the NHS be compatible with safe water delivery?

The following experts attended the Forum:

• 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;
• 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 then CIBSE KS21 re-write;
• Alyson Prince, former NHS Infection Control Nurse and specialist in the built environment, now an Independent Infection Prevention and Control Nurse consultant in the healthcare 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.

The scale of the challenge

In October 2020, the NHS committed to reaching carbon Net Zero by 2040 — making it the world’s first health service to do so, publishing its Delivering a ‘Net Zero’ National Health Service report, which sets out its ambitions and targets. While the ambition of the NHS cannot be understated in its aims, the scale of the service, and the challenge it faces, are vast. For water, the lack of direct and standardised monitoring is a key barrier to truly understanding where water and heat are being wasted — and therefore opportunities for reduction.

More data monitoring the consistent usage of both hot and cold water is a necessity to understand the real wastage of water. However, this monitoring of data cannot be centralised or focused on a few locations. Instead, data is required from across the different Trusts for useful comparisons and contrasts to be made, as well as for generalised and Trust-specific plans to be put in place.

How recent is the data?

Where data is being gathered, there are further issues to overcome — principally as regards how recent the data is, with the lead time for data publication often leaving Water Safety teams working with data that is more than two years out of date. The availability of water data is a stark contrast to clinical data, where real-time feeds are available. However, this isn’t the case globally. The federalised system in the US allows for the devolution of data gathering, and could be implemented within the UK for individual Trusts to collect, analyse, and act on water data. Yet this solution relies on establishing a baseline that Trusts can work from and then build on, making it easier to measure progress across the NHS, and then apply more specific solutions.

Alongside the availability of data, there are challenges when it comes to how data is valued by various stakeholders — data from Estates and Facilities is seen to be undervalued compared with clinical data, and is therefore not given the same attention when it comes to the analytics required to produce actionable insights. There’s a clear need to shift perceptions on the importance of water data as another critical solution for creating a sustainable, yet safe NHS.

Of course this perspective, and implementing an agreed baseline data collection set for all Trusts, is not something that can be done easily and consistently without significant effort and collaboration across the board. One issue is the variety in the NHS’s estate portfolio — its new projects, existing assets, and retrofitted facilities, all collect data in different ways and different formats. Depending on the age of the estate, there will be different interventions that have vastly different definitions of success as regards water and carbon efficiency.

Designing for real use

Understanding how facilities are designed for hygiene and water efficiency is therefore central to dealing with the sustainability demands of the NHS’s water use. This needs to be considered at each stage of the design process, with the clinicians consulted throughout, to assist with addressing the conflicts that come with reducing water use but maintaining patient safety. For example, a specific example raised at the Water Safety Forum was removing basins in patient bedrooms where there is already one in a bathroom. This may appear to be an simple change to minimise water usage and maintenance costs, freeing up staff for other critical activities. However, this change would present potentially severe clinical risks, encouraging clinicians, patients, and visitors to wash their hands in the bathroom where patients brush their teeth.

Collaboration is clearly key if the sector wants to set a basic level of design competency that addresses both sustainability and hygiene concerns, while understanding behavioural and cognitive factors for the design of new facilities and the refurbishment of existing ones. This knowledge then needs consistently monitoring and updating, in line with the latest learnings, to ensure the continued safety and optimisation of facilities. Currently, there are identifiable design issues that have been implemented in line with existing guides and legislation that don’t account for the variable factor — people. For example, in rooms where every bed has its own sink, patients and visitors will still use the sink in the middle of the room because it is the most visible, leaving the others underused, wasting water, increasing a facility’s carbon footprint, and offering opportunities for biofilm build-up.

Another example is the presence of hand towels above sinks, which might be seen as instinctive design, but also poses a healthcare risk when parts of the towel come apart and are flushed down the sink by users. At the core of this is the fact that design guidance itself has been too slow to evolve and be published for use by Trusts and in the construction of new facilities. Often the fact that guidance is only updated every 5 to 10 years, and that writing a guidance document can take up to two years, means that it’s seven years out of date once it comes to be used in practice.

The need to establish competency across the NHS as regards water safety and sustainability is clear, with the idea of deep, broad consistency a central pillar. However, this system needs to be implemented correctly, and to take into account the viewpoint of all roles that feed into each project, to ensure that training can be consistently and effectively applied to reduce risks to water safety. Decarbonisation is then a necessary component that needs to be integrated into this base layer of understanding — allowing contractors, designers, clinicians, and Water Safety Groups to spot opportunities for emissions reduction as instinctively as they do risks for water contamination — something that is not present in existing training.

Alongside competency, the role of accountability was highlighted at the Water Safety Forum, with the position of an Accountable Person (AP) set out in the new Building Safety Act. This new position, which assigns responsibility for a building’s safety to a single person, raises the wider concept of personal accountability for water safety and sustainability.

Impact of the Building Safety Act

On one hand, this added accountability is encouraging professionals across a project to take ownership of their actions and facilities. However, the implementation of the Building Safety Act needs to be considered in tandem with the broad relevance of water safety throughout the construction and operation of a new facility, raising two important questions — where should the Accountable Person sit?, and does the Accountable Person have the necessary competence to undertake the role properly?

This level of specific accountability is of course nothing new for clinicians, who are responsible for every professional decision. However, for many, the full implications of the Building Safety Act may not be fully realised, and the legislation runs the risk of pushing untrained individuals to take on the role in return for additional work, pay, or contracts. With a framework already in place for maintaining and assessing clinical competence, the prospect of adding similar safeguards for water safety and sustainability should be implemented.

While understanding the scale and complexity of the challenge the NHS faces with water safety and decarbonisation is key, solutions are necessary, and there is opportunity to both evolve existing rules and take inspiration from across disciplines to rethink the NHS’s approach to water safety and sustainability.

Part of driving this change will be the need for leaders in water policy and guidance in healthcare to begin to find alternatives to the robust but climate-intensive thermal control that is currently the gold standard of the battle against contamination. Instead of heating the entire system, there may be opportunities to utilise more point-of-use heating that still delivers water to patients and clinicians at the temperature they need, but isn’t required to be heated to a high degree at all times, consuming a lot of energy in the process. This comes with technical challenges, but also with added benefits for patient safety; heating water to a specific temperature helps decrease the risk of scalding for patients and staff, as water is delivered at the 38 to 40 °C that they need, rather than the 60 °C required for effective infection prevention and control. However, any significant changes made to the widely accepted ‘Keep it cold, keep it clean, keep it moving’ system need to robustly guard against infection, as well as to be sustainable, and any alternative systems to traditional thermal control would require further safeguards to ensure patient safety.

Filtration

Filtration is one such potential solution, or at least part of this solution. The technology is already implemented in some projects, though in many places still at the research and development stage, and these projects have highlighted the opportunity and challenges of filtration in water safety. An important point is that the filters shouldn’t only be aimed at bacteria themselves, but also the nutrients that these bacteria feed on. Where these filters should fit in an asset’s water system is a wide point of discussion across the healthcare sector, with pros and cons for different placements.

Point-of-entry filtration can be particularly effective for new-build developments, and the further back in the system filtration can be implemented, the cleaner the water flowing through the latter stages of the system will be, inhibiting bacterial growth by removing nutrients from the entire system, rather than just at the point of use. A key benefit of implementing this into new-builds is the cost and time savings gained from the beginning with cleaner water, rather than retrofitting this into existing systems, which would be costly and time-consuming, with the need to recirculate the entire water system. One example given in favour of point-of-entry filtration at the Water Safety Forum was a recent trial where the facility was being fed directly by rivers and streams — yet the filters were able to cope with the incoming microbes and clean water. The issue lies with the strain placed on point-of-entry filters that must filter algae and silt and become clogged quickly, resulting in the need for consistent monitoring and maintenance.

Retrograde contamination

However, point-of-entry filtration raises the issue of potential further contamination, or retrograde contamination, within the water system. Additional filters can be fitted within the water system to help keep water clean at all temperatures, but these filters would then need constant monitoring and maintenance to ensure a hygienic system — a time-intensive and costly process. Filtration is further caveated by the regional variability of different bacteria, and differences in water sources and quality, meaning a standardised filtration system is an unrealistic end goal to implement across Trusts.

While filtration is an imperfect solution, and no filter can deliver thoroughly clean water, it can play a significant role as an invaluable risk management and carbon reduction tool when customised for each facility. In each case, filtration isn’t a magic bullet that will eliminate the need for heat altogether, but the right strategy would reduce reliance on the broad and carbon-intensive heating of huge amounts of water.

Alongside filtration, biocides are an option for added protection in the absence of, or reduction in, use of thermal control. One of the first considerations for biocide use, and one of the difficulties of getting their use right, is the need to tailor the type and amount of biocide to a system’s specific risk profile. 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 with biocides.

Again, the problem of regional variability raises its head in this context, as well as the development of different microbial risks over the course of an asset’s lifetime. Other risks include the potential for biocides to mask instances of contamination that need to be addressed directly, such as broken filters, as well as the need to ensure that the biocide itself does not pose a risk to patients or staff. There is also risk inherent in the installation of the dosing units needed to dispense biocides, which could themselves become sources of infection when the flow of water is interrupted. Furthermore, a lack of wider competency and knowledge on biocide use could result in issues with using and measuring different types of biocide agents, in particular when it comes to calculating the right dose ratios needed to provide effective protection. If implemented incorrectly, biocide could cause harm to existing water systems, or increase the risk of adverse effects on patients and staff.

This is not to say that biocides will not have a role to play in the creation of a sustainable NHS. Both biocides and filtration allow the NHS to, in part, move away from carbon-intensive thermal control, but there is a long way to go to establish the processes and skills to enable this to happen on a large scale.

The consensus of the forum was that there will be no single solution to the NHS’s sustainability and water safety challenges. Instead, progress will be made up of smaller, individual technological and procedural advances that intervene at different stages of water systems, of construction and design processes, and at different points in the patient experience. This reinforces the need for efforts to make decarbonisation and water safety work in harmony to be multidisciplinary.

The regional angle was also a constant when it came to identifying the scale of the problem and implementing solutions. The call for a standardised set of more useful data was broad and consistent, but the reality of what that data looks like is varied, and more specific data is a necessity for each estate to address issues. The same goes with any attempt to move away from thermal control as a barrier to contamination — biocides and filters have to be tailored to the local situation, and that adds another element of complexity.

Complexity a key theme

Complexity itself is a challenge that spanned the whole discussion — the more complex the solution to each of the problems the NHS encounters in its work to decarbonise, the greater the cost, and the greater the potential for human and mechanical error. This puts emphasis once again on the level of training required, and the need for conversations such as those that take place at the Water Safety Forum. This is, for the most part, uncharted territory — new systems, new technologies, new expertise.

The NHS may be facing a complex task, but it’s not an insurmountable one, and the scale of the challenge didn’t undermine the optimism of the discussion among the experts at the Forum. Instead, there was a broad consensus that water safety and the move to Net Zero can work together in harmony, and even achieve a symbiotic relationship where they support one another.

To do this, however, the service will have to devise a complex solution to meet a complex problem, one which draws together teams and expertise from across the NHS. Solutions for carbon reduction, and the resulting necessary changes to water infrastructure and policy will require new standards of competence for everyone, and that means everyone needs a say in how they’re shaped.