BOTA Conference 2022 | Professor Mahmood Bhutta | Reduce and Reuse: a key strategy for sustainability in the operating theatre
Summary
This on-demand teaching session is relevant to medical professionals and will provide an overview of sustainable healthcare and how it relates to medical equipment, particularly surgical instruments, and how it can be used to reduce carbon dioxide emissions. Led by Professor Mahmoud Butter, the founder of a medical Fair Trade Group and a consultant at several hospitals in England, he will provide tips on reducing consumption, reusing equipment, recycling, and using alternative forms of anesthesia. He will also discuss public health agendas and suggest ways to promote exercise and green transport. Join us to learn how to reduce your healthcare carbon footprint.
Learning objectives
Learning Objectives:
- Understand the role of the NHS (England) and the carbon footprint produced.
- Identify strategies to reduce environmental impact, such as public health initiatives, cycling, and use of local/regional anesthesia.
- Analyze the carbon footprint of healthcare, including the elements of Scope 1, 2 and 3 emissions.
- Identify where reusing equipment would be beneficial for patient care and the planet.
- Discuss specific areas of opportunity for reducing emissions and improving sustainability, such as in operating theatres and related energy use, anesthetic gases, and consumable equipment.
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The first person I like to introduce the seed is Professor Mahmoud Butter. He is the founder off the B M, a medical Ferralet trade group in a consultant ent Certain at Brighton and Substitute oversee hospitals In 2000 and six. He found it the Medical Fair Unethical Trade Group in response to labor rights abuses in the money factor of medical products, including surgical instruments, gloves and textiles. He works with the NHS and international procurement organizations and NGOs to foster better working conditions in healthcare healthcare supply chains. Thank you very much for joining us. Press about it. Please. Go ahead. Thank you, Juliet, for the kind introduction and thank you everybody for joining today. So you've already had a long intro to tell what I'm doing. But I've been interested. Sustainability for some time on bleeding a national reporting towards sustainable surgery might look like, So I'm just gonna give you some a sort of tips. And point is as to where we need to take our strategy. Just give me a moment. I'm just gonna share now. Can you just confirm with may that you can see that with some of them, So yes, can you see my sides, but not quite yet. Uh huh. Okay, so we were just having a tech test just before this. Just to check. Everything was okay. Can get pregnant. I'll try again. College. I see. Oh, I think I think people are able to see you are able to. Yeah, yet. Great. Okay. All right. Thank you. So just to give you some background to where we can align our strategy and I'm gonna talk about start with healthcare generally. And are carbon footprint carbon being the most common metric we use to measure our environmental impact on then talking about what we can do in surgery and then hopefully a little bit of nuance. A zit comes to orthopedics. So as I mentioned, this is not something new for me. A I actually, my background is in labor rights. Concerns related to the product will be by And in 2006, I wrote an article in the Brush Medical Journal actually talking about labor, I suppose, is a social instruments manufacture, which I'm gonna talk to you about it later. But also that time I was well aware that healthcare also has an environmental impact on the run this letter in 2000 and eight as an essay show together with the family of the Center for Sustainable Healthcare. So this is nothing new, but hopefully we're finally on on. The idea of this is something important and that we should be trying to work on this. So just to give you some background to the problem and apologies of many of you already aware of this, but I'm rehearsing what you already know. So and the NHS in England is responsible for around 25 million tons of carbon dioxide. That's around 4 to 5% off total greenhouse gas emissions. So about one in 20 or all greenhouse gas emissions in this country are due to the NHS on that's equivalent in England alone to the entire complicated Croatia. So it's huge and all four U K nations have declared Teo on ambition to inform net zero for healthcare by 2045 which is a fantastic ambition, and I hope that we achieve it. 50 additional countries have signed a pledge to develop more carbon health systems, and I'll be honest, they look into the UK because we are trying to lead the field. I'm not suggesting that we know what we're doing, but we are trying. And then I think really, it's in, um, enthused by how much enthusiasm there is amongst both trainees and senior people. Onda, uh, to get this on the agenda. So what are the principles we might follow in sustainable healthcare? And I think it is, perhaps not that, uh, not rocket science really reduced should be the first principle. So that is about making sure that the care we deliver is required. Or maybe it's something that we don't need to provide. And in terms of equipment, which I'm gonna particularly focus on later on, it's Do you need that equipment in the first place? That is, of course, the best way to reduce the come footprint of anything is not to use it in the first place. Not to deliver that care in the first place, where clinically appropriate with equipment in particular, it's reused. So we need to stop this, throw a culture. We need to re use equipment wherever possible, because we know that that's better for the planet or shaves and date on that. And then people comes to write a lot on recycling and look recycling this part of the solution. But let's not kid ourselves that we're going to save the planet by recycling everything. Under optimal conditions, recycling comes around four or 5% of the carbon footprint of a product and actually in healthcare is very difficult to recycle things, because often some of things that we use may have multiple components in them. They may be infected. So to just disassemble this, in fact, all of that, you're really going to recover hardly any carbon from such a thing. And so a carbon footprint ing study showed. Like I say at best, you recover 4% is much better if you don't use it the first place. So in terms of reducing, what does that mean in terms of patient care? We do need to engage in public health agendas to prevent disease, so that includes road safety to prevent traumatic injuries. And I'm glad to see that many zones now down to 20 miles from our to reduce injuries. And actually, can we imagine a future where most city centers don't have cars, and then it behooves us, of course, to stop using the cars as our main form of transport wherever possible. Do you cycling in public transport where reasonable and possible, we need to consider where know, so she's actually required. I have my own views about cosmetic procedures and low priority procedures. Controversial topic. The past. This is something that we need to consider that we can consider these in silence. And we also need to have some honest discussions about, um, political surgery or is low chance of cure where we don't necessarily benefit the patient either, as well as not benefiting the planet. No point in my suggesting that we compromise clinical care, but I do any think we need to Monistat about this and we also anything about when you see anesthesia. And I think actually in orthopedics, there's been a huge shift that this is nothing new for things like like a femur fractures where you do it on the spinal surgery. Ah, lot of the time on, uh, carpal tunnel, which were long were you down under local anesthetic that needs to be the normal. I think we need to expand that to ever possible, because where you do need to deliver surgery. We've known that local regional anesthesia is much better for the planet. So we're gonna look at the carbon footprint of healthcare. We've got this very useful pie chart ready that's produced by the NHS in England to tell us where are calm. Footprint is on. We know that Ah, lot of it traditional was focused on the state's things like clean electricity, insulation and anything. Gneiting. That's all important, of course, but it's only part of the solution. We do need way, segregation and recycling because that's a part of this picture. We need to also eliminate toxic compounds, particularly desflurane and anesthetic gas, which I think hopefully all your nieces are trying to eliminate. Certainly we eliminated in in parts of our trust in Sussex On. That's because that's Lauren has 3000 times the global warming potential come by oxide. It's a horrendous gas, and none of it really should be released in the atmosphere. And the best way to do that not to use it in the first place. We also need to reduce nitrous oxide and because nitrous oxide has 300 times a global warming potential, off guard dioxide and people are trying to work on that or to potentially capture it after use and or crack it into nitrogen oxygen. And then there's this whole thing about transports, a remote consultation where clinically appropriate. I appreciate that many of us are living tired of remote consultation rather than rejecting the concept altogether. What I think we need to do is have to find where it is appropriate to use. We need green transport both for ourselves and our patients, and we need remote working wherever possible because that green strategy has to include these transport emissions. Why for remote consultation. We know the carbon footprint of a consultation is almost entirely determined by the transport of the patient to get to you so most patients will drive. Some will take public transport. Regardless. The majority of the car put print of it to their travel. So, for example, an ent where I work we've looked up follow up of patients where we found that actually, a lot of follow patients could be adequately have the consultation remotely on also new patients for tonsillectomy when we don't necessarily need to examine the patient. But we need do need to take a history again. We found actually high patient satisfaction about using it in that context. But I'm gonna come straight, really a bit more on the what's called scope three missions. So that's something I should have mentioned. School scope one and two missions Scope one and two Emissions directly related. What activity we're providing in healthcare. That's a scope one. A mission to scope two missions the carbon dioxide produce from the energy we're using to create to provide that. But I'm gonna contract down Scope three admissions, which is a big part of that nature. And then it's everything that we're buying to bring in toe healthcare. And that's quite a large. And and this work going on with the medical side with inhalers, for example. But asthma, which are also toxic greenhouse gases and D prescribing, sort of not providing medicines where they're not clinically indicated. You know exercise is just a a new story this morning that the NHS has suggested we should be promoting exercise instead of using statins for cholesterol reduction. Well, that was always true. We need to Mabel that we can look at digitalization, repair on furniture and things on that we can look at offering low carbon food because our addiction to meet is is completely destroying our environment both in terms of land uses. One was production of gas is such a me thing, but I'm going to really come straight now here on reducing reuse off medical equipment because that's a particular focus of mine. So on. Within that focus, the operating theater is particularly bad because the operating theater usual eyes is a huge amount. It's the most resource intensive care of the hospital. I think we all know that from my own experience after a third of our total waste of the hospital and it has normally 3 to 6 times higher energy consumption, the typical operation generates between 100 50 and 170 kg of carbon dioxide. That's the equivalent of driving a bridge federal car from London to Edinburgh for just one single operation. Some operations will be much higher than that on hot spots from a systematic of you undertook related energy use anesthetic gases Well, the anesthetic gases are actually been improved. Energy use is also becoming more efficient, and we're moving towards hopefully green sources of energy wherever possible, 100% green electricity and then consumable equipment. And it's a consumer about a quite well in particular that I'm gonna focus on as we move forward. So we've just this's data from a PhD student. Shanta Reason. She's a carbon footprint. It the five most common operations, actually just doing the data for four of them. Here, you can see there's some orthopedic procedures in there. And when we broke down, what's actually contributing to come now? Also off the products use within an operation you can see. The biggest part is that red part job. So around two thirds overall off all the total carbs printed products relates to single use equipment, particularly production, but also it's waste. So if we really want to focus on reducing the carbon footprint off our operations with the operating theater, it's that single use culture wherever possible, we need to remove on. That is true, regardless of the approach that you So. For example, these is some data from study that was done in the US, which compared different approaches to a hysterectomy with the Diovan actually approach and abdominal approach and laparoscopic approach or robotic approach. Actually, the constituents of the off the operation are pretty stable in terms. The anesthesia that's the bar on the writing. In fact, since the study was done, that would have gone down because anesthesia, as I say, are eliminating some of the gas is they were using. And then there's a bit around energy consumption and and so and that's the stuff on the left. But if you see that red circle that is around single use equipment, so the biggest difference between different approaches is actually related. Single use equipment on. Sure. If you want to do your robotic approach to a hysterectomy, that's fine. But why do you have to use so much single use equipment to do that? Why can that quick mint not be made reusable? And that's a question. We have to ask on the idea that we can achieve this and that. Maybe there's problems. If we look at, we can look elsewhere. So cataract operation in the UK is estimated have the same sort of carbon footprint as we find for most operations. About 100 80 kg of calmed outside, but a cataract operation performed with the Arab and I center in India, where they use highly efficient systems. Patients are well through and operated really in a factory. Almost they reused all those all of their equipment. The never carbon footprint of that operation around 30 fold lower 30 fold lower than what we do in the UK on Dave. Order to two million of their operations. They've gotten lower rates off in front, infected and off, for my age is after the operation. Then we report in the UK so this is better. On every single metric you can measure financial, carbon and infection rates. So what is the market? Don't know. It's a medical goods, at least this single use economy. We have this slight disconnect in healthcare in that the consumer is not the purchaser. You know, if I buy a mobile phone, I will be. The person uses that, probably the purchaser. I'll be the user we could consumer. But in healthcare, we have the user that is different to the consumer on is providing that care and the payer is often someone different to that as well. Of course, So there's this disconnect as well that we need to recognize on the supplier is trying to sort of, if you like and negotiate this complex marketplace so usually consumer, what we are interested in is products of deliver the high standards of clinical care, and sometimes those are particularly high cost products where you might be saying this is the best and that this is the best implant. This is the best electrosurgical cautery forceps that you can buy between the using the pear is tends to be local spots that they're targeting with high bony and things such as gloves and gowned. When we're using so much of them, we want them. A cheap is possible, and this is a $300 billion industry. Provisional healthcare products. It's not small by any means. So for high cost parents, what we find is they are complex often quite a lot of them very good, of course. And that means, of course, that they have high embedded carbon and that they also so. In some cases, many instances have restricted or limited number of uses, and this is from the Association of Medical Device Reprocesses, who say the medical device three processing emerged about two decades ago when a lot of manufacturing gas change certain device from reasonable to single patient use. In their view, after motivated by economic objectives, rather patient safety concerns on this is a complex area for low cost. For us, what we're looking for, what manufactures of looking for is actually cheapest possible, because that's what where are people and it's subject a free market you can often. So here is some example of some bandages being produced in Mexico, where I was a few years ago, and they're all coming off this production line, and they're all going into six different boxes. The box on the right is a well known brand name in the U. S. On the box on the left is a product sold only Mexico, a brand name you would never heard of. It's exactly the same product. So if you want to produce this, you're producing it in wherever you can, and selling it as cheap as possible, or possibly with a PSA high profit margin is possible that you could get away with the problem with outsourcing production sounds okay, but it can be two issues, and I'm going to talk to you about some of that labor rights issues that we've found through the outsourcing production of these simple products, if you like. So here's a mask being produced in a factory in the Jiang province off northwest China. These master coming into the US but also coming into the UK on what was found there was of these products were actually made using force weaker labor. I don't if you're aware of the week of situation, but this is clearly cultural genocide state sponsored force neighbor Off these off this particular ethnic group in China and also some of our gowns coming into the energetic the pandemic. What manner were also manufactured in China but using forced labor from North Korea. In North Korea, around 10% of your workers work under four slaver. That is that they're forced to work in factories and between. In this instance, between 70 to 100% of their salary was forfeited to the North Korean State and the gloves. Around 70% of all the world's graphs are produced in Malaysia and then come in to talk to you about the issues with force immigrant labor in the production off gloves that you are using every day in the chest and for surgical instruments. I'll come in to talk about baseball because for social instruments, a love of them are outsourced for manufacture in Pakistan, a chemical south, or and produce around 70% of the world. So it against rinse, including the low cost throw away ones that you might want to use in any on the high quality reusable ones that you use in theater. So the production of surgical instruments in Pakistan is not to the sort of conditions that you would hope for. Here is, it's a multistage process from war material down to final polishing, and you can see that this gentleman here is working on effectively sweatshop labor conditions even more so. Standing here, these burning metal onto his foot health and safety is an issue. Long working hours are on issues of these workers definitely work 13 hours a day, seven days a week. They get paid a piece, right? So if they don't work, they don't get paid on. Get working on grinding machines. I can tell you the stories. I heard off people getting minor injuries. Sometimes a a graze on the finger, sometimes a thumb that is crushed sometimes in an entire arm that is talking out of its socket, and these people have no compensation. So this is also some production to the cheapest possible source. And so it comes with concerns for human well being abroad. And this includes a ring, the scope blades. It includes dietary me forceps. It also includes, when last evaluated several 1000 Children. So there are 50,000 laborers working in this industry in Pakistan. On that, the last count several 1000 which you'll run. I've seen seven year old Children working on grinding regimes, making the very instruments that we are using in the NHS. So these Children normally start around the age of 12. Very few of them go to school. This is their job and they hate this work. They do know, enjoy this. They want to go to school. They want to go and play. Cricket is no just surgical instruments. You want the lowest possible price for your blood, so I'm gonna take you to Malaysia. This is a factories of a company called Top Club, which actually is the largest love manufacture in the world. You may not be aware of that brand because they make products for hundreds and hundreds of other different brand names that you may well recognize. So these gloves are producing these factories. And actually, everything looks okay when you look at it. But when you go behind the scenes, actually all of these workers work in the shop floor immigrant workers on. But they paid a legal recruitment fees for this privilege to come and work it. So most of them have come from the pole in Bangladesh to come and work in this factory. And they're told it's going to be okay to get a huge amounts of money. So some of them will sell sell land for this opportunity to come here when they arrive. Many of them were worth three months without a single day are they were worth 12 to 13 hour days and they will live in this accommodation. All of the accommodation I've seen is a renders. This is possibly the worst. Where these workers were living in shipping containers, they're life is between this shipping container and the factory. They have their passports confiscated so they're not allowed to leave the compound. There are allegations off work is being beaten at some of these factories, and I've seen some photos that are not allowed to share with you. That would be certainly upsetting. Should we say this is not the life that they started up to and when we serve a 1500 workers last year, that's two of the largest manufacturers. What we found is that 40% of them said that they had paid a large recruitment. He's averaging $2000 which is someone coming from the fall of Bangladesh is a horrendous amount of money. A third of them have been told him not to report their group of it is because they are a legal. They're working typically 12 hours a day, one in 10 have not had a day off in the last three months on one and three and and only a single day off in the last month. Half of them felt unable to leave their employment because of concerns about contraction, obligations outside and huge recruitment fees they paid. This is forced labor. By any measure. There's not much highlights. You talk up in bright way, but actually a wheeze. Other manufacturers producing Malaysia all have been found to have the same issues with forced labor in the supply chain. Using immigrant labor work is going on. That's an entire separate talk. I could give you about this T remedy. Things and things have certainly move forward, but they're still huge problems in this industry on the endemic issues within Malaysian culture to use such forced labor we don't have. Her biggest problem is that when we surveyed and try to get data, which is very, very difficult, we've got some data from Norway from my partners in Norway. And when we were able to ascertain where products were made, what half of the companies wouldn't tell you where they're paroxysmal A. Because of presumably commercial sensitivity. Or perhaps some of them don't even know because they just buy it and they bring it in and re brand it. But off those that we were able to get data for at least 40% and others we've got some other data suggest is higher than there were producing countries with very high risk of labor rights abuses. So what perpetuates is linear economy for medical products? First of all, there's a there's a myth that goes around that is better for finance or better for carbon. If you throw it away, absolutely not true. So we've done some of the analyses. Actually, his paper's very, very soon be published on Be Looked At pair of Scissors as an example of single use less is reusable on unsurprising. If you's reusable and you take a full assessment on this life cycle bleeding sterilization repair, bring it back. It's got less than 1/10 of the carb foot print off a single use. Throw away scissor on. It's per use. Cost is much lower because obviously you do pay more because you want a better quality border, but you use it so much that it pays for itself. In fact, there's been a systematic review that was published last year by Jonathan Drew on. He found, quite rightly, that just about every single circumstance reusable was better than disposable. So don't believe the hype. If anybody tells you ever that the reuse the disposed was better, it may be very specified circumstances, but any company that tells you that would have to prove it through independent, robust academic analysis. And I mentioned the robust because there's a lot of people I'm afraid tinkering in this field and getting the wrong conclusions. So the other is the idea of the methods sterility, and this I think This is really important for people to understand. There were historic problems of sterilization standard. So in the 19 nineties we had inconsistent or inadequate sterilization. There are also play machines in the back of your surgery that you could use in a GP on. That was fine in principle. What people are not cleaning instruments. They were not checking that the steroids, a shin machine was up to scratch. And so we had really inadequate or inconsistent sterilization. And together with that, we got this thing called C A. D, which is a prime disease which is incurable, can be transmitted on can lead to death. So these two things just lead to this idea that we have to have single use products for a lot of things. But we don't live in that world anymore. So and now we have robust decontamination standardization of bean to these percentages. This is for laundry. This on the left is the largest washing machine I've ever seen is bigger than my entire house on every single stages automated. There are computers that check everything that the standards have being met. So you don't need to worry about it here on the right is it is a light light box of one step for microscopic perforations in the material that you might be using, for example, a drape and checked again robust. Everything has to me a C m. 0104 for laundry, which is the highest standard in the world. And then for instruments, we have HTML of one on one and again automated, fully auditable systems. It is sterile. You really just don't need to worry about it. So that world in the 19 nineties is gone, and nobody has got CJD from any social procedures since the 19 seventies, when the standards were not there when some neuro surgeons and she took some brain electrodes, wipe them with electro. What's are working with alcohol and stuff, Um, in someone else's brain. We don't do that anymore. And single use, which is the culture in many places, may not me those standards. So last year there was an alert because if you buy a single use for it, it's not necessarily sterilize in the UK to our standards. It could be sterilized over season off, that is, and there's a company in northern Italy which have been full survive his records for years on sterilization, and we know off instances where probably lead to patient infections. At least 88 major brands are affected by this. So if you want to know sterile, get steroids are going to you can standards using Are you gay processes? So what else? Perpetuating many economy this economic off post somewhere where there's a disconnect between the post in the use of always really alluded to that models of procurement based on product quantity rather than modern such a servicing. So we should actually be telling cos, for example, for complex parents. Actually, I'm going to buy you to provide diet for me Forceps. For five years. I'm not gonna buy certain number. You just have to provide enough for us to move our service. It is then, in the purchases interest of natural. Those products last because I'm gonna make more profit rather than keep on replacing them. And there's nothing special about the manufacturer of medical products. Have already shown you some data on that, for example, and so doing a pandemic was making lots of class for us. But when they couldn't meet capacity, we know that they ask all these other companies, all these other manufacturers to make gloves on rebrand them is on cell to cell to us. So it's interesting that infirmary rather than tax we don't have equipment danger for every 1 lb spend on research. 19 lb is spent on advertising information. We also the medical devices can be designed to be reused a complex ones in the USA. There over 31 million device reprocess These supposedly single use of items can actually take it apart. Reprocess and reuse. There are Elektronik chips and some of these devices programmed to allow them to anybody used once, and it seems I'm not sure entirely why that's going on. There's also in fines in the US for legal activity. For example, some of your hip and spinal surgery implants have Bean claimed to be made in us, but actually they were manufactured in Malaysia and China. And there's no problem with that as long as the quality standards is there. Ondas, long as you're protecting workers in the industry. So when we have these lack of information and misconceptions, we get knowledge voice filling, miss the the's idea. So one of my butt bases around gloves. Gloves in none in in non sterile environment. So it is white foam misconceptions of gloves of synonymous with her analogy and data we have published or my colleagues. A published suggested more than 60% of glove use in healthcare is unnecessary. You only need to wear guards. None. Seroquel as a high risk situation went in contact with potential infected body fluids to reduce your burden on your hands. So that's mucosal services. It might be sort of, you know, feces and things like that, but I see people wearing gloves to transfer patients across on the table. It's utter nonsense and against national guidance. So we're trying to really embed this. You do need to wash your hands on washing hands is far, far better than wearing gloves, so it's a hell of a lot of class. In fact, I worked out even before the pandemic I worked out yesterday in before the pandemic, the NHS for 1.7 billion gloves. That's enough that if you put them into end, they were stretched from the earth to the moon in one year on 60% of that, at least, was not necessary in terms of orthopedics for this is controversial, so I'm probably gonna go off. So with this but laminar flow versus conventional float laminar flow for your arthroplasty is use a hell of a lot of energy on drippy tid systematic reviews of felt. It shows that there's any real benefit from them in terms of joint infections there. There are some basic science data that may say, actually, it improves the amount of bacteria within the within the environments. I'm not going to go into it. But suffice to say, in the real world environment, where actually those lamina flows are not actually really, because there are people moving through where some of the contaminants you might find in the air are irrelevant Joint infections, which is you come from skin such a staph aureus and staph aureus is not really found in the year. I'm going to leave that for now. But what I am gonna construct, um, is your orthopedic textiles. I I'm still on trying to understand why there's so much single use. Orthopedic textiles, particularly for arthroplasty, is so we can convert printed computational knee arthroplasty on. You can see that almost half of the carbon footprint off a couple tunnel when it was performed in my book, using single use drapes half of the products it was due to the single You Strips. I just don't understand why. And even with the knee arthroplasty, it was huge. That's equipment to driving 72 miles an average car from using single use textiles. Reusable textiles. Exactly one third the carbon of disposable. When you take a count, all the laundry, sterilization, transport all of that still one third the carbon of disposable. And perhaps this is historic again. The bristles possession quite rightly said drapes and gums must be made in Paris materials. I understand that completely agree. Thin cotton drugs and guns have no place in orthopedic surgeon. We don't use cotton anymore. This is parking back to the 19 nineties or 19 eighties. So what are textiles of the moment? Single. Use it if you want single use. Typically nonwoven made from petrochemicals manufactured overseas, still dominant in this country that cheap, your reusable, far better quality product, typically woven high density. My fiber, still made from petrochemicals content is not appropriate a compound for this, but actually, if you re use in many, many times, it's absolutely it. What a carbon is obviously much, much better, typically really 75 times. Do you need to worry about whether it's got penetration? Of course you don't because we have a standing year 13795, which ensures that liquid penetration of microbial penetration is maintained throughout the entire life cycle on this point, and that's why we get to 75 is after 75. There is some uncertainty there something actually, 100 times it could be reused. You don't need to worry about that. Your provider is taking care of all of that and has to order it actually, what's happening to these products if you want performance? Actually, your reusable is much, much better. Got four times higher than tens all strength, 10 times higher than tens on strength of wet. So if you're worried about tearing urine operation, why are you using single use in terms of burst? That's a puncture again, 10 times better with a reasonable textile, and you worry about limiting little particles coming up, causing infections eight times a day, with reusable so reusable. If you're worried about clinical care, reusable textiles and the only option should be using because the cheap single you stop is far lower quality and finalize to lead to problems. Do we see this? We see parallels elsewhere so you can fool. A lot of people are back bottle of water it another about bear mind water that you got available. Tap packaging, petrochemicals and transported to you cost more. No shortness of contents. Fiji water that's supposed brand leader has our sink levels are higher than will be allowed in tap water. It things plasticizers such a d H b, which are bad for your health. But yet it's a $1.5 billion industry in the UK, so to finish looking forward, we don't need to come for print everything before. Yeah, we can move to a reusable economy because we know that that's what we don't need to recycle as, ah, main strategy. It's important, but it will recover a small amount of the carpet. And it's to be where we focus on. We need to be wary of total Mr Greenwashing, I can tell you that our company is approaching me trying to say that we're making we're broke some solar panels on our on our roof, but we still make a disposable plastic promise, I can tell you that a major supply to the NHS off textiles asked me to speak on there. Webinar but they were using single use. And they asked me specifically not to talk about single use Techstars and I refuse on There are executive board with Drew my invitation because I know that I'm speaking the truth. So going forward, we have a natural part sustained within surgery, coming up next year on great in the academic analysis of creating a circle economy for medical products. Have you been able to support that? Thank you for your time, Professor. But thank you so much for that really interesting and thought provoking talk. I don't know if we've got time to to take any questions live unless we've got anything in the chat which I don't think we have. Um, thank you very much. Have you know your time? Cause I know. I know you've got a lot on this afternoon on. I think you probably got a head off, but I will try and get if anyone's got questions, I'll try and get in touch with you.