Article Summary
The NHS cannot reach net zero without redesigning where and how routine surgery takes place. Building on previous FORTIS discussions about moving appropriate care out of high-intensity acute settings, this article draws on the clinical expertise, research and evidence shared by Consultant Hand Surgeon, Mr Alistair Phillips FRCS (Tr & Orth) on how rethinking minor surgical pathways offers one of the most immediate and scalable sustainability opportunities within the elective system.
In 2020, the NHS became the first national health system to commit to reaching net zero carbon emissions. The commitment set two clear targets: net zero for directly controlled emissions by 2040, and for all influenced emissions by 2045. The figures behind that commitment were sobering. The NHS accounts for around 4-5%  of the UK’s total greenhouse gas emissions and roughly 40% of all public sector emissions. In 2019 alone, its carbon footprint stood at 25 megatonnes of COâ‚‚ equivalent – comparable to the annual emissions of Sri Lanka.
Five years later, meaningful progress has been made. Direct emissions have fallen significantly, desflurane which is the most carbon-intensive anaesthetic gas has been effectively decommissioned and estates emissions are declining. But Scope 3 emissions, those embedded in supply chain, travel and waste remain largely unchanged. They account for nearly three quarters of the NHS carbon footprint.
As Ali Phillips argues, the next phase of decarbonisation will not be achieved by swapping one gas for another. It requires something more fundamental: redesigning how and where care is delivered, and this is where minor hand surgery becomes unexpectedly important.
The Operating Theatre Problem
Operating theatres sit at the centre of the hospital’s environmental footprint. Despite occupying a relatively small proportion of the estate, they can generate between 20 and 70% of all hospital waste. They are inherently energy-intensive spaces, requiring continuous air exchanges, heating, cooling and filtration whether or not a patient is on the table. Add to that the single-use plastics, disposable surgical gowns, complex customised instrument trays and volatile anaesthetic gases and the environmental impact becomes significant.
These systems are essential for major cardiac, vascular and abdominal surgery. They are not essential for every surgical intervention that currently passes through them. Across the NHS, there are high-volume, low-complexity procedures that take between 10 to 20 minutes, that do not require general anaesthesia, do not require patients to stay in hospital overnight and can be performed safely under local anaesthetic in a clinical room with standard ventilation. Yet theatres remain the default mainly because they always have been.
The Wider Case for Minor Procedures
In a recent FORTIS discussion on how emerging surgical models could unlock NHS capacity, we explored how procedures such as carpal tunnel release can move safely out of full operating theatres and into lower-intensity clinical environments. The argument then focused on productivity, freeing acute theatres for high-acuity work and addressing elective pressures. But the same structural inefficiency that limits theatre capacity also carries a significant carbon cost. When low-complexity procedures continue to flow through high-energy theatre environments, the environmental impact mirrors the operational inefficiency. Every unnecessary air change, every oversized instrument tray and every recovery space used for a case that never required general anaesthetic adds to the footprint.
For Ali Phillips hand surgery provides one of the clearest illustrations of this imbalance. According to predicted models, around 90,000 carpal tunnel release procedures are performed in the NHS each year. When trigger finger releases, ganglion excisions and other minor hand operations are included, annual volumes rise substantially further. These are short, superficial procedures that can be delivered safely in clean, well-ventilated rooms under local anaesthetic. Yet the majority still take place inside theatre environments designed for open heart or major abdominal surgery. As Ali Phillips argues, “The issue is not safety, it is proportionality.”
The Clinical Foundation for Change
The argument for moving appropriate procedures out of theatre is grounded in clinical evolution. Across multiple specialties, techniques have advanced to reduce reliance on general anaesthesia, minimise tissue trauma and streamline perioperative requirements. In hand surgery, as Ali explains, the most significant development has been the adoption of WALANT – Wide Awake Local Anaesthetic No Tourniquet. By injecting a dilute mixture of local anaesthetic and adrenaline directly into the operative field, WALANT provides effective anaesthesia and localised vasoconstriction without the need for sedation or general anaesthesia. The patient remains comfortable and fully awake with no requirement for an anaesthetist, no inhaled gases, no recovery bed and no post-anaesthetic monitoring.
From a sustainability perspective, WALANT removes some of the most carbon-intensive layers of the traditional surgical pathway in a single step. It eliminates the very gases the NHS has worked so hard to reduce, not by substituting a less harmful alternative but by dispensing with inhaled anaesthetics altogether. It removes the need for piped medical gases, anaesthetic monitoring equipment and the heavily engineered infrastructure that dictates the design and energy consumption of a traditional theatre.
Equally important has been the formal endorsement of field sterility for minor hand procedures. The British Society for Surgery of the Hand, working alongside Getting It Right First-Time programme, has published guidance confirming that selected elective hand procedures can be safely performed outside main theatres using streamlined sterile technique in clean, well-ventilated rooms. Infection rates are comparable to those reported in full operating theatres. Taken together, these developments shift the debate. The question is no longer whether minor procedures can be delivered outside theatres as the evidence shows they can. The question is why so many still are not.
Quantifying the Environmental Difference
The most detailed quantification of the environmental dividend has come from the Lean and Green initiative in the United States, supported by the American Society for Surgery of the Hand. A prospective study at the University of Kansas Medical Centre compared the environmental footprint of WALANT carpal tunnel release across three settings: a main hospital operating theatre, an ambulatory surgical centre and a clinic procedure room. The findings were unambiguous:
| Setting | Waste per case (kg) | COâ‚‚ per case (kg) |
| Hospital operating room | 4.6 | 41.6 |
| Ambulatory surgical centre | 2.6 | 26.0 |
| Clinic procedure room | 0.7 | 8.3 |
Environmental impact of WALANT carpal tunnel release by clinical setting, table source: University of Kansas Medical Center prospective study
A procedure performed in a clinic setting generated approximately 85% less solid waste and 80% fewer greenhouse gas emissions than the same operation delivered in a main hospital theatre, using identical surgical technique. The only meaningful difference was the environment in which the care was delivered. These are American data and the healthcare systems differ considerably, however the physics of waste and carbon do not observe national boundaries. The underlying principle is that a space designed for open heart surgery consumes vastly more energy and material resource than one calibrated for a short procedure under local anaesthetic and this applies with equal force to an NHS procedure room in Hampshire as to a clinic in Kansas.
Applied to the UK, the implications are significant. If 53,000 NHS carpal tunnel releases alone were migrated from main theatres to clinic-based settings, the Lean and Green data suggest a potential annual saving in the region of 200 tonnes of solid waste and 1,750 tonnes of COâ‚‚ equivalent from those procedures alone. Extend the calculation to include trigger finger releases and other high-volume hand operations and the aggregate reduction multiplies further.
The Hidden Footprint
Travel by patients, visitors and staff accounts for a meaningful proportion of the NHS carbon footprint. Acute hospital campuses are frequently peripheral, car-dependent environments. For many patients, even a short procedure requires a dedicated journey, parking infrastructure and often an accompanying driver. When multiplied across tens of thousands of minor procedures each year, those journeys carry a measurable environmental cost. Decentralising appropriate surgical activity into community settings following the governments “Health on the High Street” agenda, changes that equation.
Minor procedure hubs embedded in town centres or neighbourhood health facilities allow patients to walk, use public transport or combine appointments with everyday journeys. When procedures are performed under local anaesthetic without sedation, as in WALANT pathways, patients do not require post-anaesthetic supervision or a lift home. Every one of those journeys that WALANT eliminates, when multiplied across tens of thousands of cases, carries a measurably lower carbon cost than a drive to a hospital on the ring road. Sustainability, in this context, becomes inseparable from estate strategy.
The Operational Opportunity
The blueprint for high-throughput, low-footprint surgical delivery already exists in the NHS. Ali gave the example when ophthalmology completed a similar transition over the past two decades, moving cataract surgery from inpatient general anaesthesia to ultra-efficient ambulatory pathways under local anaesthetic. High-volume, low-complexity models are now embedded within NHS policy through the HVLC programme. Minor procedures across multiple specialties are structurally suited to the same approach. Each procedure, performed in a streamlined clinic room rather than a main theatre, carries a fraction of the waste, a fraction of the energy consumption and a fraction of the travel emissions. It also frees theatre capacity within acute trusts for the complex cases that genuinely require it, contributing directly to the government’s target of restoring the 18-week referral-to-treatment standard by the end of this Parliament.
One common concern is logistics, particularly sterilisation for higher-volume community lists. But centralised sterile services models already operate successfully across the UK, with instrument trays collected, reprocessed and returned via tracked systems. Crucially, these units work with surgeons to streamline trays, removing instruments that are routinely sterilised but rarely used. Lighter trays mean less material, lower energy use per autoclave cycle and reduced transport load. The impact is simple but significant: less waste, lower energy consumption and a smaller supply-chain footprint. This decouples surgical delivery from on-site sterilisation infrastructure and makes community-based, high-volume lists both practical and environmentally responsible.
The Structural Shift
The NHS has already demonstrated that it can take decisive action on emissions it directly controls. Phasing out desflurane was not simple, but it was achievable because the intervention was discrete and measurable. Scope 3 emissions are different. They are not confined to a single gas, device or energy system. They are embedded in patterns of care in where procedures happen, how infrastructure is specified and how patients move through the estate. That is why minor surgery matters. Not because of the specialty itself, but because it raises a broader structural question: how much of our estate reflects historical habit rather than clinical necessity?
When low-complexity procedures occupy high-intensity environments, the consequence is not only constrained capacity; it is embedded carbon. Every oversized ventilation system, every unnecessary recovery bay and every redundant instrument tray becomes part of the emissions baseline. The next phase of decarbonisation will not come from technological substitution alone; it will come from proportion, aligning infrastructure with acuity, location with need and estate design with contemporary clinical practice. Hand surgery provides one of the clearest examples of what that alignment looks like in practice. The evidence is established, the guidelines are written and the operational model is proven. For a health service legally committed to net zero within two decades, with 7.4 million patients on its waiting list and a policy commitment to move care closer to communities, the case for scaling this approach is not speculative. It is sitting in plain sight.
