Waste Management 25 (2005) 606–615

www.elsevier.com/locate/wasman

Healthcare waste management: a case study from the National

Health Service in Cornwall, United Kingdom
a,*
T.L. Tudor , C.L. Noonan b, L.E.T. Jenkin a

a
Camborne School of Mines, School of Geography, Archaeology and Earth Resources, University of Exeter in Cornwall,
Tremough Campus, Treliever Road, Penryn, Cornwall TR10 8ER, UK
b
The Utilities Department, National Health Service in Cornwall, Cornwall Partnership Trust, Sewing Room Complex,
St. LawrenceÕs Hospital, Boundary Road, Bodmin, Cornwall PL31 2QT, UK

Accepted 13 October 2004

Available online 10 December 2004

Abstract

This paper looks at steps taken towards the development of a 10-year strategy for the management of healthcare waste from the
National Health Service (NHS) in Cornwall, United Kingdom. The major issues and challenges that affect the management of waste
by the NHS, including its organisational structure and collection infrastructure, are outlined. The waste flows of the main acute
medical site are detailed, using waste audits of domestic and clinical bags, redundant equipment, bulky waste, and special waste.
Some of the common barriers to change, such as staff habits and public perceptions, are also identified. Recommendations are made
with respect to improvements in the overall organisational infrastructure and increased localised control. The recommendations also
centre around the formation of strategic partnerships, within the site, between sites and at the broader level between the NHS and its
surrounding community. An important challenge to be overcome is the need to progress from the concept of Ôwaste managementÕ, to
one of sustainable decision making regarding resource use, including methods of waste minimisation at the source and recycling.
Staff training and awareness underpin several of the short and medium/long term solutions suggested to reduce the waste at the
source and recover value from that produced. These measures could potentially reduce disposal quantities by as much as 20–
30% (wt.) and costs by around 25–35%.
Ó 2004 Elsevier Ltd. All rights reserved.

1. Introduction et al., 2004), India (Patil and Shekdar, 2001), Saudia

Waste minimisation in the United Kingdom (UK)
healthcare sector is not a new concept. Within the recent
past, there has been a growing interest in the area (Po-
cock, 1999, 2000; Olko and Winch, 2002; Forster,
1999; NHS, 2000). The focus of attention has however
been directed mainly at the reduction of clinical waste.
Much of the research work into the overall management
of healthcare (medical) waste, however, has been done
outside of the UK, in countries such as the United States
of America (Health Care Without Harm, 2001; Lee
*
Corresponding author. Tel.: +44 1326 371821; fax: +44 1326
371859.
E-mail addresses: t.l.tudor@exeter.ac.uk, t.l.tudor@csm.ex.ac.uk
(T.L. Tudor).
Arabia (Almuneef and Memish, 2003), Tanzania (Mato
and Kassenga, 1997), The Netherlands (Dijkema et al.,
2000) and Finland (Ponka et al., 1996). This has been
due primarily to stricter legislation and higher landfill
costs, compared to the UK. The possible presence of
pathogens means that healthcare waste can also poten-
tially be dangerous (Henry and Heinke, 1996; Gerwig,
2001; Askarin et al., 2004). In addition, pre-sorting
and segregation of waste has been shown to significantly
reduce uncontrolled emissions, reduce ash volume and
its toxicity (Office of Technical Assessment, 1990). It
has also been estimated that disposal savings of between
40% and 70% could be realised through the implementa-
tion of a healthcare waste reduction programme (Health
Care Without Harm, 2001).

0956-053X/$ - see front matter Ó 2004 Elsevier Ltd. All rights reserved.
doi:10.1016/j.wasman.2004.10.004
 T.L. Tudor et al. / Waste Management 25 (2005) 606–615
Sustainable waste management is a difficult challenge
for the UK, where the traditional approach has been to
concentrate on disposal to a cheap landfill and govern-
ment supported recycling (Read et al., 1996). Until the
UK Environmental Protection Act of 1990 (DOE,
1990), the majority of domestic, high risk and low risk
clinical wastes could be incinerated on hospital sites.
Sim (1999) notes that during the late 1980s and early
1990s, it was Ôcommon place for yellow bag clinical waste
to be incinerated in municipal plants run by local author-
itiesÕ. There was no specialised handling equipment in the
furnace area and no sophisticated flue cleansing mecha-
nisms, except removal of particles by electrostatic precip-
itators. With the Act, came a mandate for greater
segregation of healthcare waste and also for incinerators
accepting this waste and also to adhere to strict regula-
tions by 1996, or face closure. The high costs of imple-
menting these new restrictions resulted in the closure of
several incineration plants in the late 1990s.
Since then, the NHS has begun to record and monitor
bagged general and clinical waste as a result of contracts
put in place for the removal of these wastes by registered
contractors. As well as quantities measured, the costs too
are fed back to the central NHS Estates Agency and the
figures collated to produce the national estimated ton-
nage and costs of waste, per year. Coote (2002) states
that on an annual basis the NHS produces 600,000 ton
of clinical, pharmaceutical, infectious and domestic
waste, at a cost of £42 million. The legislative require-
ments, the costs involved and the improved awareness
of issues amongst the public and staff, via sustainable
development targets, have served to raise the profile of
waste in the NHS nationally over the last decade.
The main drivers that have resulted in changes in atti-
tudes towards waste, in the NHS can be summarised as
follows:
(a) Loss of Crown Immunity in 1990, which meant that
sites had to segregate their domestic and clinical
waste, rather than mixing them together (Sim,
1999).
Table 1
A summary of the strengths and weaknesses of waste management practice in the NHS
Strengths
(1) Numerous examples of management arrangements for disposal
of waste involving risk assessments and maintenance of records
(2) Examples of successful targeting and reduction of the clinical
waste stream which has often been the subject of critical audit
and review
(3) Some successful recycling initiatives introduced for some
materials such as paper and cardboard
Source: NHS, 2000.
607
(b) The introduction of the concept of ÔDuty of CareÕ
under the Environmental Protection Act of 1990,
which meant that all waste producing organisations
had an obligation to ensure the safe treatment, car-
riage and disposal of their waste (Sim, 1999).
(c) Increasingly strict legislation and policies governing
waste management. These include the EU Landfill
Directive of 1999, which reduced the amount of
biodegradable waste to landfill and bans co-dis-
posal of waste, the Special/Hazardous Waste,
Waste Incineration and Pollution Prevention Con-
trol (PPC) Regulations, the Proximity Principle
and Producer Responsibility, which all govern the
handling and treatment of waste from arising to
final disposal (Rayner, 2004; Gubby, 2004).
(d) Public fears of the emergence and spread of increas-
ingly resistant micro-organisms such as the multiple
resistant Staphylococococcus aureus (MRSA) and
recent strains of Creutzfelt-Jakob Disease (CJD)
and Bovine Spongiform Encephalopathy (BSE).
(e) Media reports of incorrect disposal of clinical
waste, leading to health hazards (Ward, 2003).
(f) GovernmentÕs overall sustainable development
strategy for all of its departments, which brought
about performance indicators and targets for the
Department of Health to meet (NHS, 2001a).
(g) The increasing cost of waste disposal, due to the
closure of several on-site clinical incinerators in
1995 and increasing costs of waste disposal, partic-
ularly clinical waste, which at about £300/Ton, is
around 5–6 times the cost of domestic waste collec-
tion and disposal.
In response to the challenges, the national advisory
agency NHS Estates, has sought to raise awareness
amongst NHS Trusts and compiled a compendium of
case studies from NHS Trusts which have sought to
tackle the problems, with a view to spreading best prac-
tice (NHS, 2000; NHS Estates, 2002a). Table 1 summa-
rises the strengths and weaknesses in waste management
practice highlighted by this report and indicates that
Weaknesses
(1) Lack of strategic waste minimisation planning involving long-term
scrutiny of the waste issue
(2) Lack of senior management targets set for reducing waste arisings
(3) A lack of recycling initiatives for a wide range of items, for example
redundant furniture and I.T. equipment
(4) Inadequate staff training and information provision
(5) Poorly developed partnerships with other agencies, statutory bodies, and
suppliers, to help facilitate resolving the waste issue
608 T.L. Tudor et al. / Waste Management 25 (2005) 606–615
holistic waste management, which incorporates minimi-
sation within the NHS, is at a low level.
As this summary illustrates, the ability to secure
short-term savings and reduce the most severe risks of
litigation have driven these initiatives to date. This has
led to the focus on management of disposal procedures,
clinical waste reduction and quick win diversions of
material from the domestic waste routes into low or
no cost recycling.
Several hospitals in England and Wales have started
to examine options for: (1) waste minimisation; (2)
waste segregation; (3) alternatives to disposal (NHS,
2001b; NHS Estates, 2002a,b). However, although there
has been progress, the lack of emphasis on waste reduc-
tion and long-term planning for waste minimisation
leaves the NHS behind other sectors of the community
including industry and householders who have been tar-
geted in a more holistic way by local authorities.
This paper outlines research carried out in the Corn-
wall NHS. It seeks to:
(1) Critically assess the organisational structure and
policies for waste management currently in place
within the Cornwall NHS and the challenges and
limitations therein.
(2) Analyse the collection mechanisms and the waste
quantities and types, which are being produced
and how they are being dealt with.
(3) Outline the drivers for change in how waste in man-
aged by medical institutions in Cornwall.
(4) Indicate the nature and structure of the Cornwall
NHS waste project and indicate how it aims to
institute best practice into the overall management
of waste by the NHS in Cornwall.
(5) Outline the steps being taken towards the develop-
ment of an overall 10-year holistic waste manage-
ment strategy, to meet the needs of the NHS and
the county as a whole.
2. The Waste It Not (WIN) project operating in the
Cornwall NHS, UK
2.1. Study area
In addition to the national pressures facing the
NHS, the geography of Cornwall presents specific
problems for waste management by the NHS in the
county. Cornwall sits in the most South Westerly cor-
ner of the UK and is a rural, peninsular county, cov-
ering an area of 876,650 acres (354,920 ha) and an
estimated population of 501,267 (ONS, 2001). It is
bounded on three ÔsidesÕ by the sea and on the other,
by the county of Devon. Many of the NHS sites in
the county are small (on average less than 35 staff
members) and their spread across the county makes
them isolated from each other and difficult to service
effectively.
As is the case across the UK, traditionally, the major-
ity of the countyÕs domestic waste has gone to landfill.
There are presently 17 landfill sites for inert wastes
and 2 for special/hazardous waste operating in Corn-
wall. These two special/hazardous waste sites are sched-
uled to close in 2006/7 and 2010 (Cornwall County
Council, 2003). With as much as 85–90% of the countyÕs
domestic waste currently going to landfill (Cornwall
County Council, 2003), there are increasing pressures
to find alternatives to landfill and much interest in forms
of community networking to develop viable solutions.
The NHS is viewed as a significant waste producer
within the county. It employs the largest workforce
and has a spread of over 100 sites, including office
blocks, health centres, a laundry, hospitals and mental
health and learning disability units, split into 5 partially
independent Trusts. Due to the low levels of industry,
the public sector institutions have become particularly
significant as waste producers, with the NHS employing
15,000 staff and delivering a range of services from a
range of sites. This makes it an important player in
any vision for community waste management. The
WIN project aims to conduct research into the current
state of NHS waste in Cornwall, with a view towards
the development of a comprehensive and integrated
10-year waste management program, to best tackle the
issues identified. The activities of the NHS in Cornwall
are spread across the entire county and in the north of
the county, there is also some overlap with the county
of Devon. Any strategy for dealing with the waste of
such a significant organisation must therefore look out-
wards to other organisations for opportunities and be a
part of a county-wide network. With waste so firmly on
the countyÕs agenda, there is much potential for effec-
tively tackling NHS waste.
As a result, the overall aims of the project therefore
are:
(a) To develop a 10-year holistic waste management
best practice plan for the 5 NHS Trusts operating
in the county by:
(i) identifying the waste streams and the factors
leading to them;
(ii) building partnerships with sectors of the com-
munity that have the potential to influence
these waste arisings and contribute to the prac-
ticalities of the hierarchy concept of waste
reduction, re-use and recycling in preference
to waste disposal;
(iii) trial structured programmes to improve cur-
rent practice, which should enable reflective
cost benefit analysis to take place regarding
options for the future.
 T.L. Tudor et al. / Waste Management 25 (2005) 606–615 609

Table 2
The principle role of each of the partner organisations within the WIN research project
Partner Description of partner
The 5 NHS Trusts in Cornwall 3 Primary Care Trusts (PCTs), 1 Mental
Health Trust, 1 Acute Trust with a waste
service centrally managed by the Mental
Health Trust
NHS Estates, NHS Purchasing & Supply Department of Health Executive
Agency (PASA) Agencies responsible for supporting/
promoting a consistent approach to NHS
estates and purchasing activity
ReMade Kernow Not-for profit organisation established by
CornwallÕs Waste Working Group (now
called ReZolve) to develop local markets
for recycled materials
Camborne School of Mines. School of A school of the University of Exeter,
Geography. University of Exeter in based in Cornwall
Cornwall
Role in project
To co-ordinate the development of a 10-year
strategy acceptable to the each NHS Trust and
which utilises and supports the evolving county
infrastructure
To promote the project as case study which can
contribute to the development of sustainable
waste practice throughout the NHS
To direct the healthcare waste into products which
can be purchased by the Trusts and others
To lead the research into factors influencing waste
arisings, and potentially appropriate technologies
for recycling and reuse

(b) To provide a best practice framework to other NHS
Trusts in the UK to guide the development of holis-
tic waste management procedures.
(c) To document experiences which could prove useful
to other complex organisations from outside the
NHS
2.2. Project structure and scope
The precise number of NHS related properties across
Cornwall is difficult to determine because of the flux in
service provision, the sharing of facilities with other
agencies and the fact that some staff work from the
homes of patients (supported domestic homes). For
the purpose of this study, 72 sites were included and
were those for which waste management is directly the
responsibility of the NHS in the county. Where the
NHS shares responsibility with other agencies, waste
can be the responsibility of another party. The study in-
cluded acute hospitals, community hospitals, health cen-
tres, mental health and learning disability inpatient
units, and offices/drop in-centres.
All of these 72 sites fall under the control of three
1
Primary Care Trusts (PCTs) (North and East Cornwall
PCT, West of Cornwall PCT and Central Cornwall
PCT), one acute Trust (Royal Cornwall Hospitals
Trust) and one mental health/learning disabilities Trust
(Cornwall Partnership NHS Trust). Cornwall Partner-
ship NHS Trust hosts the shared services, including
waste management, for all five of these Trusts.
The partnership chosen for the project is illustrative
of the vision that guided the project towards integrating
NHS waste into the wider county context as well as the
1
Primary Care Trusts are responsible for the strategic planning of
secondary care based on the health needs of the local community (The
National Health Service, 2004).
national context of the NHS. Table 2 describes each
partner as well as their principle role in the project.
This partnership approach for managing the NHS
waste has been an important guiding principle through-
out the project, enabling all involved to begin to view
the waste identified as resources with potential for
reduction, re-use or recycling as well as final disposal.
The partners external to the NHS (ReMade and the
University of Exeter in Cornwall) have been involved
in the audit stage as well as acting upon the results
gained through the research. This therefore enabled im-
proved understanding between the parties of the issues
generating the waste arisings and therefore allow for
more creative, yet practical, solutions to be proposed.
3. Current management of waste by the Cornwall NHS
3.1. Organisational structure
Cornwall Healthcare Estates and Support Services
(CHESS) provides the waste management function to
each of the five NHS Trusts in the county, which entails
ensuring that waste is collected and disposed of from all
Trust sites in accordance with legislation. One waste
manager and an administration assistant are responsible
for overseeing the logistics documented in Fig. 1, along
with other CHESS functions, such as broader environ-
mental services, as well as courier services. The waste
manager is currently heavily relied upon in this structure
to receive, translate and disseminate information and
guidance from central NHS to the Trust management
and employees. Current communication channels are of-
ten not efficient enough to guarantee dissemination from
Trust management to all employees; hence the manager
often has to liase directly with individual employees
from all of the Trusts. Hence, there are too many obli-
610 T.L. Tudor et al. / Waste Management 25 (2005) 606–615

Government/NHS Estates (nationally)

(produces waste management guidance and policies)

Waste Manager
Trust management
(interpretation to Trust/local needs)
(ratification of policies)

On-site Environmental/waste representatives

(50 % of sites)

Individual staff members Individual staff members

Fig. 1. Current waste management organisational structure for Cornwall NHS.

gations on this central post, which have to be fulfilled in
an attempt to satisfy all parties.
The strengthening of administrative structures,
capacities and linkages have been shown to be impor-
tant for maintaining the effectiveness of innovation
(Chaskin, 2001; Butterfloss et al., 1998; Johnson et al.,
2004). Johnson et al. (2004) argue that the building of
infrastructure capacity serves to create sustainability of
process, thereby driving innovation, while at the same
time enabling the flexibility to allow for change and
resistance to change. They go on to indicate that cham-
pions, resources, established administrative structures,
policies and procedures are all required for successful
innovation. At some of the community sites, staff mem-
bers voluntarily act as Environmental/waste representa-
tives, co-ordinating the waste management needs. This
scheme, although efficient in areas, is currently depen-
dent on willing individuals and is therefore variable in
success. Calsyn et al. (1997), however, state that Ôcham-
pionsÕ should span various departments and hierarchies
to ensure success.
3.2. Barriers to change
Through informal discussions with staff members
by the project team and market research of the South
West region by ReMade Kernow, a number of general
barriers to recycling/reuse have also been identified.
Some of most typical barriers to improvement cur-
rently being faced were found to fall into two main
categories – social and economic – as outlined in
Table 3.
4. Methodology for determining waste flows and costs
(a) Examination of waste transfer documentation, to
determine waste flows and costs.
(b) Waste audits of domestic and clinical waste bags.
The audits involved the sampling and categorisa-
tion of 10% of the bag waste from the domestic
and clinical bins over a two-week period and other
waste streams, such as I.T. equipment and redun-
dant equipment, from each of the 72 sites included
in the study. A total of 142 domestic bags and 116
clinical bags from the acute site and 63 clinical and
73 domestic bags from the community sites were
sampled. The contents of each bag were then emp-
tied onto a table and hand sorted into the identified
waste categories, and each category was then sepa-
rately bagged and the weights determined. These
results were then used to determine average quanti-
ties, to allow for an estimation of annual waste
arisings.
(c) Prioritisation of waste streams for action. Each
waste stream was assessed against the following
criteria:

Table 3
The main barriers to change of current practice
Social barriers
 A perception that all waste from healthcare facilities is contaminated
and infected
 Variation in staff habits and acceptance of waste issues
 Some staff perceived waste as someone elseÕs problem, leading to a
lack of participation in seeking solutions
Economic barriers
 Lack of viable markets for recyclables in the South-West of the UK
 Some of the items which could potentially be recycled, or reused, had
residual and non-residual contaminants (e.g., food)
 A lack of a long-term investment in the waste problem within the
NHS
 T.L. Tudor et al. / Waste Management 25 (2005) 606–615 611

1. Environmental – refers to the potential environmen- 5. Results

tal benefits relating to landfill diversion, hazardous
substance control and utilisation of raw materials
which could arise from tackling a particular waste
stream and was strongly related to estimated
tonnage.
2. Cost – refers to the potential cost savings available
from alternative approaches to disposal. Waste
streams with currently high disposal costs scored well
against this criterion.
3. Feasibility – refers to the practicality of impacting on
a particular waste stream and draws on knowledge
gained surrounding barriers to change as well as
opportunities for alternatives.
For each criterion, a score was allocated through
team discussion. Each criterion could be scored a maxi-
mum of 100 (100 being high, 0 being low) enabling a
particular waste stream to score a maximum total of
300. The waste streams were then given a priority rating
based on their score as follows: (1) Priority 1: over 200;
(2) Priority 2: 100–199; (3) Priority 3: 50–99. Scoring is
based primarily on current market conditions for the
various streams.
5.1. Waste flows and their associated costs
Table 4 shows the estimated waste quantities derived
from audit measurements at the largest site surveyed
(hospital A), as well as the sources of the waste, treat-
ment routes and costs. As this site was found to produce
50% of the total amount of waste, the table is represen-
tative of approximately one-half of the waste from
throughout the county. Despite the fact that there were
variations in the quantity of waste at each site, the re-
sults shown in the table are representative of the main
items, which were typically found in the bag waste
stream, as well as those in other waste streams such as
food, bulky waste, and I.T. equipment waste, across
the county.
Generally, there is no one specific source for the
various waste streams. The main exceptions to this
were found to be food waste coming from the kitch-
ens and restaurants/canteens, cytotoxics and items
such as pallets and building materials, which were
found primarily in the Estates departments, or deliv-
ery areas.

Table 4
Waste generation patterns and disposal costs at the largest NHS site in Cornwall
Waste stream Estimated wt/yr (ton) Current treatment route Main sources of waste stream Estimated disposal cost £/yr
Yellow bag waste 477.4 Incinerated All clinical areas 20,571.40
Mixed paper+ 125 Landfilled All areas 6800.40
Food/organics+ 100.5 Landfilled All areas 853.00
Food 110.5 Treated with Kitchens Within sewage charges
waste water
Bulk waste 180.6 Landfilled Whole site 2080.00
News/magazines+ 41.7 Landfilled All areas 1112.00
Office paper+ 35.3 Landfilled All areas 1306.50
PS, PET, HDPE, LDPE, PP+ 57.1 Landfilled All areas 4768.60
Card+ 30.2 Landfilled All areas 2754.60
Cardboard, office paper, HDPE, 327.4 Recycled All areas 8069.00
confidential paper and glass
Unknown plastics+ 26.1 Landfilled All areas 1717.70
Miscellaneous+ 29.4 Landfilled All areas 720.50
Glass+ 8.2 Landfilled All areas 95.00
Aluminium and iron/steel+ 29.7 Landfilled All areas 1000.40
Surgical gloves+ 14.5 Landfilled All areas 132.60
Scrap metal 37.2 Re-used All areas 0
Cytotoxics 4.5 Incinerated Intensive treatment areas 1791.00
Composites+ 2.5 Landfilled All areas 214.00
PVC+ 0.8 Landfilled All areas 194.50
Radioactive 0.1 Incinerated All areas 1468.00
Plastic drums 10,944 drums/yr Re-used Estates department 0
Wooden pallets 300 pallets/yr Re-used Estates/deliveries 0
Cartridges (printer, etc.) 1400/yr Recycled Whole site 1000.00 (received
as income)
Batteries 3000–3400 ZnCd/yr, Landfilled as Whole site –
20 lead – acid/yr special waste
Information Technology 2–5 units/month Re-used and landfilled All areas 120.00
(I.T.) equipment
+, Black bagged waste.
612 T.L. Tudor et al. / Waste Management 25 (2005) 606–615

At hospital A, 41% of the total quantity of waste
was being landfilled. This quantity represented 42.5%
of the disposal costs. Across the county as a whole,
the quantity being landfilled was on average in the range
of 50–60%, due to the lack of dedicated waste operatives
and collection schemes. An estimated 32% of the waste
was incinerated, at a cost of around £22,000.00/yr,
(38% of total costs). Recycling accounts for 20% of
the overall waste produced at this site. At sites across
the county, recycling activity was found to vary from
0% to as high as about 60%. The highest rates were usu-
ally found at smaller sites, with very motivated and ded-
icated staff.
The main components of the domestic streams were
found to be mixed paper (125 T/yr), food/organics
(110.5 T/yr) and plastics (57.1 T/yr). The most costly
items to dispose of at the site were clinical waste
£20,571.40/yr, mixed paper £6800.00/yr and plastics
£4768.00/yr. Approximately 26% (wt.) of the domestic
bag waste items, which are currently going to landfill,
could be diverted. Currently these items account for
about 426.6 T/yr and require 33% the disposal cost at
£18,689.70/yr. This is particularly true for streams such
as mixed paper (8%), food/organics (6%) and the plastics
(3%), particularly polypropylene (PP), high density
polyethylene (HDPE) and polyethylene terepthalate
(PET) bottles and containers, as well as polystyrene
(PS) cutlery and containers.
5.2. Prioritisation of waste categories
Clinical waste was the only Priority 1 waste stream,
reflecting its high quantity, intensive disposal route
and significantly higher costs compared to other waste
streams, as shown in Fig. 2. There is also potential for
improved segregation in the short term and alternative
treatment in the long term. It can be assumed that some
of the Priority 2 items including bulky waste would rate
more highly if the cost for disposal of these items was
higher, illustrating the importance of cost on decision
making. Other streams which offered real possibilities
for being potential resources (as income earners, or for
reuse/recycling) included bulky waste, office paper, card,
newspaper/magazines and food, as well as I.T.
equipment.
6. Discussion
The results indicated that there were three main areas
which the NHS in Cornwall needs to address in the
development of its 10-year strategic waste management
plan: (1) improving its organisational structure, which
currently does not effectively cater to the overall waste
management needs of all its sites; (2) facilitation of a clo-
ser working relationship between its geographically
widespread sites; (3) reducing the current concentration
on disposal and incineration of waste, in favour of holis-
tic approaches to whole-life assessment of resource use.
6.1. Improving the organisational structure
There is a need for the implementation of a more
decentralised operational infrastructure and standar-
dised operating practices across all sites, as shown in
Fig. 3. The proposed structure incorporates area repre-
sentatives, who are responsible for their local Trust area,
as a means of better serving the many sites, a number of
which are relatively small, rural and far-flung. The area
waste representatives would also assume some responsi-
bility for the interpretation of waste management policy,
thereby reducing the dependence on the waste manager/
Trust managers. These representatives would have a de-
gree of control, thereby decentralising power and would
also have the benefit of a waste team, whose role would
be to act as facilitators and trainers. Environmental/

250
200
150
Score

100
Environmental impacts
50
Cost
0 Feasibility
PS
Mixe Card
I.T./e Green

PET
Food
Offic ulky

own p etals
al

ood

News nfidential aper

Black ectronic
er

/maga aper

s
zines

lastic
Clinic

e pap

bag f
B

M
dp
p
l

paper

Unkn
Co

Waste streams

Fig. 2. The determination of the priority waste streams for treatment from the NHS in Cornwall, against the costs, feasibility and environmental
impacts of managing the waste.
 T.L. Tudor et al. / Waste Management 25 (2005) 606–615 613

Government/NHS Estates (nationally)

(produces waste management guidance and policies)

Waste Manager
Trust management
(interpretation to Trust/local needs)
(ratification of policies)

Waste Team
(interpretation to Trust/local needs)
Trained Area representatives from each of the Trusts
(interpretation to local needs)

Site based Environmental/waste representatives

Individual staff members

Fig. 3. Proposed new organisational new waste management structure for Cornwall NHS.

waste representatives would also be in place at sites in all
of the Trusts and the role would be a contractual, rather
than voluntary one.
6.2. Facilitating closer working relationships
Another measure for improving organisational struc-
ture and better servicing (including collection services)
of all sites, is to seek to enhance the furthering of part-
nership building between neighbouring sites and local
regional control. This arrangement would be facilitated
by a central team, within an overall structured frame-
work. Partnerships would however be taken in its
broadest sense to include (1) at the Trust level between
key departments such as such as Infection Control,
Health and Safety, Sterilisation Services and Risk Man-
agement, (2) at the site level, between neighbouring sites,
(3) between the NHS sites and private sector organisa-
tions, including the waste contractors, other government
organisations, including Local Authorities, and (4) the
NHS and the community at large. This approach en-
ables the exploitation of the potential benefits which
can be accrued from managing the waste in a holistic
and sustainable manner. This would be made possible
through the pooling of skills and resources, while at
the same time vitally allowing for the organisation, in
this case the NHS in Cornwall, to focus on its core task,
that of providing healthcare to the community. Another
key partnership required for improved efficiency is clo-
ser working relationship between the patient admissions
monitoring department, i.e. the Performance Manage-
ment department and the waste department, as a means
of assessing future needs, based on patient numbers.
This partnership approach is also particularly important
for the standardisation of process across sites, which is
crucial not only for ensuring continuity as staff move
from one site to another, but also allowing temporary
staff to fit easier into the system. These measures are
in keeping with the theories of Chaskin (2001), Butter-
floss et al. (1998) and Johnson et al. (2004) to strengthen
administrative structures and create linkages, in order to
drive innovation.
Implicit within the improvements in organisational
structure is deemed to be the need for increased staff
training and awareness (both at induction and ongoing).
These measures are important to bring about change in
attitudes and habits and reduce the social barriers iden-
tified. Variation in practice at different sites means that
training will have to be tailored and structured in such
a manner as to accommodate this. The presence of envi-
ronmental/waste representatives, as ÔmotivatorsÕ at the
various sites, allows for the continuation of programmes
after implementation as well as to offer a channel of
feedback for staff members. In addition, the setting up
of a web site provides information, on all aspects of
dealing with waste, allows staff to access information/
data, and is another important means by which the flow
of knowledge and awareness has been improved. Effec-
tive communication and feedback are crucial for
answering questions and getting staff involved. In addi-
tion to the use of media such as newsletters and posters,
a web page was launched, with contact numbers and
e-mail addresses, so that staff knew where they could ac-
cess information and direct their queries. This is an
important tool for communication, which has allowed
the research team to provide information and organise
614 T.L. Tudor et al. / Waste Management 25 (2005) 606–615

Table 5
Proposed short and medium/long term waste to resource solutions for Cornwall NHS
Priority Waste stream Recommended options for further investigation Recommended options for further
(short term) investigation (long term)
1. Clinical (yellow bag waste) 1. Staff awareness 1. Thermal treatment
2. Implementation of segregation systems
Bulk Waste and metals 1. Implement zones for collections and 1. Develop waste exchange system,
begin to segregate for re-use and recycling between sites and other healthcare
(focus on clearouts) facilities in the county
Office paper (high quality) and 1. Staff awareness and segregation systems 1. Buy recycled
confidential paper 2. Reduce initial consumption and encourage 2. Assess potential for increase in
re-use in-house shredding, pulping and reuse
2. Food 1. Reduce waste at source through Patient Power 1. Utilise enclosed biological treatment
2. Improve procedures for waste minimisation 2. Small outlying areas utilise Green Cone
through awareness and segregation digestors for food and paper mix
I.T. equipment 1. Continue utilising current collector & formalise 1. Development by NHS and partners, of
contract to ensure compliance with Duty of county wide collection schemes and
Care legislation further use of used systems
2. Implement a ÔtakebackÕ scheme with
suppliers
Card and newspapers and 1. Staff awareness and segregation systems 1. Continue with recycling
magazines 2. Reduce incoming products through green 2. Utilise for biological treatment
procurement 3. Use for animal bedding
Mixed paper 1. Divert as much as possible from domestic and 1. Biological treatment
clinical waste stream, through segregation and 2. Replace towels with dryers in selected
training areas, such as public wash rooms
3. Separated plastics – (PS and PET) 1. Reduce use of PS cutlery 1. Energy recovery
2. Staff awareness 2. Turn into other products (e.g.,
3. Reduce incoming products through green plaswood and bollards)
procurement
4. Trial segregation systems

responses to staff queries and provide valuable informa-
tion for long-term strategic planning.
6.3. Realising the resource potential
As well as improving the organisational and commu-
nication structures, the first step towards minimising
waste at source and realising potential for reuse for
the NHS in Cornwall, is through the creation of a cen-
tralised database inventory of waste stream quantities,
sources and costs. This not only allows for the waste
streams to be more accurately recorded and tracked,
but also enables the introduction over time of lists of Ôre-
sourcesÕ, such as redundant equipment, which could be
used in an exchange/auction scheme. The introduction
of this scheme would not only mean that these resources
were no longer wasted, but could also ÔcreateÕ space by
shifting items which were taking up valuable space. A
stable source of raw materials would also be established
and a buy back/recycling loop could be created through
the return of resources to the NHS.
For each priority waste stream, there is the potential
for short and long-term solutions. These proposals, as
outlined in Table 5, seek to move away from the concept
of Ôwaste managementÕ to one of sustainable decision-
making regarding resource use (Lisney et al., 2003)
and to reduce the quantity going to landfill and inciner-
ation and the associated costs. An important strategy
for dealing with some of the waste streams, for example
packaging waste, is to tackle it at generation, as well as
at the source. There is therefore a need to implement a
ÔgreenerÕ form of procurement and also to investigate
the options of local purchasing and the institution of
Ôtake backÕ arrangements into contracts with suppliers.
Emphasis has been on waste minimisation, recovery of
value and provision of options for business development
through partnerships. The solutions have therefore been
broken into short and medium/long term and items were
prioritised in order to achieve these goals. Segregation of
materials, for example food, from other dry recyclables,
such as paper, was thought to be the most effective first
step to increasing the value of the streams. Segregation,
therefore features prominently in the recommendations
for resource recovery. Waste streams which are recycled
can be collected for a nominal fee, making this the most
economic option compared to disposal. The results
showed that of the 41% (wt.) being landfilled at the larg-
est site, at 42% of the disposal costs, some 26% (wt.)
potentially divertable, with a 33% reduction in disposal
costs. While this represents potential only, taking into
account the overall landfill average across all sites as
around 50–60%, it is believed that with the implementa-
 T.L. Tudor et al. / Waste Management 25 (2005) 606–615
tion of the measures suggested above and in Table 5, on
average 20–30% (wt.) of the waste could be diverted,
with a corresponding reduction in disposal costs of
around 25–35%.
7. Conclusions
The development of an effective 10-year strategy for
the management of healthcare waste in as large an orga-
nisation as the NHS in Cornwall has to involve a step
change in policies and practices throughout the organi-
sation. In order to achieve success, it must seek to: (1)
encourage and facilitate the local control of the re-
sources of all of its far flung, rural sites within an overall
framework; (2) build bridges between the NHS and its
neighbours in the community; (3) find ways of both
reducing waste at the source and recovering value from
that which is produced.
Acknowledgements
The authors acknowledge the input of the entire WIN
team in the collection of data and to thank County
Environmental Trust (CET) through the Landfill Tax
scheme and all of the other partners, for financing and
facilitating the study. We thank Professor Paul S. Phil-
lips for providing critical guidance with earlier drafts
of this paper.
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