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The disposal of Surgical instruments is a tricky issue for GPs, especially under new sterilisation rules. Jennifer Taylor reports

For GPs aiming to make their practice more environmentally friendly the disposal of medical instruments is a particularly challenging area.

The choice of whether to sterilise surgical equipment or use disposable surgical kits has environmental and cost implications. But as of 31 March, all instruments used must comply with the Medical Devices Directive.
Complying with the rules requires practices exclusively to use single-use instruments, or send instruments to a fully accredited sterile services department, or a combination of both. The Healthcare Commission will police whether standards are met.

Martin Alpin, Surrey Sussex decontamination project manager at Hastings and Rother PCT, says it is not cost-effective or practical for practices to sterilise their own surgical instruments. For example, to meet its requirements costs £4,000, plus £3,500 each year to operate. These include regularly testing the machine, sterile water to fill it up each day and practice staff time. And you retain all the risks of processing the instruments yourself.

To move away from self-sterilisation, first ditch your autoclave.

'There's no point in having one at all,’ says Mr Alpin.

Secondly, find out what surgical instruments you can buy as single-use. If some are not available, contact your primary care organisation (PCO) to find out what decontamination services there are locally. There is no centrally held list of central sterile services departments (CSSDs), but the PCO's decontamination lead should be able to tell you which hospitals or private-sector companies have a service that you can use.

The DoH's national decontamination programme is working to set up regional decontamination centres but the project is in its infancy. So for many areas there is still no service.

Brighton GP Dr Christine Habgood's practice exclusively uses single use surgical instruments. She says: 'The local sterilisation units could not cope with any extra capacity.’

Meeting the standards

Suffolk GP Dr Karol Silovsky says some of the instruments that his practice uses are not available as disposables.

But he adds: 'Our local hospital does not meet the required standards for sterilisation, so I will have to send them further afield, needing to purchase more surgical equipment to combat losses or delays in return.’
Mr Alpin says most GP practices are better serviced with single use surgical instruments. That is unless you have a large practice and carry out a lot of procedures, in which case a mixture of CSSD for sets and single use for particular individual surgical instruments may be preferable.

So what are the environmental and cost implications? Mr Alpin says there are 'limited recycling opportunities’ for single-use instruments, which are either sent to landfill or incinerated. The surgical instruments can be disposed of with your other clinical waste, at a cost of £500 to £1,500 per tonne.

The cost will be towards the upper end if you have to label an instrument as hazardous.

Mr Alpin has carried out research with GPs in his area and found that one practice of six GPs was spending £11,000 a year on decontamination costs. He calculated that this could be cut to £5,000 if the practice used single use surgical instruments, plus a CSSD service where single use surgical instruments was not available.

Some practices would break-even and a few would save £1,000 to £2,000. But you're paying somebody else to take the risk’, says Mr Alpin.

Transport is another consideration. Singe use surgical instruments are delivered by post or courier and disposed of in the sharps clinical waste.

Rising costs

But for CSSD services, because instruments must be cleaned as soon as possible, you will need a weekly collection and delivery service, which adds to your costs and the environmental impact.

On the one hand, sending single use surgical instruments to landfill is not ideal and incinerating them produces carbon emissions. But decontamination uses energy to produce high pressure steam at 134^oC and needs chemicals and detergents in the process.

Single-use also requires a mindset change. 'It takes a bit of a mental effort to drop it in the waste bin,’ says Mr Alpin. Berkshire GP Dr Niall Riddell agrees.

'It breaks my heart throwing away perfectly good scissors and forceps.’
Case study Dr Sally Whale

Dr Sally Whale's practice in Ipswich, Suffolk, uses a mixture of single use surgical instruments and disposable. As a result of the new regulations, they are planning to move to using only disposables since a suitable sterilisation service is not available. But finding a decent disposable IUCD set for a reasonable price is difficult.

'I cannot find a kit I like under about £30,’ says Dr Whale. 'Coil fitting is already only marginally viable for the directed enhanced service payment using reusable instruments sterilised in-house,’ she says. 'The move to disposables pushes it into a service offered at a small loss.’

The practice has not arranged for the single use surgical instruments to be recycled, but Dr Whale says: 'According to our PCT adviser, all of the metal ones are recycled by melting them and then reforming them into instruments for animal use.’