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Greener Operations: Sustainable Peri-Operative Practice PSP Protocol


Purpose of the PSP and background

The purpose of this protocol is to clearly set out the aims, objectives and commitments of the Sustainable Peri-Operative Practice (“Greener Operations”) Priority Setting Partnership (PSP) in line with James Lind Alliance (JLA) principles.  The Protocol is a JLA requirement and will be published on the PSP’s page of the JLA website.  The Steering Group will review the Protocol regularly and any updated version will be sent to the JLA.

The JLA is a non-profit making initiative, established in 2004.  It brings patients, carers and clinicians together in PSPs.  These PSPs identify and prioritise the evidence uncertainties, or ‘unanswered questions’, that they agree are the most important for research in their topic area.  Traditionally PSPs have focused on uncertainties about the effects of treatments, but some PSPs have chosen to broaden their scope beyond that.  The aim of a PSP is to help ensure that those who fund health research are aware of what really matters to patients, carers and clinicians.  The National Institute for Health and Care Research (NIHR – coordinates the infrastructure of the JLA to oversee the processes for PSPs, based at the NIHR Evaluation, Trials and Studies Coordinating Centre (NETSCC), University of Southampton. 

How the PSP came together

Healthcare has a complex relationship with the environment: climate change has been identified as ‘the biggest public health threat of the 21st century’ and is therefore a pressing concern for healthcare providers, yet healthcare makes a substantial contribution to anthropogenic global warming and environmental pollution. This ‘double standard’ has led to the increasing profile of the environmental impact of healthcare. Building on legislation such as the Climate Change Act, the NHS, which is responsible for around 4% of the UK’s national carbon footprint, has recently committed to become ‘net zero’ by 2040.

Peri-operative practice makes a substantial contribution to the NHS’ environmental impact: inhalational anaesthetic agents account for approximately 5% of the carbon footprint of acute hospitals, and each operating theatre produces roughly 2.3 tonnes of solid waste per year.

Viable opportunities have been identified to reduce environmental impact. These include different anaesthetic techniques, advances in peri-operative medicine to reduce complications and critical care admissions, and waste segregation and recycling. The Get It Right First Time (GIRFT) initiative shows variation between healthcare providers in the interventions performed on similar patients, which are likely to have similar variability in terms of environmental impact.

However, because research in this field is relatively sparse in comparison to clinical or basic sciences research, the efficacy, acceptability and safety of environmentally sustainable practice remains under-investigated, limiting the scope for implementation. Aiming to focus on sustainability during his presidency of the Manchester Medical Society and with access to funding via philanthropic donation, David Jones collaborated with Cliff Shelton to identify ‘Sustainable Peri-operative Practice’ as an appropriate area for a PSP. This will establish the priorities for research in environmentally sustainable operating theatre practice, which is vital in order to attract funding and provide a focus for future research efforts, and ultimately evidence based sustainable peri-operative care.

Aims, objectives and scope of the PSP

The aim of the Sustainable Peri-operative Practice PSP is to identify the unanswered questions about Sustainable Peri-operative Practice from patient, carer, healthcare professional and public perspectives and then prioritise those that patients, carers, healthcare professionals and the broader public agree are the most important for research to address.

The objectives of the PSP are to:

  • work with patients, carers, healthcare professionals and the broader public to identify uncertainties about environmentally sustainable practice within peri-operative care.
  • agree by consensus a prioritised list of those uncertainties, for research.
  • publicise the results of the PSP and process.
  • take the results to research commissioning bodies to be considered for funding.

The scope of the Sustainable Peri-operative Practice PSP is defined as:

  • Peri-operative practice, which for the purposes of this project is defined as care provided from or in the secondary care setting to patients who may benefit from surgical management, including:
    • pre-operative assessment and optimisation (e.g. pre-operative clinic)
    • counselling and shared decision-making (including on decisions regarding the appropriateness of surgery, and different approaches to peri-operative management)
    • pre & postoperative hospital care (including outpatient, ambulatory, virtual and inpatient care)
    • intra-operative management (including surgical and anaesthetic techniques)
    • both clinical (e.g. surgical and anaesthetic techniques) and non-clinical (e.g. energy, water, waste management and recycling) aspects
    • the implementation of these practices within organisations / departments
    • achieving positive peri-operative outcomes

The PSP will exclude from its scope questions about:

  • Care received by surgical patients beyond the early postoperative period (e.g. prolonged recovery, rehabilitation).
  • Denying the management of illness purely on the basis of environmental sustainability.
  • Broader aspects of environmental sustainability outside the peri-operative context (e.g. location of hospitals, general building design).
  • Non-UK practice.

The Steering Group

The Steering Group is responsible for discussing what implications the scope of the PSP will have for the evidence-checking stage of the process. Resources and expertise will be put in place to do this evidence checking.

The Steering Group includes membership of patients carer and public representative and healthcare professionals, as individuals or representatives from a relevant group.

The Sustainable Peri-operative PSP will be led and managed by a Steering Group involving the following:

Patient carer and public representative/s:

Bob Evans Patient, Carer & Public Involvement & Engagement (PCPIE) Member
Jenny Dorey PCPIE Member, Centre for Peri-operative Care (CPOC) Lay Committee Member
Becky Knagg Morecambe Bay Maternity Voices Chairperson
John Hitchman PCPIE Member

Healthcare professional representative/s:

Cathy Lawson Specialty Registrar in Anaesthesia and Critical Care Medicine, HEE North East
David Riding Specialty Registrar in Vascular Surgery, HEE North West
Louise Bates  Specialty Registrar in Anaesthesia, Wessex Deanery
Fiona Brennan Consultant Anaesthetist, Cardiff and the Vale University Health Board
Michael Donnellon Operating Department Practitioner, College of Operating Department Practitioners
Victoria Pegna Specialty Registrar in Colorectal Surgery, HEE Kent Surrey and Sussex
Mike Kinsella Consultant Anaesthetist, St Michael’s Hospital Bristol
Jennifer Strong Senior Sustainability Officer, Manchester University NHS Foundation Trust
Dan Morris Consultant Ophthalmologist, University Hospital of Wales
Tim Sheppard Consultant Obstetrician and Gynaecologist, University Hospital of Wales
Tracey Radcliffe Registered Nurse; Governance Lead, Glan Glwyd Hospital
Yasmina Hamdaoui Pre-operative and Surgical Pharmacist,  Ysbyty Gwynedd Hospital
Beck Diedo Senior Lecturer; Perioperative Nurse, University of Brighton

Project Leads:

Cliff Shelton Consultant Anaesthetist and Senior Clinical Lecturer, Wythenshawe Hospital, Manchester University NHS Foundation Trust / Lancaster Medical School, Lancaster University
David Jones Medical Examiner and Retired Consultant General and Colorectal Surgeon, Wythenshawe Hospital, Manchester University NHS Foundation Trust

Project Co-ordinator:

Kathryn Hilton Administrator, Sustainability Department, Manchester University NHS Foundation Trust

James Lind Alliance Adviser and Chair of the Steering Group:

Jonathan Gower James Lind Alliance

Information specialists:

Hrishi Narayanan Specialty Registrar in Anaesthesia, HEE North West
Max Clayton-Smith Specialty Registrar in Anaesthesia, HEE North West

The Steering Group will agree the resources, including time and expertise that they will be able to contribute to each stage of the process, with input and advice from the JLA.


Organisations and individuals will be invited to be involved with the PSP as partners.  Partners are organisations or groups who will commit to supporting the PSP, promoting the process and encouraging their represented groups or members to participate.  Organisations which can reach and advocate for these groups will be invited to become involved in the PSP. Partners represent the following groups:

  • Patients who have had, or may need, surgery
  • Carers of patients who have had, or may need, surgery
  • Healthcare professionals involved in peri-operative care

Organisations who have confirmed ‘partner’ status:

  • The Association of Anaesthetists
  • The College of Operating Department Practitioners (CODP)
  • The Royal College of Surgeons of Edinburgh
  • The Royal College of Surgeons of England
  • Centre for Perioperative Care (CPOC)
  • Bay Wide Maternity Voices
  • North East and Cumbria Academic Health Sciences Network
  • The Association of Coloproctology of Great Britain and Ireland
  • British Anaesthetic and Recovery Nurses Association
  • UK Health Alliance on Climate Change
  • Perioperative Care Collaboration
  • Centre for Sustainable Healthcare
  • Regional Anaesthesia UK
  • Royal College of Anaesthetists
  • Students Organising for Sustainability
  • Greener Anaesthesia and Sustainability Project
  • Health Innovation Manchester
  • Intensive Care Society
  • Faculty of Intensive Care Medicine
  • Society for Cardiothoracic Surgery in Great Britain and Ireland
  • Green Health Wales
  • The United Kingdom Clinical Pharmacy Association
  • Royal College of Nursing Perioperative Forum
  • Ysbyty Gwynedd Green Group
  • Royal College of Ophthalmologists

Exclusion criteria

Some organisations may be judged by the JLA or the Steering Group to have conflicts of interest.  These may be perceived to potentially cause unacceptable bias as a member of the Steering Group.  As this is likely to affect the ultimate findings of the PSP, those organisations will not be invited to participate.  It is possible, however, that interested parties may participate in a purely observational capacity when the Steering Group considers it may be helpful.

The methods the PSP will use

This section describes a schedule of proposed steps through which the PSP aims to meet its objectives.  The process is iterative and dependent on the active participation and contribution of different groups.  The methods used in any step will be agreed through consultation between the Steering Group members, guided by the PSP’s aims and objectives.  More details of the method are in the Guidebook section of the JLA website at where examples of the work of other JLA PSPs can be seen.

Step 1: Identification and invitation of potential partners

Potential partner organisations will be identified through a process of peer knowledge and consultation, through the Steering Group members’ networks.  Potential partners will be contacted and informed of the establishment and aims of the Sustainable Peri-operative Practice PSP.

Step 2: Awareness raising

PSPs will need to raise awareness of their proposed activity among their patient, carer and healthcare professional communities, in order to secure support and participation.  Depending on budget, this may be done by a face-to-face meeting, or there may be other ways in which the process can be launched, e.g. via social media.  It may be carried out as part of steps 1 and/or 3.  The Steering Group should advise on when to do this.  Awareness raising has several key objectives:

  • to present the proposed plan for the PSP
  • to generate support for the process
  • to encourage participation in the process
  • to initiate discussion, answer questions and address concerns

Step 3: Identifying evidence uncertainties

The Sustainable Peri-operative Practice PSP will carry out a consultation to gather uncertainties from patients, carers and healthcare professionals.  A period of 3-6 months will be given to complete this exercise (which may be revised by the Steering Group if required).

The Sustainable Peri-operative Practice PSP recognises that the following groups may require additional consideration.

The Steering Group will use online surveys as the predominant method of data collection (written surveys will be available on request). These will be promoted by:

  • email +/- inclusion in literature distributed via partner organisations
  • social media, via the @SusPeriopPSP twitter account and shared by partner organisations

Existing sources of evidence uncertainties may also be searched

  • research recommendations in academic papers concerning sustainable peri-operative care, including research reports, systematic and narrative reviews, and editorials
  • research registration databases and published protocols for ongoing or planned research

Step 4: Refining questions and uncertainties

The consultation process will produce ‘raw’ questions and comments indicating the areas of uncertainty suggested by patients, carers, members of the public and healthcare professionals.  These raw questions will be categorised and refined by Dr Hrishi Narayanan and Dr Max Clayton-Smith into summary questions which are clear, addressable by research, and understandable to all.  Similar or duplicate questions will be combined where appropriate.  Out-of-scope and ‘answered’ submissions will be compiled separately. The Steering Group will have oversight of this process to ensure that the raw data is being interpreted appropriately and that the summary questions are being worded in a way that is understandable to all audiences.  The JLA Adviser will observe to ensure accountability and transparency.

This will result in a long list of in-scope summary questions.  These are not research questions and to try and word them as such may make them too technical for a non-research audience.  They will be framed as researchable questions that capture the themes and topics that people have suggested.

The summary questions will then be checked against evidence to determine whether they have already been answered by research.  This will be done by Drs Hrishi Narayanan and Max Clayton-Smith.  The PSP will complete the JLA Question Verification Form, which clearly describes the process used to verify the uncertainty of the questions, before starting prioritisation.  The Question Verification Form includes details of the types and sources of evidence used to check uncertainty.  The Question Verification Form should be published on the JLA website as soon as it has been agreed to enable researchers and other stakeholders to understand how the PSP has decided that its questions are unanswered, and any limitations of this.

Questions that are not adequately addressed by previous research will be collated and recorded on a standard JLA template by Drs Hrishi Narayanan and Max Clayton-Smith.  This will show the checking undertaken to make sure that the uncertainties have not already been answered.  The data should be submitted to the JLA for publication on its website on completion of the priority setting exercise, taking into account any changes made at the final workshop, in order to ensure that PSP results are publicly available.  

The Steering Group will also consider how it will deal with submitted questions that have been answered, and questions that are out of scope.

Step 5: Prioritisation – interim and final stages

The aim of the final stage of the priority setting process is to prioritise through consensus the identified uncertainties about Sustainable Peri-operative Practice. This will involve input from patients, carers, members of the public and healthcare professionals.  The JLA encourages PSPs to involve as wide a range of people as possible, including those who did and did not contribute to the first consultation.  There are usually two stages of prioritisation.

1. Interim prioritisation is the stage where the long list of questions is reduced to a shorter list that can be taken to the final priority setting workshop.  This is aimed at a wide audience, and is done using similar methods to the first consultation.  With the JLA’s guidance, the Steering Group will agree the method and consider how best to reach and engage patients, carers and healthcare professionals and the public in the process.  The most highly ranked questions (around 25) will be taken to a final priority setting workshop.  Where the interim prioritisation does not produce a clear ranking or cut off point, the Steering Group will decide which questions are taken forwards to the final prioritisation.

2. The final priority setting stage is generally a one-day workshop facilitated by the JLA.  With guidance from the JLA and input from the Steering Group, up to 30 patient, carer and public representatives and healthcare professionals will be recruited to participate in a day of discussion and ranking, to determine the top 10 questions for research.  All participants will declare their interests.  The Steering Group will advise on any adaptations needed to ensure that the process is inclusive and accessible.

Dissemination of results

The Steering Group will identify audiences with which it wants to engage when disseminating the results of the priority setting process, such as researchers, funders and the patient and clinical communities.  They will need to determine how best to communicate the results and who will take responsibility for this.  Previous PSPs’ outputs have included academic papers, lay reports, infographics, conference presentations and videos for social media.

It should be noted that the priorities are not worded as research questions.  The Steering Group should discuss how they will work with researchers and funders to establish how to address the priorities and to work out what the research questions are that will address the issues that people have prioritised.  The dissemination of the results of the PSP will be led by Cliff Shelton and David Jones.  

The JLA encourages PSPs to report back about any activities that have come about because of the PSP, including funded research.  Please send any details to

Agreement of the Steering Group

The Sustainable Peri-operative Practice PSP Steering Group agreed the content and direction of this Protocol on 1st February 2021. Version 1.5 was agreed on 12 June 2021.