Standpoint on Sustainability (SOS): David Lockington

Our new online series sees key opinion leaders in the ophthalmic space discuss how they are addressing the pertinent issues in ophthalmology and sustainability.

In this installment, Power Lister David Lockington advocates for a meaningful discussion on the impact of ophthalmology on the environment that tempers the current environmental concerns with the broader societal value of the profession.

How did you first get involved in the sustainability discourse?
 

In 2010 I was asked to write about whether economics and the environment should drive changes in ophthalmic care, a counterpoint to some of the literature on green issues in ophthalmology. That was pretty hard to do, as one doesn’t want to be painted as an eco-villain!

In light of the 2008 recession, however, we decided to focus on inefficiency and resource allocation. It led to what I think is one of the best opening lines in an article: “We should be thankful to Neil Armstrong's bosses at NASA that they did not adopt the attitude of ‘one small step for man, one giant carbon footprint for mankind!’”

We wanted to ensure the discussion regarding the impact of a major industry (ophthalmology) on the environment would be tempered with real-time context of the technological benefits to our lives, both in sickness and in health.

What are the most urgent sustainability priorities and challenges in the field?
 

The principles of “reduce, reuse, recycle” sound great – but what is the reality? It all depends on the financial climate, restraints, and incentives of the systems in which we currently live and work. If all our efforts towards sustainability simply end up reducing a health budget deficit in a creaking healthcare system, rather than changing the culture leading to direct reinvestment into our ophthalmology services, then it’s going to be hard to avoid cynicism and ensure buy-in from all users.

We really need to disrupt the whole system to institute a new prioritization of these principles, from clinicians to industry to government, to deliver high-quality care which is also better for eyes, economics and our environment.

What would you say has advanced in terms of how practitioners and the industry have addressed sustainability in the last decade?
 

We have moved from paying lip service to the problem to showing what can be done in terms of best practice. EyeSustain is a great initiative that shows and tells us how to take the lead in reducing costs and waste.

In the NHS in Glasgow we have standardized surgical packs, changed to small drapes and smaller gauze sizes, we use alcohol-based surgical scrubs to reduce water wastage, clean the periocular area with prep from multidose betadine bottles, and have been performing immediate bilateral cataract surgeries with topical anaesthesia alone (where possible). Local optometrists now perform the only post-op review at one month for the vast majority of our routine cataract surgery patients.

But more importantly, we strive for excellence in surgery, to get it “right first time” and reduce patient travel back to our clinics. There is a lack of knowledge as to the true costs of a surgical complication, which is why I published an article in The Ophthalmologist a few years ago about the attitudes and implications of using surgical adjuncts called “If You Think of It, Use It!” Mandatory engagement with ocular simulation continues to reduce the complication rate in our trainees and trainers.

Sustainability is a ubiquitous subject at events and meetings. But is there still a problem of communicating the right message?
 

This is a controversial area – “greenwashing” seems to be an increasingly easy accusation to make, without offering effective and achievable alternatives. We need to remember that taking a small number (surgical footprint) and multiplying it by a big number (number of procedures) ends up with an even bigger number. Ophthalmology does an enormous quantity of high impact procedures worldwide, so the numbers get big, but it should be considered in the context of the real-world benefits of enabling many patients to get back to work and contributing meaningfully to society.

So, the question becomes, “How can we deliver more efficiently with less waste?”

Well-intended initiatives run the risk of undermining the sustainability message, if they are simply token gestures without context. For example, providing reusable conference water bottles for all delegates may just mean that there are now a lot more of these items in the world than previously. Could we not just bring our own?

We would do well to understand that effective worldwide solutions require a united, global response. Outlawing print programs and conference bags is not going to save a world which groans under an enormous ongoing carbon footprint from the continual atrocities and destructive nature of wars.

Is It realistic to achieve truly global buy-in to the sustainability mindset?
 

As mentioned in our 2010 article (1), embracing better technology and medical advances should enable clinicians to address conditions early, rather than having to deal with the more complex and expensive complications from neglect, delays, or mismanagement. Addressing that basic need through timely medical intervention would reduce avoidable waste and improve sustainability on a global scale. Better resource allocation will improve efficiency and outcomes through a long-term perspective on investment, which is often sadly missing in our hospital budget systems. Simply cutting costs will not cut it. Being a good steward of the health budget and our resources is just common sense and should not require a climate change slant to be adopted. I believe that promoting a more pragmatic mentality would lead to greater global buy-in.

How can ophthalmology stakeholders work together to reach goals in sustainability?
 

Unfortunately the only green issue which seems to talk is the “greenback”! The fundamental issues needing addressed are legislation and lucre. We have theoretical prion transmission rules and draconian infection control policies, which often dictate clinical and surgical behaviours. Such policies need to be evidence-based and real-world adapted to help deliver our aims. We need clinicians, industry and government to work together to ensure a viable pathway of recycling, and incentivise reducing and reusing where possible.  We also need to address reimbursement models where unnecessary waste seems to be encouraged as an additional billable bonus.

What goals would you like to see the profession achieve in the next 5-10 years?
 

Alongside fully adopting the “reduce” principle in our clinical and surgical behaviors, I would love to see the “reuse/recycle” principle being properly endorsed, supported by ophthalmic research. I’m less concerned about removing superfluous paper instructions from IOL packaging (which can already be recycled), compared to addressing over-restrictive legislation that prevents the recycling/reuse of metal micro-surgical instruments, or plastic items.

For example, I love having single-use instruments on the shelf for complex cases – or as I call them, undamaged instruments! It is not cost-effective or sustainable to have to open multiple reusable instrument sets to get an item with opposable tips. So, my hope is that we develop a robust system of metal instrument recycling bins which actually get recycled locally, practical research to prove these instruments can be repurposed and reused for intraocular surgery, and then the necessary resources to deliver that (3). That would be a wonderful step forward in reducing our footprint, for the benefit of our patients and our planet.

David Lockington, MB BCh BAO (Hons), FRCOphth, PhD, is Consultant Ophthalmologist with subspecialty interest in cataract and cornea, at the Tennent Institute of Ophthalmology, NHS Greater Glasgow & Clyde, and the Nuffield Glasgow Hospital, Scotland, UK.

He is also the editor of Eye News in the UK.