Article Text

Download PDFPDF
Green endoscopy: using quality improvement to develop sustainable practice
  1. James B Maurice1,
  2. Andrew Rochford2,
  3. Sarah Marshall3,
  4. Shaji Sebastian4,
  5. Anjan Dhar5,
  6. Bu'Hussain Hayee6
  7. Green Endoscopy Group
    1. 1 Hepatology, Imperial College Healthcare NHS Trust, London, UK
    2. 2 Gastroenterology, Royal Free London NHS Foundation Trust, London, UK
    3. 3 St Mark’s Bowel Cancer Screening Centre, London North West University Healthcare NHS Trust, Harrow, UK
    4. 4 Gastroenterology, Hull University Teaching Hospitals NHS Trust, Hull, UK
    5. 5 Gastroenterology, County Durham & Darlington NHS Foundation Trust, Bishop Auckland, UK
    6. 6 Department of Gastroenterology, King's College Hospital, London, UK
    1. Correspondence to Dr James B Maurice, Hepatology, Imperial College Healthcare NHS Trust, London W2 1NY, UK; jamesmaurice{at}

    Statistics from

    Request Permissions

    If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.


    Climate change has been described as ‘the biggest global health threat of the 21st century’.1 Medical professionals have a vital role in mitigating the impact of healthcare systems on the environment and protecting vulnerable people through the development of sustainable clinical practices.

    We have previously written about how gastroenterologists must act now to change our endoscopy practice and make it more aligned with core principles of environmentally sustainable healthcare. But it is clear there is a significant lack of evidence to accurately define the scope of the environmental impact of gastroenterology services, or models of best practice to shape policy and move the field in a new direction.

    This article aims to provide a framework for us to design and implement quality improvement projects (QIPs) in gastroenterology as a strategy to deliver a more sustainable future in line with the National Health Service (NHS) Net Zero targets.2 Mortimer et al have described the key principles required,3 4 and we aim to apply these to a gastroenterology context and specifically endoscopy services.

    The triple bottom line

    The value of a healthcare intervention relates to the outcomes delivered against its cost, and the benchmark for cost-effectiveness set by the National Institute for Health and Care Excellence is £20–30 000 per quality-adjusted life year gained.5 However, economists interested in sustainability recognise that costs also need to recognise the social and environmental impact of what is consumed: the so-called ‘triple bottom line’.6 Value can thus be presented using this schematic formula as described by Mortimer et al 3:

    Value=outcomes for patients and populations/environmental+social+financial impacts.

    Considered in this way, every healthcare intervention has not only financial implications, but also a social cost on the patient and their family/carers, and environmental implications from resource use and carbon footprint, against which the clinical benefit needs …

    View Full Text


    • Twitter @jamesbmaurice, @andrewrochford, @SarahTom123, @anjan_dhar6, @IBDdoc

    • Collaborators We wish to thank the other members of the 'Green Endoscopy' group for their contribution to the ideas resulting in the development of this article: Keith Siau, William Stableforth, Emma Wesley, Swapna Gayam, Nitin Ahuja, Sandeep Sidhi and Andrew Veitch.

    • Contributors JBM conceived and wrote the manuscript and designed figure 2. BH assisted in manuscript conception, designed figure 1, provided important intellectual content and critically reviewed the manuscript. AR wrote the section on dealing with the COVID-19 backlog and critically reviewed the manuscript for important intellectual content. SM, SS and AD provided important intellectual content and critically reviewed the manuscript.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests JBM reports non-financial support from Norgine, personal fees and non-financial support from Intercept Pharma outside the submitted work. SS reports research grants from Takeda, Pfizer, Tillotts Pharma and AMGEN; speaker fees and or advisory board honoraria fees from Pfizer, Takeda, Tillotts, Pharmacocosmos, Jaansen, AMGEN and Abbvie outside the submitted work. BH reports grants from Fujifilm Europe, other from Ampersand Health, other from Surgease Medical outside the submitted work.

    • Provenance and peer review Not commissioned; externally peer reviewed.