Sustainable Clothing Procurement – Uniforms in the NHS Environmental Resources Management Ltd with Brook Lyndhurst and Colour Connections A research report completed for the Department for Environment, Food and Rural Affairs

April 2011

Published by the Department for Environment, Food and Rural Affairs Department for Environment, Food and Rural Affairs Nobel House 17 Smith Square London SW1P 3JR Tel: 020 7238 6000 Website: www.defra.gov.uk © Queen's Printer and Controller of HMSO 2007 This publication is value added. If you wish to re-use this material, please apply for a Click-Use Licence for value added material at: http://www.opsi.gov.uk/click-use/value-added-licence-information/index.htm Alternatively applications can be sent to Office of Public Sector Information, Information Policy Team, St Clements House, 2-16 Colegate, Norwich NR3 1BQ; Fax: +44 (0)1603 723000; email: hmsolicensing@cabinet-office.x.gsi.gov.uk Information about this publication is available from: SCP&W Evidence Base Defra Zone 5D, 5th Floor, Ergon House c/o Nobel House, 17 Smith Square London SW1P 3JR Email: scpevidence@defra.gsi.gov.uk

Aumônier, S., Cadman, J., Hartlin, B. and Pierce, A. – ERM; Patterson, P. – Colour Connections; and Fell, D. and Giorgi, S. – Brook Lyndhurst (2011). Sustainable Clothing Procurement – Uniforms in the NHS. A research project for Defra EV0446.

Final Report to the Department for Environment, Food and Rural Affairs April 2011

The project team would gratefully like to acknowledge the assistance and co-operation of the NHS Trusts, NHS Supply Chain, Department of Health and the Suppliers contacted in the course of this research.

This research was commissioned and funded by Defra. The views expressed reflect the research findings and the authors’ interpretation; they do not necessarily reflect Defra policy or opinions.

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TABLE OF CONTENTS

Executive Summary ................................................................................................. 3

1 Background Context and Project Aims.......................................................... 5

2 Method and Approach ................................................................................... 10

3 Limitations ...................................................................................................... 15

4 Results ............................................................................................................ 17

5 Conclusions and Analysis............................................................................. 31

6 Annex A: Initial Flyer...................................................................................... 38

7 Annex B: Tailored Pilot Outlines .................................................................. 40

8 Annex C: Additional Tailored Information Provided ................................... 49

9 Annex D: Staff Representative Topic Guide for Interview .......................... 54

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Glossary

Defra Department for Environment, Food and Rural Affairs

CHP Combined Heat and Power

CRC Carbon Reduction Commitment

EA Environment Agency

ERM Environmental Resources Management Limited

ETI Ethical Trading Initiative

EU GPP European Union Green Public Procurement

HDPE High-density Polyethylene

HSTTS High Street Textiles Testing Services

ICLEI International Association of Local Governments for Sustainability

KPI Key Performance Indicator

LCA Life Cycle Analysis/Assessment

MRSA Methicillin-resistant Staphylococcus Aureus

NHS National Health Service

OGC Office of Government Commerce

SCP Sustainable Consumption and Production

SME Small and Medium Enterprises

SPP Sustainable Public Procurement

SPTF Sustainable Procurement Task Force

UK GBS United Kingdom Government Buying Standards

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Executive Summary

Sustainable public procurement (SPP) is a key policy in the suite of initiatives that the Government can use to reach sustainable consumption and production targets. SPP addresses the environmental, social and economic impacts that Government Departments, their Agencies and affiliated bodies have in the course of carrying out their operations and business. Alone, this is working towards self-set goals in reducing these impacts, such as the Sustainable Operations on the Government Estate (SOGE) targets (1). With public authorities accounting for nearly 17% of the EU’s gross domestic product (2), SPP plays a major role in indirectly influencing industry and supply chains to consider and to improve the products they produce and the services they provide to the public sector, whilst maintaining the imperative of value for taxpayers’ money. It is with this context that the current project was formulated and undertaken, the specific aim being to show the business case and experience of a public sector organisation procuring clothing using sustainable procurement criteria. Working with a selection of NHS Trusts, the NHS Supply Chain and uniform suppliers, the project team investigated the feasibility of procuring nurses’ uniforms to the standards of the European Union’s Green Public Procurement (EU GPP) criteria (3). Furthermore, it explored the merits of including other environmental and social impacts beyond the EU GPP of manufacturing, using and disposing the uniforms, as well as the behavioural aspects of the staff who wear the clothing. Through in-depth interviews with people from procurement functions, laundry managers and staff representatives, as well as experts from the supply base, and coupled with desk-based research, the team was able to describe the current state of procurement of nurses’ uniforms within the NHS. This information was used to draw conclusions with respect to meeting the EU GPP and to make recommendations for improvements in the future. Many of the conclusions are transferable to other public sector organisations that purchase uniforms. This research shows that currently the supply base for the NHS is largely, if not totally, meeting the demands of the EU GPP core criteria, and is making significant strides in other aspects, such as ethical sourcing. Similarly, many of the Trusts, whilst buying from these suppliers, are making their own good efforts in this arena, albeit not always primarily for reasons of sustainability. For example, using fabrics with anti-microbial properties can have benefits in terms of product lifetime and laundering necessity, whereas working with textiles recyclers can reduce the environmental impact at end-of-life. Some Trusts are looking more pro-actively at sustainable procurement in terms of procuring organic or Fairtrade products whilst others, having assessed material production, are moving on to aspects such as packaging to minimise impacts and costs.

(1) http://www.ogc.gov.uk/sustainability_soge_targets.asp

(2) http://ec.europa.eu/environment/gpp/what_en.htm (3) http://ec.europa.eu/environment/gpp/gpp_criteria_en.htm

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These are good examples of sustainable procurement across the NHS Trusts; however, with their fragmented and complicated purchasing structure, there are many different ways of achieving what is, in many cases, fundamentally the same outcome. Moreover, the demands on the NHS for clinical excellence, reducing waiting list times and infection control, mean that sustainability often comes lower on the list of priorities, meaning less time for staff to research and to understand the various impacts and trade-offs involved. The research undertaken here has shown that a more coordinated system of purchasing would bring greater consistency to the situation, whilst not wanting to hamper the specific needs of each Trust in deciding what it should be buying to meet its clinical needs. Initially, this would be in demonstrating compliance with EU GPP, if this is deemed to be necessary to meet the European Union’s 50% target for all procurement to be at least at their entry level of criteria. Importantly for other life cycle and socio-economic impact reduction, this entry level issue would be suitably backed up by an opportunity for shared learning between the Trusts. This could be supported through vehicles such as the NHS Sustainable Procurement Forum, the NHS Supply Chain and possibly the Regional Procurement Hubs (although they are in a process of change). In parallel, greater contact and engagement with suppliers should be made as the evidence to hand suggests that many, but not all, items are purchased from priced catalogues, rather than through direct engagement and discussion of needs, whether for clinical, comfort or sustainability outcomes. Specifically, the NHS and other uniform-procuring organisations can consider a range of issues beyond the EU GPP criteria to reduce environmental and social impacts. These can include the consideration of different materials that have lower production and laundering impacts, such as polyester, in coordination with choosing transparent supply chains to ensure worker’s rights and pay. Indeed, the evidence from the research suggests that stipulating criteria for ethical standards does not appear to be a hurdle to procurement. Working with suppliers can start to address many of these aspects, as well as end-of-life recycling and processing of the uniforms such that they do not simply end up in landfill. When it comes to staff acceptance of uniforms, there are some clear priority issues, namely: comfort; fitness for purpose (e.g. meets infection prevention and control protocols); durability; cost (more relevant to procuring staff); appearance (professional); and identification of role and grade. This means that environmental and social issues often receive a lower priority. However, if uniforms meet the needs regarding these main issues, then having clothing that has low environmental and social impacts is seen as an added bonus. Moreover, interviewees generally appeared more concerned about the social rather than environmental impacts of their uniforms. This project has shown progress in the understanding of sustainable procurement of uniforms and that there is an appetite for further improvement. However, with the many other demands and targets in the NHS there remains considerable opportunity for further gains.

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1 Background Context and Project Aims

1.1 Background Context

Procurement is a complicated process in the NHS. Trusts can buy through a variety of routes: either directly from suppliers; from the NHS Supply Chain; or via regional procurement hubs and confederations. These are services funded by a small group of Trusts to negotiate and undertake procurement on their behalf; or via all three, as depicted in the diagram below. To add to this, there are 452 NHS Trusts in England (4) each with its own needs, specifications, resources and demands. Agreeing on one simplified system might appear to be attractive, but comes with its own problems.

Figure 1.1 Routes to Procuring Clothing in the NHS

Sustainable Procurement in the UK

UK Government spends approximately £236 billion annually on the ‘everyday’ goods and services it

procures to run public services (5). It is incumbent on purchasers that they obtain products of high quality, that meet a specific need and that give good value for money over their lifetime. It is also important that they procure sustainably - this means buying products that have a lower environmental, social and economic impact compared to others available on the market. Demonstrating that Government is leading the way in sustainably procuring the products it buys and uses is critical in setting the right example to wider business and society, and acts as a market driver to encourage innovation and a change in purchasing habits. To meet this obligation, the UK has had sustainable public procurement policy and associated purchasing criteria since 2003, known as the Quick Wins. These stemmed from the ‘Report and

(4) There are 545 according to http://www.nhs.uk/NHSEngland/thenhs/about/Pages/authoritiesandtrusts.aspx#care - this includes Acute, Ambulance, Care,

Foundation, Mental and Primary Care Trusts (PCT), as well as Strategic Health Authorities and Special Health Authorities. It is due to change though PCTs

disappearing soon.

(5) http://ww2.defra.gov.uk/environment/economy/purchasing/ This excludes specific medical and military equipment

NHS Trusts

Suppliers

NHS Supply Chain

Procurement Hubs

Procurement Confederations

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Recommendations of the Sustainable Procurement Group’ (6), a cross-Governmental group of Sustainable Consumption and Production (SCP) experts. The criteria were initially a simple set of statements devised for a wide range of products that focused on the main environmental impacts of those products. Products were chosen as: those that Government buys a significant amount of; those that have an appreciable environmental impact; those with an impact that could be reduced through sustainable procurement; and those that come under some related policy, eg timber procurement policy, the EU Energy Label regulation, the Enhanced Capital Allowance Scheme and the EU Ecolabel. The range included: • white goods (e.g. refrigerators, dishwashers etc); • electronics (e.g. TV, DVD); • information and communications technology – ICT (e.g. computers and imaging equipment); • HVAC (Heating, Ventilation and Air Conditioning; e.g. boilers, air-conditioning systems etc); • lighting; • detergents; • textiles; • paints and varnishes; • paper and wood; and • others. Over time, the Quick Wins were developed to include more products and new criteria and they were updated as technologies progressed. This was especially the case for consumer electronics and ICT. The Quick Wins were re-branded in 2010 as the UK Government Buying Standards – UK GBS (7). Working in conjunction with this process, the Sustainable Procurement Task Force (SPTF) developed a set of prioritisation tools and methods in 2006 for improving public procurement, and it made links to the standards work of the Quick Wins (8). In parallel, Defra has been furthering its Product Roadmap workstreams (9) as part of its Sustainable Products and Consumers area. For ten product areas, Defra is researching the key environmental impact areas across the different product groups, one of which is clothing, to better understand: 1. environmental impacts and improvement through technology; 2. consumption behaviour; 3. knowledge, awareness and education; 4. markets and drivers; and 5. supply chain traceability. The five key areas of focused research are being used to address three high-level aims: 1. to establish the impacts that occur across the life cycle of each product; 2. to identify existing actions being taken to address those impacts; and 3. to develop and to implement a voluntary action plan to address any gaps. Working groups have been set up and research projects undertaken to assess issues in textiles such as: the life cycle environmental impacts of textiles production, use and disposal; developing and encouraging new fibres; investigating ways of reducing the environmental impacts of cleaning clothes; increasing levels of reuse and recycling; as well as ascertaining the public’s understanding of

(6) Sustainable Procurement Group, Report and Recommendations of the Sustainable Procurement Group, January 2003. (7) http://sd.defra.gov.uk/advice/public/buying/

(8) Procuring the Future, Sustainable Procurement National Action Plan: http://www.defra.gov.uk/sustainable/government/documents/full-document.pdf (9) http://ww2.defra.gov.uk/environment/economy/products-consumers/

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what sustainable clothing is. All of this work will help Government to understand where policy interventions can be made and where working with industry can be encouraged to further the goal of improving supply chain sustainability. This current procurement trial forms part of this suite of research, as depicted in the diagram below.

Sustainable Procurement in the EU

Since 2007, the European Commission has set in place a process for developing Green Public Procurement criteria – EU GPP. These took a similar line of choosing products with determinable impacts and those that are purchased by Government. A range of precursor research reports (10) were used to generate a list of products that are commonly bought by Government procurers across the EU and whose environmental impacts have been, or could be, determined. This list settled on ten priority products: paper; cleaning products & services; IT equipment; construction; transport; furniture; electricity (power); food & catering services; textiles; and gardening products and services. The programme developed a background report for each of the ten product groups, aimed at procurement professionals, discussing the life cycle environmental impacts of a particular product as well as the associated legal and regulatory conditions. It also produced a set of procurement criteria at two levels: core and comprehensive. Quoting the EU GPP website (11): “The core criteria are those suitable for use by any contracting authority across the Member States and address the key environmental impacts. They are designed to be used with minimum additional verification effort or cost increases.

(10) including EIPRO and RELIEF (11) http://ec.europa.eu/environment/gpp/index_en.htm

Figure 1.2 Sustainable Clothing Action Plan: Headline Areas

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The comprehensive criteria are for those who wish to purchase the best environmental products available on the market. These may require additional verification effort or a slight increase in cost compared to other products with the same functionality.”

Harmonisation

Harmonisation of national and EU-wide procurement policy is one of the aims of the European Commission. As such, there is a political target that EU Member States can demonstrate having met the EU GPP core criteria for at least 50% of their procurement (12). To understand the implications of this, Defra is undertaking a process of assessing the applicability of the voluntary EU GPP criteria within the UK context of public procurement and how they can be woven into existing UK GBS, mandatory for Central Government and their related organisations. This involves various studies and impact assessments to understand where criteria can be ‘imported’ and where EU GPP criteria need to be amended to take account of UK legislation, market conditions, and other issues. Defra has published a timeline of when and where this research is needed (13). This current project forms part of the wide-ranging research funded by Defra to investigate the possibilities for extending sustainability across the supply chain of textiles, and uniforms in particular.

1.2 Aims of the Project

As part of Defra’s Product Roadmaps, and the wider target of the UK procuring its goods and services more sustainably (in line with the European Union’s GPP initiative), Defra commissioned a study in 2010 to assess the opportunities and barriers to government organisations, in particularly NHS Trusts, procuring staff uniforms, specifically nurses’ uniforms, to at least the level of the EU GPP by incorporating sustainable development in more procurement exercises. The condition on delivering more sustainable products was that they still achieve value for money and do not compromise on quality or function. The key outcome of this research project was ‘to show the business case and

experience of a public sector organisation procuring clothing using green/ sustainable procurement

criteria’. To meet these aims, the project took two parallel approaches: to assess environmental and social aspects of meeting stringent procurement criteria; and to understand staff responses and attitudes to the sustainability of their work clothing. By working with a range of enthusiastic NHS Trusts the NHS Supply Chain and several uniform suppliers, the project was able to assess approaches to increasing the levels of sustainable procurement of nurses’ uniforms and to capture the experiences of doing so along the way. The NHS Supply Chain was on the Steering Group and provided the research team with guidance on purchasing systems and procedures within the NHS. The five main topics covered in the research were: • potential cost variance in using more stringent (EU GPP) criteria (14); • any issues of market availability and supply issues;

• what the behavioural, awareness and understanding or training requirements raised by staff and procurement officials might be to the environmental and social criteria of their uniforms;

• what the implications are for maintaining product quality whilst increasing levels of sustainability in the products; and

• any legal issues, particularly around ethical criteria.

(12) http://sd.defra.gov.uk/advice/public/buying/background/green-public-procurement/ (13) http://sd.defra.gov.uk/advice/public/buying/whatsnew/

(14) http://ec.europa.eu/environment/gpp/pdf/toolkit/textiles_GPP_product_sheet.pdf

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In undertaking this research, the scope explored the level of awareness of NHS Trusts and suppliers alike of the EU GPP criteria, as well as related issues such as organic and recycled content textiles, ethical supply considerations in the manufacture of the garments, availability of such fabrics and garments, and what impacts these all have on market prices for the clothing. The benefits to the Trusts involved in this project were the potential for delivering carbon savings, as well as mitigating risks related to social and environmental issues in the supply chain. Moreover, participation offered them the chance to plan ahead for increasing the degree to which sustainability needs to be included in procurement decisions. As well as this report, the research also developed public-facing and effective case study material to demonstrate the feasibility of including sustainability to a greater extent in tendering exercises and to encourage others to consider greater inclusion of sustainability issues when procuring uniforms. The outcome of the research is a better understanding of the procurement landscape for NHS uniforms. More widely, it also shows how the lessons learnt may be transferable to other public sector uniform procurement and textile products more generally. The original flyer generated to stimulate interest in the research trial can be found in Annex A. This study was delivered by a consortium of organisations. It was led by Environmental Resources Management Limited (ERM) a consultancy with experience of supply change management, procurement cycles and sustainability. ERM was supported by Colour Connections and Brook Lyndhurst. Colour Connections is a specialist consultancy with expert knowledge on the environmental impact of different fabric processing techniques. Brook Lyndhurst is a niche research consultancy specialising in public research on progressing towards a more sustainable society and on behaviour change theory and practice.

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2 Method and Approach

2.1 Research Approach

As the Aims of the Project section stated, the approach followed two main strands: • Focusing on the environmental and social aspects of clothing procurement;

o the feasibility, economics and availability of meeting the EU GPP criteria, as well as implications of organic, recycled content and ethically produced textiles; and

• Simultaneously investigating staff attitudes to uniforms that are produced and procured with

sustainability taken more into consideration; and o whether the more sustainable products still meet comfort and maintenance

expectations and demands.

The project consisted of three key stages, as shown in Error! Reference source not found. below.

Figure 2.1 Summary of Proposed Approach

2.2 Stage 1 – Scoping

The first stage of the research consisted of selecting NHS Trusts with whom to work. The overarching principles were to opt for Trusts that have different attitudes and experiences towards sustainable procurement, both positive and negative. Likewise, Trusts that varied in size and location – geographical and urban/rural and other influential factors such as level of existing sustainable procurement, types of uniforms procured, etc were considered. Whether or not the Trust was entering a procurement phase was important to the process. This process was undertaken between the project partners and the Project Steering Group, consisting of Defra, the Department of Health and NHS Supply Chain. The Steering Group settled on a total of four Trusts being a suitable number to get a spread of the experiences listed above. Although this is

Stage 1 Stage 2

SCOPING

Task 1: Inception meeting

Task 2: Scoping the project

REPORTING AND DISSEMINATION

Task 5: Draft final report

Task 6: Case study publication

Task 7: Dissemination

workshop

TRIAL AND ANALYSIS

Task 3: Procurement trial

Task 4: Analysis of findings

Stage 3

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merely 1% of the number of Trusts in England it was felt to be an appropriate number given the tasks involved, level of commitment and the availability of NHS Trust staff who could collaborate on this project. Clearly the findings will be limited to some extent as a result of this and extrapolating them across other Trusts will be difficult. Nonetheless, the outcomes will be useful for other Trusts and organisations looking to improve the sustainability of their clothing procurement. A project flyer was developed, available unformatted in Annex A, to promote the research trial to a wider audience at the NHS Sustainable Procurement Forum and to elicit their interest. The outcome of this process was the selection of the following four Trusts:

• Welsh Health Supplies;

• Royal United Hospital Bath NHS Trust;

• Salisbury NHS Foundation Trust; and

• East Lancashire Hospitals NHS Trust. Once the four Trusts had been selected, they were then directly engaged in the detail of the research project and specific pilot objectives were developed for each. Through a process of introductory teleconference calls, subsequent detailed face-to-face meetings on-site at the Trusts’ primary locations and follow up discussions, tailored research scoping documents were developed for each case. Common to all, these pilot objectives consisted of: assessing the feasibility of meeting the core EU GPP criteria; the costs and supply availabilities of doing so; and also any environmental and social impacts and what the implications might be for the staff having to wear the uniforms. In some more detail the research assessed the following aspects: • potential cost variance in using more stringent (EU GPP) criteria; • any issues of market availability and supply issues; • what the behavioural, awareness and understanding or training requirements raised by staff and

procurement officials might be to the environmental and social criteria of their uniforms; • what the implications are for maintaining product quality whilst increasing levels of sustainability

in the products; and • any legal issues, particularly around ethical criteria. As a further refinement to the research and bespoke interests of each Trust, specific issues were drawn out of the various meetings relating to particular goals and objectives that each Trust had within its sustainability and procurement efforts. In summary, the extra, tailored issues for each Trust were as follows: • Welsh Health Supplies – end-of-life disposal of uniforms and associated packaging;

• Royal United Hospital Bath NHS Trust – Fairtrade and ethical uniforms;

• Salisbury NHS Foundation Trust – laundry improvements and cost savings; and

• East Lancashire Hospitals NHS Trust – anti-microbial finishes to garments.

These outline pilot briefs were created, edited and presented to the Trusts in the same format as the original flyer, and are available in Annex B.

2.3 Stage 2 – Trial and Analysis

The research then moved into direct engagement with the Trusts and their suppliers around the issues highlighted above.

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Engaging with the Trusts

Through the discussions outlined above, the project delved into the detail of clothing procurement, use and disposal, using the EU GPP criteria as the starting point for discussions. By working with the Trusts and asking them to speak with their suppliers, the project explored the following issues and questions listed below. This involved engagement with not only their procurement functions, but also with other staff with relevant areas of expertise and influence, such as laundry managers and staff representatives to provide a rounded response to exploring sustainability in clothing.

Table 2.1. Research Areas and Questions

Aspect Detail

Current baseline for clothing procurement in each Trust

• What sustainably criteria are used? • How many suppliers do you use? Do they change frequently? • Are there market availability issues? • What is the awareness and understanding amongst suppliers of what

NHS is looking for?

Textiles criteria set out in the EU GPP

• Do they appear feasible? • What issues or barriers can you foresee? • Specifically, are there any known issues with organic textiles,

reusable textiles, textiles with recycled fibres, less toxic textiles and fairly traded garments?

Cost implications of tougher sustainability criteria

• What is the difference? • If costs are higher, can they be offset against other cheaper

products?

Availability of more sustainable clothing

• Do they foresee problems of getting a consistent and regular supply of material and product?

• Will different suppliers have to be engaged? How long will this take?

• Are there any promotional issues that suppliers, and procurement staff, will have to manage?

Time it would this take to put in place with procurement staff

• What existing behaviour patterns exist that might prove to be barriers?

• What extra training or awareness activities might be needed? • Could further sustainability be readily incorporated into existing

procurement systems? What other tools might be needed for this? • What perceptions or barriers would need to be overcome to enable a

change in practice?

What the legal implications, barriers and concerns might be of introducing social and ethical criteria in to the tender documents

• Where would they go? Technical award or contract performance clauses?

• What are the issues with each of these? • How do suppliers feel about providing evidence of this for tenders

and the associated time and cost implications to them, and hence product price?

• Industry trends Following the initial calls and face-to-face meetings, regular phone calls were held between the project team and Trusts to assess and to gauge progress and developed knowledge. All the

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information and data gleaned from these conversations were captured in a log sheet with headings for the key issues. The kinds of areas covered included the following: • progress to date;

• questions or concerns arising through the course of the trial;

• issues and barriers faced, and how they might be overcome;

• level of awareness and support amongst the wider staff body; and

• data on price, number of suppliers, availability etc. Subsequent to this harvesting of information, analysis was undertaken to assess the practicalities of embedding sustainability further into the procurement of nurses’ uniforms and what the wider implications are for the procurement of other uniforms in the public sector and textiles more generally. This analysis covered environment, socio-economic, supply chain and procurement, and behavioural aspects of the whole process. Where it was suitable, any evidence gathered was assessed for its robustness, meaning its reliability, credibility, objectivity and transferability. As well as this analysis, the project team also provided the Trusts with free expert advice on issues pertinent to them, such as identifying clothing solutions with lower impacts whilst not adversely affecting value for money. This included not only the discussions on sustainability that were held, but also briefing documents created by the research team on key aspects of clothing technology, for example on anti-microbial finishes for East Lancashire Hospitals NHS and disposal options for Welsh Health Supplies. These were devised to be non-exhaustive ‘crib sheets’ to give the purchasing teams in the Trusts a good overview summary of the main aspects of that given issue. These are available in Annex C.

Engaging with Suppliers

A similar approach was undertaken when engaging with a selection of companies that supply uniform and corporate clothing, some of whom supply to NHS Trusts, to ascertain their opinion on the feasibility of the EU GPP and other associated environmental and socio-economic issues. For this part of the research, the project team engaged with Alexandra, OMCC, Dimensions and Worn Again. The team also discussed specific end-of-life issues with certain textiles charities and businesses such as the Salvation Army Trading Company, Wilcox and BCR Global Textiles that collect clothing for reuse and recycling. The same kinds of questions were put to the suppliers in terms of the reality of meeting the EU GPP criteria and what affect this and other issues like organic or ethically traded fibres might have on garment price and fibre availability. Furthermore, certain specifics were explored that were pertinent to the Trusts in the trial. For example, what suppliers might be doing to encourage the minimisation of in-use and end-of-life impacts of clothing, whilst extending the useful life of their products, ie the ability to wash at lower temperatures and / or the possibilities and practicalities of collection and reuse or recycling of uniforms.

Engaging with Staff Representatives

Ideally, the project team would have engaged with a staff representative from the beginning of the pilot and then at regular intervals of six weeks though to the end of the pilot. However, as the chapter on limitations below highlights, it was difficult to gain access to appropriate staff representatives and to ensure their engagement in the pilot. Therefore, we opted for an in-depth telephone interview with the staff representatives in order to gauge staff’s interest, understanding and appreciation of environmental and social criteria. The interviews were structured around three main themes:

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• views and attitudes around the nurses’ uniforms; • behaviour and any changes; and • scenario setting around some hypothetical developments.

The full topic guides, with all the detailed questions used to conduct these interviews, can be found in Annex D. Interviewees were asked to provide their personal opinion on questions as well as, given their role as staff representative, an overview of nurses’ attitudes in order to have insight into the broader views of nurses in that particular Trust. Across the four Trusts, we interviewed seven staff representatives. The table below outlines the range of respondents interviewed, their roles and whether they themselves wore the uniform in question.

Table 2.2 Research Areas and Questions

Trust Staff representative’s role Wears the nurses’

uniform?

Welsh Health Supplies

Dual role: Sister in Accident & Emergency and Nurse Practitioner

Yes

Royal United Hospital Bath

NHS Trust

Dual role: Clinical Manager/Accident & Emergency Matron

Yes

Senior Nurse – Infection Prevention & Control Team

Yes

Directorate Senior Nurse - Surgery No, due to management nature of her role

Salisbury NHS Foundation

Trust

Dual role: Senior Sister of Surgical Ward and Deputy of Directorate of Nursing

Yes

Infection Prevention & Control Matron Yes East Lancashire Hospitals

NHS Trust

Infection Prevention & Control Matron Yes

The staff representatives were selected by our Trust contacts who were leading the pilot from the procurement and laundry teams. In most instances, interviewees were managers of a team of nurses and acted as staff representatives on uniform groups, infection prevention committees, linen user groups and procurement meetings etc. However, it should be borne in mind that these interviews remain only snapshots of insight into the opinion of nurses. They should not be generalised as representative of the entire nurse population.

2.4 Stage 3 – Reporting and Dissemination

As well as this policy report, the project partners have developed four case studies to highlight the opportunities and barriers to more sustainable procurement of clothing in the NHS. The case studies also show how these findings might be transferable to other public sector organisations that purchase uniforms, and, more widely, how they might be applied to non-governmental organisations. Structured so that they are succinct and clearly written, the case studies are to be used to demonstrate what has been done and what could be done to improve sustainability in textile supply chains, and to keep staff and colleagues ‘on-side’ whilst maintaining the imperative of value for money. Further to disseminate the results and outcomes of the research, a workshop has been organised to discuss the findings with relevant contacts in the supply chain and to start to develop plans for where Defra, the Department of Health and NHS Trusts could progress this agenda.

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3 Limitations

The limitations of this study relate both to micro-level issues such as individual procurement cycles and access to the appropriate staff, and to macro-level issues, for example, the global recession and resulting NHS reforms. The initial phase of the project included a scoping stage, which served as an introduction to the project for the Trusts and as an opportunity to identify potential challenges that may arise when developing a procurement programme. Pilot participants were screened to minimise known limitations, such as lack of staff availability or reluctance to engage in a procurement trial, and to allow the team proactively to prepare for those that may arise. Following the scoping stage, each NHS Trust was provided with a succinct summary document outlining the scope of the project and what it means to the Trusts in terms of resources required and desired output. The aim of this document was to prepare the Trusts for the development of a procurement programme and to foresee and to mitigate any potential issues that may arise. A copy of the scoping documents can be found in Annex B. Throughout the course of the project, several limitations arose and these are discussed below.

3.1 Schedule of Procurement Cycles

Procurement cycles vary between Trusts and are a function of supply and demand as well as budget and other variables. Nurses’ uniforms are ordered on an ad hoc basis for many Trusts, whilst others have a systematic or routine replenishment program based on Trust-wide initiatives and/or budgeting requirements. A number of procurement cycles were extended to accommodate the necessary approvals and resource constraints, as well as changes to procurement systems – these were unrelated to the pilot studies. However, issues such as these affected the pilot such that procurement actions were limited during the twelve-month course of the study. Nonetheless data, information and stakeholder opinion were collected regarding the feasibility of extending sustainable procurement in NHS clothing. Due to the voluntary nature of the Trusts participation in this work, the proposed procurement pilots were forced to be set aside on several occasions to allow for higher priority procurement issues to be handled effectively and efficiently (eg implementing a new internal procurement system). Once addressed, the pilot study was revisited.

3.2 Commercial Issues

The global recession had a far-reaching effect and included a major UK-based NHS uniform supplier going into administration during the project. This unforeseen event stalled procurement processes until the company was acquired and contracts were restructured and/or renegotiated. All four Trusts participating in this study used the supplier in question to source their uniforms.

3.3 Access to Appropriate Staff

The four Trusts participating in this work should be commended for their effort and willingness to take part in the study and for their desire to advance their understanding and management of sustainable procurement. Those that volunteered did so solely out of a personal interest to improve

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performance. However, resources in public sector organisations are often limited. Lack of availability, and the need for reminders due to other higher priority commitments within the Trusts, slowed the progress and degree of impact of the trials. A lack of communication or linkage between some departments within the Trusts that would be relevant for sustainable procurement was noted. For example, those who may work to promote energy efficiency often have no link to procurement. Likewise, identifying appropriate staff representatives proved difficult and took far longer than expected. However, once the contacts had been secured, the process of setting up and conducting the interview ran smoothly.

3.4 Priority of Sustainability

Those who volunteered for the pilot had a personal interest in improving sustainability rather than a mandate to include sustainability in their role. In comparison to other key performance indicators (KPIs) such as budget, availability and speed of delivery, sustainability was found to be either low on, or entirely omitted from, the agenda. There was no staff pressure noted to be driving the procurement departments to explore more sustainable options. The focus of staff was on comfort, durability and aesthetics.

3.5 NHS Reforms

The NHS is currently undergoing major and far-reaching reforms and restructuring affecting virtually all aspects of each Trust. A drive to explore more sustainable options can only be accomplished if obvious and immediate cost savings are evident. For the Trusts, the pilot was often perceived as an additional burden, given the more pressing priorities at hand.

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4 Results

The ERM consortium worked directly with each Trust over a six month period to develop an approach for uniform procurement that considered sustainable development aspects. Through an initial meeting, group working and focused support we assisted the Trusts to work through issues, overcome barriers and realise opportunities in the sustainable procurement of uniforms. The core objective of each pilot was to assess the feasibility of: meeting the core EU GPP and UK GBS criteria; the costs and supply availabilities of doing so; any environmental and social impacts; and what the implications might be for the staff having to wear the uniforms. The scoping process as well as the specific research areas and questions posed to each Trust are detailed in Section 2 of this report. After the initial scoping exercise, it was evident that each Trust had specific sustainability concerns that did not necessarily have a direct link to the EU GPP core criteria or UK GBS. These issues were incorporated into the pilot to help address current and relevant issues for the Trusts. A high level summary of the pilots is presented in Table 4.1, followed by an introduction to each Trust and detail of the pilot objectives and results. Further detail on the pilot objectives and processes can be found in Annex B – Tailored Pilot Outlines.

Table 4.1 Summary of Pilot Study Objectives

Objectives Welsh Health

Supplies

Royal United

Hospital Bath

NHS Trust

Salisbury NHS

Foundation

Trust

East

Lancashire

Hospitals NHS

Trust

Review suppliers’ understanding of environmental criteria � � � �

Investigate and, possibly, test different packaging for the uniforms �

Explore different disposal options for former uniforms �

Draw out key lessons for other trusts �

Understand staff attitudes towards uniforms � � � �

Explore procuring Fairtrade uniforms more widely �

Investigate energy and economic savings that could be achieved through uniforms being made of different fabrics and mixes

�

Investigate different types of antimicrobial coatings �

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4.1 Welsh Health Supplies

Welsh Health Supplies is responsible for contracting and the subsequent purchasing, storage and distribution of commonly-used products and services across all NHS Trusts in Wales. It is currently rolling out 150,000 new nurses’ uniforms to the 30,000 nursing staff operating across all Welsh Trusts. At the time this report was written, the roll-out has been completed for approximately 25% of nursing staff. The Contracting Team has experience in the sustainable procurement of uniforms through its current roll-out of nurses’ uniforms. It stipulated within its tenders a preference for Fairtrade fabrics, as well as compliance with the Ethical Trading Initiative (ETI) Base Code throughout the manufacturing process of the garments. Welsh Health Supplies also worked with High Street Textiles Testing Services (HSTTS), a qualified audit body, as an expert partner, providing advice on audits, non-compliances and corrective actions. As a consequence of the large-scale procurement, Welsh Health Supplies had concerns about the environmental impact associated with the amount of waste generated from the individual garment packaging, as well as the high volume of old uniforms that would require disposal once replaced.

Pilot Objectives

The objectives agreed with Welsh Health Supplies were to:

• review suppliers’ understanding of environmental criteria including EU GPP, UK GBS and what opportunities there are to meeting these standards;

• investigate and, possibly, test different packaging for the uniforms with their main supplier;

• explore different disposal options for former uniforms taking account of the environmental impacts of the different alternatives;

• draw out key lessons for other trusts from their novel experience of requiring social and ethical criteria to be met across the supply chain; and

• understand staff reactions and attitudes to the change in uniforms.

The Process

The ERM project team provided Welsh Health Supplies with a list of questions (refer to Annex B) to help further engage with suppliers with regards to EU GPP and UK GBS. The objective was to determine whether suppliers understood the issues surrounding sustainable procurement of textiles and uniforms, quantified where possible in terms of price differentials, etc. This was complimented by further direct supplier engagement conducted by ERM, which is detailed in Section 4.5. In addition, Welsh Health Supplies was provided with summary guidance of the different types of plastic packaging and how they can be recycled as well as other packaging options. A list of different disposal options for the uniforms with their environmental was provided to the Trust and has been included in Annex C. Welsh Health Supplies also provided details of a staff representative to speak to in order to unpack the benefits and drawbacks in terms of the new uniforms compared to the former ones.

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Findings

EU GPP and UK GBS

During the time of the pilot, Welsh Health Supplies was not able to engage with suppliers on additional questions related to EU GPP/ UK GBS. Efforts for the pilot were then focused on the remaining objectives. ERM engagement with suppliers on the same issues is reported in Section 4.5. Uniform Packaging A number of packaging reduction options were proposed to Welsh Health Supplies that could reduce the overall environmental impact.

• Plastic type: seeking a commercial recycler who has the capability to handle HDPE bags and wrap to divert waste from landfill.

• Recycled content: using plastic bags with a recycled content rather than virgin material to reduce the impact associated raw material production and by not using landfill or incineration of the old material.

• Light weighting: reducing the thickness of both the plastic wrap and cardboard boxes to lower the environmental impact and costs of the packaging.

Although dependent on supplier and Trust location, it is recommended that the availability of recycling options are discussed prior to requesting a change in packaging type. Eliminating the individual bags and instead having a single larger, but lighter, box liner would reduce the associated manufacturing emissions with raw material use and the amount of waste generated. Through contact with uniform suppliers, we discussed the possibility of plastic bags that could be dissolved in water, or that contain recycled content, being used for uniforms. In addition, a contact from a commercial Welsh recycler of plastic bags was forwarded to Welsh Health Supplies that could solve its plastic bag disposal issue. At the time of this report, these options had not been further to the extent where costs could be provided. Recycling all the plastic bags used to package the uniforms has the potential to divert up to 1,500 kg of plastic from landfill. Increasing the recycled content of the bags to 50% would reduce carbon emissions by approximately 30% if they were recovered and recycled into new products. Waste Uniforms

Currently, there is no single system for the collection and disposal of nurses’ uniforms and various Trusts deal with the issue in different ways or have no formal system in place. Typically, uniforms are either passed on to a local textile recycler or end up in the municipal waste stream, which generally goes to landfill. Reuse and recycling of nurses’ uniforms have the lowest environmental impact. If the uniforms cannot be recycled, energy from waste is another option that would lower the environmental impacts of disposal compared to landfill. It was generally agreed by uniform suppliers and Welsh Health Supplies that a take-back or alternative scheme to reuse or recycle the worn uniforms would increase cost per garment. It would also put a substantial strain upon both the Trust’s and the supplier’s resources, due to the high volume of uniforms. Welsh Health Supplies is currently engaged in a process to contract the disposal of uniforms in a manner other than landfill, which aligns with both EU and national waste policy, which give priority to the waste hierarchy. At the time this report was written, the waste tender has not been finalised and cost implications can not be reported.

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Key Lessons for other Trusts The uniform change-over at Welsh Health Supplies was instigated to provide patients with more clarity on the roles of the nurses; however, this opportunity was used to source uniforms with additional sustainability criteria, most notably those related to improved ethical standards. Including additional requirements in the tender documents allowed Welsh Health Supplies to procure more sustainable uniforms at no additional cost. However, it should be noted that the Welsh Health Supplies also worked with High Street Textiles Testing Services (HSTTS), a qualified audit body, as an expert partner, providing advice on audits, non-compliances and corrective actions. The costs associated with this will vary depending on need. The request of Fairtrade uniforms posed a supply issue and was not pursued. Staff Attitudes From the point of view of nurses at Welsh Health Supplies , the three main concerns about uniforms were that they needed to:

1. provide on-the-job protection and be fit for purpose; 2. enable easy recognition of role and grade; and 3. be functional yet smart.

To date, nurses have experienced minor difficulties with the new uniforms, including removing a contaminated tunic, finding the appropriate size and creased uniforms needing ironing. Some nurses had experienced rashes and itchiness when wearing the new uniforms, but after having washed them a couple of times this was resolved. Our interviewee thought that employees generally would not be concerned about the wider social and environmental issues of how uniforms were manufactured. The interviewee had not noticed or participated in the efforts of the procurement team to integrate sustainability criteria in the uniform specification. There were two major concerns voiced by nurses generally about the uniforms. Firstly, the prolonged roll-out and delivery of the uniforms was an issue. The second concern was specific to a particular rank of nurses who wanted to be distinguished by a different colour uniform from the lower band of nurses. Regarding the disposal of old uniforms, at the time of the research, employees were being asked to hold on to them. However, they would, eventually, be collected on-site and most likely donated to charity. The interviewee had noticed that other staff (e.g. healthcare support and dental staff) had been wearing the old uniforms, which may suggest a formal re-use of the uniforms within the Trust. Some nurses were given the opportunity to take part in trials where employees were asked to provide feedback on the uniforms. However, it was thought that at times the feedback provided to management was not always considered. The interviewee suggested that there was a sense amongst some staff that the procedure could have been more collaborative, with a formal consultation period. However, this may not have been the sentiment across all the Trust encompassed by Welsh Health Supplies. Overall, from the staff representative interview, nurses had become accustomed to the new uniform, were satisfied with it and preferred it to the old uniform. They found the uniform easy to care for, as it was washed with their main wash at 40 degrees at home (15).

(15) We are aware that Department of Health guidance concludes for employers that “A ten-minute wash at 60C is sufficient to remove most micro-organisms”

and that this differs to the washing practices of the staff at this Trust. See Department of Health and NHS (September 2007). Uniforms and Workwear An evidence base for developing local policy. http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_078435.pdf Accessed on April 27th 2011

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Outcomes

Welsh Health Supplies has shown best practice for integrating sustainable compliance into the procurement tender document. Including additional requirements in the tender documents allowed Welsh Health Supplies to procure more sustainable uniforms without significant additional costs or resource burden. This was accomplished by stipulating within its tenders a preference for Fairtrade fabrics, as well as compliance with the Ethical Trading Initiative (ETI) Base Code throughout the manufacturing process of the garments. Welsh Health Supplies also worked with High Street Textiles Testing Services (HSTTS), a qualified audit body, as an expert partner, providing advice on audits, non-compliances and corrective actions. It was found that suppliers are willing to work with NHS Trusts, as well as with other customers, to find specific solutions to their environmental, social and economic concerns. Welsh Health Supplies can benefit from recycling the packaging from the uniform roll-out, which will contribute to the target of recycling 70% of waste in Wales by 2025. This may also benefit other Welsh organisations that can recycle their plastic packaging through joint contracts. Communication opportunities exist for Welsh Health Supplies and others to promote the environmental benefits of recycling and the decreased use of landfill to staff and the public. Other uniform-using organisations can learn, from Welsh Health Supplies, how to incorporate social and ethical criteria into their uniform procurement and prepare for the potential difficulties when procuring and disposing of large quantities of uniforms. This could assist in finding better environmental solutions with their suppliers or waste contractors and promote zero waste to landfill. Although staff opinion on the uniforms did not concern sustainability issues directly, it is noted that the procurement of new uniforms may pose problems and staff engagement is essential.

4.2 Royal United Hospital Bath NHS Trust

Royal United Hospital Bath NHS Trust employs approximately 4,800 staff to serve the population in Bath and the surrounding towns and villages in North East Somerset and Western Wiltshire. They procure uniforms on an ad hoc basis for new staff and to replace older worn garments. The Trust has many different types of uniforms for nurses, with different colours for grades and some senior positions having bespoke patterns. The Trust underwent a significant change to nurses’ uniforms a few years ago. Royal United Hospital Bath NHS Trust had previously procured Fairtrade polo shirts for porters, but has not otherwise requested specific environmental or ethical criteria in previous tenders from suppliers. The Trust was interested in expanding the use of Fairtrade uniforms during the search for replacement garments through the NHS supply chain. By changing to Fairtrade uniforms, the cotton portion of the fabric would be certified back to the farmer, to ensure a minimum price is paid for the raw cotton, which in turn ensures that sustainable production costs are met. Although Fairtrade criteria are not part of the EU GPP or UK GBS, and these have not been further explored previously, it does represent an important sustainability component in the value chain.

Pilot Objectives

The objectives agreed with Royal United Hospital Bath NHS Trust were to:

• review suppliers’ understanding of environmental criteria including EU GPP, UK GBS and international social/ethical standard (e.g. Ethical Trading Initiative, ETI) and what opportunities there are to meeting these standards;

• unpack staff’s interest, understanding and appreciation of environmental and social criteria of their uniforms; and

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• explore procuring Fairtrade uniforms more widely.

The Process

The ERM consortium provided Royal United Hospital Bath NHS Trust with a list of questions (refer to Annex B) to help further engage with suppliers with regards to EU GPP/UK GBS. The objective was to determine whether suppliers understood the issues surrounding sustainable procurement of textiles and uniforms, quantified where possible in terms of price differentials, etc. This was complimented by further direct supplier engagement conducted by ERM, which is detailed in Section 4.5. Royal United Hospital Bath NHS Trust also provided details of a staff representative to speak to in order to unpack the benefits and drawbacks in terms of the new uniforms compared to the former ones. Supplier discussions were also used to explore procuring Fairtrade uniforms more widely.

Findings

EU GPP and UK GBS

Royal United Hospital Bath NHS Trust discussed the issues with their suppliers and put ERM in direct contact. The information collected is relevant to all Trusts and is reported in Section 4.5.

Staff Attitudes

Our interviewee at Royal United Hospital Bath NHS Trust stated that nurses’ uniforms needed to be: 1. user-friendly to ensure ease of movement and comfort (e.g. vents in the back, split at the

bottom of the tunic, etc.); 2. infection control friendly; and 3. smart in appearance so as to portray a corporate and professional image.

Overall, the main reason for changing the nurses’ uniforms was that by rationalising the stock it would decrease costs as well as delays in delivery of orders. The other motivation for changing the uniforms was to portray a better and more harmonised public relations image. With the introduction in 2008 and subsequent roll-out of the uniforms, the most frequently mentioned barriers mentioned were the loss of unit identity as the uniform was standardised to eight main types, and allergies due to the polyester-cotton mix. However, when these worries were investigated, it was discovered that they tended to be stylistic concerns rather than allergies with the fabric, as the replacement uniforms chosen were of the same poly-mix material. Although the interviewee did not know of any staff-wide concerns about the social impacts of the uniforms, the interviewee hoped that they came from an ethically-sound source, which abided by labour legislation in terms of working age and conditions. The interviewee felt that other employees would have the same social concerns for their uniforms. This aligns with the interest from the procurement team to investigate the possibility of sourcing Fairtrade uniforms specifically for the porters’ polo shirts. The interviewee did not know how the old uniforms (pre-dating 2008) were disposed of. However, staff members were allowed to keep uniforms that did not come from a bespoke Trust uniform budget. For example, some of the discontinued polo shirts without Trust logos or identification badges that were not from a specific uniform Trust budget were being informally reused by staff members at home (e.g. for gardening).

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With time, staff members have become accustomed to the uniforms. This was due to the fact that staff members were given a platform to voice their complaints and concerns via the Uniform Group meetings. All cases were heard, investigated and reviewed. At times, the outcome favoured the individual employee’s position and at times this was not the case, but all concerns were given a fair hearing. Over the past few years, nurses have not had issues with caring for the uniforms. A staff deposit linked to their specific uniform encourages them to take care of their uniform and to return it when they are no longer using it (e.g. if they change roles internally or if they leave the Trust). Fairtrade Fairtrade uniforms can be up to 20% more expensive than an ethically-certified counterpart (e.g. ETI), because of the higher minimum cotton content required and a greater level of detail needed when auditing the supply chain. However, if a wide range of ethically-certified uniforms were procured, the supplier stated that a net cost saving could be found because of lower prices for high volume garments such as nurses’ uniforms. The Trust stated that the porter’s polo shirts had a lower cost per unit, but the volumes purchased had to be higher. Uniforms that are designed to meet other social sustainability standards have the benefit that they can be manufactured to current typical cotton/ polyester specifications, where Fairtrade uniforms require a higher minimum cotton content, which may not coincide with staff requirements.

Outcomes

The availability of Fairtrade porter shirts at a lower cost than a conventional garment is a prime example that some aspects of sustainable procurement are not only cheaper but that they require no additional resourcing effort when procuring for the first time. It is important that Trusts pose questions to their suppliers and are aware of their options when placing new orders, regardless of the number of garments ordered. Likewise, suppliers must take an active role in raising awareness of what sustainable options may be available, whether Fairtrade, organic or ethically-sourced garments. It is equally important that the Trusts raises awareness about the social criteria used to source certain types of uniforms amongst employees, as this is of interest to certain staff members and can support communication efforts. Trusts and other uniform-using organisations could realise cost savings when opportunities to order high volumes include Fairtrade garments and/or those that meet other ethical criteria. Fairtrade is a recognised and respected brand that can positively promote an organisation’s initiative to drive sustainability and increase user satisfaction with their uniform. Fairtrade uniforms have received a positive response from the Trust and its supplier stated a wider general demand from NHS Trusts for ethically-sourced uniforms, as they generate a positive perception.

4.3 Salisbury NHS Foundation Trust

Salisbury NHS Foundation Trust has 3,000 nurses. In January 2008, they switched to scrub uniforms, which are laundered on-site. The motivation behind this was largely driven by infection control and public perception around efforts to stop methicillin-resistant staphylococcus aureus (MRSA). Nurses and employees more broadly agreed with, and signed up to, the principle of managing infection control issues. The Trust was due to procure more uniforms during the pilot period and was interested in testing different fabrics and sounding out suppliers’ willingness and ability to procure to certain standards.

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Given the unique feature of the on-site laundry facilities and a standard uniform specification for nurses, one of the aims of the pilot with this Trust was to investigate the energy and economic savings that could be achieved through uniforms being made of different fabrics and mixes.

Pilot Objectives

The objectives agreed with Salisbury NHS Foundation Trust were to:

• review suppliers’ understanding of environmental criteria including EU GPP, UK GBS and what opportunities there are to meeting these standards;

• investigate energy and economic savings that could be achieved through uniforms being made of different fabrics and mixes; and

• examine what the attitudes and behaviours of staff are around the recent change of uniforms and whether they have any environmental or social concerns when it comes to their uniforms.

The Process

The ERM project team provided Salisbury NHS Foundation Trust with a list of questions (refer to Annex B) to help further engage with suppliers with regards to EU GPP/UK GBS. The objective was to determine whether suppliers understood the issues surrounding sustainable procurement of textiles and uniforms, quantified where possible in terms of price differentials, etc. This was complimented by further direct supplier engagement conducted by ERM, which is detailed in Section 4.5. Salisbury NHS Foundation Trust also provided details of a staff representative to speak to in order to unpack the benefits and drawbacks in terms of the new uniforms compared to the former ones.

Findings

EU GPP and UK GBS During the time of the pilot, Salisbury NHS Foundation Trust was not able to engage with suppliers on additional questions related to EU GPP/UK GBS. Efforts for the pilot were then focused on the remaining objectives. ERM engagement with suppliers on the same issues is reported in Section 4.5. Different Fabrics The majority of nurses’ uniforms are made out of woven cotton, woven polyester, blends or knitted cotton. Most of the fabrics are procured from the mainstream industry and are standard fibres produced by standard production techniques. If the NHS was a small boutique, there would be many options to showcase new, ‘green’ fibres in small volumes. However, with NHS Trusts, orders are relatively large with a lower budget and also specific performance requirements. As such, the business case to test different fabrics and mixes is not strong and could not be justified for this pilot. The use phase impacts (i.e. washing and drying) of textiles are well-studied and documented in several reports, including those published by Defra (16). Polyester fabrics are durable to wash and dry in a shorter time, decreasing energy requirements during laundering. Washing temperatures are generally mandated by each Trust to kill bacteria. However, optimising load capacity, detergent formulations and dosages can offer significant environmental savings. Overall, the most important aspect determining the environmental impact of laundering is the age and energy rating of the machines. It is important to note that the benefits achieved can only be achieved through awareness and operational controls.

(16) http://www.defra.gov.uk/environment/business/products/roadmaps/documents/summary-clothes-cleaning.pdf

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Over the life time of a typical garment, 50-150 washes, the reduction in energy for drying can be significant. It should be considered whether industrial laundry loads are sorted by fibre type, as polyester-only loads will be very quick and easy to dry. The production impacts are outweighed by use/laundry benefits for products that have a long life-span.

Staff Attitudes

Across the interviews conducted with staff representatives of Salisbury NHS Foundation Trust, nurses needed their uniform to be:

1. comfortable; 2. non-restrictive in terms of movements; and 3. recognisable in eyes of other staff members, patients and visitors.

At this Trust, there is an annual programme that reviews the uniform policy and examines government initiatives that need to be followed. In mid-2010, as part of a wider review, this Trust undertook a thorough evaluation of the uniforms from the perspective of users of the uniform. This review was considered a key element in the delivery of the uniform policy. The evaluation highlighted, and our staff representative interviews concurred, that the three main barriers with the uniforms were:

1. their appearance - as they did not have a smart and professional finish after the drying phase of the on-site laundering process;

2. their fit - as the trouser length is a universal size and therefore does not fit properly on many staff members; and

3. their lack of recognition - as all nurses (Registered or not) are in the same uniform, this makes it hard to tell what roles different nurses have and who is in charge on a particular ward.

Given their responsive and active attitude towards feedback, the Trust is currently working on ways of addressing these barriers (e.g. bigger name badges, reject bags for uniforms in bad condition, hanging up individual uniforms in the tunnel air drying process rather than using bulk dry, etc). Our interviewees thought sustainability was often equated to durability by staff members rather than any wider environmental impacts linked to the manufacturing of the uniform. In the evaluation process, no wider concerns were voiced with regard to social impacts. However, some ‘water-cooler’ discussions around the dichotomy of keeping costs down and ensuring better labour standards from the suppliers have taken place, particularly with staff members involved in the procurement of uniforms, rather than the average employee. According to our interviews, nurses were required to return old uniforms. They were collected on-site and then sent to charity. Perhaps due to the consultative process undertaken and having a team (in this case the Infection Prevention and Control team) to champion and to embed uniform practice, employees have become accustomed to the uniforms and are satisfied with them. One of the issues mentioned by all three interviewees was a lapsed attitude towards caring for the uniform by the nurses. It was thought that this was due to a lack of ownership over the uniforms, as they were not individually assigned and that the responsibility of caring for the uniforms was placed on the on-site laundry facility. Furthermore, as the uniforms looked scruffy (due to the on-site laundry finishes), nurses lacked that pride in their appearance that they had before when they cared for their own individual uniforms.

Outcomes

The possibilities of laundry efficiency improvements were realised and of interest to the Trust. The project team sourced an external company specialising in improving efficiency in such areas at no cost, in order to support the pilot exercise. However, arrangements for an on-site audit were not made

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during the time of this pilot. The laundry team has also tested chemicals that reduce the water that garments retain, making them easier to dry and therefore saving time, money, energy and water. Environmental savings from this have not yet been quantified. Further investigations on how to improve the drying phase in terms of the appearance of the uniform would also be beneficial, especially from the users’ perspective. In addition, from the Trust’s previous procurement experience, it was found that suppliers are generally willing to sign declarations that state that all of their suppliers operate in an ethical manner with fair labour principles. However, it was found that nurses’ uniforms made from 100% Fairtrade material are approximately 40% more expensive than conventional uniforms. Although only 20 NHS Trusts operate on-site laundry facilities, other organisations with on-site operations can achieve financial and environmental savings through a series of actions that reduce electricity and water consumption whilst optimising the operations. Many of these do not need additional capital or infrastructure. Ensuring load optimisation, sorting loads by material type and not over-drying garments are simple ways to reduce environmental impacts. Innovative products to reduce water use and investment in more energy-efficient machines can further enhance both cost and environmental savings. Staff interviews found that sustainability was often equated to durability rather than any wider environmental impacts linked to the manufacturing of the uniform.

4.4 East Lancashire Hospitals NHS Trust

The East Lancashire NHS Hospitals Trust is an Acute Trust located in Blackburn, Burnley and Pendle serving the local urban and rural communities, and staffed by some 3,000 employees. In 2007, it standardised its uniforms across the region and it currently has a procurement budget of nearly £250,000 for clinical uniforms. It is drawing to the end of its current three-year contract for uniforms, and at this juncture it is intending to explore options for working with the NHS’ North West Collaborative Commercial Agency. The Trusts’ uniforms are made of polyester and different grades are distinguished by coloured epaulettes (i.e. an ornamental shoulder piece/insignia) rather than sewn-on badges or logos. If a member of staff is promoted, they simply change epaulettes to denote the new grade. All uniforms have anti-microbial finishes for reasons of infection control before the trial started. It should be noted that anti-microbial finishes are generally associated with infection control issues rather than sustainability, but can have sustainability impacts related to the production of the coatings and on how the uniform is washed. As with most large organisations with uniforms, large batches are bought at the beginning of a procurement phase, with top-up purchases made throughout the period for newly joining staff and to replace worn-out clothing. Polyester was deliberately chosen as it is hard wearing and can withstand the higher wash temperatures expected for medical wear. Moreover, being synthetic, it dries more quickly than cotton, which means that it can be re-worn more quickly. It also means less need for tumble-drying. Many uniforms are washed at home, but some are washed at the on-site laundry. Staff were involved in the procurement process three years ago, and gave positive feedback on the choice of uniforms. Rather than having a costly take-back scheme in conjunction with suppliers, the Trust currently sells on any old uniforms it collects to local rag merchants for recycling, returning the modest return to the uniform budget. However, this doesn’t include all uniforms that have reached the end of their lives. as there is no obligation to return old uniforms.

Pilot Objectives

The objectives agreed with East Lancashire NHS Hospitals Trust were to:

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• review suppliers’ understanding of environmental criteria including EU GPP, UK GBS and international social/ethical standard (e.g. Ethical Trading Initiative, ETI) and what opportunities there are to meeting these standards;

• investigate different types of antimicrobial coatings based on their environmental impact and sustainability credentials; and

• unpack staff’s interest, understanding and appreciation of environmental and social criteria of their uniforms.

The Process The ERM project team provided East Lancashire NHS Hospitals Trust with a list of questions (refer to Annex B) to help further engage with suppliers with regards to EU GPP/UK GBS. The objective was to determine whether suppliers understood the issues surrounding sustainable procurement of textiles and uniforms, quantified where possible in terms of price differentials, etc. This was complimented by further direct supplier engagement conducted by ERM, which is detailed in Section 4.5. The project team provided the Trust with a briefing paper (Annex C) on the advantages and disadvantages of anti-microbial coatings on textiles products, to assist them in devising suitable questions in the tendering phase for new contracts with suppliers. East Lancashire NHS Hospitals Trust also provided details of a staff representative to speak to in order to unpack the benefits and drawbacks in terms of the new uniforms compared to the former ones.

Findings

EU GPP and UK GBS

The project team liaised with Trust staff both in the procurement and in the laundry services teams to ascertain how sustainability might be embedded to a greater extent into purchasing decisions and how uniforms are subsequently washed and ultimately disposed. Having spoken with the main suppliers to the East Lancashire Hospitals NHS Trust, it is understood that its products meet the core criteria of the EU GPP. Products that come with anti-microbial coatings confer not only infection control benefits – their primary purpose– but also the ability to wash the product less frequently and at lower temperatures. This obviously needs careful consideration to ensure that infection control and public understanding and acceptance is maintained, but is a potential area for investigation on addressing both laundry maintenance costs (reducing the energy used to wash and dry), as well as extending product lifetimes for some uniform-wearing organisations. Any Trust looking to buy in garments with such coatings would need to consider the associated extra costs against the potential benefits of longer-life products and the less tangible benefit of improved patient relations. It is unlikely that reduced washing frequency would be considered an option in a NHS Trust at this time. East Lancashire Hospitals NHS Trust already has a uniform recycling scheme in place. Although the economics are not overwhelmingly advantageous, the modest returns from sale to the textile trade are put back into future clothing procurement, simultaneously reducing the impact of the clothing by diverting them from landfill.

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Staff Attitudes

When the interviewees of this Trust were asked about the most important factors that nurses need their uniforms to adhere to, the following were mentioned:

1. comfort (that they fit well); 2. function (not restrictive when handling patients and doing manoeuvres); 3. smart and professional appearance; 4. durability (in terms of the uniform washing and wearing well); and 5. easy identification (which different roles and grades to be distinguished).

The interviewees thought that nurses did not seem to like the appearance and fit of the uniform, as they sometimes looked of poor quality and restricted movements (e.g. tight waist, large trouser legs, etc.). Over the years, nurses have gradually become accustomed to the appearance and fit of the uniforms. However, there are still concerns over the lack of identification, as all nurses wear the same uniform with epaulettes to distinguish certain roles. Neither interviewee remembered how the old uniforms were disposed of. When asked about how the uniforms were cared for or washed, it was thought that half of nurses washed them with their domestic wash, while the other half washed them separately with all their uniforms at the end of their week’s rotation. Both interviewees stated that the uniforms were washed at 40 degrees, regardless of whether they were washed together or separate from the domestic washing (17)

.

No wider concerns were mentioned by either interviewee in terms of social or environmental impacts of the production of the uniforms. One of the interviewees mentioned that being informed that the uniforms were sourced properly and abided by fair labour standards would be reassuring personally. However, this interviewee stated that it was probably not a good idea to make the social impacts of the uniforms widely known to the staff. The interviewee explained that even if staff had concerns over the social impact of the uniform, they would still have to wear it, as they would not have a choice. Therefore, according to the interviewee for staff’s own peace of mind, it would probably be best not to know. Although the uniforms of nurses were coated with an anti-microbial finish, the interviewees and the staff more generally did not know this.

Outcomes

Without deliberately considering sustainability in its purchasing programme, East Lancashire Hospitals NHS Trust has taken measures to address impacts through being part of a textile recycling scheme as well as sourcing from a supply base that meets the core criteria of the EU GPP. Further improvements can be made through the exploitation of the sustainability benefits of anti-microbial finishes. Where uniforms are laundered on-site, washing them every other day, rather than daily (except in necessary circumstances when they are soiled), would result in both financial and carbon savings associated with energy and detergent use, and could be anywhere up to 50%. This may not be an option for NHS Trusts due to the nature of the work, but could be considered for other uniform-wearing organisations. Notwithstanding the barriers to this, due to staff and patient perception, the reality would be somewhere lower than this maximum, due to the nature of the work conducted. But if an annual laundry bill is in the region of £100,000, even a modest reduction in throughput would result in significant savings. The sale and recycling of old uniforms is an area that other Trusts, and other uniform-using organisations, could learn from to address the end-of-life disposal issues for old garments through

(17) Again we are aware that this is different to the guidelines highlighted in Department of Health and NHS (September 2007). Uniforms and Workwear An

evidence base for developing local policy. http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_078435.pdf Accessed

on April 27th 2011

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onward recycling, and even upcycling (a process of recycling material into goods with a higher value), rather than supplier take-back schemes. Staff representatives noted that being told that the uniforms were sourced properly and abided by fair labour standards would be reassuring, but could pose a challenge if staff had concerns without a choice of alternative uniforms to wear.

4.5 Suppliers

The main issue of the EU GPP is known to them and most say that it is already achievable. For example, one supplier stipulated that the fabrics they procure from their suppliers are tested for residual chemicals to meet the Ökotex standard, which was one of the criteria sets that the EU GPP was based on, along with the EU Ecolabel (18) . Moreover, supply chains are included in some suppliers’ International Standard Organization (ISO) management systems to take a more holistic view of the production process. Likewise, ethical production issues are taken into account through various mechanisms such as Supplier Ethical Data Exchange (SEDEX) and Fairtrade. However, there seem to be divergence of opinion when it comes to compliance with more extensive schemes such as organic cotton and Fairtrade products. Some suppliers believe that customers are not ready or willing at present to pay higher costs to meet these standards. However, others maintain that the costs can be evened out over a large order, balancing off higher and lower prices. Moreover, whilst some organic cottons are available, one supplier raised the issue of quality, durability and suitability of the cotton for the demanding role it has in uniforms and corporate wear, as opposed to the lower demands of high street clothing products.

Availability

All suppliers that were contacted expressed a similar view that there is a good and steady, but limited, supply of products that come with some level of sustainability accreditation, whether environmental or social. Furthermore, were demand to rise dramatically and quickly, there may be a shortfall in supply to meet this demand. On the positive side, suppliers have not encountered any problems with procurement rules when it comes to including provision for ethically-produced garments, despite the concerns around how ethical criteria should be dealt with in the tendering process. There is room, interest and a level of uptake in the market for these higher specification garments. However, at present they are not mainstream specifications. Indeed, many Trusts that have purchased ethical or organic products have reported positive public relations responses from both staff and patients back to their suppliers.

Use Phase

Reducing use phase impacts is taken into account by suppliers to some extent, in that care and maintenance advice is given on the laundry processes suitable to the garment. However, once the garments are delivered, the suppliers have no control over how the clothing is washed and dried; at what temperatures, and with what detergents, or whether it is at the hospital site or at the wearer’s home. Using the correct laundering process will extend the lifetime of the clothing products, generally stated as being two years for nurses’ uniforms.

(18) For the Core criteria products meeting either the Öko-Tex Standard 100 label or the European Ecolabel for textiles will comply with the specifications":From

the Background Product Report for the EU GPP Criteria for Textiles,

http://ec.europa.eu/ environment/gpp/pdf/toolkit/textiles_GPP_background_report.pdf

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Durability and Finishes

Likewise, some suppliers deliberately look at aspects of the clothing that could wear out sooner, such as zips and other fastenings, and have put measures in place to strengthen these to prolong their useful life. Taking a different tack, other areas have been investigated and made available, such as the use of anti-microbial and anti-static finishes to clothing. Whilst the primary purpose of these finishes is not to extend the lifetime of the product (they are usually for reasons of increased hygiene control) they nonetheless confer benefits in that the clothing might not need washing as frequently or at high temperatures. As with all additional items, these finishes cost more, and a cost-benefit analysis needs to be undertaken by each Trust into the balance between advantages gained or required and the extra cost.

End-of-life

There was agreement that end-of-life impacts can and should be addressed through reuse, recycling or energy recovery. Indeed, most suppliers have existing routes to dispose of unwanted products, depending on the sensitivities / confidentialities of the product and its branding in question. This is through: donation of non-branded items for reuse; shredding for recycling of the fibres into other textile products; secure and certified landfill for more sensitive items; or incineration. However, it should be stressed that this is for unsold, excess stock, rather than ‘post-consumer’ clothing that has reached the end of its lifetime. Most Trusts and suppliers agreed that the costs of initiating and running full take-back schemes for reuse or recovery outweighed the financial benefits of recycling the uniforms at end of life. Indeed, in some cases the gate fees for incineration were higher than for landfill. If a supplier were to offer a take-back scheme as part of its service this would impact negatively on process and competition, which would be unacceptable to the industry. However, suppliers also agreed that if Trusts were to demand take-back schemes at the tendering stage, perhaps in the contract clauses, and therefore make it mandatory to all applicants; it would make the process more transparent and equitable. Welsh Health Supplies attempted to add this clause, but found the complexity of the issue slowed down the bidding process to an extent that is was later removed. When it comes to reusing old uniforms, it was generally agreed that this was not viable due to the nature of the clothing. There is no real market for reusing old uniforms – the clothing reuse market is primarily focused on high street clothes that can attract a commercially viable price. Moreover, many uniforms come with the sensitivities mentioned above, including organisational and corporate branding and logos. Often, these logos are embroidered on to garments and therefore hard to remove. In essence, this means the clothing is only fit, commercially, for shredding and recycling into items such as mattress fillers and insulation material and is therefore a lower value product. In practice, reusable high street clothing is often sold to onward customers in bales that contain an agreed proportion of unusable garments that are destined for shredding. Notwithstanding the adverse economics of collecting and sorting used uniforms, some pioneering companies are taking old corporate uniforms for customers to upcycle them into new textile products such as bags and coats. This has been achieved with some major organisations, in both the private and the public sector. However, there are two major issues with this approach. The first is that of hygiene and infection control associated with the used medical clothing, which be considered a medical waste and have to be disposed of accordingly. The second is that of volume – the NHS produces so many used uniforms each year that an upcycling industry would find it hard to find applications for all of it. Other end-of-life impacts occur for the packaging of the products. Although this is a lesser issue compared to the main clothing product, some suppliers are actively working in this area to develop new packaging solutions. These use recycled content or are made from water-soluble polymers, such that they can be disposed of down the drain, or in a composting facility.

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5 Conclusions and Analysis

5.1 Context

In undertaking this research, there have been several outcomes that add to the evidence base on sustainable procurement in general, and specifically on the procurement of clothing, textiles and the functions of NHS Trusts. These should be considered in the context that approximately £1 billion is spent by HM Government on uniforms, clothing and textiles annually (19). Of this, some £700 million is spent on clothing and uniforms. This total will include not only the NHS, but the Ministry of Defence, HM Revenue & Customs, executive agencies like the Environment Agency and other non-departmental public bodies. Furthermore, every organisation has its own clothing requirements, consisting amongst other things of indoor and outdoor clothing that need to withstand different uses. This study focused on four NHS Trusts in England with varied experiences in the sustainable procurement of their clothing. Due to the fact that there were only four Trusts involved (representing 1% of the number of Trusts in England) the findings will be limited and therefore not necessarily representative of the whole of the NHS. Broad conclusions will be possible, but not detailed extrapolations, when segregated by Trust size, location or other parameter. The Trusts participating in this project were enthusiastic; however, there is still a gap between what is desired and what is known or could be done about procuring more sustainably. Some progress has been made, as the results section highlights. For example, recycling of old uniforms at end-of-life, and the purchase of Fairtrade and / or organic clothing. However, these efforts seem to be the exception rather than examples of the rule. The five main aims of the study were to research the following set of questions and themes:

• what, if any, cost variance exists in purchasing clothing that meets the EU GPP criteria; • what issues of supply and market availability might exist for clothing that meets the EU GPP;

• what the implications are for maintaining product quality whilst increasing levels of sustainability in the products;

• what legal issues may exist, particularly around ethical criteria; and

• what the behavioural, awareness and understanding or training requirements raised by staff and procurement officials might be to the environmental and social criteria of their uniforms;

Conclusions for each of these have been made below, grouping where appropriate.

5.2 Detailed Conclusions

5.2.1 The EU GPP Criteria and Market Availability

Several Trusts were familiar with the EU GPP initiative; however, most did not know what it encompassed and how it was relevant to their role. Indeed, some of the Trusts stated that they did not include environmental or sustainability criteria in their tender documents. This is not surprising, due to the overriding pressures on time and priorities in the NHS to demonstrate value for money; infection control; quality of product to stand up to the rigours of medical care; and staff acceptance. Furthermore, the EU GPP criteria are not mandatory purchasing criteria. It is the conclusion of the

(19) Sustainable Procurement Task Force SPTF, Procuring the Future, 2006

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research team from having undertaken this investigation that it is unrealistic for the NHS to focus on achieving a high-level of sustainability criteria within their clothing procurement, as their chief priority is with patient care and hygiene. Rather, they need to take sustainability into account with all the other demands listed. It was clear from the research that procurement officials do not have sufficient time in their roles to investigate sustainability of clothing in depth with their suppliers when procuring new uniforms. Mechanisms need therefore to be put in place that take account of sustainability whilst minimising the burden on procurement officials. This could be, for example, through adding texts about clothing products’ sustainability to existing routes and information portals, such as the NHS Supply Chain, supplier’s catalogues, and information provided by Procurement Hubs. The picture was similar in the supply base that was consulted. Some were aware of and understood the extent and ramifications of the EU GPP. These had taken measures to manage compliance with the EU GPP, such as using fabrics from suppliers tested to the Ökotex standard. For others, the focus was on different, but inextricably related, issues such as organically-grown fibres and fairly-traded materials. Clearly, there is a diverse set of suppliers and supply chains, some mainstream and others niche providers, selling their product on a particular issue or issues. Nonetheless, it seems from the research that the demands of the core EU GPP criteria can and are being met by most suppliers. In terms of the market for clothing, the NHS is markedly different to mainstream fashion. The fashion industry supply chain has a single brand at the top with a large number of garment makers and an even greater number of raw material suppliers. As such, the power to influence change lies with the end customer, i.e. the brand. For the NHS, the situation is different, due to the fragmented nature of the many Trusts. From this research, it seems that most buy from a small number of sustainability-aware garment makers who source from a broad raw material supply base, as depicted in Figure 5.1. The power to influence lies with the garment makers, due to their relatively small numbers compared with end customers. Whilst it is certainly good that the NHS procures from suppliers who are aware of the sustainability issues in and around their industry and its supply chains, Figure 1.1 shows that the system from which these garments are procured appears unnecessarily complicated from the outside. This is possibly due in part to the number of different organisations procuring in the English NHS. This situation will not change significantly unless the Department of Health, together with NHS Supply Chain and the NHS Trusts, changes its procurement strategy and develops coherent and non-negotiable requirements for all suppliers and to buy centrally to reduce the complication, as Welsh Health Supplies currently does.

Figure 5.1 Market Place Description for Fashion Clothing and NHS

Suppliers are largely meeting the demands of the core criteria within the EU GPP. This is clearly of direct benefit to the Trusts concerned and other organisations reading this report, in that most of the work has been done for them already.

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Although there is opportunity for Trusts to request clothing of a higher sustainability standard, for example organic or fairly traded materials, it was reported that supply might fall short of demand for large orders. Moreover, going for a higher level of sustainability is not, as discussed, the NHS’s priority. As such, any planned changes to procurement criteria and demands should be considered in the wider context of what the supply chains can withstand. It is recommended that Trusts need only request proof of compliance with the EU GPP from suppliers. Better still, that suppliers provide this information in any tender action, or are required to do so when supplying into the NHS Supply Chain or Procurement Hubs.

5.2.2 Maintaining Product Quality whilst Reducing other Environmental Impacts

In terms of environmental issues, the research demonstrated that the EU GPP criteria as they currently stand do not encompass the full life cycle environmental effects of clothing. Rather, they are rooted in the growth and or production of fibres, and focus on excluding certain chemicals. Many other issues might need to be taken into account, and both suppliers and Trusts can work together to achieve these whilst keeping the same level of product quality required by nurses and other medical staff. The following table summarises the main environmental impacts by different fibre types. This table is by no means exhaustive in textiles choice nor the impacts covered. With this kind of knowledge, matched with the necessary staff understanding and acceptance of a change in uniform material and the related issues of comfort and maintaining product quality, decisions can be made more appropriately on the choice of fibres.

Table 5.1 Main Fibres and their Main Environmental Impacts

Fibre Main Impacts

Cotton Very high water use in growing, pesticide and fertiliser use is increasing (conventional) and impacts on surface and ground waters are significant, high water and energy demand in dyeing and significant effluent loading.

Flax Low water use, energy use low except for dyeing and finishing processes (which is similar to cotton), pesticide use generally low.

Wool Low energy and water use in production, but higher energy and water use in dyeing and finishing processes.

Polyester High energy in raw material and fibre production. Significant energy demands and water use for dyeing and finishing but less than for cotton. Use phase impacts for washing and drying are lower than that for cotton.

Nylon High energy in raw material and fibre production. Significant energy demands and water use for dyeing and finishing but less than for cotton.

Whilst fibres recognised for their environmental credentials, such as organic cotton and recycled polyester, have their qualities and are better than the standard cotton and polyester respectively, there are other low environmental impact options such as lyocell that do not get the same exposure. It is important to emphasise that production methods contribute significantly to overall environmental impacts. Therefore, running an efficient plant can reduce the environmental impact of the fibre, often to a similar extent as alternative growing methods. Following the care instructions provided by manufacturers will achieve the design lifetime of the garments. Washing less frequently and at lower temperatures will result in reduced laundering costs and environmental impacts, assuming the right materials (e.g. anti-microbial coated uniforms) and understanding are in place.

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Addressing product end-of-life management will not necessarily reduce a Trust’s direct environmental impact, but will contribute to reducing wider environmental impacts outside their direct control and hence it is important to do. By including the disposal of clothing in the procurement process, the wider impacts and costs of uniforms will be visible to the Trust and its suppliers. The Trust might gain reflected benefit, if this is publicised in the right way, and financial advantages from end-of-life clothing sales might also be secured. Nonetheless, there is general agreement from the research team, the suppliers consulted and the wider literature (20) that the core GPP criteria are already being covered by existing legislation or current business practice. Therefore, this is not perceived to be a barrier to procurement. This is further enforced when suppliers demand certain things from their suppliers, such as fabrics that have been tested to the Ökotex standards. There are other opportunities beyond the EU GPP for reducing environmental impacts, and potentially making cost savings too, whilst maintaining product quality and durability. Choosing fibres and material finishes that extend the lifetime of products is one way, as is considering laundering processes for optimisation. There are of course associated barriers, namely more expensive clothing made from different fibres and the need for hygiene control. If these can be addressed, through whole-life costing approaches and laundry trials, then there may prove to be other routes to reducing impacts and overheads.

5.2.3 Socio-economic Impacts and Ethical Criteria

Despite the generally higher cost for garments that are fairly-traded (or organic), the evidence collated has shown positive public relations feedback to the Trusts that explicitly use them, for example with porters’ uniforms bearing the Fairtrade logo. Other data (21) shows the growth in sales of Fairtrade cotton in the UK from virtually nothing in 2005 to £36million in 2007. This is a good example of benefits offsetting some higher costs. Nonetheless, reassurance that ethical standards are being met in the supply chain can be achieved at lower cost using auditing and assurance systems to provide the necessary robustness. Working with suppliers, the NHS Supply Chain could look to doing this in some capacity. Furthermore, not every case is the same, with the correct purchasing strategy, overall costs need not be higher. This has been demonstrated previously, for example with the Environment Agency (22) working with its suppliers on Fairtrade and organic-in-conversion shirts, where overall costs were slightly lower. Another example from Zürich (23) showed the cost difference between organic cotton shirts and conventional alternatives to be negligible. Market availability for fibres and textiles accredited Fairtrade or organic must be taken into account. Their availability is still relatively low, albeit that it is growing in comparison to the wider market. As such, spikes in demand for particular accreditations might cause a shortfall in the supply for such fabrics. In addition, this research has shown that stipulating ethical criteria in the tendering process is not problematic. Notwithstanding the refinement of where ethical criteria may be included in the tender (e.g. technical specifications or award criteria as Local Governments for Sustainability (ICLEI)

(20) ‘Economic and Environmental Costs and Benefits and Market Evaluation of European Union GPP Criteria against UK sustainable

Standards. Product Group: Textiles’, Final Report, February 2009, Entec for Defra (21) Defra Product Roadmap for Clothing http://www.defra.gov.uk/environment/business/products/roadmaps/clothing (22) Promoting and sharing good practice in sustainable procurement Case Study: Fairtrade ‘Organic in Conversion’ clothing with Burlington

Uniforms, Environment Agency, 2009 (23) EU GPP Textiles – Textiles Background Product Report, ICLEI 2008,

http://ec.europa.eu/environment/gpp/pdf/toolkit/textiles_GPP_background_report.pdf

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promote (24), or contract management clauses as the European Public Procurement Directive 2004/18/EC and the Office of Government Commerce (OGC) recommend (25)), there is at least precedence of their inclusion. Other than cost in some situations (depending on order size and content), there did not seem to be significant barriers to including ethical considerations in tenders. Indeed, some Trusts reported public relations benefits from doing so, which by their nature are hard to quantify or monetise. It seems therefore that there are opportunities for other Trusts, and other uniform organisations, to follow a similar route should they wish to. However, along with the price variance, these Trusts should also be mindful of issues such as availability should the demand suddenly spike and whether or not the material provides the same durability requirements as other materials. Moreover, it should be determined whether or not this is a core consideration when buying clothing.

5.2.4 Wider Environmental Conclusions

The additional conclusion of this research is that there is an opportunity for shared learning between the Trusts. This could be achieved through existing infrastructure such as the NHS Sustainable Procurement Forum, the NHS Supply Chain and possibly cascaded down to the Regional Procurement Hubs. In these, staff can share their experiences of clothing recycling, drafting procurement specifications on environmental criteria, staff uniform consultation processes and so on. In parallel, there should be greater contact and engagement with suppliers. The evidence suggests that many, but not all, items are purchased from priced catalogues, rather than through direct engagement and discussion of needs, whether for clinical, comfort or sustainability outcomes. It is recommended that there is greater value for the NHS, and lower cost, in building up this knowledge base about sustainable procurement than instigating anything more involved than collating compliance with the EU GPP’s core criteria from suppliers (or the form that takes in the UK). This approach gives Trusts flexibility in their own geographic, cultural and financial landscapes to action further initiatives that go beyond the EU GPP. These might be on anti-microbial coatings, recycling schemes or centralised laundering systems, albeit very few have their own laundries at present. Moreover, this kind of approach can have further benefit in influencing other uniform-using organisations and the wider market for corporate clothing. These are all good and valid considerations to be made in the tendering process. Whilst you could instigate coherent and non-negotiable requirements based on the EU GPP for all clothing suppliers to meet (through NHS Supply Chain for example) these others considerations would have to be made in the context in which each Trust operates, rather than in a mandatory, top down, procurement process. Each of the NHS Trusts in England is different in size, resources and community served. There would be no value, for example, in imposing obligatory take-back schemes for uniforms if the Trust is doing something different, but equally valid, from an environmental perspective, such as reusing uniforms for other workplace or domestic functions. Likewise, even though they are all fundamentally offering the same kinds of services, differences in procurement cycles, volumes and purchase levels means that one unified system would be cumbersome to initiate, to run and ultimately to verify. These conclusions chime with that of the Cambridge Institute for Manufacturing (26) on the future for reducing the environmental and social impacts of clothing and textiles (itself echoing Defra’s own

(24) RESPIRO Guide, ‘Guide on Socially Responsible Procurement of Textiles and Clothing’, ICLEI, 2007,

http://www.procuraplus.org/fileadmin/template/projects/procuraplus/files/Intranet_Publications/Topics/Social_Aspects/RESPIRO-

Textiles-final-www.pdf (25) ‘Social Issues in Purchasing’, OGC, February 2006, http://www.ogc.gov.uk/documents/Social_Issues_in_Purchasing.pdf (26) ‘Well dressed? The present and future sustainability of clothing and textiles in the United Kingdom’ - University of Cambridge Institute for

Manufacturing, 2006 http://www.ifm.eng.cam.ac.uk/sustainability/projects/mass/UK_textiles.pdf

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Sustainable Clothing Action Plan (27). This was that a change in the clothing and textiles sector to reduce its impacts will occur if (amongst other things not relevant to Government purchasing) the following are achieved. • New products that are chosen (for purchase) are made with the least energy and least toxic

emissions, made by workers paid a credible living wage with reasonable employment rights and conditions.

• Clothes are washed less often, at lower temperatures and using eco-detergents, air-drying them where possible and avoiding ironing.

• Disposing of used clothing and textiles through recycling businesses that would return them for second-hand sale wherever possible, but otherwise extract and recycle the yarn or fibres.

And specifically on removing barriers: • UK government policy on the environment should be changed to promote the reduction of total or

embedded impacts in products, not just those arising in the UK.

• The UK’s involvement in negotiating international agreements on trade could be used to promote environmental and social responsibility.

Finally, the impetus for these kinds of ‘additional’ actions beyond the EU GPP core criteria (based on production methods) has to come from the Trusts working together with their supply base and NHS Supply Chain. By providing a level playing field, as suppliers engaged in this research process have agreed, further opportunities to reduce environmental and social impacts can be explored. Having the right knowledge, advice and guidance and tools to enable this is important, and can be provided by experts within experienced Trusts, the Department of Heath, as well as Defra. But developing a constructive dialogue with suppliers and assessing the market before and during the tendering process are key to ensuring a good outcome. Engaging with suppliers, along with suitable training and policies on sustainable procurement, is one of the five main strands of the Sustainable Procurement Task Force’s (SPTF) Flexible Framework, and is key to progressing the sustainability agenda.

5.2.5 Specifics on Consumer Behaviour and Attitudes

At the end of each staff representative interview, respondents were asked a few hypothetical questions, concerning environmental, social and anti-microbial impacts and factors. These included the following:

• How would you feel if nurses’ uniforms were:

o Made from organic materials? Recycled fabric? Textiles with less chemical content?

Textiles with a lower environmental impact?

o More ethically sourced from suppliers that looked out for, aspects, like working

conditions?

o Coated with an antimicrobial?

In general, staff representatives were not overly concerned about these factors. From the perspective of the user, a uniform needs to adhere to different criteria including, in no particular order:

• comfort (so as to not restrict movement); • function (needs to be fit for purpose and hygienic – abiding by infection prevention and

control protocols); • durability (needs to stand specified washing conditions and wears well);

(27) Sustainable Clothing Action Plan, Defra, 2008, http://www.defra.gov.uk/environment/business/products/roadmaps/clothing/action-

plan.htm

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• costs (needs to fit well within agreed budget especially given financial climate and across the board cuts);

• appearance (needs to look smart and professional, and encourage pride in appearance); and • identification (needs to allow for easy recognition of role and grade).

Across all interviews, respondents stated that if uniforms fit the six main criteria above, then having low environmental and social impacts and an anti-microbial coating would be an added and welcomed bonus. It is worth noting that there was a degree of scepticism amongst certain interviewees about the true benefits of anti-microbial coating, so it is recommended that a Trust interested in procuring such uniforms invests in an awareness campaign with a strong research evidence base. Interviewees generally appeared more concerned about the social than the environmental impacts of their uniforms, to the extent that social impact was even ranked before anti-microbial in a couple of instances. The table below presents the results of interviewees being asked to rank environmental, social and anti-microbial issues as selection criteria for procuring uniforms, in order of most important to least important. Table 5.2 Results from the Staff Interviews Aspect Ranked

Anti-microbial Ranked first by five; ranked second by two Social Ranked second by four; ranked third by one; ranked first by two Environmental Ranked third by six; ranked second by one These findings provide an insight into the perception of nurses across these four Trusts. However, they are only indicative of and provide insights into attitudes within these Trusts, and should not be taken as representative across the board or extrapolated to other Trusts. A further lesson from the attitudinal and behavioural research is that a collaborative and inclusive consultation process, and a team championing the new uniform internally at the Trust, helps to ensure staff satisfaction and correct use of the uniform. From our staff representative interviews the main factors of concern to nurses are that the uniform is comfortable, functional and durable. Interviewees also voiced concern over the uniform’s appearance as it needed to look professional and allow the distinction of different roles and grades. Social and environmental factors linked to the manufacturing of uniforms were not front of mind issues for our interviewees as other priorities took precedence. Trusts looking to procure uniforms with social and/or environmental credentials need to engage with and empower their staff through investing in an awareness campaign, consultation process and have a team internally championing the uniform and its wider benefits.

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6 Annex A: Initial Flyer

Defra launches a forward-looking study on procuring sustainable

uniforms with the NHS – this is your chance to be part of it!

Defra has commissioned a study to investigate how staff uniforms can be procured in the public sector with a greater emphasis on sustainable development (SD). The project will provide expert guidance on including significant aspects of SD in procurement exercises to deliver more sustainable, value for money solutions that do not compromise on quality or function. The project aims to record and understand the impacts of procuring more sustainably: the opportunities; barriers; and lessons learnt; in order that we can produce effective case study material to encourage inclusion of sustainability when procuring uniforms. This Defra study is looking to work with a range of enthusiastic NHS Trusts to trial approaches and capture experiences of sustainable uniform procurement. Why your Trust should get involved

Addressing sustainability aspects in uniform procurement can help to deliver carbon savings as well as mitigating risks related to social and environmental issues in the supply chain. However there is a clear need to also meet the demands of cost and product quality. Achieving this balance is exactly what this study is seeking to form a view on. Participation in trials through this project will provide:

• Expert advice – access to free expert advice and support will be provided to apply the principles of sustainable uniform procurement within an NHS setting.

• Assessment of opportunities for financial savings – we will work with you in applying environmental criteria whilst simultaneously addressing the dual imperative of value for money.

• Identification lower environmental impact solutions - participation will help to identify areas within your textiles procurement process where you could reduce environmental impacts and meet supply chain targets.

• Risk assessment and mitigation plans – you will gain a deeper understanding of your textile supply chain and a better ability to manage supply risks, such as consistent textile production quality.

• Support to develop ‘Best Practice’ Case Studies – we will provide a succinct, business-facing case study to highlight best practice that can be used to disseminate the results of the pilot to other Trusts and public sector organisations.

Context

This pilot study builds on work being undertaken by Defra to understand and reduce the environmental and social impacts of clothing consumption, known as the ‘Sustainable Clothing Roadmap’. This process is complementary to the EU’s Green Public Procurement (EU GPP) initiative. The EU GPP is an on-going programme to develop support for procurement professionals across Europe to buy products, including textiles, more sustainably. It consists of technical criteria and guidance documents for a range of goods and services. EU Member States have set out a political aspiration of procuring at least 50% of their public needs to the level of the EU GPP criteria.

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The benefits of a similar exercise were demonstrated in this example from the Environment Agency: 'As part of the Environment Agency's continuous supplier development programme, we worked

with our SME corporate clothing supplier to switch our high volume cotton lines to Fairtrade,

organic-in-conversion for no extra cost. This positive change has many benefits both

environmentally and socially. These include a transparent supply chain which ensures that the

International Labour standards are met, such as not using child labour and that farmers are helped

to convert from conventional farming to 100 per cent organic.'

How it will work

ERM, Brook Lyndhurst and Colour Connections are working with Defra to deliver this project. There are two main approaches: firstly to include consideration of SD into procurement projects; and secondly to assess the benefits of completed procurements that had substantive inclusion of SD. For the first of these the ERM consortium will work directly with you over six months to develop an approach for uniforms that incorporates consideration of sustainable development aspects. Through an initial meeting, group working and focused support we will help you to work through issues, overcome barriers and realise opportunities in the procurement of uniforms. This will draw on existing knowledge of textiles supply chains, SD impacts and the EU GPP as a starting point. Free expert support

There is no charge for participation in the project as all expert support is funded by Defra. Clearly the success of the project will rely on some time input from staff in the Trust but the support has been structured to be flexible and to minimise these impacts.

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7 Annex B: Tailored Pilot Outlines

Welsh Health Supplies

Focus of pilot: To investigate the different options for uniform

packaging and disposal

Agreed Pilot Scope and Objectives

Welsh Health Supplies (WHS) is mid roll-out of a new standardised nurses’ uniform across all Welsh NHS Trust. Our contacts at WHS on the Contracting Team were particularly interested in investigating different packaging and disposal options as part of this pilot. The objectives agreed were:

• To review suppliers’ understanding of environmental criteria including EU GPP (Green Public Procurement), UK Government Buying Standards (formerly Quick Wins) and what opportunities there are to meeting these standards;

• To investigate and, possibly, test different packaging for the uniforms with their main supplier;

• To explore different disposal options for former uniforms taking account of the environmental impacts of the different alternatives;

• To draw out key lessons for other trusts from their novel experience of requiring social and ethical criteria to be met across the supply chain; and

• To understand staff reactions and attitudes to the change in uniforms.

Key issues from site visit

WHS is in the middle of rolling out 150,000 nurses’ uniforms to the 30,000 nursing staff operating across all Welsh Trusts. To date roll-out has been completed for 25% of nursing staff.

The main impetus for this standardisation of uniforms came from the Welsh Minister for Health and Social Services and patient feedback as it was difficult to recognise the grades and roles of staff. This overhaul saw the number of uniforms decrease from 44 to 7 different uniforms made of a two thirds/one third poly-cotton mix.

In the experience of WHS’s Contracting Team despite stipulating a preference for a Fairtrade fabric no supplier offered it as an option in their tenders. Our contacts had looked at the EU GPP (Green Public Procurement) criteria when specifying the tender documentation but found that it confused bidders. One of the innovative elements of the procurement undertaken by WHS is that they requested that the full supply chain from fabric manufacture to dyeing process and garment production through to warehousing was compliant with the Ethical Trading Initiative (ETI) Base Code. The winning contractor, Alexandra, conducted social audits of factories across the supply chain in order to fulfil this requirement. The rationale behind including this requisite was driven by internal policy whereby certain projects over a certain financial threshold are required complete an internal sustainable risk assessment tool.

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Furthermore, there was a political as well as internal interest of fair and ethical trading standards especially with regards to labour issues. WHS highlighted three main success factors from their experience of including ethical criteria in their procurement:

• Having high-level ministerial support; • Requiring compliance with the ETI base code rather than attempting to assess bidders’ ethical

approach; and • Working with High Street Textiles Testing Services (HSTTS) – a qualified audit body – as an

expert partner who provided advice on audits, non-compliances and corrective actions. Pilot process

Over the coming weeks we will be providing the following to WHS: • A summary guidance of the different types of plastic and how they can be recycled as well as

other packaging options; and • A list of different disposal options for the uniforms with their environmental impacts using

online resources, for example www.uniformreuse.co.uk. Once we have put together this information we will pass it on to the Contracting Team at WHS with some questions and prompts for them to ask their suppliers with regards to packaging and waste handlers with regards to disposal. In the meantime, if the project budget permits, we will be in touch with HSTTS to gauge their opinion of the process and the appetite for environmental and social criteria amongst suppliers. WHS will also be sending us details of a staff representative that we can speak to in order to unpack the benefits and drawbacks in terms of the new uniforms compared to the former ones. As there was an iterative consultation process where the uniforms were altered with respect to the feedback received it will be particularly interesting to explore attitudes and behaviours. Questions for Suppliers of the Core Part of the Pilot – EU GPP

The following is a non-exhaustive list of questions surrounding the procurement of sustainable textiles that we would like you to discuss with your suppliers in forthcoming discussions.

• Have they considered any environmental or social factors for their uniforms? o If yes, which ones, how and to what extent have they been considered? o If no, is there any reason they haven’t (ie no customer demand, not possible given their

supply chain providers, too expensive etc)? • Are they aware of the EU GPP (Green Public Procurement) criteria for clothing?

o If yes, do their products meet these standards? o Are there any cost or market availability implications of products that meet these

standards? o If no, are there other standards which they adhere to? o Specifically, what is their experience with organic textiles, reusable textiles, textiles with

recycled fibres, less toxic textiles and fairly traded garments? • Are your fabric production, dyeing and uniform manufacture factories audited to an

international social/ethical standard (eg ETI)? o If yes, do they have documents that show the date etc (they normally do)? o If no, would they agree to having their factories (that you get uniforms from) audited to

an international standard?

What we would need to get back from these supplier conversations is a strong indication of the issues surrounding sustainable procurement of textiles and uniforms, quantified where possible in terms of

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price differentials, etc. This will assist us in drawing conclusions as to the possibilities for the way forward. The same applies for any extra areas of research such as packaging and end of life management.

Schedule and next steps

• To provide the information as outlined above to WHS in the coming weeks;

• To have an informal telephone conversation with HSTTS;

• To have a telephone conversation with a staff representative in order to explore some of the attitudinal and behavioural issues further; and

• To set up a telephone conversation with our contacts in late October / early November 2010 after they have had a chance to talk to their suppliers and disposal agencies with regards to the outlined suggestions.

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Royal United Hospital Bath NHS Trust

Focus of pilot: To investigate with suppliers and staff the appetite

for uniforms with lower environmental and social impacts

Agreed Pilot Scope and Objectives

Royal United Hospital Bath NHS Trust’s Procurement Team will be tendering for a top-up of uniforms in early 2011. It was, therefore, decided that the most appropriate focus for this case study was twofold:

• To explore suppliers’ awareness and understanding of environmental and social criteria including EU GPP (Green Public Procurement), UK Government Buying Standards (formerly Quick Wins) and international social/ethical standard (e.g. Ethical Trading Initiative, ETI) and what opportunities there are to meeting these standards; and

• To unpack staff’s interest, understanding and appreciation of environmental and social criteria of their uniforms.

Key issues from site visit

Our contacts at this Trust stated that their purchasing of uniforms to date had mainly been driven by costs and suitability, i.e. fit for purpose for nurses, porters, estate staff, etc.

They had recently made a purchase of Fairtrade t-shirts for their porters because they came to a lower cost than non-Fairtrade t-shirts.

In terms of their current nurses’ uniforms they are made from a 70/30 polyester-cotton mix and they have eight different types to reflect the different grades and roles. Besides some minor cases of skin irritation staff were thought to be satisfied with the uniforms. Prior to the contract with Alexandra, which has been in place for approximately five years, the Procurement Team had to deal with many separate suppliers and was often ordering from a catalogue. Having the contract in place with a single supplier has meant savings both in economic terms and time for the Trust, as well as the opportunity to tailor their uniforms as desired. The Procurement Team have good relationships with all suppliers as they meet up at least quarterly to review orders and pricing agreements. Pilot process

Over the coming weeks our contacts at this Trust are due to meet both with Alexandra and their Fairtrade t-shirt supplier, OMC. The ERM team has already drafted questions for them to put to both parties.

In addition the Uniform Group, which has several staff representatives as members, is due to meet on 19th October 2010. The ERM team has already supplied questions and prompts to our contacts to help us investigate the second main research objective of this pilot.

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Questions for Suppliers of the Core Part of the Pilot – EU GPP

The following is a non-exhaustive list of questions surrounding the procurement of sustainable textiles that we would like you to discuss with your suppliers in forthcoming discussions.

• Have they considered any environmental or social factors for their uniforms? o If yes, which ones, how and to what extent have they been considered? o If no, is there any reason they haven’t (ie no customer demand, not possible given their

supply chain providers, too expensive etc)? • Are they aware of the EU GPP (Green Public Procurement) criteria for clothing?

o If yes, do their products meet these standards? o Are there any cost or market availability implications of products that meet these

standards? o If no, are there other standards which they adhere to? o Specifically, what is their experience with organic textiles, reusable textiles, textiles with

recycled fibres, less toxic textiles and fairly traded garments? • Are your fabric production, dyeing and uniform manufacture factories audited to an

international social/ethical standard (eg ETI)? o If yes, do they have documents that show the date etc (they normally do)? o If no, would they agree to having their factories (that you get uniforms from) audited to

an international standard?

What we would need to get back from these supplier conversations is a strong indication of the issues surrounding sustainable procurement of textiles and uniforms, quantified where possible in terms of price differentials, etc. This will assist us in drawing conclusions as to the possibilities for the way forward. The same applies for any extra areas of research such as packaging.

Schedule and next steps

• To arrange a teleconference call with our contacts, Environmental Manager and Senior Assistant Director of Nursing as a staff representative for the end of October to understand what has been discovered so far.

• Subsequent to this follow-up call to plan out the remainder of the pilot and assess progress.

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Salisbury NHS Foundation Trust

Focus of pilot: To trial different uniform types especially with

regards to the laundering as this is all done onsite

Agreed Pilot Scope and Objectives

Salisbury District Hospital has 3,000 nurses and two years ago they switched to scrubs uniforms which are laundered onsite. The motivation behind this was largely driven by infection control and public perception around efforts to stop MRSA.

Given the unique feature of the onsite laundry facilities the aims of the pilot with this trust will be:

• To explore suppliers’ awareness and understanding of environmental and social criteria including EU GPP (Green Public Procurement), UK Government Buying Standards (formerly Quick Wins) and what opportunities there are to meeting these standards;

• To investigate energy and economic savings which could be achieved through uniforms being made of different fabrics and mixes; and

• To examine what the attitudes and behaviours of staff are around the recent change of uniforms and whether they have any environmental or social concerns when it comes to their uniforms.

Key issues from site visit

Our contacts at the trust stated that as they are due to procure more uniforms in the next few months they are interested in testing different fabrics and sounding out suppliers’ willingness and ability to procure to certain standards.

From their previous experience they know that suppliers are willing to sign declarations which state that all of their suppliers operate in an ethical manner with fair labour principles.

They had also done some research into sourcing their nurses’ uniforms from a 100% Fairtrade material and found it to be approximately 40% more expensive.

The laundry team have also tested chemicals which reduce the water that garments retain making them easier to dry and therefore saving time, money, energy and water.

Overall, it was stated that some of the initiatives undertaken at Salisbury District Hospital appeared to be driven in part by public perception and media profile.

Pilot process

Over the coming weeks we will be providing Salisbury District Hospital with a few different options in terms of fabric and mixes for the nurses’ scrubs uniforms in order to reduce the environmental impact at the laundry stage. If possible, these options will be trialled in practice. If not possible, due to timing or budget constraints, they will be tested by asking the suppliers for the economic costs and relying on published literature for the environmental impacts.

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Questions for Suppliers of the Core Part of the Pilot – EU GPP

The following is a non-exhaustive list of questions surrounding the procurement of sustainable textiles that we would like you to discuss with your suppliers in forthcoming discussions.

• Have they considered any environmental or social factors for their uniforms? o If yes, which ones, how and to what extent have they been considered? o If no, is there any reason they haven’t (ie no customer demand, not possible given their

supply chain providers, too expensive etc)? • Are they aware of the EU GPP (Green Public Procurement) criteria for clothing?

o If yes, do their products meet these standards? o Are there any cost or market availability implications of products that meet these

standards? o If no, are there other standards which they adhere to? o Specifically, what is their experience with organic textiles, reusable textiles, textiles with

recycled fibres, less toxic textiles and fairly traded garments? • Are your fabric production, dyeing and uniform manufacture factories audited to an

international social/ethical standard (eg ETI)? o If yes, do they have documents that show the date etc (they normally do)? o If no, would they agree to having their factories (that you get uniforms from) audited to

an international standard?

What we would need to get back from these supplier conversations is a strong indication of the issues surrounding sustainable procurement of textiles and uniforms, quantified where possible in terms of price differentials, etc. This will assist us in drawing conclusions as to the possibilities for the way forward. The same applies for any extra areas of research such as packaging.

Schedule and next steps

• To provide the information as outlined above to Salisbury District Hospital in the coming weeks; and

• To set up progress teleconferences for late October / early November (which would include a staff representative) to understand the outcomes of discussions with suppliers to date and delineate the steps going forward.

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East Lancashire Hospitals NHS Trust

Focus of pilot: To investigate with suppliers and staff the appetite

for uniforms with lower environmental and social impacts as well

as antimicrobial finishes

Agreed Pilot Scope and Objectives

East Lancashire Hospitals NHS Trust is an amalgamation of two Trusts which came together three years ago. They are soon coming to the end of their procurement contract with Alexandra. They are looking to go to tender in early 2011 in order to provide staff with replacement uniforms as some are reaching the end of their life. With this in mind the aims of the pilot with this Trust will be:

• To explore suppliers’ awareness and understanding of environmental and social criteria including EU GPP (Green Public Procurement), UK Government Buying Standards (formerly Quick Wins) and international social/ethical standard (e.g. Ethical Trading Initiative, ETI) and what opportunities there are to meeting these standards;

• To investigate different types of antimicrobial coating based on their environmental impact and sustainability credentials; and

• To unpack staff’s interest, understanding and appreciation of environmental and social criteria of their uniforms.

Key issues from site visit

The unique angle of the uniforms in place at East Lancashire Hospitals is the fact that the two thirds/one third polyester-cotton mix nurses’ uniforms have an anti-bacterial coating which was apparently applied more for a PR point of view rather than infection control.

Both representatives of the Procurement team and the Laundry team had a pragmatic approach to the boundaries of a pilot study as long as the design and colour of the uniforms remained the same. The uniforms were selected based on their durability and ease of care as well as their cost.

Our contacts at this Trust have a good relationship with their suppliers and previously when they had asked about the location of manufacturing factories they were always forthcoming with information. They expressed an interest in ethical criteria as well as it provides good publicity and enhances public perception.

Our contacts also had a keen interest in locally sourced products, but, despite the good public perception of locally sourced textiles, it would probably be too costly or even impossible in practical terms.

Pilot process

Over the coming weeks we will be providing East Lancashire Hospitals Trust with a summary of various antimicrobial finishes and their environmental impacts and sustainability benefits. Our contacts at the Trust, in due course, would liaise with their suppliers to see what they are able to provide and with what difficulties. We would also provide our contacts with information for the EU GPP criteria and ETI which they can include in tender documentation and discuss with suppliers when contacting them.

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In return our contacts would provide us with a lead matron who would act as a staff representative and would enable us to investigate the attitudinal and behavioural motivations and barriers with regards to their new uniform. We would also explore the extent to which staff are interested in environmental and social criteria when it comes to their uniforms.

Questions for Suppliers of the Core Part of the Pilot – EU GPP

The following is a non-exhaustive list of questions surrounding the procurement of sustainable textiles that we would like you to discuss with your suppliers in forthcoming discussions.

• Have they considered any environmental or social factors for their uniforms? o If yes, which ones, how and to what extent have they been considered? o If no, is there any reason they haven’t (ie no customer demand, not possible given their

supply chain providers, too expensive etc)? • Are they aware of the EU GPP (Green Public Procurement) criteria for clothing?

o If yes, do their products meet these standards? o Are there any cost or market availability implications of products that meet these

standards? o If no, are there other standards which they adhere to? o Specifically, what is their experience with organic textiles, reusable textiles, textiles with

recycled fibres, less toxic textiles and fairly traded garments? • Are your fabric production, dyeing and uniform manufacture factories audited to an

international social/ethical standard (eg ETI)? o If yes, do they have documents that show the date etc (they normally do)? o If no, would they agree to having their factories (that you get uniforms from) audited to

an international standard?

What we would need to get back from these supplier conversations is a strong indication of the issues surrounding sustainable procurement of textiles and uniforms, quantified where possible in terms of price differentials, etc. This will assist us in drawing conclusions as to the possibilities for the way forward. The same applies for any extra areas of research such as packaging and end of life management.

Schedule and next steps

• To provide the information as outlined above to East Lancashire Hospitals in the coming weeks; and

• To set up a teleconferences in late October / early November (which would include a staff representative) to assess the progress to date.

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8 Annex C: Additional Tailored Information Provided

East Lancashire Pilot Study: Anti-microbial finishes on nurses’ uniforms

The use of anti-microbial finishes on nurses’ uniforms is of interest to East Lancashire Hospitals NHS Trust. ERM, in conjunction with Colour Connections, have summarised anti-microbial finishes available and the impact of their use. This is provided below. 1.0 Background

The term ‘microbe’ can apply to bacteria, fungi and yeasts and ‘anti-microbial chemicals can kill or restrict the numbers of one or more of these. The most high profile microbial issue has been with MRSA (Methicillin Resistant Staphylococcus

Aureus) infections in hospitals. Methicillin is an antibiotic drug that has been used to control Staphylococcus Aureus bacterial infections; however, some bacteria have now developed resistance to this specific antibiotic, resulting in so-called ‘super bugs’. Although resistant to Methicillin, these ‘super bugs’ are easily killed by a number of alternative anti-microbial agents including many that can be applied to textiles. The other main concern of hospital infection control teams is clostridium difficile and the fact that this organism produces spores that are very difficult to eradicate. It is unreasonable to expect anti-microbial uniforms to eradicate or significantly reduce hospital infections without many other measures being taken (for example, general hospital and personal hygiene make a significant difference ) but their use can only make the infection control situation better (28). In general anti-microbial textiles work. They are not a gimmick and, depending on the type of chemical used, can drastically reduce the numbers of potentially harmful microbes on the uniforms, thus reducing the chances of cross-contamination. 2.0 Environmental aspects

From an environmental perspective, anti-microbial textiles are interesting in that they may not have to be washed as frequently as untreated textiles – they remain microbiologically ‘clean’ because they kill the microbes that land on them but will have to be washed periodically to remove dirt, grease and stains.

(28) Provided active chemicals do not cause anti-microbial resistance

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However, it should be noted that not all anti-microbial agents kill a wide spectrum of microbes and any trials to reduce washing frequency of uniforms must be carried out in conjunction with infection control teams/microbiologists to ensure that the specific anti-microbial chemical is active against the specific microbes that are present in the specific hospital environment. Although the use of anti-microbial coatings may allow clothing to be washed less, most Trusts stipulate that uniforms must be washed after one day’s wear. The environmental impacts of those that are washed in hospital laundries are relatively easy to calculate but where uniforms are laundered at home the environmental impacts are fragmented and more difficult to assess. Reducing washing frequency is very difficult concept to promote because of assumptions and behaviours and it is unlikely to be supported by hospitals. Conventional domestic laundry tends to remove microbes via detergency rather than actually killing them but it is effective in reducing the numbers of microbes on a textile – high laundry temperatures (above about 70oC) are required for an effective kill and that is why hospital laundries (and high temperature washes in general) are relatively high in terms of energy consumption. One aspect of anti-microbial textiles that should not be under-estimated is the fact that they are very, very effective at reducing odour – keeping individuals far more comfortable when working in hot environments. 3.0 Type of technologies

There are a number of different anti-microbial technologies available for textiles and they can be divided into two broad categories:

1. Industrial: chemicals that are used to protect textiles that do not come into frequent or prolonged contact with humans (eg shower curtains, tents, awnings etc); and

2. Consumer: chemicals that are used with the intention that they may be in frequent and prolonged contact with humans (eg bedding, clothing).

Nurses’ uniforms therefore come into the second category and anti-microbial chemicals should be selected that are safe and effective. There are two main methods of making uniforms anti-microbial.

1. Applying an anti-microbial chemical to a standard textile: this is the lowest cost method and leaves the fabric supplier with the flexibility of choosing whether to apply the finish or not. The active ingredient is concentrated on the surface of the fibres where it is most effective.

2. Using fibres that have anti-microbial agents embedded in them or applied as a coating

at the point of manufacture: this is usually a higher cost option, because a more active ingredient is used (some is embedded in the centre of the fibre in most cases) and the volumes of fibres produced are low.

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4.0 Chemical finishes

Finish Description

Quaternised

silicones This product is safe, relatively inexpensive and easy to apply to a wide range of fabrics. It is a durable product that remains active for over 50 washes on fashion apparel. It is effective against many bacteria and fungi and would be a low cost, low risk option. It is more durable on cotton than polyester. The market leader for this product is Aegis.

Polyhexamethylene

biguanide (PHMB) This product is also safe, relatively inexpensive and easy to apply but is only applicable to cotton and other cellulose fibres. It does not work effectively on polyester. The market leader for this product is Purista.

Silver salts There are a number of different silver anti-microbial products on the market. Most are silver salts (such as silver chloride) and they can be applied on their own or with a binder system for added durability.

Inherently anti-

microbial fibres

There are a number of inherently anti-microbial yarns available containing chemical agents that kill bugs on contact. Examples include Amicor (acrylic with triclosan – this ingredient may not be desirable as it is known to leach – see below) and Magic Silver, which is polyester with silver salts.

X-Static

This is a synthetic yarn coated in metallic silver – the advantage is that you can see that a fabric is protected (i.e. you can see the silver), the drawback is that it is so expensive that it is usually only applied in stripes, rendering the majority of the fabric ineffective at killing microbes.

5.0 Conclusions and Recommendations

When choosing an anti-microbial fibre or finish there are several points to consider:

• the active ingredient must be effective (ie kill the microbes you want to kill);

• the effect must be durable for the lifetime of a garment;

• the active ingredient must be safe for the wearer and the workers involved in manufacturing;

• the active ingredient must not be implicated with the development of ‘super-bugs’;

• the active ingredient must not transfer to other items in a laundry process unless the transfer is well profiled and desirable (eg transfer from uniforms to sheets); and

• the active ingredient must not leach off the surface onto a wearer’s skin.

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WHS Pilot Study: Disposal of Old Uniforms and Packaging

Disposal of old uniforms and the packaging associated with new ones were identified by WHS as areas where a better understanding of the best environmental option was needed. 1.0 Disposal

Currently there is no single system for the collection and disposal of nurses’ uniforms and different Trusts deal with the issue in different ways. Typically, uniforms are passed on to a local textile recycler or end up in the municipal waste stream, which generally goes to landfill. The same ‘waste hierarchy’ principles are promoted across the UK and Europe from the European Commission to Waste Awareness Wales (WAW) - all stating that landfill disposal is the least preferred option. Reuse or recycling is the best method to handle uniforms at end of life, followed

by energy recovery (ie incineration).

Source: www.wasteawarenesswales.org.uk/hierachy.html

1.1 Reuse and Recycling

There is an ambition in Wales to recycle at least 70% of waste by 2025 and to be a zero waste nation by 2050. Defra research on the disposal of UK clothing shows that the reuse and recycling of textiles offers the best performance in terms of energy, waste and resources. There are several reuse/recycling options for textiles such as: genuine recycling (producing new fibres from old textiles, producing rags, use as stuffing/filling or reuse by selling to another market. However, uniforms do not have a very wide prospect of reuse at end of life due to health and/or security concerns and the ease of removing the branding. Careful consideration should be taken when sending uniforms abroad to ensure they do not end up as a waste product in their final destination.

1.2 Energy from Waste

Energy from waste facilities needs an environmental permit from Environment Agency Wales, which set strict operating standards and emissions limits on facilities to protect the health of local people and

Shoddy recycling

Fabrics are ripped apart and the fibres used

to spin new fabrics of lower quality than

the original.

Chemical recycling

Polyester fabrics are broken down and

formed into new fibres by a melting

process or by a depolymerisation and re-

polymerisation process.

Shoddy recycling

Fabrics are ripped apart and the fibres used

to spin new fabrics of lower quality than

the original.

Chemical recycling

Polyester fabrics are broken down and

formed into new fibres by a melting

process or by a depolymerisation and re-

polymerisation process.

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the environment. New research from WAW reveals for the first time the high level of Welsh support for burning non-recyclable waste to create energy. It is recommended that WHS pursue this option for old uniforms that can not be reused or recycled.

2.0 Packaging

The impact associated with the plastic packaging used to individually wrap new uniform garments could be significantly reduced though a number of options, including: type of plastic, recycled content and/or light weighting the materials used.

• Plastic type: single use plastic bags and wrap are typically made from HDPE, which is readily recyclable in many parts of the UK. However, it is noted that plastic bags are not currently part of most municipal recycling systems in Wales. It is recommended that WHS seek a commercial recycler who has the capability to handle this product.

• Recycled content: using HDPE plastic with a recycled content rather than virgin material will reduce the impact associated raw material production and from not using landfill or incineration for the old material.

• Light weighting: reducing the thickness of both the plastic wrap and cardboard boxes can lower the environmental impact and costs of the packaging. If double-walled boxes are currently in use, a change to single walled could reduce weight and material use if it does not effect the performance characteristics required.

Availability of recycling options should be considered prior to requesting a change in packaging type. Eliminating the individual wraps and instead having a single larger, but lighter box liner would reduce the associated manufacturing emissions with raw material use and the amount of waste generated. Requesting your supplier to explore alternative designs is recommended. Generally, avoiding coloured plastics and packaging with different types of polymers (eg known as a composite) is recommended as they are more difficult to recycle. 3.0 Conclusions and Recommendations

• Seek to reuse and recycle old uniforms where possible, verifying that they are reused or recycled, rather than being landfilled elsewhere.

• Seek incineration opportunities for textiles that are not suitable for reuse or recycling.

• Investigate packaging options with suppliers: recycled content in materials; thinner bags and wraps; and availability of recycling with waste contractors in Wales.

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9 Annex D: Staff Representative Topic Guide for Interview Time Instructions Purpose of section

• Introduce yourself and Brook Lyndhurst – interview is confidential and anonymous • Purpose of interview:

o For interviewer: To understand staff’s interest, understanding and appreciation of environmental and social criteria of their uniforms

o For interviewee: To talk about their opinion of the uniforms: both personal and collective

Warm up.

Es

15 mins Exercise 1 – Views and attitudes around uniforms

• What do you/your colleagues think of the (new) nurses’ uniforms?

o If necessary Could you describe your nurses’ uniform for me?

o How do the new uniforms compare to the previous ones? Anything you/your colleagues like more? Anything

you/your colleagues dislike more?

o If not covered previously In your opinion, when it comes to choosing a uniform what are the main features/things

you/your colleagues need it to do? Probe for any environmental issues.

• Do you/your colleagues have any wider concerns, for example, about the way the uniforms are produced or manufactured?

o If not covered previously Have you/your colleagues ever thought about the environmental and social impacts of the

uniforms?

o Would you/your colleagues be interested in knowing more about the environmental and social impacts of your

uniforms or is it something is not of interest?

• How, if at all, has staff opinion changed over the course of the roll out/since the introduction of the new uniform?

o Have they become accustomed to it?

o Have they become champions of the change?

o Have they experienced any barriers? Aspects like less clear rank distinction may be mentioned

To explore interviewees’ likes,

dislikes and expectations of the

uniforms.

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10 mins Exercise 2 –Behaviour and any changes

• How do you and staff more generally take care of the (new) uniforms? (E.g. frequency of wearing, washing, drying, ironing,

etc.)

• How are old uniforms disposed of?

o How do you/ staff general dispose of old uniforms?

o What could be done to make their disposal easier?

o Have you ever considered the environmental impact of getting rid of old uniforms?

• What, if any, barriers have there been with the up-take of the new uniforms?

o Issues with wearing and caring (maintenance implications) for the uniform (e.g. washing, drying)

o Issues with visual appearance (patient point of view)

• If relevant How were any difficulties overcome? If probing is needed Was there a need for extra training or awareness activities

or special work groups?

To explore behaviour and any

changes around the uniforms over

time.

5 mins Exercise 3 – Scenario setting

• How would you feel if nurses’ uniforms were:

o Made from organic materials? Recycled fabric? Textiles with less chemical content? Textiles with a lower

environmental impact?

o More ethically sourced from suppliers that looked out for, aspects, like working conditions?

o Coated with an antimicrobial?

To unpack any preconceived ideas

about quality of different types of

more sustainable uniforms.

Thank and close

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