Guest: Melissa Pegg, Senior Research Consultant — Environmental Sustainability in HTA, York Health Economics Consortium (YHEC), University of York **Host:** Frederik van Deurs **Recorded:** 22 June 2026

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Frederik: Hello, and welcome to the Sustainable Healthcare Podcast. Today I have a guest on the show, Melissa Pegg, who is an expert on environmental sustainability in health technology assessments. This really excites me, because day to day at Care Pathway Consulting we talk to pharma companies producing innovative medicines, and HTA is actually the process for how new drugs get to market and get approved. So if we want to fix environmental sustainability in healthcare, looking at HTAs — health technology assessments — could be a very viable pathway. Without further ado, Melissa, welcome to the show.

Melissa: Thank you very much, Frederik. It’s an absolute pleasure to be on your podcast today.

Frederik: Where are you calling in from?

Melissa: I’m based in the beautiful city of York. I’m 10 minutes from the university, so I’m ideally located to not use my car too much.

Frederik: This is the old York, not New York?

Melissa: This is the old city of York, yes — the original York.

Frederik: I’ve never been, but I’d like to go. I hear it’s really beautiful.

Melissa: Please do. We’d have to meet up for a coffee.

Frederik: For sure — and I’d love to meet your cats; you told me you have cats. Before we dive into the professional life of Melissa, what do you like to do when you’re not working on sustainability and health technology assessments?

Melissa: I’ve been doing yoga for 30 years — that’s 3-0. I started quite young. I graduated as a teacher for the British Wheel of Yoga in 2016, so I can teach children, teens and adults yoga, and also yoga nidra — nidra means sleep in Sanskrit. I have two boys, and I like to spend all my time with them when I can. I also like to do DIY and read philosophy.

Frederik: Amazing — the boys, the DIY, the yoga, the cats and the philosophy. It might be good to do them one at a time and not mix too many of those elements.

Melissa: Indeed. Definitely.

Frederik: If you extracted yourself from the yoga sessions and the DIY and the reading of philosophy and mothering the two boys, and you ran into a nurse at a hospital and got into a conversation — how would you describe yourself and the work you do?

Melissa: Living a life of yoga, we strive — and I emphasise that word, because I’m not perfect at what I do — to reduce the environmental impact of what goes on around us, and to help facilitate that movement to more environmental sustainability considerations globally. I like to weave that into every part of my life, and that includes the sustainability of my own being: looking after myself, my family, my friends, the people I work with. That extends through my work to developing more sustainable healthcare decision-making.

Part of what I’m doing is working with HTA and health economics, where we have a real opportunity as a gatekeeper. HTA — health technology assessment — covers health technologies including digital, AI, preventative, diagnostic, vaccines, medical devices, pharmaceuticals and public health interventions — anything that has an impact on healthcare provision, which might be a system change along the care pathway. Often one of the most effective things is to look at what’s already being used and how we can use it better along the care pathway. HTA is a very systematic process undertaken to elicit the value of an intervention — to evaluate it, for example against its comparator, and to look at how best to spend the money in a fixed budget such as the UK NHS. When you have a pot of money, and spending in one area takes it away from another, we need to spend it to the best of our knowledge, because it’s public health spending.

Frederik: Is the framework of health technology assessment defined at a national level, an EU level, or a global level? Where does the definition stem from?

Melissa: That’s a wonderful question. We have World Health Organization strategies and European strategies that feed into the more localised national HTA — what we call reference cases. There are global strategies, such as moving towards value-based procurement and lower-carbon alternatives, that help progress the response of HTA agencies at a national level. For example, in the UK we have NICE — the National Institute for Health and Care Excellence — and that’s in England. We’re made up of devolved nations, so in Scotland there’s the Scottish Health Technologies Group. Those HTA agencies have their own remit and their own reference case, and that reference case provides the agreed methods and approaches to valuing health technologies.

Frederik: That was news to me — that within the UK there’s still the country split between England, Scotland and the rest. So NICE is England only, and the other countries have something comparable, and they all use the same definition of a health technology assessment?

Melissa: Broadly speaking, yes. I did a master’s in HTA with the University of Glasgow a few years ago, and many references for HTA were defined within — I’ll give you a fantastic reference — Cliff Goodman produced the most fantastic book on HTA, which is used globally.

Frederik: Melissa, you’ll have to write the name of the author and the title of the book in the chat so we can get it in the show notes, because I know I’ll be asked about that.

Melissa: Absolutely, I will. HTA is based predominantly on principles, and then each agency within its jurisdiction defines a set of parameters and methodologies it uses to evaluate how best to spend its money. So the agencies in each devolved nation have a similar type of approach, but there may be nuances between them. The agencies in Wales, Scotland and Northern Ireland will have their own strategy, but as a United Kingdom they tend to approach it from the same angle.

Frederik: That makes sense. So the principles translate across borders, but the national agencies are the ones adopting the HTA principles and regulating on the backbone of that — is that correctly understood?

Melissa: Indeed, yes. Some jurisdictions — and I’m speaking very broadly for Europe — might not be looking so much at price but more at innovation. If an HT agency has a threshold — now we’re speaking more about health economics — if there’s a cost-effectiveness or cost-utility analysis approach, then within NICE the cost-utility analysis is the focus, to look at the value of the technology. In other countries price might not be such a focus — for example in Germany the health economic approach is different, and that’s where you see quite big differences.

Then there are the different perspectives. Is it a healthcare perspective you’re looking at when you consider costs, or a broader societal perspective that takes into account costs across the care pathway? You might look beyond the healthcare setting at societal costs, which can then look towards evaluating, hypothetically, a more sustainable approach to HTA.

Frederik: So we’re still looking at the classical parameters: making certain the technology is safe; making sure it’s effective in doing what it’s supposed to do; then looking at price to make sure it’s feasible and can be afforded by the system. And then as a fourth parameter, you’re suggesting we look at the environmental impacts of introducing the technology — evaluating whether it has an increased impact on the environment, or a potential to reduce impact by providing an alternative to existing solutions. Is that a fair playback?

Melissa: Indeed, absolutely. If we take a step back — we depend on the air we breathe, on food availability, on water availability. It is critical that the environmental component upon which we all depend is taken into consideration. You mentioned the safety component, which is critical as a domain for HTA. When you start to think about the safety of our environment, it’s an interesting discussion among all the perspectives in HTA — there are seven perspectives — to bring in the domain of risk and safety when you look at that environmental component.

Frederik: Safety for whom? Normally we’d talk about safety for the patient and the staff using the technology, in a classical sense. But it sounds as if you’re introducing a new stakeholder — the environment, and the harm that could be caused to it — as part of a safety measure. Was that my Danish-English grammar, or what you meant to say?

Melissa: Well, it wasn’t, but that’s an excellent point. Something that comes up quite regularly is: where is the planetary health perspective in the seven perspectives in HTA? I’ll come onto that in a moment. What I was referring to — and you’re absolutely right — is that the current distinction is the direct impact on patient outcomes, patient safety, the direct costs to the healthcare system. When we start to bring in that planetary health perspective, it broadens the consideration and the language we use. Climate change knows no boundaries — we will all be impacted, some much worse than others. We’re clearly seeing the impact on human health from climate change and other planetary health domains. So when we talk about safety, risk and environmental management, we talk about the risk profile a lot: what’s the risk if we don’t take this action? What’s the risk to population health? If we’re talking about the impact on population health, we surely need to consider the broader implications beyond the safety profile of the health technology within the healthcare setting — to extend the question of safety to the technology’s environmental profile.

Frederik: That makes perfect sense. So it starts off as another evaluation criterion — looking at the environmental footprint of introducing the technology, this pill versus that pill, or this med-tech device versus that one. But then the larger perspective becomes almost an existential question about how we want to organise society and what impacts we can tolerate. I’m curious from your perspective, Melissa: we have a lot of clients asking us what we’re going to do when sustainability criteria enter into HTA or the evaluation criteria. What can we do if this becomes a way to gain or lose market share in certain markets? What if there’s asymmetry in how it’s adopted across markets? If anyone tries to educate themselves on sustainability and HTA, your name comes up after a couple of seconds of a literature search. So what are the great case examples? Can we get concrete — has this worked anywhere before, or is it still an academic exercise?

Melissa: If we had a week to talk about this subject it still wouldn’t be long enough. It’s important to take some steps back before trying to answer what might happen in the market if we embed environmental sustainability in HTA. There are a number of approaches we can take together first. If we consider the potential impact on health technology developers, on patients, on healthcare professionals accessing health technologies — the opportunity really lies in the education piece, the knowledge sharing, the data sharing: getting environmental data into HTA without necessarily doing anything with it at the moment.

So an approach might be an “information conduit” — providing environmental data without necessarily doing anything yet with it in HTA. That would be a huge step forward for HTA to broaden its value-based approaches. One example: a few years ago I worked with the Scottish Health Technologies Group, while I was doing my HTA master’s. Prior to that I’d been working as a fellow in sustainable surgery for the British Medical Journal, with many incredible healthcare professionals who’d been working in sustainable healthcare for some time. There’s clear evidence, broadly speaking — many peer-reviewed publications — that reusable medical devices are more cost-effective and less environmentally harmful, by around 50%. So going into that research with the Scottish Health Technologies Group, I had background knowledge and experience working with different perspectives on developing sustainable surgical pathways.

The strength of that opportunity was being able to provide environmental data to look at reusable versus single-use endoscopes. That research project was also looking at patient outcomes, acceptability, safety and tolerance; they did an economic impact assessment and looked at budget impact; and my job was to look at the environmental footprint. So the real strength lies in undertaking case studies alongside our health economic counterparts, bringing in the environmental expertise to apply HTA methodologies — qualitative and quantitative approaches, scenario and sensitivity analysis. Literature searches are essential as a first step to see what data is out there, and then you can take a pragmatic, practical approach to generating a carbon footprint, looking at both technologies — both product and along the care pathway — bearing in mind the limited data, but strengthening it through sensitivity and scenario analyses, and applying assumptions, which are useful. We assume lots in different areas of HTA anyway, but you need to be transparent in reporting that environmental data, making it apparent that there is limited data. The carbon-footprint results comparing those two technologies were very much in line with the literature already available.

For that data to be published alongside — coming back to the information-conduit approach — is something HTA can do now, because we’re not expecting expertise within the HT agencies at this time; there are sizeable capacity and resource challenges. So another approach is a parallel approach — which is what we did with the Scottish Health Technologies Group: reporting environmental data alongside (and I emphasise alongside) the other components, the health economic components, so that in due course we can sit down in a room together, look at all the data with expertise across HTA — call it the “rainbow of HTA,” the different perspectives — and deliberate on how to move forward, along with health technology developers, patient experts, patients and lay persons, to drive this space forward together.

Frederik: So this is a historical case where you were looking at endoscopy and mapping out what happens in one case versus another. Can you attach some figures, or give us a sense of the actual impact picture? Was it tremendously more environmentally impactful to use a reusable endoscopy device versus single-use?

Melissa: This is a fantastic case study to demonstrate that we can move forward, hopefully in a comfortable way, without trying to solve all the bigger issues right now. What was demonstrated was that the reusable endoscope — and there are cost limitations, because it depends on the setting these technologies are used in; there’s still space for single-use at the moment because of limitations around infrastructure in healthcare settings, so it’s important to highlight that and come back to this “just transition” space. This isn’t about changing over everything right now; we haven’t done that in the energy sector either.

What was demonstrated was that the reusable endoscopic device was around 50% less environmentally impactful than the single-use comparison. The budget impact analysis was more positive — in favour of the reusable — and the patient was tolerating the reusable device in terms of safety and compliance, and the quality-adjusted life year was more favourable, just slightly, but still in favour of the reusable endoscope. So everything was in favour of the reusable endoscope.

Frederik: At the end of the day, some of the questions you’d get back would be: the reason we got into single-use, or a big part of the narrative, is that we needed to make sure it was safe and clean and fast for the medical staff — you pop out a new one, unwrap it, and you’re ready to go. The second one is around the sterilisation process and access to sterilisation plants. And one parameter we often see challenged is how many uses we’re assuming in the calculation — are we sure the devices can withstand that, because life in a clinic is tough? How did you approach those?

Melissa: If I could provide some context first. I worked in industry for 18 years before moving to academia. I’ve been present in the surgical room over a thousand times, with many different types of health technologies, working with incredible staff. I’ve run down the corridors hundreds of times trying to get hold of kits, running down to sterile services to ask when the kit’s going to be turned around — all sorts of situations. So I understand the challenges, and I’m exceptionally grateful to everybody involved, especially the sterile services department when they work wonders.

It comes back to that just transition. If we take specific examples of health technologies where it might be — and I emphasise might be — easier to move over to reusables. On your excellent point about safety: when I worked as the fellow for the British Medical Journal before this role, I collaborated with the Infection Prevention Society. I’ll share this reference with you, Frederik — I think it was 2023, a landmark report on green surgery. There’s an excellent section that really puts to bed this argument on safety. The many hundreds of healthcare professionals I worked with in my previous role were very much in favour of moving from many single-use devices — I’m speaking generically — across to reusable for many different types of technologies. And then regulation needs to be considered. This is where, as one incredibly important perspective within HTA, those voices need to be in the room when these decisions are made, because there’s so much support for this across different healthcare professional trade organisations. I’m speaking from a UK perspective, but there’s international movement towards reusable as well.

Frederik: One concern is “single-use is fast and safe and clean.” Another is sterilisation facility access — not all hospitals have it. And the third is the number of uses you’re comparing against. In this concrete example, were you looking at two-time use, ten-time use? How many counts did you put in, and what was the reasoning? Because I see that as one of the most challenged metrics.

Melissa: This is where we go back to the strength of the different methods that can be applied from a multidisciplinary perspective. If we apply scenario and sensitivity analysis to that research with the Scottish Health Technologies Group: I first did a literature search and found interesting data applying “technological representation.” That means I didn’t necessarily have the data I needed for those particular endoscopes, but if we looked at the material composition, we could broadly say it was technically aligned with the health technologies I was looking at. So I could use that literature data as proxy data.

That enabled me to state an estimated number of uses for the reusable of 3,000 uses, compared to one use for the single-use device. When we apply sensitivity analysis to that scenario — and even halved or quartered it — what I had in mind was: what would be challenged here if I didn’t do this sensitivity analysis? Someone’s going to challenge me on “I don’t think you can get 3,000 uses out of that endoscope.” So with that in mind I applied the sensitivity analysis, and it was still in favour of the reusable, interestingly enough. As long as you’re aware of the challenges that might come up, you can harness the opportunity — you use the methodologies HTA has (it has hundreds, thousands of methods), transparently report it, and make it reproducible. Going back to the principles of HTA: when data is reported transparently and at as granular a level as possible, it strengthens the recommendation.

Frederik: That makes sense. Thanks for elaborating. This is also one of the areas where all of us trying to promote sustainability in healthcare need to roll with the punches of these conversations and educate ourselves on the narrative — asking “what would need to be true for this to be the case?”, which is always a good question in research. Melissa, we’re approaching the end of this episode, but I’d love to have you back to dive into more examples. There’s a lot more to talk about in the HTA space, particularly zooming in on innovative medicine — that’s on everybody’s minds with the new types of therapies in the research pipelines. There will be a lot of attention on this for innovative medicine, and it’s likely to shape the future of healthcare. But before we round off — working in this space of sustainability and planetary health, there’s a lot of reasons to be pessimistic, a lot of doom-scrolling, and we’re recording this in the middle of a heatwave. What makes you hopeful?

Melissa: What makes me hopeful is looking at how happy my children are, and how people working in this space have children too, and are all working together to try to change what we’re doing to ourselves, our children’s future, and ultimately Mother Nature. That’s powerful, because when we bring in our children’s health, they’re being impacted now — by air pollution, by allergies increasing, and other things we maybe don’t see right now. It’s frightening. But if we focus — you mentioned doom-scrolling; I don’t do social media apart from LinkedIn, “grown-up Instagram” — then the focus on what you want to do that comes from your heart, and looking after yourself, is important to keep that hope and that fire and that desire to help, alongside many other wonderful researchers and people around the world doing everything to support planetary health and keep universal health coverage going as long as we can — to help healthcare be more sustainable and free at the point of access, which is one of the most special services we have available to us.

Frederik: It indeed is, and we’ll need to protect that. Thanks for sharing the examples with the kids — I think that’s really powerful and resonates deeply with me. Doing this for the kids, appreciating the sound of a kid laughing, when all your grown-up worries can go away for a second — it makes the hard work worth it. Melissa, where can listeners find your work?

Melissa: I’m very happy to share my email: melissa.pegg@york.ac.uk. You can find me on LinkedIn, or you can Google me — in fact, please use Ecosia instead of Google, because that will plant trees, which is wonderful. I’m leading some free webinars this year. If you go on the York Health Economics Consortium website, you’ll be able to access resources and register for the webinars.

Frederik: Amazing — we’ll provide a link for that in the show notes if you share it with me. Thank you so much, Melissa.

Melissa: Thank you, Frederik. It’s been an absolute pleasure.

Frederik: Let’s round it off and say thank you to our listeners. You’ve been listening to an episode of the Sustainable Healthcare Podcast. My guest today was Melissa Pegg, an expert in sustainability and HTAs. Please remember to like, subscribe and share the show if you liked it, and give us suggestions for folks you’d like to have on. We really appreciate your feedback and that you’re listening. Thank you.

Melissa: Thank you, Frederik. Take care. Namaste.