Financial and environmental benefits from transitioning from MLB under GA to TNO biopsies under LA in ENT

Project completed as part of the University Hospitals of Northampton Green Team Competition.  

Team members 

Rohan Bidaye – ENT surgeon, Hayley Steptoe - Advanced Clinical Practitioner, Macmillan Head and Neck Clinical Nurse Specialist, David Adegbite – ENT Resident Doctor, Austin Ventre – ENT Resident Doctor   

Setting / patent group:  

Patients undergoing biopsy for suspected laryngeal and pharyngeal lesions. 

Issue: 

Diagnostic microlaryngoscopy and biopsy (MLB) under general anaesthetic (GA) has traditionally been used for suspected laryngeal and pharyngeal lesions, but this pathway is resource intensive, environmentally impactful, and dependent on access to theatres and large multidisciplinary teams. Increasing referral volumes, extended waiting lists and pressure on theatre capacity have highlighted limitations in the GAbasedmodel, delaying diagnosis on urgent suspected cancer pathways. GA carries additional clinical risks and contributes significantly to carbon emissions due to volatile anaesthetic agents and energy intensivetheatres. Prior to this evaluation, the ENT service had begun informally shifting appropriate cases to outpatient local anaesthetic (LA) transnasal oesophagoscopy (TNO), but the financial, environmental and patientcentred impacts had not been formally assessed. 

Intervention:  

The project evaluated a service change in which approximately 300 diagnostic biopsies previously performed under GA were instead carried out using LA TNO between 2022-2025. The team analysed staffing levels, theatre utilisation, consumables, anaesthetic drugs, carbon emissions, pathway costs and patient experience for both approaches. Patient selection and procedural workflows were refined to support safe and effective delivery of the LA pathway without requiring additional capital investment. 

Outcomes: 

Clinical 

Transitioning to LA TNO biopsies supports faster access to diagnostic procedures, enabling earlier biopsy and potentially earlier cancer diagnosis. LA TNO avoids risks associated with GA and maintains high diagnostic yield. Complication rates are low, tolerability is high, and only a small proportion of patients require GA for repeat or confirmatory biopsy. 

Environmental 

Carbon footprint analysis demonstrated a saving of 15.39 kgCO₂e per case swapping from GA to LA. An annual saving of 1539 kgCO₂e was identified based on 100 procedures per year, the equivalent to driving4529 miles driven in an average car. Major contributors to carbon reduction included elimination of volatile anaesthetics, lower consumable use, reduced energy demand, and fewer staff requiring travel for theatre sessions. 

Financial 

Swapping from GA to LA delivered a financial saving of approximately £880 per case and an estimated annual saving of £75,879.  This was based on consumables, pharmaceuticals, energy and waste savings, along with saving over 700 staff-hours in theatre, recovery, preassessment. 

Social 

Patient reported experience for LA TNO biopsies reported experience for LA TNO biopsies was highly positive, with 97% of patients rating their experience of 8 or above out of 10. LA procedures reduced patient disruption by avoiding fasting, hospital admission and prolonged recovery. Staff reported reduced workload intensity and dependency on theatre staff, supporting improved workforce wellbeing and service resilience. 

Key learning point  

Strong clinical leadership and close collaboration between ENT, anaesthetic and theatre teams enabled the change, improving patient selection and counselling. Most carbon savings came from reduced staffing and staff travel, underlining the need for wider low‑carbon commuting initiatives. Early challenges included managing patient tolerance and maintaining GA access for those who need it. The LA TNO pathway is now embedded in routine practice, is easily transferable to other ENT services, and has the potential to reduce diagnostic delays, improve access, and support NHS net‑zero goals.