Sustainable Healthcare Plastic Products: Application of the Transition Engineering Design Approach Yields a Novel Concept for Circularity and Sustainability

Abstract

Durable plastics are a sustainability challenge for healthcare products. Orthopedic products are regulated with strict specifications for human tissue interactions. Healthcare engineers and managers select plastic to meet the full range of material properties. Plastic is plentiful, low cost, and reliable, with established supply chains. Used plastic products can be discarded using existing waste management systems with low externality costs for orthopedic businesses. However, plastic is produced from fossil petroleum, raising issues for sustainability commitments of healthcare product companies. Barriers to the transition away from single-use plastic toward circular systems and bio-based healthcare products have been studied, but the transition is a goal that has yet to be realized. This research article reports on a transition engineering design sprint with a medium-sized orthopedic company specializing in orthoses for children and teenagers. The design sprint process engages company experts with systems perspectives on the role of unsustainable plastic in orthopedic healthcare and illuminates opportunities for capturing value in business transition. Two system transition project concepts were co-developed. The first concept is a plastics value map that aims to converge the satisfaction of essential needs with the usefulness of plastics under the limitations of a biophysically constrained future economy. The second concept is an orthopedics library data system concept that would allow reusing of fit-for-purpose used products and to inform the refurbishment of used products. In addition to an explanation of the design of the two concepts, the article presents reflections of co-design stakeholders on the usefulness and usability of the concepts. The article provides a real-world application of the co-design processes in transition engineering and the reflection by the company on the value of the results. The results indicate that the co-designed concepts could enable the company to address its sustainability aspirations and potentially resolve the dissonance of sustainability and business viability.

1. Introduction

1.1. Background and Motivation

Healthcare products have benefited greatly from biomedical engineering research, particularly in materials and systems that interact with the human body. Today, plastic is an indispensable material for medical assistance products, particularly in orthopedics. Despite the outstanding material properties of healthcare plastic, the products are single use, made from finite resources, and create problematic harm along the value chain such as microplastic pollution, climate change, and waste in general [1]. Thus far, the problems associated with medical plastic waste have been widely acknowledged (see

Table 1. Calls for and commitments to sustainable plastic consumption in healthcare.

Healthcare Stakeholders	Calls and Commitments
Plastic industry associations	Commitments to eco-friendly product design, circular economy policies, and sustainable plastic sources [3,4]
Healthcare bodies	Commitments from the British National Health Services in England, Scotland, and Wales to net zero energy and circular resource use in the coming decades [5,6,7]; the commitments are now part of statuary guidance by UK law [8]
International Hospital Federation	Guidelines for waste reduction, sustainable supply chains, and procurement and sustainable hospital food [9]
Research	Calls for more recycling, sustainable product design, bio-based plastic, and biodegradable plastic [10]

). Despite a range of commitments and ongoing material science research, the amount of clinical plastic waste is increasing and is expected to continue to grow into the future [2].

Orthopedic products, whether for surgical [11], prosthetic [12], or orthotic use, are mostly made from plastic. Plastic is used because of its flexible but durable material properties, market availability, hygienic properties, patient comfort, and low cost [13]. However, the use of plastic does not meet sustainability objectives. When a product design is both optimal and unsustainable, the situation can be classified as a wicked problem. Wicked problems do not have solutions and resist current problem-solving approaches. Wicked problems cannot be solved through incremental improvements and require a systemic, iterative inquiry [14]. The transition away from plastic healthcare products to sustainable systems will present numerous wicked problems. The plastic materials provide successful products for suppliers and hygienic and safe systems for medical practitioners and patients, yet orthopedic enterprises are under pressure to meet sustainability goals [11].

1.2. Research Gap and Research Question

Sustainable healthcare systems should maintain an economic focus while balancing patient and worker needs and integrating environmental costs and long-term objectives [15]. Designing sustainable healthcare systems and products requires bottom-up, systemic, transdisciplinary approaches, focused on the whole supply chain [1]. The key concepts of eco-design, design thinking, and circular economy strategies have emerged to address sustainability, and engineering research has focused on more sustainable manufacturing and materials and recycling [16]. Relevant prior work in sustainable orthopedics had a strong emphasis on orthopedic surgery products and tools [11,17,18,19]; however, orthotic devices remain underexplored. There is a lack of studies on the problem of engineering the transitions of orthopedic enterprises, including their business models, products, and services. The research question is “How can an incumbent orthopedic enterprise overcome the wicked problem of strategic redesign of an unsustainable plastic product?” The objective of the study was to investigate feasible pathways for navigating the wicked problems that an orthopedic enterprise faces when dealing with the redesign of unsustainable products.

1.3. Approach

This study used transition engineering methods to explore insightful new options for reducing the enterprise’s unsustainable footprint while remaining a viable business. Current engineering approaches to the healthcare system transition are focused on technology development using circular economy design principles [20]. However, if the problems are wicked, then transdisciplinary engineering is required to deploy integrative approaches that address the root causes of wicked problems [16,21]. Transition engineering is an emerging approach for tackling wicked problems and for designing, developing, and delivering real-world steps aimed at downshifting systemic unsustainability [22,23]. Transition engineering encompasses the workflow, process, and methods for conceptualizing and delivering participatory transformative impact. Participatory transformative impact is enabled by a co-design approach that actively focusses on systems redesign for downshifting unsustainable resource, fossil fuel, and energy use, while uplifting economic and social values. The workflow for transition engineering is based on the general transdisciplinary research process of problem framing, co-design, and real-world application of knowledge [24]. The outcomes of the transition engineering approach are shift projects for realizing a stepwise shift from the current unsafe and unsustainable trajectory.

1.4. Contribution

We report on a co-design process carried out with experts of a medium-sized orthopedic healthcare company using the transition engineering interdisciplinary transition invention, management, and engineering (InTIME) design approach [23,25]. The application of InTIME design is informative for product designers. In particular, the application contributes to whole-system sustainability for orthopedic healthcare systems from micro (company-level, patients) and macro perspectives (industry, markets, doctors, economics). A new frame of reference on the wicked problem of plastics in sustainable orthopedic healthcare was co-created with company experts through a wicked problem investigation. The main contribution is a viable transition pathway for the orthopedic company which is co-designed and validated by the company. Company feedback was elicited to evaluate the transition pathway and barriers to the transition of sustainable orthopedic healthcare enterprises.

The article starts with a review of background literature on healthcare system transitions, focusing on orthopedic enterprise transitions. Barriers and proposed transition pathways are examined, and the research gap is developed from the reviewed literature. Then, the transition engineering InTIME design sprint method is explained, the co-design stakeholders are characterized, and the methods for data collection are specified. The results contain the record of the co-design process, the co-developed transition concepts, and the concept evaluation with company experts. The discussion puts the results and the developed concepts into perspective within the existing work in the field of sustainable healthcare systems and orthopedics.

2. Background Literature

The literature review was carried out through a Scopus search using the search strings (“sustainability”, “healthcare”, “transition”), (“orthopeadic” OR “orthopedic” AND “sustainability”), and (“orthosis” OR “orthoses” AND “sustainability” OR “sustainable”).

2.1. General Sustainable Healthcare with Special Focus on Orthosis

Sustainable healthcare encompasses the sustainability of human and environmental health [26], involving management, stakeholder behaviors, and technologies of the healthcare sector [27,28]. The following barriers to the transition toward sustainable material use in healthcare have been identified by [29,30,31,32,33,34,35]:

• Social and cultural barriers, such as consumer expectations of new and unused products, the wasteful habitual behavior of staff, and the lack of perceived trust in sustainable medical equipment design;
• Engineering system barriers due to a lack of waste collection, sorting, and recycling facilities;
• Governance and organizational barriers caused by conflicting management aims and a lack of standardized directives;
• Policy and regulation barriers based on a lack of enforcement policies and legal support for sustainable and circular practices;
• Supply chain and industry barriers caused by incumbency in training and business models and a lack of demand and supply for eco-friendly alternatives;
• Economic barriers due to the high costs of new infrastructure, technology, and training;
• Hygiene barriers, with the sterilization requirement of some products precluding their reuse;
• Procedural barriers, with current siloed approaches being unlikely to successfully resolve systemic wicked problems;
• Safety barriers, as improper handling of recycled or refurbished products can impact human health, with manufacturers consequently often favoring single-use equipment for its economic advantages.

Work on overcoming these barriers highlights the requirement for co-creation to give system stakeholders the opportunity to draw on their experiences in a purposeful co-design approach [36,37]. Approaches for incorporating sustainability aspects in the early phase of the design stage use design support tools such as the six design principles proposed by Adler et al., which include continuous improvement, proactive service, efficiency, empowering costumers, costumer experience, and cost savings for sustainable features [38].

Remanufacturing has been identified as a method for ensuring circularity. A recent study uncovered that even in the worst case scenario, the climate change impact of a remanufactured catheter decreased about one third compared to a standard catheter [39]. Post-market approaches aim to increase the lifetime of legacy products [40,41]. An example is the lifetime extension of sensors, whose life span could be increased through design thinking approaches [42]. General guiding principles for circularity have been established in the ISO 59004 Standard [43].

2.2. Sustainable Orthopedics with a Focus on Orthoses

Progress in the field of sustainable orthopedics has been made related to improved waste management [19]. Calls for reducing, recycling, or reusing the equipment used during orthopedic surgery have been made [11,18,44], but implementation remains challenging due to the identified barriers to sustainable healthcare. Efforts were made to use biomaterials for orthopedic implants [45]. However, little attention has been put on the sustainability of orthoses products. Three-dimensional-printed ankle foot orthoses could increase material efficiency, but energy consumption and costs remain too high for providing competitiveness [46]. A recent study highlighted the potential for the reusability of 3D-printed orthopedic casts, indicating an opportunity for moving away from single-use orthopedic products [47].

Three research gaps emerge from the literature review. (1) Research related to sustainable healthcare revolves around making a specific product more sustainable using methods such as life-cycle-assessment (LCA) or design thinking, (2) sustainable orthotic products are an underexplored field of research, and (3) existing research does not focus on the company-level challenges of the transition of orthopedic enterprises. In order to respond to these three research gaps, this study sought to take at a whole-system, place-based, and participatory approach for the transition of an orthopedic company while focusing on the improvements of specific products.

3. Method

This section explains the research method. The transition engineering approach is outlined, the co-designers are characterized, and the methods for data collection are explained.

3.1. Aim and Research Design

The transition engineering approach has four distinct stages (discovery, invention, demonstration, and development) carried out in an agile workflow (see Figure 1). The discovery stage builds the cohort of co-designers, identifies pressures for change, and explores a wicked problem of relevance for the cohort. The discovery stage investigates what core issues lie at the heart of the wicked problem to provide a frame of reference for the co-design. The invention stage takes on the wicked problem into the 7-step InTIME Co-design sprint. The co-design is carried out with design experts in a charrette-like sprint. At the end of the sprint, a shift project concept is developed and presented to the wider cohort for deliberation and decision making regarding a go/no-go into development and demonstration. The demonstration and development stages provide the engineering of the shift project concepts, engaging in prototyping, scaling, and acceleration and involving product design and regulation sandboxes.

Details about the procedures, tools, and workflow of transition engineering have been published before. The transition engineering framework, background, and fundamentals are laid out in a textbook [23]. The InTIME design approach and the wicked problem investigation have been reviewed and explained in detail in [25,48]. The overall workflow of applying transition engineering methods in real-world settings has been explained in [22,49,50] with case studies in the fields of transport behavior, business model innovation, and residential energy. The transition engineering research methodology is based in action design research [51].

3.2. Co-Designers

An InTIME design sprint was carried out with three key experts from an orthopedics company over a three-month timeframe, encompassing the discovery stage and InTIME design. The company is a medium-sized enterprise with approximately 50 employees spread over multiple retail and production sites in a region of Germany. The company experts were from management, engineering, and research and development. The research was carried out in co-design studios (see Figure 1).

3.3. Data Collection

This study embraced a qualitative action research approach. The presented results encompass the desk-based literature research, the results of the co-design process, and insights from a semi-structured interview in Co-Design Studio 5. The researchers and authors of this paper had both the roles of facilitator and participant in the co-design studios. The company co-designers gave their consent to take part in the study and for their data to be published anonymously. Ethics approval was granted for this research. The ethics approval document and the notes taken and canvases produced during the co-design studios and can be reviewed upon request.

4. Results

The results section presents the co-design results of applying the transition engineering approach with a local orthopedic company. The work consisted of the preliminary discovery stage and an InTIME design sprint in the invention stage. The outcomes of the transition engineering project are reported, and the shift project concepts are explained in detail. The results section is structured according to the transition engineering workflow (see Figure 1). The results of Co-Design Studio 1 explain how the orthopedics company (henceforth referred to as “the company”) perceives their sustainability pressures. Co-Design Studio 2 reports on the outcomes of the investigation of the company’s wicked problem. The insights of Co-Design Studios 1 and 2 are that current pathways for sustainable orthopedic products do not align with the operations of a real business and that the core issue of the wicked problem is a lack of understanding regarding the value of plastic in society. Co-Design Studios 3 and 4 report on the outcomes of applying InTIME design with the company stakeholders, with a detailed description of the co-developed shift project concepts. Lasty, Co-Design Studio 5 presents stakeholder reflections of the usability and usefulness of the co-developed shift projects.

4.1. Co-Design Studio 1: Transition Clinic

The company is a medium-sized enterprise with several stores in the region and connected to upstream and downstream supply chain and waste management systems. All logistics are subject to regulations, existing infrastructure, and use of fossil fuels. The company specializes in custom-made orthoses for children. The products are made from plastic and are single-use items as it is the standard in the industry. Used products are discarded in the black bin (residual waste) after a use phase of approximately six months. The cost of the products are covered by the German health insurance providers with little to no extra cost to the customers. The company experts reported their sustainability problem to be the amount of plastic waste that currently is discarded. The plastic waste is technically recyclable, but the volumes are too small to either establish an on-site recycling facility or to sell it to recyclers. Potential recycling facilities claimed that the coloring of the orthoses are a further problem for economic recycling. The plastic suppliers had been contacted, but there was little interest in taking back the used products for reuse or recycling. Another local company takes on some of the plastic waste for injection molding processes; however, this option still wastes the orthoses and the embodied plastic eventually.

The company has a commitment to remaining innovative and sustainable in the future. The company’s motivation to be more sustainable comes from environmental consciousness and corporate responsibility, as well as the pressures from politics and society. The company has the commercial interest and social responsibility to remain a viable business. The activities aimed toward greater sustainability were production process optimization and market research on new and more sustainable plastic materials. Potential improvements such as 3D printing have been discussed in the past. However, investing into new machines was not seen as a viable option because health insurance providers are unlikely to pay for the added costs. Some of the used products are shipped to developing countries as part of humanitarian programs, but it was reported that the products cannot be optimally reused without refurbishment and rigorous testing. An opportunity was seen by the company in combining local, low-volume waste streams from other companies into a “recycling cluster” to allow for economic recycling volumes.

The clinic meeting in the first design studio demonstrated that the company is eager to improve their environmental footprint. While circular economy options had been discussed in the past, no solution fit the company’s needs within their economic margins. The outcome of the clinic meeting was an agreement that a new approach to the company’s sustainable transition is required, and a commitment was made to further engage in the transition engineering approach.

4.2. Co-Design Studio 2: Wicked Problem Investigation

A wicked problem investigation was carried out in Co-Design Studio 2 (see Figure 2). The essential activity was identified to be helping children participate in everyday activities, which was being realized through the provision of medical orthopedic products. This system was successful due to plastic being cheap, available, and durable. The business is approved by health insurance providers, up to standard and regulations, and profitable. The provision of orthopedic products is fair because everyone has access to the products. However, the company’s operations are not sustainable because of the use of fossil fuels in the petrochemicals to supply the plastic for the orthopedic products. Nonetheless, the company satisfies needs by employing workers and giving children a state-of-the-art medical service.

Yet, some harms are caused by the downstream plastic and microplastic pollution as a result of the discarding of plastic (landfill or thermal destruction). There is some dust pollution and resin fumes during the production process, but workers are equipped with up-to-standard health and safety equipment. Some psychological harms were reported from children who were bullied for wearing visible orthopedic products, but the company works against this through children-friendly designs using colors and animal stickers. Green solution propositions exist related to circular economy (renewable materials, biodegradable materials, recycling), additive manufacturing, process optimization, and product optimization. However, green solutions are unlikely to resolve the company’s sustainability targets at the moment because new green solutions involve new and expensive technologies, health insurance providers are understood to be unlikely to pay for additional costs without immediately added value, approval processes and standards prohibit rapid adoption of new processes, and there is a lack of viable alternative plastic materials on the market.

The wicked problem investigation revealed a novel insight into the wicked problem of sustainable orthopedics. On the one hand, there is a society that takes care of its vulnerable members through the embodiment of a health-insurance-funded orthopedic company using the best materials known for the task. On the other hand, plastic is recognized as unsustainable, creates unacceptable harms, and is unlikely to be available at similar quantities in the future. On the micro level, the company appears to be under the same pressure to find circular and green solutions as, for example, that faced by drink bottle manufacturers, fast fashion outlets, or the consumer product packaging industry—perhaps even more so, because the company cannot pass the problem on to the end user in the form of sorting and recycling. On the macro level, it was found that the core issue involves a missing understanding of the value of plastic, and the insight was that not all plastic waste molecules are created equally. The core insight of the wicked problem investigation was a shift of perspectives around the real value of plastic in society.

4.3. Co-Design Studio 3: InTIME Design Management Phase

• Step 1: History

The core issue of the wicked problem was found to revolve around the value understanding of plastic and the provision of orthopedic healthcare. Historical research showed that one of the first orthopedic clinics was established in 1780, and doctors would receive training in orthopedic treatments. The discipline of orthopedics was the result of the enlightenment process that “discovered” that people with orthopedic conditions have the same intelligence as that of other people and that an upright posture would allow for an upright life. The introduction of orthopedic treatments allowed patients to engage in everyday activities [52]. However, even in the 19th century, people with orthopedic needs were still considered to be “cripples”. The church and the German health insurance at the time were seeking donations for their “cripple homes” (see the Prussian Cripple Care Act and the 1901-founded German Association for Cripple Care) [52]. It is apparent that some level of societal caring for people with orthopedic needs has historically been present, but people were mostly placed in “care” homes with minimal treatment.

In the early 20th century, orthopedic products were made from easily reusable and reshapable materials such as wood, leather, and metal. According to the experts, these products were heavier but also more skin friendly. The first synthesized duroplastics went into mass production with a rapid uptake of plastic consumption after World War 2. Orthoses products began to be made from plastic only in the 1980s. The development of universal healthcare in Germany after World War 2 enabled fairer access to medical services and products.

• Step 2: Today

The company produces approximately 500 products each year, using 180 plastic sheets and generating 2.6 t of plastic, plaster, and fabric waste. The company has fixed contracts with health insurance providers to guarantee how much money will be reimbursed per product by the insurance. The company’s product process uses energy (electricity) and resources (plastic, plaster, basalt, carbon) in the production process of new products. The company has a management team and employs trainees, engineers, and retailers. The products are supposed to be handed back by the customers to the company, where they are collected and discarded at certain points throughout the year. The plastic sheets are supplied on demand through online or phone orders. The delivery of these sheets is undertaken by a third-party delivery company. The waste management is done by the municipal waste disposal company.

The process of producing an orthopedic product starts with a medical prescription provided by a doctor. The customers then come into the store, and an initial screening report is forwarded to the health insurance. If the proposed treatment is accepted, then plaster is used to take the shape of the affected body part. The plaster model is used as a negative for the final plastic product. Multiple iterations of fitting the product to the customers are possible. After the product has been handed to the customer, the final receipt is sent to the health insurance.

4.4. Co-Design Studio 4: InTIME Design Invention and Engineering Stages

• Step 3: Future Scenarios

Expected future scenarios for increasing the sustainability of plastic were identified from research, industry, and company perspectives. The scenarios were then analyzed with the company experts to understand how effective any existing solution would be in addressing the company’s wicked problem and what the risks would be in implementing the potential solutions. The most common propositions for managing plastic waste are recycling, thermal destruction, and deposition [53]. More systemic propositions such as avoiding and reducing plastic waste in the first place and closing materials loops in general are recognized by the German polymer industry (see Table 1).

In the co-design studio, three main scenarios were identified:

• Using alternative plastics as feedstock (biodegradable, recyclable etc.);
• Optimizing the material and energy consumption in the production process (i.e., additive manufacturing, renewable energies);
• Using circular economy strategies such as design for X (i.e., X = reuse, repurpose, avoid).

Alternative materials could replace the petrochemical plastic currently used for the products. Common propositions in the orthopedic sector are either using biodegradable plastics to eliminate the end-of-life problem of plastic or using bio-based plastic to reduce fossil-fuel consumption. Process optimization involves trying to reduce the material and energy consumption while retaining the same output. The central proposition of the circular economy in the orthopedic sector revolves around the recycling of used products. Sustainable design strategies aim at avoiding or reducing the overall amount of waste coming out of any industrial or consumptive process through reuse, repurposing, or sufficient consumption systems. A PEST (political, economic, social, technological) risk analysis was carried out in the co-design studio meeting for evaluating the viability of business-as-usual solutions for healthcare plastic. The company experts found that while some of the existing solution propositions for plastic in the orthopedic sector sound promising, no single solution would help them overcome their immediate wicked problem for resolving the dissonances between sustainability and business viability. The propositions showed regulatory, economic, social, and technological risks.

• Step 4: New Century

None of the proposed solutions discussed in Step 3 are technologically impossible. However, none of the proposed solutions is viable for the company for reasons already mentioned. If current solutions are unlikely to solve the wicked problem, then inventions are required. In InTIME design, the invention phase starts off with a creative path-breaking leap into the 100-year future. The forward operating environment trajectory of the company was agreed on to be an at least 80% reduction of energy and material consumption (in accordance with climate science resource consumption corridors [54,55] and with upholding the essential activity of providing medical services and products to society). The general observations of the future vision exercise was that in 100 years, the company would still exist to supply essential medical products to people in need. While the influence of new manufacturing capacities or AI on the medical sector are unclear and unpredictable, it is likely there will still be the need for an enterprise to manufacture and supply medical products in one way or another. Another macro-level observation was that children would still be able to engage in everyday activities, no matter the disability, requiring some level of medical support. Single-use plastics were projected to be non-existent in a 100-year future vision, and the essentiality of some plastics would be understood by industry, manufacturers, and end users. System-level concepts of reuse, repair, sufficiency and frugality are normal in product design, values and culture. The future vision is a highly subjective exercise and does not claim to predict or forecast likely future scenarios. It is possible that revolutionary therapy methods could make the orthopedic craft redundant. However, solutionist and techno-centralistic visions are set-aside for not having to rely on miracle technologies to achieve urgently required transitions.

The general observations of the creative future vision was followed by a sandboxing exercise. A sandbox is used to build-up, discuss, and refine emerging system-level concepts coming from the future vision. Sandboxes are a testbed for new system concepts to better understand the requirements for future regulation [56]. Sandboxes have boundaries to make sure that the investigated concepts do not oppose required values and scientific requirements. In the co-design studio, the boundaries of the sandbox to construct more tangible future system concepts were agreed on to be economic viability (orthopedic enterprises provide real value to society and are viable businesses), social values (essential needs need to be taken care of; fairness and equity should be maintained on a societal level), regulatory safeguards (safe business practices for end users and employees, standardization and approval processes), and biophysical sustainability (energy and resource sustainability, petroleum constraints). The concepts that came up during the sandbox activity revolved around the following:

• Connected data and physical infrastructure systems for managing and allocating resource flows between system actors in a circular economy;
• Product design for low energy and resource consumption, through use of principles of reusability, repairability, sufficiency, and frugality;
• An economic system, including markets, that can operate with energy and material limits and use plastic opportunistically for essential applications;
• A societal paradigm that can understand the essentiality of plastic with a non-acceptability of single-use plastic;
• New business models that operate within the biophysical limits of a renewable energy system with a fraction of today’s virgin material extraction. Propositions were “DIY construction stores” for reusing and repurposing used goods and production machinery, along with a deposit system where orthopedic companies could take back used products for reuse, refurbishment, or repurposing.

• Step 5: Backcasting and Trigger

The backcasting looked at how the future system, outlined in the new century step, could work and what is fundamentally different between this future system and today. Backcasting is an established practice for determining missing steps between now and an envisioned future [57]. Figure 3 shows a system dynamic vision of how the future system could operate. The system dynamic vision is based in the system dynamic feedback control model, which applies basic principles of feedback control theory to the operation of sustainable societies [23]. The directive of the system is seen as the outset of people wanting to survive in a thriving environment, which entails that essential needs must be satisfied. Essential needs refer to elements such as subsistence, protection, or affection [58]. The reference signal is compared to the feedback signal that determines if everyone’s medical needs are met within planetary boundaries. If the feedback matches the reference signal, then no corrective action is required. However, if for example, medical services are required, then people will ask for medical help. Decisions are made in the context of economic activity, which is necessary for the allocation of individual decisions with the physical means of production. In the case of the orthopedic enterprise, the activity in the physical system entails the cooperation of industry, suppliers, and orthopedic businesses for providing the materials and manufacturing of the required product. The product can then be used by the person requiring medical services, and if the product meets the medical needs, safe system operation is achieved. If the economic activity system is regulated such that exponential overshoot and growth is not possible and if the physical system is designed and built to produce what is required for satisfying essential needs, then safe system operation is achievable.

The backcasting then looked at what this society in the 100-year future has that society currently does not have to determine the scope of transformative intervention today. It was found that on a societal level, the knowledge and enterprise for taking care of essential medical needs without single-use plastic is what a future society may have that the present one may not. This involves an understanding of what plastics should be made and what plastic should not be made within a profitable supply chain, supplying materials for essential needs, and operating at less than 80% of today’s fossil fuel levels. At the heart of this path-break future lies a shared understanding of the essentiality of plastics between industry, suppliers, manufacturers. and the wider society.

Given the current trajectory of plastic production, end of life. and realistic solutions for the company, it was agreed that the current system cannot operate like the envisioned system in the path-break future. As long as the economic activity system and the built environment are not operatable within planetary boundaries, consumer behavior and individual decisions will not be able to achieve sustainable system operation. Transition engineering is required for changing the built environment, business models, supply chain infrastructure, regulation, and policy as a systemic shift project.

Transition triggers are planned or unplanned events that could shift the current system trajectory toward the envisioned path-break future. Exogenous transition triggers were identified to be energy price shocks and global plastic supply chain disruptions, while endogenous triggers were identified to be a deliberate engineering and business model pivots for future-proofing the business within a constrained and unpredictable transition landscape.

• Step 6: Shift Project Concepts

The steps into the future and the backcasting highlighted two main areas to focus transition efforts on. Two shift project concepts were co-designed and evaluated with the company experts as part of transition planning toward rebuilding the orthopedic sector in a future essential economy. The first concept was the plastics value map, which could determine which plastics should be produced. The second concept was an orthopedics library, which would allow for the systematic reuse of fit-for-purpose used products and inform the refurbishment of used products.

(1)

Plastics Value Map

Plastic has outstanding material properties that are useful for packaging, safety, and hygiene. Plastic is lightweight, durable, reusable, and technically recyclable. Therefore, the problem is not plastic but its overconsumption. State-of-the-art design and material research has established the need for lifecycle thinking and technological possibilities for end-of-life treatments, such as the application of plastic waste in road pavement [59]. What is missing is an understanding of what is worth producing in the future to engineer, design, and manage the transition to a future essential economy and the transition plans for industry, suppliers, and manufacturers. The plastics value map converges what a society views as essential with the usefulness of plastics under the limitations of a biophysically constrained future economy.

The plastics value map can be understood as a tool for market regulation (see Figure 4). The current market involving plastic products has a price signal to indicate the utility of a product as the result of supply and demand dynamics. The market is already subject to a range of regulations, including those pertaining to material and health safety, and anti-cartel and monopoly laws. Critique of the liberalized market economy system revolves around the disproven view of the human behavior in the economy and the role of supply and demand in the overshoot of earth system resource consumption [60,61].

The plastic value map does not replace market interactions but acts as a tool for industry, suppliers, manufacturers, legislators, and regulators to inform what products should be produced as a priority within planetary boundaries. The plastic value map locates different products, such as orthopedic products, in the map and compares the essentiality of the products with their footprints and required material properties against the biophysical constraints of an economy within planetary boundaries.

The plastic value map can be a tool for informing a biophysical “demand on supply” system. The underlying principles are as follows:

• The availability of recycled plastics based the energy consumption of recycling processes and the available surplus energy from a renewable-energy-based system with drastically downshifted fossil fuel in compliance with climate failure limits;
• The availability of virgin plastic material based on downshifted petrochemical feedstocks;
• The availability of used plastics for reuse, refurbishment, and repurposing.

The knowledge of the biophysically sensible availability of raw, recycled, and used plastics can then inform the constraints that a market for plastic has to incorporate. An understanding of the essentiality of plastic products supports the decision making of the involved industry, suppliers, and manufacturers regarding which product is worth producing and marketing. For example, in a resource-constrained future, the real value of plastic bottles for soda drinks will differ from that of plastic feedstocks for essential medical services. A tool such as the plastic value map could inform decision making where a continued use of plastics is biophysically sensible and justified by the satisfaction of essential needs and derived from the essential activities identified in the previous wicked problem investigation and where the use of plastic is not justified.

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Orthopedics Library

The orthopedics library is a proposed data system at the intersection of digital and built infrastructure. The orthopedics library can be understood as a supply chain tool for orthopedic businesses to operationalize the high-level calls for circular economy measures. The orthopedics library contains anonymous information about all orthopedic products produced in an orthopedic company and can help find matching end users with similar needs. The underlying premise is that orthopedic artifacts are made from durable plastics and are expected to last longer than the current single-use timeframe. The overall concept is to reuse products where appropriate or refurbish where required to reduce the overall amount of waste in a frugal way.

The orthopedics library contains information about existing products, customers, and prices for trading products between orthopedic businesses. The shipping process ideally utilizes rail freight mechanisms and low-emission vehicles for the last mile delivery. The system matches existing products with customers based on a database including product geometry and customer body dimensions.

An exemplary process enabled by the orthopedics library is as follows. First, a patient registers with an orthopedic company. The patient’s needs are recorded, and measurements of the affected body part are taken. The patient’s data are put into the orthopedics library software to investigate if a suitable product exists in house or in another outlet. The data about the product also contain information about the potentially required redesign. Information about the product’s physical state determines the potentially required refurbishments. An order can then be placed if a matched product is located in a different company.

The orthopedics library also informs novel adaptive product design. The information about how body dimensions change over time and product durability data determine how future orthopedic products will need to be designed for allowing maximum adaptability when patients grow. This can lead to higher rates of reusability and longer product lifetimes. Future products are then made adjustable and reusable according to changing body dimensions. A graphical schematic of the back end and front end of the orthopedics library is shown in Figure 5.

4.5. Co-Design Studio 5: Transition Foresight and Stakeholder Jury

The embodiment of the plastic value map could demonstrates how an orthopedic company provides essential products and services at a comparably low environmental and energy footprint. An orthopedic company would therefore be prioritized to continue using plastic in a future when access to fossil fuels and petrochemicals declines in line with climate science. It was discussed with the experts if and how the plastic value map would help in relieving the company’s sustainability pressures. The company experts reported concerns that using the plastic value map as a justification to continue their business as usual might be viewed as greenwashing. However, the experts emphasized that the plastic value map could lead to raising awareness of the essentiality of plastic and that not all plastic waste is generated equally in quantity and quality. The experts agreed that it will be worthwhile to pursue the development of the plastic value map as a tool for industry, suppliers, manufacturers, and end users but that the plastic value map alone would not achieve a transition of the orthopedics industry to the sustainable supply of essential orthopedic products by itself. In order to address the issue of greenwashing, the plastic value map could be aligned with EU’s “Unfair Commercial Practices Directive” and the “Consumer Rights Directive”. This would require all companies to adhere to the EU guidelines for corporate sustainability reporting.

The orthopedics library was found to strongly address the company’s sustainability aspirations. The company experts found that most of the current orthoses’ designs are not ready for reuse or adaptation and highlighted the requirement to engage in research to realize adaptive product design. Experts discussed that an essential field of research for demonstrating the orthopedics library is to identify which parts of orthopedic products will need to be adaptively designed to allow both growing patients to continue using the product or to adapt the product to new patients. A research gap was identified to build up the data infrastructure as a foundation for the adaptive product design. The required data are as follows: the most common orthopedic needs, special needs, the material quality of used products to identify the general suitability to reuse products and to estimate required structural improvements due to wear and tear, and the observation of typical growth and change of body dimensions of patients over time to identify common ranges in which orthopedic products will need to be adaptable. For example, experts highlighted that some products are completely worn down after 6 months, whereas other products are as good as new after being used by one patient. A proposed data exchange campaign could involve using 3D scans each time a patient visits the store.

A major challenge for the orthopedics library was identified to be regulatory processes and certifications. The current regulations and certifications of medical products would put a hard stop to the orthopedics library due to hard restrictions on what counts as safe and hygienic products. Also, the current accounting process between companies and health insurers is a barrier since health insurers would only pay the company after receiving proof that a new product has been made. The required research would therefore involve a regulation sandbox with orthopedists, legislators, and health insurers to review the current certification and accounting processes and to investigate how current processes would need to be adapted. Further research should also be allocated to investigate the relationship between storage and long-term durability of plastics to ensure the safety of the patients with products that might have been stored for a longer period. The trading mechanisms for trading used or refurbished products between companies who are part of the orthopedics library also require further investigations, specifically related to the logistics of transporting the products and how prices for used or refurbished products are designed.

In general, the experts viewed the two shift project concepts as novel and formerly unseen in the industry. Reuse and repurposing as part of a transition plan are currently on the agenda but have not been applied in industry practice. The experts hypothesized that this is because the industry views custom-made design as the state of the art. A potential barrier to the research and implementation of the orthopedics library including adaptive design could therefore be the current incumbency of the individualization of products. Future research focusing on the embodiment and prototyping of the plastics value map and the orthopedics library should include comparative life-cycle assessments of current product systems versus new product systems to ensure improved product sustainability. Measures of merit should be primary energy use, raw material consumption, and greenhouse gas emissions.

The experts found the transition engineering approach helpful in developing a systematic understanding of the wicked problem and in designing concepts beyond business-as-usual green engineering:

• Research student: “I enjoyed the vision into the future, because I believe that society thinks that sustainability is essential, but sustainability is not a concrete goal. The future vision enabled us to understand what sustainability would actually mean. The back casting then allowed us to think about ‘how can we reach this future?’. This is also why the process broadened our perspectives beyond engineering and technology solutions by also thinking about social and societal aspects”.
• R&D engineer: “I found the way of getting to the shift project concepts really interesting. We came across points that we were not thinking about before. Especially the history and future steps made me aware of what we want to reach in the future but also how things worked in the past. I liked the general approach to the process. During our workshops we came across problems and solutions that were not looked at before. I also liked the step-by-step way of approaching the problem”.

5. Discussion

The findings align with the goals set for sustainable healthcare by the literature. Whole-system approaches to circular economy, sustainable procurement. and R-strategies (reduce, reuse, recycle, etc.) were identified as subject to high-level policy and government action [10,62]. In addition to highlighting the importance of policy for initiating transformative change, the results of this study present a complementary proactive transition engineering perspective of a ground-level enterprise in the healthcare sector. Our results aimed to open the possibility space for an orthopedics company to become active in a sustainable transition. The company experts highlighted the role of governance and regulators in enabling the co-designed transition plans and reducing barriers to implementation. Similarly, Andersen et al. pointed out that one underlying problem of healthcare unsustainability is centered on the predominant single-use paradigm and how circular economy strategies are not just a matter of engineering but also of regulation, safety, and liability [39].

The co-designed shift project concepts follow best principles of design for sustainable and circular healthcare [32]:

• Maintain (or improve) quality, function and usability of the original device when introducing circular strategies—the needs-based approach of the system transitioneering process enabled the co-design to maintain the quality, function, and usability of the essential activity;
• Combine different circular strategies as much as possible—the co-designed shift projects demonstrated principles of the reuse, refurbishment, and reduction of single-use products;
• When integrating circular strategies, make sure to mitigate safety risks for intended use of the device/material/system—in Co-Design Studio 5, the co-designers identified potential risks arising from the shift projects;
• Increase device value and lifetime where possible—the orthopedics library was developed to increase the value and lifetime of the orthoses by enabling reuse and repurpose.

Ward et al. claim that the systemic change in the healthcare sector should be focused on the culture change, system change, action. and sense-making of the change process [63]. The feedback of the co-designers provided the evidence for potential culture change through the plastic value map (for shifting attention away from the current single-use paradigm), system change through both shift projects (for addressing whole-system aspects of markets, regulation, supply chain, logistics and product engineering), action (co-designed shift project concepts were perceived as actionable). and sense-making (in that the co-designers identified the required next steps for realizing the shift project concepts).

The findings highlight the importance of working across silos and disciplines between industry, providers, and patients in co-production processes for sustainable healthcare [34]. Pareno and Eriksson used a visioning approach with healthcare system stakeholders for envisioning a sustainable healthcare future. Our approach used a bounded future vision focused specifically on a place and activity. We argue that a bounded future vision approach can be of valuable if the subject of the transition is a company; otherwise. the vision risks becoming too broad for informing tangible ground-level change. Pareno and Eriksson applied the three horizons framework to sustainable healthcare and found that “green [business-as-usual] healthcare” is currently implemented but is not sufficient for a deep transition [34]. Disruptive and transformative healthcare innovation needs to focus on new supply chain models and circular resource models, which support the outcomes of this study.

A limitation of this study is the composition of the expert co-design group. The study included company employees from engineering, development, and management within the company but did not include end users (see [37]) or other system stakeholders such as health insurance providers or regulators. While company stakeholders identified the potential for transformative impact and usefulness of the co-developed shift project concepts, this study did not engage with wider healthcare system stakeholders (i.e., end users, insurance providers, policy makers, regulators. or other orthopedic companies) to provide further evidence for the impact of the concepts. As the outcome of this study was a conceptual co-design, we propose to include more diverse stakeholders in the prototyping and testing phase. A limitation to the efficacy of the co-developed shift project concepts lies in the challenge for a single company being able to change the market or the value proposition of plastic for orthopedic uses. It is unlikely for one company to change the value of plastic or the best practices in the whole orthopedic enterprise, but a combined shift in policy, business models, product design. and supply chain design could achieve the transition.

6. Conclusions

The wicked problem of essential plastic in orthopedic healthcare was addressed using the transition engineering approach with co-design experts from an orthopedic healthcare company. This study added to the body of literature a formerly unseen whole-systems perspective of sustainable orthopedic healthcare products. The research carried out in this study responded to the real-world needs of a healthcare company under pressure for change and thus demonstrated real-world significance.

The first contribution was a systems perspective to the wicked problem of sustainable healthcare. The wicked problem investigation enabled the company to develop a systems perspective on the plastic waste problem. Before the wicked problem investigation, the experts reported that their biggest problem was not having the means to take part in the circular economy. Circular economy was perceived as being able to recycle the company’s plastic waste and take on recycled feedstock. During the wicked problem investigation, the experts went beyond aspects of recycling and circular economy and were able to understand the problem as the combined economic, technological, and behavioral issue around single-use plastic.

The second contribution was a perspective shift in the solution space. The concepts of reusing, refurbishing, and adaptive product design have been proposed for a long time. The co-developed shift project concepts converged these existing ideas into a new transdisciplinary perspective on what can be done next. The experts reported that the developed shift project concepts were formerly unseen in industry and would address the company’s sustainability efforts. The results indicate the usefulness and transformative impact of the transition engineering approach. A group of co-designers applied the process of wicked problem investigation and InTIME design for generating path-breaking concepts for downshifting unacceptable harms and unsustainability. However, the whole-system perspective also indicated that the regulations in the healthcare sector remain the biggest barrier to implementing the co-developed concepts. The experts reported that the transition engineering approach enabled them to think holistically about the problems and solutions, beyond business-as-usual engineering solutions.

The third contribution is the co-designed shift project concepts. Orthotic products have not been subject to sustainability transition research in whole-system contexts before. The transformative impact of the shift project concepts lies in the potential for value shifts in the whole-system understanding of plastic and for operationalizing the principles of a circular economy. Company experts reported the novelty of the shift project concepts and confirmed that the transition engineering approach and the co-developed shift project concepts would enable the company’s aspirations to become more sustainable.

Our recommendation for future research therefore is to focus on the prototyping of the concepts while engaging with industry, suppliers, health providers, and patients in regulation and policy sandboxes for overcoming the regulatory barriers.