1. Introduction
1.1 Like all community resources, healthcare resources must be managed appropriately
to ensure that all patients are able to receive the best quality care, now and into the
future.
1.2 As a profession, doctors are entrusted by the wider community to use healthcare
resources wisely and responsibly, thus playing an important role in contributing to and
promoting the sustainability of healthcare resources.
1.3 Doctors have an ethical and professional responsibility to serve as stewards of
healthcare resources. This involves caring for the resources available to improve health,
avoiding wasteful expenditure and enhancing the safety and quality of the care in order to
protect patients from harm while considering the resources that will be required to provide
care into the future.1

1.4 Stewardship requires doctors to balance their primary duty to protect and promote the
healthcare interests of the individual patient with their broader societal duty to use
healthcare resources responsibly and sustainably; however, doctors may face challenges
when trying to achieve this balance and undertake effective stewardship in their day-to-day
clinical activities. This position statement highlights many of these challenges, guides
doctors in how to manage these challenges in their clinical practice and identifies how the
wider medical profession, healthcare institutions, governments and the wider community
can support doctors in achieving effective stewardship of healthcare resources.
2. Ethics and stewardship of healthcare resources
2.1 Stewardship relates to the thoughtful and equitable use of resources, not the rationing
of healthcare. The aims are to achieve the best possible health outcomes while minimising
adverse impacts and wasteful expenditure, reducing the environmental impact of healthcare
and promoting sustainability and our ability to meet future health resource needs.
2.2 Stewardship must take into consideration fairness, equity, cultural safety and must not
add further to health inequalities.
2.3 There are many dimensions to effective stewardship of healthcare resources such as the
identification and avoidance of low-value care which encompass tests or treatments
recognised as providing little or no benefit to patients.
1 Effective stewardship also involves
the promotion of preventive strategies both for individual patients and for communitiesi
including those that address the social determinants of ill health
3. What are the challenges facing doctors in practicing effective stewardship of healthcare
resources?
3.1 Doctors face a range of challenges when practicing effective stewardship of healthcare
resources in their clinical practice such as:
• responding to patients’ expectations that they will receive some form of diagnosis
and/or treatment when seeing their doctoriii
• patients’ beliefs that more tests and treatments lead to better healthcareiv
• patients seeking inappropriate tests or treatments recommended by alternative health
practitioners
• patients seeking inappropriate tests or treatments arising from direct to patient
marketing
• feeling a need to practice ‘defensive medicine’ by ordering tests and treatments to
help protect from the perception of liability (this may be particularly relevant for
doctors who have already experienced a medico-legal matter)iii
• fearing missing a diagnosis resulting in the patient experiencing an adverse eventiii
• resisting change to one’s ‘usual’ practices
iii
• responding to “indication creep” (e.g. using new technologies for indications where
effectiveness has not yet been proven)iii,iv
• responding to limitations on consultation times (e.g. it may be quicker to recommend
an unnecessary treatment or procedure rather than taking the time required to
discuss why a treatment or procedure is not necessary)iii
• being unaware of the most cost-effective treatments (e.g. data is not always available to
provide guidance)
• having a lack of confidence or experience to make a judgement call
• a lack of institutional commitment to reducing the environmental impacts of
healthcare
• corporate and business pressures applied to practitioners in their decision-making
• a lack of effective clinical engagement strategies and fragmentation of care.
4. How should doctors practice effective stewardship of healthcare resources?
4.1 Reduce wasteful expenditure in day-to-day practice
4.1.1 While overall funding decisions involving healthcare expenditure are often undertaken
at a higher institutional, systems or government level, the individual doctor can play a pivotal
role in reducing wasteful expenditure through responsible stewardship within their day-today practice. By practicing effective stewardship, an individual doctor’s primary duty to care
for their patients should, in general, not conflict with their obligation to ensure healthcare
resources are available for the wider community.
2
4.2 Avoid recommending tests or treatments that offer little or no benefit
1 If patients are not appropriately informed of the risks and benefits of particular tests
and treatments, they may overestimate the benefits and underestimate the harms, leading
them to request services that are inappropriate or of little or no medical benefit.
4.3.2 Doctors have a duty to ensure that patients are making informed health-care decisions.
This involves discussing the treatment options that are available along with their associated
risks and benefits in a way that the patient can readily understand and apply to their
particular circumstances. Where relevant, this may also involve discussing why particular
interventions the patient has requested are inappropriate or of little or no medical benefit to
their personal health situation. Such discussions will not only support the patient to make
informed healthcare decisions but will reduce the chance for conflict between the patient
(or their family members) and the practitioner.
4.4 Develop and maintain knowledge and skills to practice effective stewardship of
healthcare resources
4.4.1 At present, there should be more guidance on stewardship of healthcare resources in the
curricula from medical schools, through vocational training and into professional practice.
4.4.2 Education on stewardship of healthcare resources should also be included in curricula for
doctors in positions of medical leadership as these doctors will be more involved in decisions at
a higher systems level.
4.4.3 Continuing education is necessary to ensure that patients receive the most appropriate,
best available, evidence-based and cost-effective care. It is important for doctors to be kept
informed about healthcare costs including how their clinical decisions affect resource
availability and overall healthcare expenditure. Clinicians have a right to expect such guidance
from professional bodies and this guidance should be contemporaneous and actionable.
4.4.4 While doctors have a responsibility to maintain currency in their clinical knowledge and
skills, institutions such as hospitals, colleges and other bodies have a parallel responsibility to
provide guidance and support in understanding the financial implications of clinical decisions.
4.4.5 There should be federal government funding for key programs that encourage research,
education and quality improvement in relation to stewardship of healthcare resources
4.4.6 Senior doctors should set an example for and support doctors-in-training to ensure they
are able to develop skills in stewardship of healthcare resources and navigate the health
system.
4.5 Participate in the development and revision of clinical practice guidelines
4.5.1 Clinical practice guidelines should be used to assist doctors in determining the most
appropriate tests, treatments and procedures for their individual patients based on the best
available evidence; however, in many clinical situations it is impossible to generalise and
doctors must have the freedom to apply their professional judgement to the individual
patient’s health situation.
4.5.2 Even where best practice guidance recommends against using particular tests,
treatments or procedures, doctors must be able to facilitate access for individual patientsfor
whom such tests, treatments or procedures are clinically warranted.
4.5.3 Clinical practice guidelines should always be developed and continually updated in
consultation with doctors. The institutions to which such guidelines apply also should
provide support for doctors who practice good stewardship and educate patients and theirfamilies about the importance of overall stewardship of resources.
4.6 Participate in the development of healthcare financing and funding initiatives
4.6.1 The AMA’s Code of Ethics 2016v
, as well as the Medical Board of Australia’s code of
conduct Good Medical Practicevi
, advises doctors to use their knowledge and skills to assist
those responsible for allocating healthcare resources to develop informed, reasonable
policies. This can be undertaken at the individual practice or institution (e.g. hospital) level
as well as the higher government or organisational level (e.g. health insurers).
4.6.2 Where decisions involving the allocation of healthcare resources are being made,
doctors have a responsibility to advocate for the best interests of patients, the
improvement of health outcomes and the sustainable use of resources at a community
level.
4.6.3 A role in clinical stewardship of healthcare financing is required to ensure the
perspective of doctors is put forward and taken into account in decisions about the
performance of current healthcare arrangements and services, proposed changes to existing
financing of healthcare services or implementation of new healthcare services or
arrangements. Without the clinical stewardship perspective, there is a significant risk that
decisions will be driven primarily by government, financing and political perspectives.
4.6.4 Major decisions affecting healthcare taken without clinical involvement may lead to
inappropriate resource allocation or incentives. Doctors can provide a practical and informed
perspective of clinical practice to healthcare financing and funding decisions. This includes
advising on the distinction between high-value care and low value care (including whether
interventions are evidence-based) and what such decisions will mean for clinical care in
practice.
Specific advice from a doctor may include:
• how a healthcare proposal will work, or not work, from a clinical perspective
• whether a proposal includes clinical practices that result in low value care
• the potential positive and negative impacts a proposal may have on clinical care,
including its ‘fit’ with clinical workflow and the practical operation of medical practice
• the impacts of the proposal on the wider health system, including unforeseen and
adverse impacts
• the sustainability of the proposal over time
• overall, to what extent does or will the proposal contribute to improved health
outcomes, and how will this be measured.
4.6.6 Doctors should advocate to protect their clinical independence and professional
autonomy when making individual healthcare decisions and when providing a clinical
stewardship perspective on healthcare financing and funding.
4.6.7 Doctors should advocate that the process for developing and revising healthcare
resourcing and expenditure policies should be transparent, accountable, consultative
(including with patients), include appropriate oversight and be consistent with good medical
practice.
4.6.8 Doctors should be involved in leadership and strategic organisational decision-making
bodies.
5. What can the wider medical profession do to support effective stewardship of
healthcare resources?
5.1 The medical profession can address its responsibilities to good stewardship of healthcare
resources by:
• maintaining patient-centred medical care
• encouraging cross collaboration amongst health professionals
• ensuring visibility of the issue
• supporting education of patients and the community
• encouraging research and improved understanding
• advocating to the institutions and governments that deal with and provide those
resources.
6. What can be done at a wider systems level to support effective stewardship of
healthcare resources?
6.1 Provide an environment that promotes responsible stewardship
6.1.1 The wider healthcare system must provide an environment that promotes responsible
stewardship and explicitly recognises the scientific-based holistic perspective and role of
doctors in stewardship of healthcare resources. 
2 Address medico-legal concerns to enable doctors to practice stewardship with
confidence
6.2.1 A doctor practicing in accordance with good medical practice should be able to practice
responsible stewardship of healthcare resources. Defensive medicine, where tests,
treatments and procedures are undertaken to help in the perception of protecting doctors
from medical liability, undermines effective stewardship and is potentially harmful to
patients.
6.2.2 Doctors have a responsibility to alert the facility where they work if they become
aware of issues related to stewardship which threaten the provision of quality patient care.
Facilities should have mechanisms in place that enable doctors to voice their concerns in a
timely, easily accessible and confidential manner without fear of reprisal.
6.2.3 In accordance with the AMA’s Code of Ethics,
v doctors should alert appropriate
authorities when the healthcare service or environment within which they work is
inadequate or poses a threat to health. The doctor who reasonably believes that significant
harm will occur to the public as a result of the delivery or non-delivery of healthcare would
be open to taking whistleblowing action. Contemporary protections for whistleblowers
should be supported by doctors.
6.2.4 Medical liability reform should promote professional judgment andaddress systemic
barriers that impede responsible stewardship.
6.3 Facilitate better collaboration and coordination between healthcare areas and
providers
6.3.1 A high priority for clinical engagement should be embedding systems that optimise the
integration, coordination and effective communication between different healthcare areas
and providers with the aim of reducing duplication of tests and treatments.
6.4 Increase investment in public health
6.4.1 Investment in public health is cost-effective, particularly through health promotion and
illness prevention interventions proven to reduce the burden on healthcare.
vii In addition,
good public health system measures increase the productivity within the community.
6.4.2 Maintaining a strong focus on preventive care, and addressing the social determinants
of health, are important for reducing the overall burden of disease andhence use of
resources for the detection and management of established disease.
6.4.3 In addition, by encouraging and facilitating healthy behaviour and choices, preventive
health campaigns and supporting policies can minimise the incidence and severity of infectious
and chronic diseases. Keeping populations healthy alleviates pressure on the acute care system,
by reducing the need for complex procedures, more intensive processes and longer hospital
stays.
Further, the effects of pandemics and other health crises, both on the government’s
capacity and willingness to fund healthcare and on individuals’ health and financial
circumstances, have made considerations of resource expenditure even more critical now.ix
Moving forward, the anticipated effects of climate change on community health add an
additional layer of urgency to addressing strains on healthcare resources and facilitating good
stewardship.
x
6.5 Support environmental sustainability in healthcare
6.5.1 The provision of healthcare has a substantial effect on the environment and these
environmental impacts often have adverse consequences for people remote from where
care is provided.xi Within the healthcare sector, environmental sustainability occurs when
resources are used as efficiently as possible, without compromising the quality of care for
patients.xii Improving environmental sustainability within the Australian healthcare sector
will bring benefits for human healthand additional efficiencies for the sector.
6.5.2 In addition, enhancing environmental sustainability through reducing carbon
emissions, curtailing waste, and managing resources efficiently will deliver better outcomes
for patients and provide broader social and economic benefits.
viii
6.6 Increase public education and awareness of stewardship of healthcare resources
6.6.1 Effective stewardship of healthcare resources requires community, government and
healthcare sector support.
6.6.2 Public awareness campaigns should focus on educating the community to better
understand the limitations and uncertainties associated with healthcare and the need to
ensure the sustainability of the healthcare system into the future.
6.6.3 Ensuring the community has more realistic expectations of the efficacy of particular
tests, treatments and procedures and a greater understanding of healthcare costs and
resource limitations will enhance community acceptance of and engagement with
stewardship initiatives.
6.6.4 This understanding should be complemented by publicly-funded work to improve
health literacy, both in terms of individual health needs and responsibilities and how
healthcare is organised and works at the system level.3
Improved health literacy through
government funded education programs will help patientsto make informed healthcare
decisions and support doctors as stewards of the health system.