Resource stewardship and the ethical duty to prevent waste

On 6th November, Radio 4 last broadcasted a discussion about whether doctors have an “ethical duty” to prevent waste. The debate was prompted by the launch of a new report commissioned by the Academy of Medical Royal Colleges and co-authored by Dr Daniel Maughan, the Royal College of Psychiatrists’ Sustainability Fellow 2013-15.

The report, “Protecting resources, promoting value: a doctor’s guide to cutting waste in clinical care” discusses inefficiencies in the use of clinical resources (such as over-medication, duplication of tests or avoidable admissions) and gives examples of how doctors can act systematically to reduce these, thereby improving value to patients. In a groundbreaking move, environmental costs (in CO2e) are included alongside financial costs throughout the document.

At first glance, you might think there is nothing new in suggesting that health professionals have a responsibility to make best use of resources. After all, every medical student learns about the four bioethical principles: Beneficence, Non-maleficence, Autonomy and Justice - being fair or just to the wider community.

But the truth is that the prevalent medical culture does not emphasise the role of clinicians in maximising value from resources. On the contrary, respect from patients, colleagues and society is often in proportion to how intensive and technologically advanced one’s practice is perceived to be. 

As the authors point out, there are many influences on doctors which can lead to an overuse of resources, such as “individual practices, defensive practices, time pressures, and responding to senior or patient pressures”. In order to balance these, there is need for a cultural shift which will “value the targeted use of clinical resources to provide greatest benefit to patients”. We might call this resource stewardship.

The report identifies clinical and leadership skills of a value-promoting doctor (listed below), calling upon LETBs and medical schools to support their development. Please share your ideas on how this can be done better on the SHE network.

Fundamental attributes of a value-promoting doctor (Box 1, p20)

• A skilled diagnostician: forms intelligent differential diagnoses and can discern which investigations are truly necessary to diagnose and treat the patient effectively.
• Patient-centred: skilled in eliciting patients’ needs and expectations, understands the family and social context, skilled in supporting patients to understand and co-manage their conditions.
• A good collaborator: has a good understanding of the care system within which they are working, enabling them to efficiently access the most appropriate care for their patients
• An agent of change: takes active part in shaping care systems to improve value
• A focus on health: recognises and has skills to act upon opportunities to promote healthy behaviours