Quantity and quality

American surgeon and health researcher Atul Gawande’s new book, Being Mortal: Medicine and What Matters in the End, is an extremely readable, radical and powerful critique of contemporary society’s approach to the inevitable questions of ageing and dying. He argues that much of conventional medicine’s approach to these stages of life runs counter to the expectations of patients and their families.

This is not intended to be a book review — Gawande’s work speaks for itself — but rather to raise in the New Zealand context the issue which he speaks about. Already our Health Quality and Safety Commission is starting to become much more involved in this space, and will be hosting Dr Gawande when he visits here in a couple of months.

There has been concern for some time that resources dedicated to a person in their last five years of life are substantial and go well beyond a level and type of care that they may actually want.

At the same time, there is increasing focus on the last six months of life and its management, although as an eminent French oncologist, with a typically Gallic shrug of the shoulders, said at a conference I was at in the United States recently, “How do you know when the last six months begin?” There are signs in New Zealand of health care providers starting to think more laterally about these matters, and to realise that the quality of intervention rather than the quantity is the true reflection of effective and responsive health care.

Only a couple of weeks ago I was pleased to be at Enliven’s Cashmere Home in my own electorate, when it became just the second elder home in New Zealand to achieve the 10 Eden Standards for elder care, a hallmark lauded by Gawande as marking the way of the future in residential elder care.

Gawande’s approach can be replicated across the entire health care system, from elder care through to terminal and other restrictive conditions. What he is focusing on is a patientcentred approach, understanding and meeting a patient’s needs and wishes, not forever trying to shape the patient’s requirements to fit the prevailing medical model.

There is a link here with the government’s better public services approach, where the focus is on delivering services in a more convenient and client-centred way.

So far the emphasis has been on the achievement of specified targets, and considerable progress has been made in that direction. There is no reason, however, why it cannot be extended to encompass what Gawande is advocating.

The significant common point is that the provision of quality public services is no longer about fitting everyone into a particular structure and then making that work as best it can, but much more about services that meet actual needs, expectations and convenience.

While Ministers, senior policy-makers and citizens are increasingly getting it, the real challenge will be ensuring those who actually provide the services get it too.

Gawande has released an exciting proposition — one in the end which will impact upon all our lives, and change them for the better.