Health care policy at a crossroads?: A discursive study of political discourse moments and patient roles in national health quality strategies between 1993 and 2015 (original) (raw)
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Nursing Inquiry, 2018
The Danish health care sector currently undergoes changes that imply a gradual transition from an evidence based activity model to a value based quality model centered on patient involvement and value-based governance. The patient naturally occupies a central position in health care, and the transition therefore raises important questions about health care quality and how successive national health quality strategies value quality and ascribe roles and agency to patients. To explore the complexity of these quality strategies, we analyze and discuss how political discourse moments influence the contents of the national health quality strategies and how variation in the construal of patient roles and agency indicate discursive struggle in Danish national health care policy. Underlying theoretical concepts are informed by New Public Management, the welfare state, health communication and discourse theory. Our analytical approach is inspired by Critical Discourse Analysis and combines content analysis with linguistic analysis.
Nursing Inquiry, 2016
The Swedish welfare debate increasingly focuses on market liberal notions and its healthcare perspective aims for more patient-centered care. This article examines the new Swedish Patient Act describing and analyzing how the patient is constructed in government documents. This study takes a Foucauldian discourse analysis approach following Willig's analysis guide. The act contains an entitlement discourse for patients and a requirement discourse for healthcare personnel. These two discourses are governed by a values-based healthcare discourse. Neo-liberal ideology, in the form of New Public Management discourse, focusing on the value of efficiency and competition, is given a hegemonic position as laws and regulations are used to strengthen it. The new Swedish Patient Act seems to further strengthen this development. The Act underlines the increased entitlement for patients, but it is not legally binding as it offers patients only indirect entitlement to influence and control their care. To safeguard the patient's entitlement under the Patient Act, healthcare personnel should be made aware of the contents of the Act, so that they can contribute to the creation of systems and working methods that facilitate respect of the Act's provisions in daily healthcare work.
The anti-politics of healthcare policy and its blurring effects on care work in Norway
The aim of this article is to explore discourses of public healthcare sector transformation in Norway. These discourses are part of a wider European neoliberal discursive terrain shaped by policies that focus on competition, choice and 'integration' in healthcare. The method applied here is a combined Foucauldian and post-Marxian discursive approach with a political theoretical focus on how issues are given meaning in specific contexts, emphasising discourse as a situated social phenomenon that encompasses a materiality constituted by and constitutive of discourse. Person-centred care has emerged as a new trend in healthcare in Western countries over the past decade, and is in Norway articulated at policy level as 'the patient's healthcare service'. This article recognises person-centredness as a valuable ideal in care relationships and practices at the individual level. However, the article argues that the focus of person-centredness, embedded in a broader ideological trend of individualisation, may also mask a change in the relationship between the state and its citizens that has a depoliticising effect on healthcare at the institutional and structural level of society. As a result, in Norway one of the effects of recent healthcare policy and intervention has arguably been a depoliticisation of care work. Depoliticisation through the trajectory of naturalisation, has the effect of re-informalising care work, clouding its socioeconomic value and making it 'invisible'. This process is discussed as representing a potential challenge to the key societal value of gender equality, since care work is thereby domesticised and re-feminised. The contribution of this article regarding implications for practice development is to inspire professionals to reflect critically on both contemporary discourses and policies of healthcare and some of the potential effects on care work. Finally, the article also aims to provide practitioners with a framework for understanding policy and its articulations at various levels, and thus, it is hoped, contribute to their empowerment.
This paper presents results from a qualitative analysis of official documents dealing with the deregulation of the Danish medicine distribution system, 2001. In an attempt to clarify how consumerism within health care is manifested in policy, this study explores how central actors in the political process explicitly referred to the needs, interests and problems of the users of medicine. The results show that explicit references to the users of medicine by central actors in the political process were limited. Based on this we argue that in this case, although the debate centred on liberal ideas it seems as if chief values of classic liberalism were lost in the process of translating a political idea into political practice. r
Journal of Public Policy, 2010
One would expect the common agenda of improving the quality of care in hospital sectors across nations to bring about a convergence of their quality assurance systems. However, one finds great variations in the ways in which such schemes are constructed and communicated to the general public in different countries. This paper examines three universal health care systems (England, Sweden and Japan) and explores the degree to which political institutions and public opinions affect the processes of quality assurance system building within them. It argues that the inputs from governments in response to public concerns are the key to understanding the changes in this seemingly profession-dominated policy domain; therefore policy changes are significantly affected by dynamic interactions between events, public discourses and governance structures within these countries. The findings also demonstrate that public access to information has begun to have a large impact on policy debates in al...
Nursing Inquiry, 2017
Patient participation is one of the most prevalent focus areas in the Danish healthcare debate. Patient participation is generally presented as a fundamental democratic right, and is stated in an objective language with legal requirements for healthcare professionals to ensure that patients systematically participate in their own courses of care and treatment. In the research literature, it is not clear what is meant by 'patient participation', and several discourses on patient participation exist side by side. This study explores how discourses of patient participation unfold and are at play in the articulations in official legal and political documents and patient records relating to a Danish psychiatric context. The documents and patient records have been analyzed using a Fairclough-inspired critical discourse approach which is concerned with how power is exercised through language. The research findings show that patient participation within Danish psychiatric healthcare is governed within a neoliberal discourse where underlying discourses; discourse of biomedicine, paternalism, management, evidence and ethics of care are embedded, and a discourse that seems to ascribe stigmatizing traits to mentally ill patients.
Ambiguous expectations for intersectoral action for health: a document analysis of the Danish case
Critical Public Health, 2017
Ideas about intersectoral action and policymaking for health (ISA) are prominent among public health professionals. They are often presented as effective ways to address root causes of poor health and health inequality, and as such the best way to promote population health. The implementation of such ideas has proven difficult though. In this paper we argue that neo-institutional theory can help us conceptualize implementation challenges by pointing to implicit expectations and contradictions associated with the ISA idea itself. With Denmark as empirical case, we conducted a document analysis of recommendations for municipal ISA. The analysis shows how the recommendations provide a very abstract conceptualization of ISA that does not give much practical guidance for action. We show how ISA is discursively constructed with buzzword qualities as the natural way to organize health promotion, by being presented as a means to produce better quality services, more cost-effective operations, and ensure the future of the welfare state, while at the same time hardly changing much at all. By applying the lens of institutional logics we show how ISA, although being vaguely defined, offer ambiguous normative and symbolic repertoires for action. We discuss the implementation challenges associated with this advocacy rhetoric and suggest that the domination of the corporation logic may appear to reduce the political character of ISA and potentially conflict with the ideals of health as a matter of social justice and human rights.
International Journal of Integrated Care
Introduction: In response to increase of patients with complex conditions, policies prescribe measures for improving continuity of care. This study investigates policies introducing coordinator roles in Norwegian hospitals that have proven challenging to implement. Methods: This qualitative study of policy documents employed a discourse analysis inspired by Carol Bacchi's 'What's the problem represented to be?'. We analysed six legal documents (2011-2016) and selected parts of four whitepapers presenting the statutory patient care coordinator and contact physician roles in hospitals. Results: The 'problem' represented in the policies is lack of coherent pathways and lack of stable responsible professionals. Extended personal responsibility for clinical personnel as coordinators is the prescribed solution. Their duties are described in terms of ideals for coherent pathways across conditions and contexts. System measures to support and orchestrate the individual patient's pathway (e.g. resources, infrastructure) are scarcely addressed. Conclusions and Discussion: We suggest that the policies' construction of the 'problem' as a responsibility issue, result in that neither diversity of patients' coordination needs, nor heterogeneity of hospital contexts regarding necessary system support for coordinators, is set on the agenda. Adoption of rhetoric from diagnosis-specific standardized pathways obscures unique challenges in creating coherent pathways for patients with complex needs.
2015
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