Purpose and theoretical framework
The purpose of this thesis is to identify and illustrate the displacement, in Sweden, of the patient position in health care between the years 1970 and 2000. The questions examined are: What were the conditions of possibility to talk of the sick in terms of customers (1), how did this displacement of the notion of the sick appear and (2) what does such a displacement entail (3)?
Based on these questions the thesis is divided into three parts. The first part introduces the arrival of market ideas and notions on individual rights for patients. The second part discusses the discursive formation of a customer position in health care. The third part deals with the merits that such a position either supply or eliminate. The theoretical analytic framework is inspired by Michel Foucault’s understanding of discourse. The discursive formation and the order of discourse are the analytic tools used (Foucault 1972, 1993).
The summary below is concerned with the three research questions.
1 The arrival of market ideas and ideas on patient rights
A new kind of market ideas, which has attempted to replace previous public administration ideals in health care, has gradually transformed health care in the end of the 20th century (Rose 1999). The conditions of possibility for this transformation of health care, which are discussed in the fist part of the thesis, have been the social impact of the market discourse and the discourse on patient rights. The market discourse can be described as a homogeneous system of ideas, a positivity (Foucault 1972), organizing words like freedom, market, choice, customer and competition in strategic statements and themes. Health care, previously described as a combined utility, was, in the mid 1990ies, reconceptualized, through the influence of the market discourse, in order to comprise services that are priced, bought and sold on an internal, pseudo-characteristic market (Dean 1999, p. 6). At the same time we are witnessing an extensive privatisation of hospitals, the signing of private health care insurance and increased rates on health care services.
The development toward a marketization of health care have followed two main lines of thoughts, one was the efficiency line, in the late 70ies, which were composed of organizational transformations, the use of various techniques for economical management and the introduction of market mechanisms.
The other main line of thought emphasized the patients changing role and reinforced position in health care, from the mid 1990ies and onwards. One of the motives behind the second line was to give the patient the opportunity to choose a care giver, yet another, that it was considered a democratic and personal right for a patient to be a self-determinate part of the health care process; a third motive was that the patients status had to be strengthened by legal means through legislation.
2 The discursive formation of a customer position in health care
There is a prevailing discursive order in health care which control the practice through which speech and writing is produced and interpreted, for example in dialogue between doctor and patient. The order of discourse gives rise to a situation where some discourses are practiced and others excluded (Jörgensen & Phillips 2000, p. 76). Previously, the welfare discourse and the medical discourse were predominant in the order of discourse. These are now being challenged first of all by the economic discourse, subsequently by the market- and management discourse, like the discourses of New Public Management and Total Quality Management, and added to this the legal discourse on patient rights, which have all made their way into the order of discourse of health care.
At the end of the 1990ies the market discourse and the discourse on patient rights, brought about a discursive break in the discourse order of health care. This was a consequence of the fact that words from both discourses were displaced towards health care and were used in phrases such as “the right to choose hospital and physician” and “the right to participate in choosing of treatment”.
I argue that the view of the sick person is displaced from patient to a customer with certain personal rights. The choice of the word displacement suggests that the change in linguistic usage, which I have noted and analysed, and which I interpret as a displacement, appear as a dynamic process. It is possible to illustrate the dynamics by analysing the way a theme like the voucher concept circulates between various discursive fields. By applying Foucault’s theory of how a discursive formation appear, it is possible to analyse how the voucher concept circulates in various texts, reappear with new words like voucher for care and capitation, is reorganized in new phrases and used in new contexts.
With the support of an analytic scope inspired by Foucault, we can understand how a certain idea is gradually reinforced. It is the displacement of concepts and themes from one discursive field to another, which ultimately leads to a displacement from the position of patient to the position of customer.
The first conclusion which may be drawn is that 75 years have passed since cardinal Bourne talked about the appropriateness of providing British families with a school credit, which would allow for the free choice of schools. This idea is the basis of current discussions on the voucher concept in elderly care and in health care.
The second conclusion which may be drawn is that the voucher concept is dispersed when it is combined with the idea of a freedom of choice. A new theme is then created, namely the concept of customer choice. The voucher thus becomes a device for realizing a political idea, the idea of creating a market within the health service and health care sectors, based on customer choice. The practical experiences of the introduction of the voucher in schools and elderly care (“skolpeng och äldrevårdspeng”) signals the importance that the voucher concept might have on the formation of a health care market.
The third conclusion is that the voucher concept is dispersed in a form, which is reminiscent of an inter-textual chain that connects a series of texts under a long period of time by incorporating elements from other texts in each text.
Fourthly it is clear that it is specific types of statements and groups of concepts that appear and create themes, such as the concept of customer choice.
The example of voucher should be understood as an inter-discursive transformation, which means that borders between various discourses and within a specific discursive order are displaced.
The discursive formation generate legitimacy for the customer position
The notion of perceiving the sick person as a customer was preceded by the discursive formation of a customer position in health care. This formation consists of several influential voices, which are spreading accounts carrying specific concepts that subsequently are shaped into themes in various customer discourses.
Economists and consultants within the area of management use the costumer concept on a regular basis. The think tanks Timbro and The Stockholm Network use economical terms such as corporation and market to describe the future of health care. The Federation of Swedish County Councils uses the term customer in its qualitative instrument QUL. Certain journalists at the morning paper Dagens Nyheter endorse market solutions in health care. Several directors of medical services started incorporating the term customer in their vocabulary at the end of the 1990ies. Physicians in managerial positions say that they have accepted the term but stress that it should not be used in direct health care since the concept lack legitimacy in the interaction between doctor and patient. Lawyers argue that patients are entitled to patient rights while politicians mix words from the market- and welfare discourses and the discourse on patient rights when they talk about the patient position.
When these influential voices refer to freedom of choice, health care guarantee and voucher in care, when talking about health care, the implications of this is that the market discourse in health care is being legitimised. This does not imply that there is no lingering resistance against the market discourse. However, the aim of this thesis was not to analyse this resistance.
3 The characteristics of the customer position and its implications
The market discourse presupposes that the price, supply and demand of services are fixed by customers and producers on a market while the population related budget governance proceed from an economic framework, for a need estimated by politicians. Hence we are dealing with two separate discourses, the discourse based on needs and the market discourse, which speaks via politicians.
In practice it might come to the point where politicians establish market mechanisms but at the same time do not take into account how these mechanisms effect the consumption of health care, which is increasing, or the total cost development, which is rising or the demands for financing which will be the result of this. Hence the economic framework will adjust to the development of the operation later on, and not the other way around. The function of the overall budget as a halter is thus put out of play by the market discourse and the deficits have become part of the everyday discourse in health care.
The effect of different voices formulating customer themes is a generalization of a vocabulary embracing concepts like customer (Fairclough 1995, p. 231), which is regarded as yet another effect of a marketization. A similar generalization is evident in primary municipalities (Forsell & Jansson 2000, p. 44)
Through a generalization of concepts like customer and service in health care, the attitude towards how operational issues will be managed are changing, and an adjustment towards this approach of dealing with customers is evident, which interviews with various physicians have confirmed.
Conclusion: Patient and customer
With support in Foucault’s discourse theory, I have come to the conclusion that the market discourse, based on the discourse on personal rights for patients, despite opposition, constitutes a customer subject position which is evident in an increasing degree of personal choice, care guarantee, personal rights and right of self-determination in health care. A displacement of the market vocabulary toward health care has brought about a displacement of the notion of the sick person from a passive patient to an active customer who makes active decisions and participates in the care process. The constitution of the customer position does not entail however that the patient concept is being replaced but rather completed by the customer concept.