出版社：Utrecht University, Maastricht University, Groningen University
摘要：Introduction : A central value in the political, organizational and healthcare professionals’ debate is that a patient’s care, treatment and rehabilitation across sectors must be based on a Coherent and Holistic Patient perspective (CHP). Healthcare professionals in hospital settings and in municipal communities point out that the solution to issues in across-sectors communication and collaboration lies in seeing a patient’s health within the context of a CHP. Based on my analysis of empirical work I will present and discuss how CHP is historically and institutionally situated. I discuss how paradoxes and tensions are a part of the-taken-for-granted talk about CHP. Finally, I propose why these questions seem to stay unsolvable and why it is necessary to reflect on utilizing a coherent and holistic patient perspective across sectors. Theory and Methods : Data were analysed using a governmentality structured analysis of empirical data informed by Michel Foucault. The data comes from a Danish Action Research project: Communication between health care professionals when elderly patients are discharge from hospital. The action research project included 36 qualitative semi structured interviews, fieldwork, workshops, picture- and narrative analyses, interventions and evaluating sessions. The governmentality analysis was based on the following questions: what determines the truth about the problem and the solution in the first place? How does governing take place? What kinds of complex problems do these presuppositions and which tension and paradoxes are in play? Why do these questions seem irresolvable? Findings : 1. Since the 1970s, politicians in Denmark, administrators, health professionals and citizens have talked about CHP as a critical part of solving problems related to increasing economic costs in health care, inappropriate allocation of resources across of sectors and unsatisfied patients. These discussions do not include reflections of a health care system that is historically 2. The analysis of the healthcare professional's practice shows how they are exposed to management through strategies such as IT systems, coordination and referral programs, economic framework, management and self-management, LEAN, local and regional health care agreements with punishment and reward systems. These techniques are part of the governmental policy statement and legislation, as well as national and international benchmarking. 3. The analysis of the data also show that health professionals talk about CHP in a taken-for-granted way. They do not discuss or share their different understandings of CHP. 4. Paradoxes, tension and competitions that are in play include: a. The health professionals talk about acting with a CHP, while working within an increasingly fragmented specialty-medical orientation and a system of divided sectoral healthcare services. b. The health professionals talk of a high priority of CHP, yet are situated within a context that demands fast, diagnosis-oriented admissions and discharge of the patients. c. Despite discussions of CHP, it is often impossible to implement because of daily work routines and logistic circumstances. Furthermore, the analysis shows that different discursive struggles take place about the right to define the truth about CHP. Discussion : The findings of the analysis show that to implement CHP in a medical-oriented health care system is a complicated process. Many projects about CHP have been completed, but pervasive issues around actual implementation seem to be irresolvable. As Foucault highlights: how governing produces subjects and how the subjects in a discursive practice have the opportunity to act. In my analysis, it is obvious that a CHP discourse isn´t strong enough to resist pressures from a medically-oriented discourse and a new public management discourse. Conclusion : Key findings to data are that discussions about a Coherent Holistic Patient perspective are a-taken- for-granted and do not encompass reflections of the health care professionals’ different understandings in integrated care. Additionally, there are few discussions among politician, administrators and health care professionals about how it is possible to work with a CHP in a strongly medical-oriented and divided health care system. Limitations in this study are that it only focuses on the health professionals’ possibility of acting. This study does not include an examination of the patients ` experience as a patient in a CHP. This merits further exploration in future research.
