The care for chronically ill in Denmark is developing rapidly. This is due to the growing number of patients with one or more chronic conditions. Until now, the Danish Healthcare system has been designed to treat acute illness, but it has an urgent need to adapt to treatment of chronically ill patients. As it is right now, caring for chronically ill takes up 70-80 % of the resources in the public health care system. To meet this “chronic challenge” the Danish Government and the National Board of Health has taken the initiative to create a new approach to provide high-quality and affordable health and social care for people suffering from chronic diseases, this was announced in 2005. The approach is built upon a model called The Chronic Care Model. For this approach to work, the patient needs to be "active and informed" in order to get "improved results" out of the collaboration between practice team and patient.
This new approach (chronic care approach) is an example of neo-liberal government, where the patient must act and behave responsible and be active in the pursuit of the best way of living with a chronic illness. The role of the patient is changed in the chronic care approach. Here, the patient must be an equal part in the treatment of the illness. This marks a shift in the perception of the patient. Earlier, the patient was dependent upon the healthcare system to treat the illness, now greater autonomy and independence is expected. Thus in this thesis I ask:
How are people, who suffer from a chronic illness, governed to become active and informed patients in the Danish chronic care approach?
I employ Foucault’s governmentality-perspective to understand and explain, how the healthcare system seeks to govern the patients into changing behaviour, to become active and informed. As I employ the governmentality-perspective, I work with three dimensions. These dimensions constitute my analytical focus points. Firstly, the object of government - who is to be governed, secondly, the strategy and technology of government - how to govern and finally, the subject of government – what/who is the goal. The empirical basis for answering the question is existing
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documents from the Danish Government, The National board of health and a document collecting and analyzing attitudes and experiences from different actors in the more practical execution of the chronic care approach. The documents are mainly aimed at the professional level.
Risk and risk-calculation is what the healthcare system uses to narrow down the object of government. People with a chronic illness are a high risk group. They enter this special group, when they are diagnosed with a chronic illness. Through measurement of their illness and an assessment of their ability to self care, they get stratified into three different levels. Through knowledge of the patient, the healthcare system has the power to stratify him into a certain level of risk. Here the patient is assumed to have certain needs of help.
The strategy of government is empowerment. Empowerment of the patients is seen as necessary to create a patient who is able to act out the expected patient role, and become able to be a self-conducting individual. The dominant technology of empowerment is patient education, both self-management education and more disease specific education. The problem is that is does not reach the intended target groups. In addition to this, the doctors are hesitant of referring the patients to these classes. First of all, there is no systematic way of doing this yet, secondly, it is very hard to get an overview of the different offers available and thirdly the offers are seldom evidence based, which means that the effects and the quality of the class is not tested in a medically approved manner. This means that the empowerment process is not yet working properly, because the approach is kept in a bio-medic perception of the patient and treatment, and this is a problem in relation to chronic illness.
What the governing of the patients seeks to create, is a rational patient. One who can admini-strate the illness in a way the system recognizes as responsible, which means a patient, who can calculate what to do and what not to do in relation to living properly with the illness. This means avoiding risks that can worsen or complicate the illness - which means reducing the use of re-sources in the healthcare system. The behavior must be appropriate in the eyes of the healthcare system. As it turns out, this is also prerequisite to act in the chronic care approach.