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“Patient-ness” as a resource for neoliberal health systems to administer their own crisis

What is a patient? An obvious, intuitive answer is that a patient is a person receiving healthcare. The patient exists as long as medical attention or treatment is received, and then it disappears, either because treatment is not needed anymore or, more commonly, because medical or professional health care simply stopped happening. “Patient” is a contingent role that people play in certain times and spaces.

Another, more interpretive approach focuses not on what a patient is but on what it means to be a patient. Questions about meaning are usually led by interest on experience. How do things – including treatment – feel o look like when people are at the receiving end of services, what are the processes involved in the transition in and out of that role, how the patient emerges in interaction with services and doctors, how people uses or refuses being a patient, etc.

In this short essay, I’d like to propose another way of describing what a patient is, one that seeks to understand it not as a concrete person, role or experience, but as a “resource” of a larger institutional field (healthcare), a field subjected to economic and political pressure. I want to move the focus out from the personal attributes of the subject-as-patient and place it on the features and requirements of the institutions that produce health care within specific social contexts. Features and requirements are shaped by neoliberal policy agendas and intensified by large scale crises such as the Covid-19 pandemic.

Instead of replacing one definition for another, in order to depersonalise the idea of patient, I will use a simple metaphor. Let’s think of a house and inside that house is a small room, a storage room where we put those things that we don’t use but do not want to throw away. Over time, unless the house is extended, more items are thrown there in an undifferentiated way. Everything that does not have a place in the clean and rational order of the house finds its place in that small room. Eventually, that room not only stores what is potentially useful: the order of the house depends on the disorder of that space. The storage room gives the “wiggle room” that prevents the internal collapse of a place that became too small.

Let’s now imagine the patient’s situation in the context of health services as the situation of that room in the context of the house. Everything that does not work in the healthcare organisation is thrown at the patient. If a clinician is late, if the blood tests are failed, or if a referral doesn’t arrive on time, it’s the patient who must adjust. The time and the place of treatment are changed, and the patient is moved around. The doctor is late, the prescription is mislabelled, the digital file is corrupted, the internet is not working, and all of this will have to be dealt with by the patient. The focalisation of health care resources driven by the pandemic only intensifies this tendency.

All the inaccuracies, errors, and limitations of the chain of processes called “health care” are dumped into the patient. This is not due to some perverse attribute of the subjects who manage the processes that lead to medical care. It’s not simply an expression of “blame culture”. As in the case of the house, the order and functioning of clinical and administrative activities depend on the existence of a corner where the mess can be discharged, especially when resources, spaces and time are scarce. The relentless rationalisation of resources associated with neoliberal doctrine pushes health systems to rely more and more on people’s adaptability. Passivity becomes an invaluable resource. Patientness is the name of this resource.

Policy agendas and academic engagements around the “patient” has expanded over decades. Concerns around voice, experience and representation are a source of perennial normative and epistemic claims, producing influential frameworks and philosophies such as patient-centred care, shared decision making and all sort of empowerment and involvement strategies. But, if patients are the dumping ground of system limitations and pressures, then there are limits to what can be understood -or transformed- by adopting the patient perspective. At the same time, solutions do not depend entirely on the knowledge and attitudes of those who participate in the production of care. No set of skills around “patient-centred care” or “empowerment” will reverse the patient’s passivity if that passivity is a buffer for the permanent collapse of health systems.

In simple terms, the “patient” is a mechanism for neoliberal health systems to administer their own crisis. Policy agendas and academic engagements around patientness need to consider this. The sole aim of this piece is to facilitate this consideration through a metaphor.

About the Author: Cristian Montenegro (@Cris_Monteneg) is a Research Fellow at the Wellcome Centre for Cultures and Environments of Health (University of Exeter). His research focuses on service-user activism and policy transformations in the mental health field, the social and cultural dimensions of psychiatric deinstitutionalisation in the global south and the complex interaction between mental health policy and human rights frameworks.