The representation of primary care and primary health care in New Brunswick health policy: A critical discourse analysis
University of New Brunswick
In Canada, the social practice of health care is organized hierarchically, privileges some groups over others, and reinforces power relations that enforce constraints over directions in which health care as a social practice can move (Turner, Keyzer, & Rudge, 2007). In this research, I focus specifically on the discourses of primary care (PC) and primary health care (PHC) and how these discourses are evident in health care reform and the implementation and ongoing practice of nurse practitioners (NP) in New Brunswick (NB), Canada. The distinctions between the discourses of PC and the broader PHC are not always clear or consistently represented. Based on my experience in the healthcare field, the general lack of consensus on what constitutes each discourse and differential support for each discourse creates challenges for interprofessional collaboration, health care provider role exploration, patient-centered care and health system reform and transformation (Muldoon, Hogg, & Levitt, 2006). I use critical discourse analysis to investigate how government documents and discipline-specific documents from nursing and medicine organize and advocate for health care reform. Discourse analytic work in this research draws on the influence of Foucault (1972, 1973, 1977, 1988); Bacchi (1999, 2000, 2012 a,b,c, 2016) and Fairclough (1992, 1995, 2003, 2010) to explore overlying impacts of governmental, professional and organizational policies on individual and community health. These analyses of PC and PHC in health policy reveal consistencies, contradictions, and gaps between the meanings of these discourses and their effects. The overall analyses of the 12 selected policy texts from government, medical and nursing professions, revealed emerging discourses, diverging discourses, and converging discourses. Converging or intersecting discourses included the use of neoliberal discourse in close relationship with PC. There was clear evidence of how these two combined discourses (PC and neoliberalism) argued for improved access to PC at a lower cost, with effects that attenuated the presence and influence of PHC. The presence of PHC diminished steadily in the government policy texts and was rarely (if ever) present in the medical text. This pattern was in contrast to the nursing texts where there was more continuity demonstrated in sustained use of PHC over the 30 years examined. Within the government texts, a hybrid neoliberal-PC discourse emerged that favored PC and included some elements of PHC. Government, texts, although advocating for reform, also subscribed to fiscal responsibility and value for money discourse. Nursing texts promoted PHC reform but also broader scopes of practice and greater responsibility for the profession of nursing. The medical text, although somewhat aligned with government reform direction around interdisciplinary PHC teams, promoted continued authority and privileged positions for physicians. The introduction of NPs in 2002 did not significantly change the complex privileging and related hierarchal power structure which remained relatively unchanged over the 30 years examined. The study points to far-reaching implications for addressing health inequities. PHC committed to social justice and health equity is critical in addressing health inequities. It requires coordinated action from a broad scope of health care professionals working together in teams rather than the narrow scope of primary medical practice, remunerated by fee-for-service payment, which remains the dominant model of community care in the province.