The individual and primary care: Service user, reflexive choice maker and collective actor

Abstract

Many health policy interventions reflect implicit assumptions of cause and effect, contestable values and partial rationales - particularly in healthcare systems based on notions of entitlement and obligation. The objective-oriented nature of policies and the potential cacophony of narratives that underpin such interventions are not, though, explicable solely in terms of the achievement of particular ends envisaged by different policy actors. These ends reflect, often opaquely, notions of responsibilities, rights and ideas of social justice - issues central to perennial debates around 'welfare citizenship'. But, just as notions of entitlement, rights and obligations are open to challenge and change, so too are discourses around the meaning and implications of far more fundamental phenomena: the individual and individualism. In this paper we focus on the evolution of primary healthcare in the UK in order to demonstrate that changing ideas of the 'individual' and individualism are central to the implicit and explicit narratives and parameters that underpin the formulation of health policy. The individual and individualism are seen as malleable phenomena that can act as the focus for renegotiations of the relationship between systems of healthcare and the patient-citizen at a personal and collective level. Contestable and contested notions of the individual are thus, at one level, fundamental to the meanings and thus the ultimate nature and outcome of health policy interventions.