New Public Management (NPM) has added new aspects to the conflict between political-bureaucratic steering and professional autonomy in the search for a substance use treatment system (SUT) that is economic and characterized by high quality, accessibility, and professional discretion. This article analyses if and how organizational aspects of NPM imply additional challenges for professionals and SUT. The experiences of 29 social workers, in different positions in the services and administration of SUT, in six municipalities with different degrees of NPM and post-NPM, form the empirical data. Many quality problems were common across municipalities: frequent unevaluated reforms, lack of resources for SUT, and cooperation issues. Several problems were especially pronounced in statutory social work. NPM added challenges. Competition with private providers was viewed as initially (in the 1990s) having improved treatment, but the present market was regarded as creating quality problems without savings. Cooperation between providers was a special quality challenge in NPM municipalities, and NPM added to treatment continuity challenges. While accessibility for resourceful clients was linked to NPM models, treatment for less resourced users was obstructed by NPM. Workplace climate and trust issues were more problematic in the most NPM-permeated municipalities. Professional discretion was difficult to link to local NPM degree. Increased standardization and documentation were often accepted as improving quality. While a system based on competition ideology appeared destructive for treatment quality, post-NPM reforms with cooperation between needs-assessment, treatment, and economic support, conformed better with professionals’ perceptions of good treatment.

Aim: In increasingly market-oriented welfare regimes, public procurement is one of the most important instruments of influencing who produces which services. This article analyses recent procurement regulations in four Nordic countries from the point of view of addiction treatment. The implementation of public procurement in this field can be viewed as a domain struggle between the market logic and the welfare logic. By comparing the revision of the regulations after the 2014 EU directives in Denmark, Finland, Norway, and Sweden, we identify factors affecting the protection of a welfare logic in procurement. We discuss the possible effects of different procurement regulations for population welfare and health.

Data and theoretical perspective: The study is based on the recently revised procurement laws in the four countries, and adherent guidelines. The analysis is inspired by institutional logics, looking at patterns of practices, interests, actors, and procurement as rules for practices.

Results: Procurement regulations are today markedly different in the four countries. The protection of welfare and public health aspects in procurement – strongest in Norway – is not solely dependent on party political support. Existing service providers and established steering practices play a crucial role. 

Conclusion: In a situation where market steering has become an established practice and private providers are strongly present, it can be difficult to introduce strong requirements for protection of welfare and population health in procurement of social services.

Given its traditions of universal welfarism and social democracy, Sweden had already scored unexpectedly high on New Public Management by the 1980s. Health and welfare services remain primarily tax‐funded, but the production of care is increasingly transferred to a competitive quasi-market. To what extent can this development be understood in terms of right‐wing governments, and to what extent in terms of other, socioeconomic and pragmatic factors? We examined this question through official statistics on providers of institutional addiction care since 1976, and through the total expenditure and purchases by local‐level municipal social services of interventions for substance users in Sweden in 1999, 2004, 2009, and 2014. We have analyzed the distribution across publicand private providers within the addiction treatment system, and whether national developments and local differences across the 290 municipalities—which bear the major treatment responsibility—can be understood in terms of local‐level political majority, population size, and local wealth. The share of purchased services has remained stable, but the treatment system shows increasing financial turnover and an increasing share of for‐profit providers among producers of purchased care, especially in outpatient treatment. While venture capital enterprises emerged as a new actor, non‐governmental organizations lost out in importance. Bourgeois government correlated with larger shares of purchasing and purchases from for‐profit providers. However, purchasing on a market dominated by for‐profit providers has also become the “new normal”, regardless of ideology, and recent years have shown a reversed effect of left‐wing municipalities purchasing more services than right‐wing governments. Pragmatic reasons also influence local‐level purchasing.

Welfare systems in Sweden and internationally have gone through major changes regarding modes of operation and means of government in New Public Management (NPM) reforms, which have sought to balance autonomy and control. There is a lively debate about NPM, but research is scarce. NPM indicates improved performances but also unintended consequences and inconsistencies concerning ideas, demands on the services and performance incentives – such as tensions between medical and social professional autonomy and knowledge on the one hand and administrative control, auditing and a growing bureaucracy (e.g., procurement, inspections, documentation) on the other. The research project used addiction treatment with different organisations and professions as a case for studying the impact of NPM on the daily work in regional health care and municipal social services organisations.

We charted the broad steering and organisation of addiction treatment. We analysed the extent to which tendencies of NPM have conveyed advantages or created conflicting logics by comparing addiction treatment in three regions and six municipalities with varying degrees of NPM. The study used official statistics, documents, interviews and a web survey. A total of 85 interviews were made with 93 individual state, regional and local policy-makers and officials (including the previously unstudied procurers) and public and private care providers (managers and treatment professionals) in 2017–2018. The interviews formed the basis for a web survey among professionals in Sweden in 2019. Purchasing addiction services was further examined by observing a large procurement process, by organising a workshop with Nordic procurement experts, and by interviewing civil servants in Finland, Denmark and Norway.

The study shows how addiction treatment is governed and organised, highlighting developments over time with special emphasis on various NPM features. The interviews addressed advantages and tensions in the daily work and if and how professionals seek to adapt to new, perhaps inconsistent, demands. The web survey allows for comparisons across organisations and professional groups. This technical report presents the background and aims of the study and describes in detail the Swedish study setting, and the study design, methods and data sources used.

Välfärdssystemens organisation och styrning har förändrats genom New Public Management (NPM) och olika reformer som syftat till att balansera autonomi och kontroll. NPM-debatten är livlig men forskningen sparsam. Den indikerar förbättringar men även oavsiktliga konsekvenser och motsägelsefulla visioner, krav på utförarna och incitament: en spänning mellan medicinska och sociala professioners autonomi och kunskap å ena sidan och administrativ kontroll och växande byråkrati (upphandling, tillsyn, osv.) på den andra. Detta forskningsprojekt använde missbruks- och beroendevården med dess olika organisationer och professioner som fall för att studera hur NPM har påverkat den dagliga praktiken i den regionbaserade sjukvården och den kommunala socialtjänsten.

Forskningsprojektet kartlade den övergripande styrningen och organiseringen av missbruks- och beroendevården. Vi analyserade om och hur olika NPM-inslag medfört förbättringar eller skapat motsättningar genom att studera och jämföra missbruks- och beroendevården i tre regioner (fd. landsting) och sex kommuner med olika grad av NPM. Studien bygger på intervjuer, offentlig statistik, dokument och en webbenkät. Totalt gjordes 85 intervjuer med 93 enskilda politiker och tjänstemän på nationell, regional och lokal nivå, inklusive de tidigare ostuderade beställarna, samt med vårdgivare (ägare, chefer och professionella) i offentlig och privat regi år 2017-2018. Intervjustudien låg till grund för en webenkät riktad till professionella i Sverige 2019. Upphandling av missbruksvård studerades vidare genom en observation av en stor upphandling, genom arrangerandet av en workshop med Nordiska upphandlare och upphandlingsexperter samt genom intervjuer med tjänstemän i Danmark, Finland och Norge.

Studien visar hur missbruks- och beroendevården styrs och organiseras samt hur fältet utvecklats över tid med särskilt fokus på NPM. Intervjuerna behandlar fördelar och spänningar i den dagliga praktiken samt om och hur professionella anpassar arbetet efter nya och kanske motstridiga krav. Webbenkäten möjliggör jämförelser mellan olika organisationer och professioner. Denna tekniska rapport redogör för studiens bakgrund och målsättningar samt beskriver den svenska situationen och studieområdet, studiedesign, forskningsmetod och de datamaterial som används.

Objective:

Researchers generally assume that addiction treatment systems can be viewed as entities and planned with the citizens’ best interests in mind. We argue that another steering principle, the market logic, has permeated many Western World treatment systems but is neglected in research. We demonstrate how it may affect system-level planning, service provision, and the service users.

Method:

We draw on an ongoing Swedish study, with some Nordic references, using several data sources: (1) public statistics on treatment expenditures and purchases; (2) interviews with service users (n = 36) and their service providers (n = 23) on different market features; (3) an observation of a large public procurement process concluding framework agreements based on competitive tendering; (4) interviews with officials involved with steering of the system and procurement (n = 16); (5) a workshop on procurement in the Nordic countries (n = 11 participants); and (6)77 interviews with professionals, managers, and elected representatives.

Results:

We outline seven propositions that call for further research attention: public procurement, as regulated in the European Union, is not suitable for addiction treatment; marketization challenges democracy, equity, needs assessment, and treatment planning; marketization causes new accountability problems and idle monitoring; marketization causes fragmentation and obstructs coordination and continuity of care; marketization causes unification of services and favors big bureaucratically sophisticated providers; treatment professionals’ values are downplayed when a mistrust-based market logic replaces a trust- and needs-based logic; and marketization marginalizes treatment professionals and service users by limiting discretion.

Conclusions:

Findings point toward the importance of acknowledging and mitigating market principles in treatment systems to safeguard needs assessments and planning that serve the interests of the service users and the public.

Objectif :

Les chercheurs supposent en général que les systèmes de traitement des dépendances peuvent être considérés comme des entités et que les soins sont planifiés en prenant en compte le plus grand intérêt des citoyens. Nous soutenons qu’un autre principe directeur, la logique de marché, s’est infiltré dans plusieurs systèmes de traitement en occident, mais qu’il a été négligé dans la recherche. Nous en démontrons les impacts sur l’organisation du système de soins, la prestation de services ainsi que les utilisateurs de services.

Méthode :

Nous nous appuyons sur une étude suédoise en cours ainsi que sur quelques références scandinaves, en utilisant plusieurs sources de données : (a) des statistiques publiques sur les achats et les dépenses liées aux traitements; (b) des entrevues avec des utilisateurs de services (n = 36) et les professionnels qui leur ont procuré des services (n = 23) à propos des différentes caractéristiques du marché; (c) l’observation d’un vaste processus public d’acquisition conduisant à des accords-cadres fondés sur des appels d’offres; (d) des entrevues avec des fonctionnaires impliqués dans la direction du système de soins et de l’approvisionnement (n = 16); (e) un groupe de travail sur les systèmes d’approvisionnement dans les pays scandinaves (n = 11 participants); (f) 60 entrevues avec des professionnels, gestionnaires et députés.

Résultats :

Nous présentons sept propositions qui devront être approfondies par d’autres recherches : les systèmes d’approvisionnement publics, tels qu’ils sont réglementés dans l’UE, ne sont pas adaptés au traitement de la toxicomanie; la commercialisation amène des enjeux sur le plan de la démocratie, de l’équité, de l’évaluation des besoins et de la planification des traitements; la commercialisation entraine de nouveaux problèmes de reddition de comptes et nuit aux mesures de surveillance; la commercialisation amène également l’unification des services et favorise la création de grandes organisations à la bureaucratie complexe; elle marginalise les professionnels et les utilisateurs de services en limitant leur pouvoir discrétionnaire et en imposant une logique de contrat qui repose sur la méfiance.

Conclusion:

Les résultats soulignent l’importance de reconnaitre et d’atténuer le rôle des principes de commercialisation dans les systèmes de traitement afin de préserver les intérêts des utilisateurs de services ainsi que du public dans l’évaluation des besoins et la planification des services.

Objetivo:

Los investigadores generalmente suponen que los sistemas de tratamiento de la adicción pueden ser vistos como entidades y planificado con los mejores intereses de los ciudadanos en mente. Se argumenta que otro principio de dirección, la lógica del mercado, ha calado en muchos sistemas de tratamiento en el mundo occidental, pero se descuida en la investigación. Demostramos cómo puede afectar la planificación a nivel de sistema, la provisión del servicio y los usuarios del servicio.

Método:

Nos basamos en un estudio realizado en Suecia en curso, con algunas referencias nórdicos, utilizando varias fuentes de datos: (a) las estadísticas públicas sobre los gastos de tratamiento y compras; (b) entrevistas con usuarios del servicio (n = 36) y sus proveedores de servicios (n = 23) sobre diferentes características del mercado; (c) una observación de un gran proceso de contratación pública que concluye acuerdos marco basados en licitaciones competitivas; (d) entrevistas con funcionarios involucrados en la dirección del sistema y las adquisiciones (n = 16); (e) un taller sobre adquisiciones en los países nórdicos (n = 11 participantes); y (f) 60 entrevistas con profesionales, gerentes y representantes elegidos.

Resultados:

Describimos siete proposiciones que requieren más atención de la investigación: La contratación pública, según lo regulado en la UE, no es adecuado para el tratamiento de la adicción; mercantilización desafía a la democracia, la equidad, la evaluación de las necesidades y la planificación del tratamiento; causa nuevos problemas de responsabilidad y monitoreo inactivo; provoca la unificación de los servicios y favorece a los grandes proveedores burocráticamente sofisticados; y margina a los profesionales de tratamiento y usuarios de servicios al limitar la discreción e imponer una lógica de contrato basada en desconfianza.

Conclusiones:

Los hallazgos apuntan a la importancia de reconocer y mitigar los principios del mercado en los sistemas de tratamiento para salvaguardar las evaluaciones y planificación de necesidades que sirven a los intereses de los usuarios del servicio y del público.

Scientific journals are crucial for a critical and open exchange of new research findings and as guardians of the quality of science. Today, as policy makers increasingly justify decision-making with references to scientific evidence, and research articles form the basis for evidence for specific measures, journals also have an indirect responsibility for how political decisions will be shaped.

The paper discusses the relation between a concept of addiction and the terminology used for its communication, drawing on and analyzing historical citations from the Oxford English Dictionary. The history of words used in English illustrates that terms for a concept change over time, often by an existing word being repurposed. Addiction as a term existed prior to the contemporary concept, but with a descriptive meaning that did not carry the explanatory power intrinsic in the modern variant. So its use as a word for the modern conception of the addiction phenomenon was delayed well beyond the emergence of the concept. The experience in English of interplay between concept and terms is discussed in the context of two frames: of influence in both directions between medical and popular concepts and terms, and of cross-cultural variations in the concept and of terms for it.