AIMS
Welfare systems have gone through major changes in New Public Management (NPM) reforms, which have sought to balance professionals’ autonomy and bureaucratic or political steering. Such reforms have been implemented in the last decades in Sweden and in many other Western countries. The research project used substance abuse treatment (SAT) with different organisations and professions as a case for studying the impact of NPM on the daily work in health care, social services, and services run by for-profit or not-for-profit private providers. There has been a lively public debate about NPM in the last five years or so and scientists show increasing interest in these matters. Previous research indicate some improved performances following NPM reforms but unintended consequences and inconsistencies concerning visions, demands on the services and performance incentives have also been reported. We may speak of a tension 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 project studied if and how NPM has influenced the daily work in these services, and which tendencies of NPM have conveyed advantages or created problems. It studied professionals’ experiences of autonomy and control and their handling of inconsistencies. Public procurement was found to be highly decisive for the development and the work and thereby given more emphasis in the study, which has attracted great interest from scientists, practitioners, and the media. A detailed account of the project’s starting points is presented in Storbjörk et al. (2019).

METHODS
Dependency care in regional health care and services funded or provided by the local social services for substance use problems are mainly governed by framework laws, and public administrations have great freedom in how to organize these services. The project studied and compared public and private providers in three regions and six municipalities in Sweden with different degrees of NPM – i.e., traditional organisations focussing on public in-house production, administrations with purchaser–provider splits, competition and competitive tendering, etc. National level agencies were explored to chart the broad steering, control and supervision of the field.

The project used documents (e.g., reports, websites, minutes, procurement documents) and semi-structured interviews with politicians and officials at national, regional and local levels, including the previously unstudied procurers, and with treatment providers (managers and professionals) in the public and private sectors. 85 interviews were conducted in 2017-2018 with 93 individual politicians, officials and treatment providers. Public statistics were used to analyse the development of costs and purchases of care from various types of providers involved in municipal SAT (in 1999, 2004, 2009 and 2014), and owners of institutional care for adults. Such HVB homes that were active in 2016 were mapped and the development in ownership since the 1970s was charted. Public procurement was studied by participating in meetings with procurers and social service representatives during a large SAT procurement process. A Nordic perspective was applied to procurement of services through the arrangement of a workshop for procurers, and a regulation comparison across Sweden, Denmark, Finland and Norway. The interview study formed the basis for a web survey to professionals in Sweden in 2019. It generated over 600 responses from social workers, nurses, doctors, psychologists and other treatment staff in municipal, regional, and private SAT. Research methods and procedures, and data materials are described in detail in Storbjörk et al. (2019).

RESULTS
*Importance of a market perspective in research and in practice: The NPM perspective has been received as a new and welcome contribution to the international treatment systems research focussing on how to organise systems to achieve important attributes like coordination and continuity. The Introduction of a thematic journal issue expressed that our project introduces: “critical thinking that causes you to stand back and reflect upon fundamental assumptions… market logic has influenced treatment systems and is now taken into account in system planning, provision of services, and the outcomes for service users. Findings point to several cautions about the marketing process and the need to safeguard scientific approaches to assessing needs and planning activities in the interests of both service users and the public.” (Rush et al. 2019:6 at https://doi.org/10.15288/jsads.2019.s18.5)
The project demonstrated that the market perspective has affected the Swedish welfare system to a greater extent than in other Nordic countries: the field is characterized by a strong presence of for-profit companies, procurement is handled strictly and with a focus on the principle of competition, purchaser–provider splits are more common, and user involvement is given lower emphasis in Sweden. Professionals, with experience of market-oriented organisations, state that the models initially contributed to important cost awareness and improvement of service provision, but that quality eventually may suffer. Few think that service provision has become cheaper. Fragmentation is a problem and coordination and continuity seem more difficult to achieve in market-oriented organisations.

*Increased steering of SAT: The project shows how national and internal steering may be perceived as problematic if it contradicts professional ethics and knowledge. Steering in the form of care legislation, national treatment guidelines and external inspections can then be supportive. Organisation and steering can also be problematic for small areas like SAT, as regional and municipal reorganizations usually are motivated by problems in other areas of activity and by other professional groups. This may result in reforms that are less adapted for or supported by staff in SAT.

*Differences in professionals’ acts and strategies: Staff act upon steering and their work conditions. Those who experience problems handle it in different ways: support or seek support from colleagues, strive to find good solutions despite poor conditions, perform tasks that are others’ responsibility, do what they think is best for the service user regardless of what the unit demands, or look for other jobs. The control is most evident in statutory social work, while less pronounced in treatment work as those professionals more freely may rely upon their professional knowledge and experience. Similarly, those with long experience rely more on their own judgement.

FUTURE RESARCH
An issue that came up early and could be addressed was the importance of procurement in steering and daily work. Procurement is carried out locally, controlled via the EU and the Ministry of Finance and is therefore rarely handled by authorities focusing on treatment issues. Government agencies and research should seek to develop practices that are grounded in a care perspective, and balance the interests of different involved actors. The project points to several areas of future research such as conditions for reduced market power, evaluations of organizations moving towards or from NPM (regarding staff discretion, user involvement, quality of care, treatment outcomes), and studies of cost development following organizational reforms. Research is needed on the less studied regional dependency care. It appears difficult to find organizational models that support clinical work also in these regional organisations characterised by special challenges due to their large size.

INTERNATIONAL DIMENSIONS
The procurement track led us to study regulations and practices in the Nordic countries by hosting a workshop with 11 procurers/experts from Denmark, Finland, Norway and Sweden. The striking differences that emerged induced a comparative analysis of regulations following new EU directives (Stenius & Storbjörk in press). The country differences also motivated the Privatisation Network to extend its focus into “Privatisation and competitive tendering within the personal social services in the Nordic countries” when renewing this Forte funded researchers’ network in 2018. Nordic scientists have been invited.

The NPM perspective has been requested internationally. Storbjörk and Stenius (2019a) authored an article highlighting the importance of a market perspective in a thematic journal issue and assisted with peer-review. NPM was introduced in a SAGE Handbook (Klingemann & Storbjörk 2016) and the project has been invited to contribute with its novel approach to a forthcoming issue of SUCHT. The team has exchanged ideas with scientists around the edges of international conferences – e.g., Buykx who led the project “Local alcohol treatment and recovery service commissioning practices and their perceived outcomes for service commission” at Sheffield University. Stenius and Storbjörk were invited as “Associate Investigators” to Ritter’s “Alcohol and other drug treatment funding, purchasing and workforce” at UNSW Sydney.

COLLABORATION
The team has collaborated with scientists through the above-mentioned journals, projects, and the Privatisation Network (which led to a joint anthology, see Storbjörk & Samuelsson 2018). The project was presented at national and international research conferences and at events targeting practitioners (see Publication list). The procurement workshop was a joint effort together with Nordic Welfare Centre (NVC) and the presentation at Socionomdagarna 2017 was performed in collaboration with FOU Södertörn. The team started a Facebook page (www.facebook.com/addiction.treatment.systems/) which facilitates dissemination of findings. Finally, the project has been visible in media and in popular science contexts.