Balancing welfare and market logics: Procurement regulations for social and health services in four Nordic welfare states

Treatment for problematic substance use in Nordic youth: a narrative review from the viewpoint of social services

BACKGROUND

Youth mortality from drugs is worryingly increasing in Europe. Little is so far known about what substance use services are available to young people. An out-of-home care placement is often used but does not suffice alone as an intervention in problematic substance use among youth. Additional interventions are needed.

OBJECTIVE

This narrative review investigated what has been done, what works, and what is needed in treating youth substance use in the Nordic countries from the viewpoint of social services. This study brought together previous Nordic studies on this topic and presented responses to youth substance use in Nordic social welfare system to the wider international audience.

METHODS

A search of the ProQuest and EBSCOhost databases revealed seven interventions reported in 17 papers. Narrative synthesis was used.

RESULTS

Interventions included the Cannabis Cessation Program (CCP), the Icelandic version of the Motivation to Change Inventory for Adolescents, the Norwegian multisystemic therapy program (MST), the Structured Interview Manual UngDOK implemented in the Swedish Maria clinics, the Finnish ADSUME-based intervention in school health care, and the Swedish Comet 12-18 and ParentStep 13-17 programs. Many interventions had originated in the US rather than in the Nordic countries and most of them were adapted from adult interventions when youth specificity was lacking. Parental involvement was deemed important, but ineffective without involving the adolescent themself. Interventions and ways for dealing with young offenders required reconsideration from the perspective of the best interests of the child. The current research focuses on universal prevention while more knowledge about selective and indicative prevention was called for.

CONCLUSIONS

Not enough is known about the cessation of problematic youth substance use and subsequent rehabilitation in social services. We would encourage further research on the multi-producer system, subscriber-provider-cooperation in youth substance use services, non-medical youth-specific substance use interventions in social services, and rehabilitative juvenile drug offense practices.

Drug treatment service procurement: A systematic review of models, goals, and outcomes

Aim: To explore the goals and outcomes of public procurement of drug treatment services in OECD countries. The study explores how these complex services are procured and delivered. Methods and data: A systematic review of the literature (1990-2020) identified four partly overlapping models of drug treatment service procurement that are here labelled traditional, value-based, outcome-based, and innovative. Results: Even though different forms of drug treatment services procurement are common, only 12 empirical studies that focused on procurement were found. The four models differ in their approaches to design and performance specifications and the role of competition and collaboration in the co-creation of value. Conclusions: Competition and incentives improve neither the efficiency nor the quality or the outcomes of complex drug treatment services. Whereas many studies focus on payment mechanisms, there are important research gaps that relate to the co-creation of value with and for the service-users and other stakeholders.

Health services in Nordic welfare states: Introducing a new category of providers through the Norwegian free treatment choice reform

Aim: We contribute to the literature on private provision of health care in Nordic countries by studying developments following the 2015 Norwegian free treatment choice reform. The reform introduced new providers of publicly financed health care. These new private for-profit or not-for-profit providers are licensed by Helfo (the Norwegian Health Economics Administration) to offer pre-defined services at pre-defined prices. They treat patients referred to specialist health care given that patients choose these providers. We focus on multidisciplinary specialist substance treatment and mental health care, areas constituting 78% of reform costs in 2019. Methods and data: We discuss three sets of questions with statistics, documents, and interview data: What developments and consequences of new providers did key actors expect? What developments of Helfo-licensed providers do we see and why? How have Helfo-licensed providers influenced collaboration between public and non-public providers and recruitment? Results: Contrary to expectations, we found that most Helfo-licensed providers have not previously collaborated with public providers through tender agreements. This complicates collaboration. So far, the establishment of new providers has not undermined public providers in terms of recruitment. Conclusion: Public providers with Helfo-licensed providers in their area still experience some pressure on recruitment and express concerns for future negative reform consequences. The introduction of new private providers may influence the level of market-orientation in the Norwegian welfare state.

A transition of power in opioid substitution treatment: Clinic managers' views on the consequences of a patient choice reform

Objectives: Opioid substitution treatment (OST) is often described as a strict and highly regulated treatment method, in which patients have limited influence over their treatment. In 2014, a reform was introduced by the regional council of Skåne in southern Sweden, which allowed OST patients to choose their treatment provider, thus transferring power from care providers to patients. The aim of this study was to examine what this increase in patient influence has meant for the clinics that provide OST in Skåne, and how these clinics have dealt with the new competitive situation that has arisen following the introduction of the reform. Methods: The study is based on two waves of semi-structured interviews with clinic managers at all OST clinics in Skåne. Results: The clinic managers described the increase in patient influence as a positive change, which had led to the patients being treated with more respect. The competition among clinics was expressed, among other things, in the form of differing views on the prescription of benzodiazepines, which initially gave rise to dissatisfaction among clinics with a more restrictive approach to such prescriptions. The reform did not lead to any clear diversity between clinics, apart from different approaches to the prescription of benzodiazepines. The incentive for competition-based diversity is, however, limited by the strict national regulatory system and by the reimbursement system, which restricts the ways in which clinics can conduct treatment activities. Conclusion: OST-clinic managers were largely positive about the increased patient empowerment and the shift in power balance associated with the patient choice reform. The introduction of the reform did not lead to any clear diversity between treatment providers, apart from differing views on the prescription of benzodiazepines, which by some managers was regarded as unfair competition.

How Substance Use Treatment Professionals Manage Organisational Tensions

Abstract. Aims: The study examined how substance use treatment professionals managed problems and tensions in their work, and explored if the strategies varied by organisational features related to New Public Management (NPM). Methods: A total of 69 semi-structured interviews (2017–2018) with treatment staff in nine sampled local/regional areas formed the basis for constructing a web survey administered to staff across Sweden in 2019 (n=606). The means showed how often the different strategies were used. Regression analyses examined organisational differences, and central strategies were illustrated by the interview study. Results: Treatment professionals in general reported satisfactory freedom in their work. Staff in more NPM-like organisations were less likely to report autonomy and more inclined to report conflicting demands. When conflicts emerged, the staff used both passive strategies indicating adaptation or resignation, and active strategies including boundary spanning, protest, and liberty-taking. Some challenging strategies such as looking for other jobs or reporting one thing but doing another were more common in more NPM-like organisations. The opposite was found for customer orientation. Conclusions: While NPM features on customer orientation and steering methods appeared to create fewer problems, more NPM-like organisations appeared to be less favourable overall and should be applied with caution.