In recent decades, professionals in the public sector have been faced with increasingly detailed demands concerning accountability and performance. It is often argued that this increased accountability and its bureaucratic pressures limit professionals’ discretionary space and autonomy. However, this critique is hardly based on empirical research on the experiences and perceptions of professionals themselves. In this article we present an investigation into these perceptions and experiences with accountability in one particular brand of the public sector, namely youth care.
Our research indicates that professionals in youth care are hardly interested in greater autonomy or discretion. They rather want clarity, security and options for learning. Moreover, we found ‘bureaucratic attachment’: attachment to bureaucratic procedures particularly as a reaction to increased fears to be sued when something goes wrong with clients. In the recurrent arguments for reduction of bureaucracy, this other face of bureaucracy is often disregarded.
Regarding working conditions however, the professionals we interviewed do want more discretion. Especially concerning occupation of beds, as the requirement for permanent occupation is viewed to augment risk. We therefore argue for better backing of professionals in youth, for a more precise battle against unnecessary bureaucracy, and for professionalization in order to handle more discretion.

In order to facilitate the creation of a regulated market, Diagnostic Treatment Combinations (DBC’s in Dutch) have been introduced in Dutch mental health care in 2008. DBC’s are developed to distinguish and price the ‘products’ of health care, in order to make comparison and competition between health care providers possible. In this qualitative study we analyzed mental health care professionals experiences with the DBC-system. We focused on two questions: (1) what does the DBC-system and the related introduction of marketization of mental health care mean for professionals? and (2) how do professionals cope with the DBC-system in their daily practices? We found that the logics of the market and bureaucracy, both incorporated in the DBC-system, often conflicted with the values and ethics of mental health care professionals. Mental health professionals experience deterioration of professionalism and quality of care. They were coping with conflicting values by non-compliance with rules and pragmatic use of the DBC-system. It is argued that the efforts of professionals to protect the quality of their work might actually lead to invisibility of the problems they encounter, which reinforces the policy they criticize.

In recent years the Dutch welfare state has invested substantial sums of money in activation of citizen’s initiatives in deprived neighbourhoods. As a policy concept citizen’s initiatives refers to enhancements by citizens to the quality of life in their neighbourhood. Is this activation policy productive or counterproductive for citizen participation? This question is answered by analyzing the representativeness of the activated citizens, the nature of their initiatives, the type of relations they develop with institutions, and whether they develop more competences due to their initiative(s). Our findings indicate that the activated citizens are more often female, below 50, lower educated, and 40 percent is migrant, which makes them more representative than the participation elite (male, 50+, white, and higher educated). They form a new vanguard that activates many participants through initiatives that focus on connecting people and on social problems such as anonymity, isolation and nuisance. Many contacts with professionals contribute for them to a partnership relation geared toward cooperation instead of consumerism or dissatisfaction. Also these citizens develop democratic, bureaucratic and social competences as well as social reflexivity and empathy for other citizens and institutions. We conclude that activation of citizen’s initiatives has positive effects on citizen participation.

Demand-steering policies in healthcare are understandable but problematic answers to the desire for democratization that dates from the seventies of the former century. Prominent critics such as Achterhuis and Illich were very critical of the undemocratic character of health care. Yet their romantic idea of society excused them from the need to articulate democratic alternatives. The empty space that they left was filled by the concept of demand-steering. Demand-steering, however, rather than strengthening democratic practices, merely undermines them, by preferring exit above voice, by putting up new bureaucratic barriers between clients and professionals and by undermining the quality of the relationship between clients and professionals.

Doing more justice to the democratic impulse is possible and desirable. A new step towards this aim is being taken by a fourth logic of steering, (next to the familiar logics of the market, bureaucracy and professionalism) that centers on improving the dialogue between clients and professionals. The one variant, democratic professionalism, starts from the position of the professional and aims at intensifying democratic control, while the other variant, collaboration, starts from the client and aims at providing him with more influence and responsibility for the health care process. This fourth logic however can only provide a new impulse to democratization when the vague notion of the dialogue is elaborated more thoroughly.