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.

'Demand-based organising' has become popular throughout public domains, sometimes complementing, sometimes working against 'fact-based' and 'market-based' organising. This raises critical questions, about ways in which 'customer' and client demands are and can be known, and how multiple demands can be aggregated. In addition, it is difficult to link demand-based strategies to public service contexts, full of professional practices. How do public managers cope with such contradictory conditions? How can they organise in demand-based ways, amidst contradictory demands? This article, firstly, explores how demand-based rhetoric and instruments have been introduced. Secondly, it explores how public managers really (can) work in demand-based settings. Thirdly, it explores how demand-based practices can be organised, so that public service contexts can be managed 'professionally'. This leads to a paradoxical conclusion. Professional public managers organise in demand-based ways by not handing-over or 'outsourcing' content to customers and clients, but by substantiating demands themselves.

The recent decline in professionalism has frequently been explained as a result of the rise of New Public Management (NPM). As will be shown in this article, however, NPM does not automatically result in a decline in professionalism; its effects differ in various professional contexts. In a case study of the work of social insurance doctors and labor specialists the authors demonstrate that NPM structures the technical aspects of professional tasks, that are the verifiable elements of the professional's judgment. NPM proofs to have strong influence on the techniques for quality insurance (performance of production, time and lawfulness). On the longer term this influence can undermine professional self-regulation. NPM has little impact on the indeterminate task aspects, the professional judgment itself, even though this part has become more 'technical' in years. The case study shows however that this is not due to NPM but to the impact of bureaucratization of the professional task. Furthermore it becomes clear that this impact is stronger in the case of the labor specialist than with respect to the social insurance doctor.