“User participation? Isn’t that what i do all day?” Implementing user participation in Norwegian mental health outpatient clinics: a street-level bureaucrat perspective

In 2019, care pathways for specialist mental health services were officially launched in Norway. These pathways were designed according to several goals to improve services. One of the overall goals was to increase user participation. The purpose of this study was to examine how professionals, in their role as street-level bureaucrats, interpreted the overall goal of increased user participation and how this interpretation influenced the involvement of patients in treatment facilitation. A case study was conducted at one outpatient clinic for adults in western Norway using 10 qualitative, in-depth interviews with treatment personnel. Additionally, user participation in the care pathway was evaluated. The results indicated that mental health professionals interpreted the overall goal as indicating that user participation are integrated into professional practice, not something that could be isolated alone. Furthermore, the idea of involving patients in treatment decisions was rejected by utilizing two coping strategies: one strategy was understood as a mechanism of ‘routinizing’, whereby providers promoted the method they practice, and the other strategy was a mechanism of ‘rationing’, whereby providers became gatekeepers of access to certain services. By investigating street-level bureaucracy theory and related coping mechanisms, this study shows how these two mechanisms may move the provision of care away from patients to benefit themselves in a public service gap where there are never enough resources.