Marlot Kuiper

48 Connective Routines Firm welfare state arrangements, based on a relationship of trust between established professions, the state, and clients started to erode from the 1980s and 1990s onwards. The rising costs of the welfare state had become untenable over the years, not in the least because of the steadily mounting costs of the health care system. In the Netherlands, like in other Western countries, the organisation of health care gradually shifted towards a more market-oriented system (Clarke & Newman, 1997; Harrison et al., 1994; Helderman et al., 2005; Kitchener & Gask, 2003; Reay &Hinings, 2009). Due to these massive managerial reform programs, Western welfare regimes got restructured. Reforms included for example the rationalization of service organisations and the improvement of service performance. Government transformed its role into ‘governing at a distance’ (Lipsky & Smith, 1993). The dual structure of bureau-professional systems herewith transformed into a ‘hybrid’ structure (Noordegraaf, 2007). Managerial control started to dominate, relying on external forms of regulation and accountability measures. Rather than self-control, professional occupations got increasingly subjected to cost control, target-setting, and performance indicators. Another challenge imposed on professionals in the welfare state, in particular by reforms in accordance with New Public Governance, is the demand for collaboration and integration of services (Denis et al., 2016). Increasing prosperity has led to an increasing life expectation, but consequently also to compound multifaceted cases. For example, patients with severe medical conditions are undergoing surgery. Patient variables can thus make even ‘simple’ surgical procedures complex tasks that require high levels of specialization, but also of communication and coordination (Øvretveit, 2000). The call for collaboration and more integrated services is at odds with the long term tendency to specialize professional work (Rosen et al., 2018). Specialization has been criticised for its lack of flexibility in response to the varying needs of clients, especially regarding the increasing amount of multi-problem cases that require a more holistic approach (Kodner & Spreeuwenberg, 2002; Noordegraaf, 2016). In short, in dealing with complex, multi-problem cases, the need for far- reaching specialization goes hand in hand with the need for multidisciplinary action (Meads et al., 2008; Noordegraaf, 2016; Rosen et al., 2018). Professional education is in transition however. Various initiatives aim to make professionals (in training) more resilient and capable of dealing with today’s care