In the 1990s, the Dutch government was concerned about the increasing levels of spending and inefficiency in the health system. Dutch leaders therefore wanted home care organisations to account for their business performance to insurers. In 1987, The Dekker Report Willingness to Change also made recommendations for a more prominent role for the family in the care of their older relatives in their own homes. This inspired a change from a publicly-subsidised institutional care system to a more privatised home-based care regime, introducing private sector management tools in the Dutch long-term care sector. These reforms followed the trend of so-called New Public Management in the public sector, which was spreading across the world in the 1990s.
These reforms were intended to increase both standardisation and specialisation, with different tasks being delivered by different types of care professionals. This was because home care companies were reimbursed at different rates according to the complexity of the care “product” delivered, introducing opportunities to boost margins. As a consequence, most home nursing organisations merged into large, regional home care organisations, where nurses had lower levels of autonomy: “nurses were, for example, provided with even more specific plans that had to be adhered to, and deviations had to be explained to managers”.
Decision powers on what care needed to be provided were handed from frontline staff to an external regional assessment organisation [Regionaal Indicatie Orgaan] (RIO). To contain costs, RIO needs assessments specified in great detail which tasks were to be provided by helpers, nursing aides, or level 4 and 5 nurses. In this way, basic domestic services such as assistance in getting dressed could be performed by cheaper resources, while medically trained personnel were freed up to administer more complex interventions. Finally, staff had to report outcomes according to set performances indicators, ensuring consistency and evidence-based healthcare.
By the mid-2000s, however, home care had become fragmented, of lower quality, and surprisingly inefficient. Despite reforms being targeted at cost containment, the sector was faced with the persistent problem of uncontrollably rising costs. The percentage of GDP spent on long-term care increased from 2.8 percent in 1996 to 4 percent in 2005, growing by more than 10 percent in some years. This resulted partly from profit incentives to deliver more care products with cheaper resources, which were pursued at the expense of preventive measures.
These reforms meant that the patient experience was also jeopardised. Some patients were seen by more than 30 different healthcare professionals, each administering a different task such as helping with bathing, giving an injection, or caring for a wound. Sometimes, patients were visited several times by different care personnel on the same day. The personal bond between nurses and patients was lost, and no one took ownership for an individual patient’s overall health and wellbeing – they lacked the incentives and autonomy to do so.
The quality of care delivered to patients was also negatively affected. Nurses regularly found patients in a condition they were unprepared for, as a significant amount of time had lapsed between the RIO assessment and their first visit. Yet because frontline care staff were only authorised to provide certain care products in an agreed timeframe, specified to the minute, the care actually needed could not be provided. Overall, the extensive need for timekeeping meant less time could be spent on actual care.
Needless to say, this left nurses disheartened and feeling that their increased responsibilities for timekeeping and documenting their tasks adversely affected personal care. A 1999 focus group of home care professionals revealed major frustrations over the paradigm shift which had stripped nurses of their professional independence in diagnosing and assessing client needs. “In the past, I could agree on things with people myself… Now I come to these people and just have to execute [on the indication that’s been given to me.] Our profession has just been eroded,” said one participant. As a consequence, many nurses experienced “burnout feelings and discouragement to remain working in the profession” with sickness absence rates as high as 10.4 percent.
Jos de Blok quit his nursing job out of frustration with the existing system of care delivery. In 2006, he and three other former nurses set up the social enterprise Buurtzorg (which is Dutch for “neighbourhood care”), taking considerable personal and financial risks to create a not-for-profit home care provider, which aimed to place humanity over bureaucracy. Jos de Blok is now executive officer at Buurtzorg Nederland.
Buurtzorg consists of three components:
- Self-governing teams of ten to twelve nurses providing both medical and supportive home care services
- An IT system relieving nurses of administrative tasks and allowing teams to self-monitor their performance
- Regional coaches promoting best practice and offering advice as needed but without their own performance goals (introduced in 2007).
Buurtzorg was founded as an alternative to the larger regional providers more common at the time. In the Netherlands, home care organisations contract with government-funded insurance companies to provide these services. The home care social enterprise set out to compete with these traditional providers and “simplify the health care system in Holland to show that a patient-centred way of working could deliver better services at a reduced cost, by empowering nurses, cutting back on management overheads and encouraging patients’ self-support and independence”. De Blok told the European Social Services Conference in 2017 that “we wanted to separate care from the administrative process. So we built an IT company which took care of admin, so that nurses could spend time on creating solutions for patients without the need for management.”
Each team only operates at the neighbourhood level (covering approximately 10,000 people and 40 patients), which empowered nurses to go beyond the mere medical management of their patients. Buurtzorg’s nurses are more like “health coaches”, who create sustainable solutions leading towards prevention and care independence. Leveraging existing support systems, “[t]hey are available round the clock and – working closely with GPs – they organise all the supporting care, drawing in families, friends, and volunteers. They see themselves as community-builders.”
Among the main objectives of the initiative were to:
- Become a financially sustainable, holistic model of community care
- Boost satisfaction of nurses by relying on frontline staff’s autonomy
- Maintain or restore patients’ independence
- Train patients and families in self-care
- Create networks of neighbourhood resources.
The public impact
Buurtzorg set out to prove that it could achieve better outcomes for the public purse, patients, and the nursing workforce through an operational model giving autonomy to frontline staff. The home care social enterprise has been very successful in achieving consistently high patient and nurse satisfaction and reducing costly hospital stays, although it has had mixed results regarding net savings and long-term patient independence.
As of 2018, there are around 10,000 Buurtzorg nurses in 900 independent teams, caring for more than 70,000 patients a year. According to de Blok, 60 percent of community nurses in the Netherlands were working for Buurtzorg in 2013: “What you see is a lot of other homecare organisations are changing their models into more self-steering teams. And it's had a big impact on the national policy of elderly care." While long-term care costs still amount to 4.3 percent of Holland’s GDP (more than in any other OECD country), it is estimated that if Buurtzorg was to provide all home care, the Dutch economy would save EUR2 billion a year.
A positive impact has been noted on patients, both in terms of satisfaction and independence:
- Patient satisfaction scores are 30 percent above the national average and in the period between 2008 and 2013, Buurtzorg’s average client rating was 9.1 out of 10
- Patients stay in care for an average of 5.5 months (as against the industry average of 7.5 months and 50 percent of the patients receive care for less than three months). This suggests that Buurtzorg is more successful in helping patients regain their independence
- However, Buurtzorg patients are admitted to nursing homes “at a lower age than the patients of other organisations”.
In terms of another key objective, Buurtzorg has improved job satisfaction so much that it won Dutch Employer of the Year five times between 2010 and 2016. Over the years, it has scored between 8.7 and 9 out of 10 in general employee satisfaction. Other indicators of employee wellbeing have also been positive:
- Lower staff turnover compared to other care providers (10 percent as against 15 percent)
- Consistently lower sickness absence – at about half the industry average
- Higher home care productivity (58 percent of hours billed to care as against 51 percent in other companies).
There is also clear evidence of financial sustainability – despite higher charges per hour, Buurtzorg has cut costs by reducing hours of care as well as hospital admissions and length of hospital stay:
- Buurtzorg’s patients consume just 40 percent of the care that they are entitled to, compared to a sector standard of 70 percent.
- Hospital admissions are reduced by one third, and when a patient does need to be admitted to the hospital, the average stay is shorter.
Some critics have speculated that this might be down to Buurtzorg’s patient selection. In an analysis adjusting for patient case-mix, the savings brought about by the new model were reduced to EUR330, at a total cost of EUR15,537 per patient per year. This was driven by significantly higher medical follow-up costs for Buurtzorg patients, indicating a shift in cost structure rather than net savings. In 2013, Regional Care Organisations, which function as politically independent payers in the Dutch healthcare system, refused to pay these additional costs, resulting in Buurtzorg’s first loss-making year.
Lastly, Buurtzorg’s “small back office means overhead costs of 8 percent, compared to Dutch average of 25 percent”.
Written by Stevan Ćirković
Public Confidence N/A
The level of public confidence in the initiative is difficult to assess. While de Blok reported anecdotally that they “didn’t meet people who said that this was a really bad idea”, the public was largely unaware of the project when Buurtzorg started up in 2006. They launched the initiative during a period, however, when the Dutch public was critical of traditional policymakers, in the wake of a controversial health reform introducing managed competition between insurers. Opinion polls from 2006 show that only 20 percent of Dutch citizens gave the government’s healthcare policy a positive mark – the second-lowest percentage among all major areas of public policy. Meanwhile, 70 percent of Dutch citizens thought the new health insurance system had a negative impact on their personal finances. Whether this provided de Blok and his colleagues with window of opportunity for their innovation cannot be determined conclusively.
Stakeholder Engagement Good
Buurtzorg is a good example of a grassroots initiative, which was launched by a small, cohesive group of friends and colleagues led by nurse-turned-entrepreneur Jos de Blok. The initiative’s stakeholders included nurses, patients, relatives, representatives from local and national government, and the community at large. “In the beginning we didn’t have many contacts,” de Blok admitted in an interview about Buurtzorg’s journey. This changed rapidly, however, after the first few nursing teams began work.
While de Blok did not systematically approach stakeholders to seek their input on how the new service should serve public needs, he did talk to a range of people including nurses and other community members from different backgrounds. He also drew on his own and his group’s experience of having worked as nurses or having been on the receiving end of care services. Moreover, the self-governing nature of the Buurtzorg teams means that the nurses are constantly engaged and responsible for the development of the organisation.
Political Commitment Good
Although political leaders were not involved in Buurtzorg’s social enterprise phase, Jos de Blok met with the Dutch health minister as early as August 2007, after appearing on national TV. Speaking directly to a group of Buurtzorg nurses, the Ministry of Health seemed convinced that the new model offered hope to the ailing long-term care landscape in Holland. Indeed, de Blok’s organisation was selected for the EUR80 million, tax-funded Transition Programme in Long-term Care (2007-2010) – a care innovation incubator aimed at “exploring and learning about radical innovations in practice, in a real-life context in which the end user is central”. 
Buurtzorg stood out from the 10 other experiments that were chosen for the incubator because of its potential to be scaled up and its willingness to share experiences with the rest of the sector. By the end of the first funding round in 2009, its size increased to 200 nurse teams (up from just 5 at the beginning), having clearly established itself in the national care landscape thanks to top-level political support, funding, and integration into innovative research projects. There was no evidence to suggest that any opposition parties were opposed to the programme.
Clear Objectives Good
While Buurtzorg lacks a founding strategy document, due to its beginnings as a local initiative, its objectives were developed progressively as the organisation expanded and interest grew in exporting the model to other health systems around the world. In a 2013 American Journal of Nursing article, de Blok outlined the goals he aimed to achieve through self-governing teams of nurses providing comprehensive home care services. These can be divided into three groups.
- Financial sustainability and cost-effectiveness
- Reversing earlier trends of fragmentation through a holistic model of community care
Patient-centred goals targeted at less care-dependent and happier patients:
- Maintaining or restoring patients’ independence
- Training patients and families in self-care
Workforce-related goals targeted at increasing nurses’ happiness:
- Relying on the professionalism of nurses, granting them operational independence
- Creating informal networks of neighbourhood resources to solve patients’ problems.
When the first teams were created in 2006/07, there was no available model for the self-management of nursing teams. Buurtzorg instead followed a trial-and-error strategy to refine and develop its decentralised home care model. In fact, the pilot team consisted solely of de Blok, his wife, and two colleagues.
Because Buurtzorg was exploring uncharted territory, the team around Jos de Blok started with small-scale pilots in increasing numbers, and based its operational model on that of the traditional district or community nurse, a model which existed in the Netherlands until the 1990s. At that time, home care “was organised by nurses, community nurses, social workers and family doctors. Only those with a few years of professional experience in hospitals, additional completion of a two-year specialist degree and high working standards were qualified as community nurses.” Relying on a highly-skilled and versatile workforce became a key element of the Buurtzorg model, with 65 percent of nurses holding bachelor degrees compared to just 10 percent in conventional home care providers. Jos de Blok had worked as a district nurse himself, enabling him to draw on considerable first-hand evidence when creating Buurtzorg.
When de Blok first began developing the Buurtzorg model, his personal drive and convictions played a crucial role, but he also consulted others extensively on its feasibility and practicality. Over time, Buurtzorg has proved financially sustainable, although its growth may face some challenges in future. “From the start I considered different perspectives to make it work, the healthcare perspective but also the organisational dynamics and the financial perspective,” de Blok says. “So I had a strong feeling myself and had it confirmed by a lot of people who thought that this was a good thing to do. I talked with a lot of people with different expertise, people who had a long history in healthcare but also people who were financial experts.”
At the beginning, many were sceptical about the operational model of Buurtzorg. Some considered it too expensive and unrealistic to be relying solely on higher-educated nurses. However, over time the model proved to be financially feasible due to its low operational costs, made possible by the flat management structure. This ensured that the initiative was financially sustainable, despite the involvement of university-qualified nurses; in fact, in both 2011 and 2012 Buurtzorg made a substantial net profit. “For five years in a row (2009- 2013), Buurtzorg Nederland has received the Golden Gazelle Award of the Dutch Financieele Dagblad [Financial Journal] for being the fastest growing big company in the East of the Netherlands.” Low overhead costs made this possible, with an average Buurtzorg nursing team achieving a profit of around EUR3 per hour of care billed.
However, Buurtzorg faces a financial challenge to its growth model. This is because the regional Care Offices, which are responsible for contracting care providers, only allow contracts based on the previous year’s production, hence impeding growth. In fact, in 2013 the Care Offices refused to pay for the overproduction of care that was provided by Buurtzorg (EUR9.5 million), which meant that for the first time Buurtzorg ended the year with a financial loss (of EUR0.5 million). This means that going forward, unless changes to healthcare financing system are made, or Buurtzorg and the Care Offices come to an agreement, the Buurtzorg project may face financial challenges.
A leading principle behind Buurtzorg was to work without managers – yet a clear governance model was in place from the start and has been continually refined to meet changing circumstances. Despite the lack of traditional top-down control mechanisms, scope and duties always remained manageable thanks to small team sizes, an IT system keeping operational burdens to a minimum, and on-demand guidance from regional coaches. Through this flat management structure, Buurtzorg was successful at creating the right incentives for people to take ownership of problems at all levels and monitor their own progress.
Firstly, the idea behind the Buurtzorg model is to enable people to manage their own lives as much as possible. In this sense, patients are a core part of the management structure. Buurtzorg leverages the intrinsic motivations and capacities of patients, as well as the informal networks including family and friends around them, to enable this self-management.
Secondly, Buurtzorg nursing teams are self-managing. As the nurses care together for a group of patients on a small, local scale, they are trusted to solve problems and make decisions autonomously and collectively. The maximum size of a team is 12 members. If a team grows larger than that it must split. No decision-making level above them is therefore needed.
Supporting local teams of nurses, BuurtzorgWeb is a unique IT infrastructure that has been developed to allow nurses instant access to patient information, work schedules, and “performance data for the purpose of self-regulation and learning”. “Teams can see every month how their productivity compares to that of other teams. The data of other teams is not anonymised or averaged out… A team that struggles in one area can identify a team… with outstanding results and ask for advice and best practices.”
Beyond this, the comparatively small overhead organisation of just 50 people in 2017 includes regional coaches that nurse teams can consult if they cannot resolve important issues among themselves. Coaches support 40 teams on average, assisting with problem-solving, locating roles and recruitment of colleagues, and they can share best practice, often based on their own professional experience in nursing. They have, however, no fixed role description, no responsibility for team performance (clinical or financial), and no decision-making power or other authority over the team.
At Buurtzorg, nursing teams are fully responsible for the organisation’s IT infrastructure and clinical and financial performance. BuurtzorgWeb, an internal social network, therefore measures the public impact that is relevant to most of the objectives, including financial effectiveness as well as patient and nurse satisfaction.
The team portal of BuurtzorgWeb displays the following information:
- Number of employees per client (minimising the number of care workers involved in the care of a person is an organisational goal)
- Client satisfaction scores (information on patient satisfaction is collected at the completion of a course of care)
- Health analytics and quality of care information
- Incidents and improvements
- “Steering information for the teams which enables them to self-monitor their performance and to take corrective action, e.g. productivity over the last year, the number of client hours per week or month, average score on team climate and employee satisfaction level [and] comparison of the team’s performance relative to other teams.”
These metrics are only accessible to the members of a particular home care team, which means the data is used exclusively for learning and self-improvement rather than top-down performance management.
Buurtzorg is characterised by strong alignment among both internal and external stakeholders. There is a strong sense of common purpose among frontline staff. In a 2013 employee survey, in response to an open question on why they joined the organisation, 20 percent of nurses “spontaneously expressed that their own vision of care delivery resonates with the Buurtzorg vision”. The governance model reinforces internal cohesion through collective decision-making on operational matters (see Management above for more detail).
Deliberations on larger strategic matters echo this principle: “When the CEO or anybody else is contemplating changes that might affect a great number of coworkers (for instance, a decision about compensation), he simply puts out the issue and the proposed solution on [BuurtzorgWeb] to collect colleagues’ advice… de Blok makes very clear to team members of the ways he takes their feedback into account.”
As Buurtzorg places great importance on creating and using local support networks, alignment with external stakeholders is a cornerstone of its model. Based on the traditional role of district nurses, Buurtzorg nurses act as care coordinators, working closely with GPs, the relatives of their patients, and local volunteers. For example, they make GPs aware of any new symptoms they notice and which may need further clinical investigation. Like health coaches, they also regularly train patients as well as family members in how to be self-sufficient as regards their care and in coping with everyday activities. In going beyond the limited role of nurses from larger care organisations, Buurtzorg nurses achieved significantly higher patient satisfaction scores.