This year, as part of our Future of Government project, we set out to explore how governments can better meet citizens’ needs by adopting alternative management and governance approaches.
We think that a different mindset is emerging in many innovative governments and public agencies around the world. Rather than focusing on improving the delivery of services directly, this approach aims to cultivate the conditions from which good solutions are more likely to emerge. We call this the enablement mindset.
One organisation that is pioneering this enablement mindset is Buurtzorg, a healthcare organisation which was established in 2007 and revolutionised community care in the Netherlands. At the heart of Buurtzorg – which means ‘neighbourhood care’ — is a patient-centred and holistic model, which relies on self-managed teams of nurses.
The results achieved by Buurtzorg in the Netherlands are impressive. Our case study finds that patient satisfaction rates are the highest of any healthcare organisation, substantial financial savings have been made, and Buurtzorg continues to be a great place for employees (Dutch Employer of the Year five times between 2010 and 2016).
We spoke to Brendan Martin, managing director of Buurtzorg Britain and Ireland, to understand how these self-managed teams work and hear about his plans to bring the Buurtzorg model to the UK and Ireland.
How it all started
Brendan is the founder and managing director of Public World, a social enterprise that supports better services, jobs and organisational performance through self-managed teamwork and workforce and community involvement.
It was after his mother began to need home care in her eighties that Brendan experienced at first hand the strengths and weaknesses of community health and social care services. “I got real-life insight into what was and wasn’t working – how services were so fragmented and divided into tasks. I could see that the professionals were mainly kind, compassionate people doing the best they could in a system that was not supporting them well. I, therefore, started thinking about how to develop a home social care organisation that could provide better care and jobs and less waste.”
In searching for healthcare organisations that were doing things differently, Brendan discovered Buurtzorg Netherlands. He then met with the founder, Jos de Blok, and found they had a similar vision of what it means to put patients’ needs first and enable caregivers to do their jobs with professionalism. This was the beginning of a deep relationship that resulted in the founding of Buurtzorg Britain and Ireland.
I could see that the professionals were mainly kind, compassionate people doing the best they could in a system that was not supporting them well
Inside the workings of a Buurtzorg team
Nurses who work for Buurtzorg are highly qualified. On a scale of qualification from 1 to 5 (where 5 is a nurse who has a bachelor degree), Buurtzorg only recruits from level 3 and above. Buurtzorg nurses work in local teams that divide themselves across neighbourhoods, and the norm is that no more than 2 to 3 nurses are assigned to each patient.
A unique feature of the Buurtzorg model is the self-managed nature of the teams. Nurses are fully responsible for the decisions that concern their own patients and there are no formal management structures.
People often struggle to believe that teams can be self-managed while at the same time being accountable for their actions and maintaining a high-quality service. But Brendan stressed :
“The key to self-management is building trustful relationships within a framework which everyone buys into. Buurtzorg’s framework includes principles such as providing support when it is needed and putting patients’ needs first, as well as how team members relate to each other and reach team decisions based on consensus. By adhering to these principles, Buurtzorg staff commit to shared values and goals that frame their professional freedom and responsibility in their everyday work. It acts like a cultural norm in the organisation.”
One of the principles of the framework is that the teams should be available 24/7. This doesn’t mean that nurses need to be available at all times, however. Instead, most Buurtzorg nurses work part-time, roughly 28 hours per week. This allows for flexibility to meet patients’ needs – another principle of the framework – and means that sometimes they are required to vary their hours.
How decisions are made within the teams is also guided by the framework. Clinical and personal care decisions are the nurse’s own to make – together with his or her client — but those that affect the wider team, such as whether they should take on a new patient, are reached by consensus. This involves a solution-driven approach, Brendan explained. For example, if a team is unsure of a proposal it might try it for a while and evaluate the results. “This way the commitment to consensus, far from being an obstacle to action, is a way of collectively learning by doing and continuously improving.”
The architecture behind a self-managed organisation
Creating an enabling architecture that provides professionals with the tools and resources to work at their best is essential for a self-managed organisation. In addition to the framework, each Buurtzorg team has a regional coach, who supports the teams to make their own decisions and tackle their challenges within the framework. “Teams mainly solve problems on their own, but regional coaches are available to provide support in difficult situations,” says Brendan. “Rather than feeding solutions to the teams, the coach’s role is to facilitate the team to get to a good solution of their own, which normally can be done without a coach’s involvement.”
To further enable the teams’ learning and development, Buurtzorg has created a trusted IT system which is constantly being monitored and improved. “There is an IT back-end team that is very responsive and works on simplifying processes as much as possible for nurses. Teams use the IT system all the time to plan their schedule, make care plans, and evaluate outcomes. They use it first and foremost because it is useful to them, and only secondly because it is useful for the back office.”
The IT system also encourages peer learning between the teams. Nurses can put their challenges out on the net to ask for help, or compare notes with other teams who might have faced similar situations.
Of course, as in any other organisation, there can be instances of noncompliance. “This is rare, but when it happens the team is in charge of fixing the problem. If they cannot reach a decision on how to tackle the problem, then they can decide to involve their coach. It is the coach’s role to steer the team back to the framework and try to help them come to an agreement – indeed, that’s why the framework is there.”
Creating an enabling architecture that provides professionals with the tools and resources to work at their best is essential for a self-managed organisation
Spreading the Buurtzorg model to the UK and beyond
Brendan and his team’s efforts in popularising the model across Britain haven’t gone unnoticed. “You now can’t go far within social care or the NHS these days without hearing about Buurtzorg.” Indeed, Buurtzorg was mentioned In a recent speech by the UK minister of health and social care, who announced that “the Dutch model delivers higher-quality care at a lower cost. I want to see it grow.”
The Buurtzorg model definitely has the potential to spread in the UK. As Jos de Blok said in his blog, “the basic problems in Britain are the same as those we set out to tackle a decade ago [in the Netherlands]: top-down command and control instead of professional freedom and responsibility; systems that are far more complex than they need to be; fragmented services instead of holistic care”.
Spreading the model to the UK does not, of course, come without challenges. Different countries have somewhat different systems, and each poses its own challenges for the Buurtzorg model. For example, according to Brendan, “one potential challenge of extending the model in the UK is that, whilst in the Netherlands it is based on a private insurance model, the UK health care is free at the point of use for all and funded through national taxation, while social care is provided on a means-tested basis through local government. This means that in the Netherlands there were already a variety of independent providers, which provided an easier environment in which Buurtzorg could start and grow.”
Another big obstacle is the risk-averse culture of many public service organisations. “Adopting the Buurtzorg model requires a strong willingness from the leadership to give up the command-and-control logic and their vested interests. Half-hearted attempts to transition to the model simply don’t work.”
You now can’t go far within social care or the NHS these days without hearing about Buurtzorg
Next steps for Brendan and his team
Over the past year, Brendan and his team have launched 15 “test and learn” experiments across Britain to discover the specific challenges of adopting the Buurtzorg model in a variety of contexts and find local solutions to local stumbling blocks. Their strategy so far has been to support existing NHS trusts and social care organisations in local authorities interested in transitioning to the Buurtzorg model, and supporting them by providing training, study visits and close collaboration.
“We found that the key to recruitment successes is to ask ‘who would like to work like this?’ and let people join ‘test and learn’ teams because they want to, not because they are told to. In some cases, we have been very successful in bringing frustrated nurses back into the system.”
Brendan added: “Both formal evaluation and our own anecdotal evidence so far shows the model can greatly improve care and job satisfaction. The bigger challenge for the organisations concerned is to repurpose their own support services to the frontline, to provide what they do need and stop doing what they don’t need. Without that they will not achieve the same results at scale as they have begun to show in the pilots, and they won’t achieve the potential financial savings either.”
Brendan and his team are increasingly turning their attention to that organisational development challenge to make sure the Buurtzorg revolution won’t stop here. They are also working on an international EU funded programme called Transforming Integrated Care in the Community, aiming to understand the challenges of spreading the Buurtzorg model to different countries in Europe. More places around the world need the commitment of teams like Brendan’s to improve public services and empower health professionals to do what they do best: care for their patients and support them to take better care of themselves.
We are exploring and debating the implications of enablement as part of our Future of Government project. Contact us at firstname.lastname@example.org if you work in the public sector or in government and would like to contribute your thoughts and reactions to this debate. #FutureGovernment
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