Don’t drive Buurtzorg: change at the speed of trust
Did I uncork the champagne on reading Camilla Cavendish’s proposal, in her independent report published last month, that the Buurtzorg model should be “driven out” in adult social care?
Surely, as founder and managing director of Buurtzorg Britain & Ireland, I am delighted that an official report by a well-informed and influential commentator puts our model top of its innovation wish list? What’s not to like?
I will come to that, but first let me say that the report’s claims about Buurtzorg’s success in the Netherlands are accurate and well-evidenced, and its point that the NHS has so far presented challenging barriers to the model’s adoption here is true.
Buurtzorg – the name is simply Dutch for ‘neighbourhood care’ – was founded in the Netherlands in 2007 by district nurse Jos de Blok and a few friends who were fed up with the impact of ‘new public management’ (NPM) on health and social care.
They wanted to combine the autonomous professional approach that had drawn Jos into nursing in the 1980s with the potential of digital technology, enabling efficient self-management of holistic care.
Since the 1990s, NPM had fragmented Dutch community care into a plethora of priced tasks, complicating relationships with clients and undermining the ability of nurses to take responsibility for all aspects of care on their patch.
Cavendish addresses the same problems here, which she says “stem from three decades of standardisation and specialisation, treating social care as a product that can be separated into different activities parcelled out as cheaply as possible.” The report notes: “Subdividing care in this way has created enormous complexity and unintended consequences.”
Fifteen years after its foundation, Buurtzorg is the leading provider of community care in the Netherlands, with 10,000 nurses in more than 900 self-managed teams, and a further 5,000 care professionals in smaller offshoots covering mental health, home help and more.
Its most recent official inspection has confirmed that it provides great care, and being named Dutch Employer of the year five times explains why nurses continue to flock to it. Buurtzorg’s asset-based approach has also cut costs by halving the average number of hours of professional time per client, and reducing overheads.
Since 2016 my social enterprise has been Buurtzorg’s British-based partner, providing learning and development support to health and care providers wishing to draw inspiration and guidance from its extraordinary success.
We started in Guy’s and St Thomas’s NHS Foundation Trust and have since worked in around 40 NHS, local government and social enterprise settings, with, as the Cavendish report notes, “mixed success”.
On the one hand, we have helped enable many nurses and care workers to work with greater freedom and responsibility, and evaluations have clearly shown benefits to them and the people they support.
On the other hand, most of the organisations involved, as well as the wider system, are proving less than ideal environments for unleashing the creativity and building the trust required to sustain and grow that progress.
There are exceptions, including Medway Community Health (which we are supporting in a partly EU-funded Transforming Integrated Care in the Community project), and the Thistle Foundation, both of which are committed to the cultural and organisational changes involved.
Others, including GSTT, are moving at various speeds in the same direction, but in no case is either success or failure a result of trying to ‘life and shift’ the Dutch model. The point is to grasp its basic philosophy and consistently enable and support professionals to find practical solutions suited to context.
“The NHS is unable to cope with two key concepts: giving staff such a high level of autonomy and operating with low overhead,” states Cavendish, adding that “the NHS has much to learn from social care about how to be responsive and human facing”. In that context, it proposes that local government rather than integrated care systems (ICSs) should retain commissioning responsibility for social care.
But must this choice be made at national level? Why not let local partnerships decide how to achieve the best outcomes, just as Buurtzorg allows its neighbourhood teams to do so within a clear and simple framework?
Which brings me back to the Cavendish proposal that the Buurtzorg model should be ”driven” into the system. Please, no! A key lesson of Buurtzorg’s growth is that it has been based on an ethos of enabling and nurturing rather than command and control.
Perhaps organic growth is easier in the Dutch system, funded by social insurance rather than tax. The challenge here is to adapt to Britain’s institutional environment without sacrificing the purpose of trying to do so.
I welcome Baroness Cavendish’s endorsement, of course, but if you want to replicate Buurtzorg’s success please hear us also about how to achieve it, for how you travel shapes where you arrive.
(First published in Health Service Journal, 8th March 2022)