More than a decade ago, four Dutch nurses decided something needed to be done about their country’s care in the community. Back then, it was almost as bad as it is in Britain now — where a recent report found that at least 400 pensioners a week sell their homes to pay for social care. Nursing in the Netherlands had taken a terrible turn in the 1990s, when the government decided healthcare should be more ‘professional’. The ensuing bureaucracy and management doubled the cost, and the quality plummeted. Nurses were forced to spend more time on paperwork and, for want of help, elderly patients ended up in hospital when they could and should have been at home. The solution the four nurses, led by Jos de Blok, came up with was a revolutionary model that they named ‘Buurtzorg’, ‘neighbourhood care’. They had three aims: better care for patients, happier staff and lower costs. And I can tell you that they succeeded because when both my parents, who live in the Netherlands, were seriously ill last year, I experienced Buurtzorg in action.
The big idea was that each team of nurses would have complete autonomy, supported by a central office for administrative matters. So Buurtzorg nurses would not only control how and when they treated patients, but also their budget, who they employed and their own planning and organisation.
Buurtzorg started with a pilot of ten teams in 2007, which has grown to 950 in the Netherlands (employing 10,000 nurses) with successful expansions in 23 other countries. Each team has a maximum of 12 nurses to ensure there is no hierarchy or manager needed to lead them. The central office is run by 50 people, with some administration, such as payroll, outsourced. There are 20 ‘coaches’ to help set up new teams or to help teams that are failing to solve a specific problem on their own. There is no call centre, no HR department, no middle management. In the 13 years since it was founded, there has been not one single management meeting. There is no CFO.
Buurtzorg is a real success story. Independent evaluation by Ernst and Young in 2009 showed that patients needed nursing care for half as long, hospital admissions were reduced by a third, and hospital stays were significantly shorter. Where Buurtzorg provides district nursing, costs are down by 40 per cent, and the organisation has won Employer of the Year in four of the past six years. The 5 per cent profit it makes goes towards further education for its nurses. Around half of the 10,000 are educated to degree level.
One of the most surprising results is that the amount of care that patients receive from district nurses has been reduced by nearly 50 per cent. This is in part thanks to the nursing teams collaborating with the patients, their support networks and local voluntary organisations. Another factor is that the teams know their patients and their needs, so less time is wasted. Most importantly, patients are improving faster, disease prevention and self-care have been improved, and so fewer hours of care are needed. The nurses and their patients assess what is needed and form a care plan together, and nurses have the freedom and flexibility to practise their craft without interference from a team of managers. A simple IT system has been developed with input from the nurses, so problems and solutions can be exchanged on a wider scale.
When my parents needed care, they found that Buurtzorg nurses would visit three or four times a day, sometimes for a few minutes, sometimes for up to an hour. I had gone to help care for them, but just as my parents were improving, I was bitten by a dog. Infection set in and the wound required twice-daily flushing and dressing for two weeks. The team organised it so that the same two nurses performed the procedure- — which was complex and painful — even on their days off. As my parents recovered, nurses brought them kefir to help with the effects of antibiotics, and high-calorie drinks to help my mother regain weight. They discussed the best food for recovery (chicken and beef broths, of course), delivered medicines, helped make beds and got my father up and moving. They also talked to the doctor, the physiotherapist and, above all, us.
So why not introduce Buurtzorg-inspired teams here? Well, the odd thing is that we have. In 2013, Brendan Martin, who runs Public World, a social enterprise consultancy, had been his parents’ main carer and experienced the best and worst of home care: ‘The care workers were good people undermined by a bad system.’ He did some research, came across Buurtzorg and set up a partnership with Jos de Blok in 2015, with the intention of working within the NHS and local government authorities to pilot the model.
But our tenacious bureaucracy doesn’t relinquish its hold easily.
‘We’ve set up 20 pilot schemes,’ says Martin, ‘But we haven’t been able to break away from the current management style of the NHS. Nurses don’t have the level of autonomy they need to succeed at scale using the Buurtzorg way.’
Martin isn’t giving up on the Buurtzorg model or something similar being adopted here: ‘I believe in their motto — “Humanity over Bureaucracy”.’ We’ve shown that the teams can work independently, and that they and their patients flourish when they do. That’s the easy part. Challenging the institutions and systems at play within the NHS and local government is the hard part.’
In the meantime, in the Netherlands, Jos de Blok has been asked to adapt the Buurtzorg model for acute care departments in hospitals and to consult on how systems could be adapted for the police. If Britain can only get Buurtzorg nursing right, it could be just the beginning of a Dutch-inspired revolution.
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