Amid all the doom and gloom about the state of health and social care in Britain, imagine if there was a practical and proven initiative that showed improved outcomes, a procession of professionals wanting to work there rather than leave, and reduced costs?
Wouldn’t you want to learn more about the reasons for such a success and to make it happen where you are?
I certainly did, which is why I took myself off to the Netherlands eight years ago to meet Jos de Blok, the founder of Buurtzorg, a social enterprise that has grown from a 2007 start-up into the leading Dutch provider of community services.
A global exemplar
Buurtzorg – Dutch for ‘neighbourhood care’ – has achieved all those results and continues to innovate through an organisational approach that has become a beacon – not only in health and social care – but as a global exemplar of new ways of working generally.
It has grown into a €400m business, with more than 900 local teams and a growing number of offshoots in mental health, homecare and more. Health and care teams all work in accordance with their professional training and ethics to do what is needed to help their clients to thrive.
They start with what matters to the person they support by considering their social environment of family, friends and neighbours. They also achieve this by drawing on community assets and other professional services to combine personal autonomy with warm social interaction.
To work in this creative, person-centred and relationship-based way, the teams must have professional freedom with responsibility. For this reason, all Buurtzorg teams of nurses are self-managing within a simple and clear framework of normative standards.
Bringing Buurtzorg to Britain
The framework defines professional expectations in terms of care quality, teamwork, and resource use. What this means in practice is setting the norms and boundaries within which the teams manage themselves.
They are supported by regional coaches, home-grown digital tools and a lean and agile administrative hub based in the small eastern Dutch city of Almelo. Jos invited me to Almelo back in 2015. We got on well and went on to found Buurtzorg Britain and Ireland and bring several delegations of British NHS and social care providers to meet and shadow Buurtzorg teams.
On the first of those visits, I was accompanied by Cepta Hamm, who at the time was the newly appointed Head of Community of Nursing at Guy’s and St Thomas’s NHS Foundation Trust (GSTT) and is now an associate with my business-to-business social enterprise, Public World.
Cepta returned from the visit inspired to apply Buurtzorg principles in Lambeth and Southwark, the two south London boroughs served by GSTT, in partnership with their local authorities. You can learn about how they got on by reading an early independent evaluation and a more recent account by some of the nurses involved.
That was the first of a number of experiments in Britain, the largest of which was the recently completed Transforming Integrated Care in the Community (TICC) project, which was part-financed by the European Union (it was arranged before Brexit).
TICC was a cross-border project involving community health and care providers in Belgium and France as well as in the United Kingdom, which was represented by Kent Community NHS Foundation Trust, Kent County Council and Medway Community Health.
With the support of Buurtzorg itself and Public World, the project partners created new teams or supported existing ones to adopt the Buurtzorg approach. The aim was to discover what gets in the way of implementing a successful innovation in one EU country into a different environment. The project also aimed to explore how to overcome the barriers and challenges, with adaptations to the original model as necessary.
Learning by doing
We certainly did identify some barriers and challenges – the TICC project report details around 250! Some were generic, such as the difficulty of any kind of organisational change and shortages of district nurses and funds. The global pandemic didn’t help either.
Others related to the model itself. For example, if you’ve worked in a ‘command and control’ environment all your professional life and have had no time to do more than assigned tasks with your clients, the shift to self-management and relationship-based care can be demanding as well as liberating.
The project enabled us to learn a great deal about how to enable and support professionals to make the transition. Also, our experience will find expression in a new set of e-learning materials and back-up workshops Public World is launching at a Buurtzorg Academy this autumn.
However, by far the largest category of barriers and challenges to optimising the potential of the model arose from mismatch between what is required to enable and support professionals to work in the Buurtzorg way and their organisational and institutional systems.
This manifested itself in a number of ways. For example, perverse performance indicators, fragmented service silos and administrative and IT systems ill-suited to the model. The project partners tried a variety of ways of overcoming these obstacles. These included workarounds and the creation of administrative bubbles, so that two different approaches were co-existing in the same organisation.
Creative and resourceful though such solutions were, they did prove limited at best. There were barriers to scale the project and evaluations from some of our other experiments at GSTT faced similar challenges.
No wonder Jos de Blok himself, having tried for some years to put his organisational thinking into practice as a senior leader in one service provider, decided eventually to go back to the basics of his training as a district nurse and build Buurtzorg from the ground up.
But that doesn’t mean necessarily that we have to do the same in Britain. Indeed,
Buurtzorg’s influence in the Netherlands and internationally suggests that important though it is to have a successful exemplar, where there is a will there are ways to apply the lessons of its success to existing organisations.
A movement for change
Our next steps are to create a Buurtzorg Care UK social enterprise to provide neighbourhood care in Britain and to build new digital and administrative infrastructure to support, not only our own teams but others willing to join us in a movement for change.
We are starting in domiciliary care, in the Cambridgeshire town of St Ives, building on the success and learning from one of our earlier experiments with Cambridgeshire County Council (Neighbourhood Cares project).
Unlike Buurtzorg in the Netherlands, this will not involve the clinical aspects of nursing, although we very much hope that, as Integrated Care Systems develop and grow in confidence, they will see how much more could be achieved by extending the model into holistic care, cutting across the institutional boundaries that the TICC project confirmed as a barrier to success. We also hope that many will join the TICC partners, the GSTT community teams and, in social care, charities such as the Thistle Foundation in applying and adapting the model to their own purposes. We invite them to join our community of practice so that we can all learn from each other.
Learning doesn’t mean copying, even though there are, of course, practices that Buurtzorg and some of our partners have developed that can help, such as our approach to team meetings that combine democratic participation with solution focus and brevity.
More fundamentally, however, to learn from Buurtzorg’s success is not to copy what it does but to go back to the first principles it applies.
That means starting from clarity of purpose – in Buurtzorg’s case it is to support people to live with as much autonomy and meaning as possible – and to enable and support the professionals to do what is needed when it is needed, learning and improving as they go.
And it means enabling and supporting the working practices required to fulfil that purpose and providing the digital and administrative back-up needed. That is where the tools we are currently developing with our IT partner Sitekit Care, with the help of a grant from Innovate UK, will come in.
Rebuilding the system
My motivation for founding Buurtzorg in Britain came from caring for my own mother towards the end of her life. I’d found that committed, compassionate and resourceful homecare staff were undermined by systems that should have been supporting them.
It showed me how everything I had learnt in an international career of supporting public service professionals to work with greater freedom and responsibility, could apply to improving homecare services.
Or, as Jos de Blok himself has put it: ‘We started working with different countries and discovered that the problems are the same: The message every time is to start again from the patient perspective and simplify the systems.’ If you’d like to know more, please follow the links in the online version of this article and give us a shout.
We’re always glad to explore collaborative possibilities with others who share our belief that the existing model of social care needs not just fixing but rebuilding.