Business Clinic
Homecare – Learning from the Netherlands

Last month’s CMM featured news about homecare teetering on the brink of collapse. The system is feeling pressure from all sides and something has to give. Is this Dutch approach the answer?

The pressures facing the homecare sector are well-known. It is a system that is already struggling to meet competing demands of more clients with higher needs, tightening local authority budgets and legal challenges over the payment of National Living Wage. Providers are becoming increasingly unable to meet the needs of the people under local authority contracts.

Added to this, the sector is now facing the new National Living Wage, which the United Kingdom Homecare Association has warned will bring ‘serious risk of catastrophic failure’ to homecare if it isn’t fully-funded by the Government. This could lead to the continued supply of state-funded homecare becoming unviable at a time when the Government needs social care services to support the NHS; particularly helping people to leave hospital promptly.

Dutch homecare sector

Buurtzorg means ‘neighbourhood care’ and is a Netherlands-based, not-for-profit homecare provider. Developed in 2007 by Jos de Blok, a community nurse who had studied economics, its approach to homecare is delivered via self-governing teams of nurses. At the time it was set up, the country’s homecare sector was becoming fragmented. Jos de Blok explained how the market worked in a recent TEDx Geneva talk. He explored how a Government policy to professionalise the industry had seen an increase in managers, a large number of different service offerings and an accompanying increased amount of bureaucracy.

As a result, nurses had to decide the type of care to deliver to each individual with many different levels of service to choose from. However, the clients’ needs hadn’t changed, just the system. This led to increased administration and staff feeling under pressure to account for every aspect of their day, from care delivered to travel times. The resulting effect was that it added to workloads and detracted from the role of delivering care. The professionalisation of the sector, Jos explained, actually led to it becoming fragmented, quality dropped and costs increased. Also, there was little continuity of care, with a number of different care workers visiting clients, plus a predicted shortage of nurses on the horizon. This all sounds familiar.

Buurtzorg approach

To counteract this, Jos de Blok set up Buurtzorg. Developed to strip out the bureaucracy, small teams of nurses work together autonomously in defined neighbourhoods. There’s no management or hierarchy, only administrative support at a small head office with Jos and his wife at the helm. The nurse teams support each other and their clients, building community links and helping to meet the needs of their clients locally by working together to solve problems. Teams of up to 12 nurses support 40 to 50 clients in small neighbourhoods, where they can build relationships and get to know everyone in the community. The nurse teams know their clients well, support them and tend to both their health and social care needs.

The nurses have shared values and openly support each other. They work together to organise their days, manage their clients, pass on important information, solve problems, lead their own training and work within the wider community too. The nurses are central to integrating the local services around the individual, including working closely with health colleagues and family carers to ensure care is co-ordinated, tailored and works. Clients include those with long-term conditions, disabilities and dementia, those in need of end of life care, older people with co-morbidities and anyone needing reablement following a hospital stay.

Although the clients are the same as those supported by homecare here, by being autonomous teams, they are not caught up with bureaucracy or paperwork. IT solutions have been introduced to reduce paperwork and administration and the back office administrative staff undertake any paperwork that needs to be completed. This leaves the nurses to get on with what they do best: care for people.

The company grew quickly from the outset, with more nurses hearing about the Buurtzorg approach and wanting to be involved. As the teams are self-managing, this didn’t have a huge impact on the company and the growth was sustainable.

In 2015, Buurtzorg has 8,000 nurses working across 800 teams. It boasts the highest customer satisfaction of any homecare provider in the Netherlands, costs are 40% lower even though nurses are highly educated, with 70% being registered nurses and 40% holding a Batchelor’s Degree. And it has been voted the best company to work for three times.

Growing interest

Although developed in the Netherlands, the approach has picked up a lot of overseas interest. It has been discussed in in Sweden, Australia and Japan. There is Buurtzorg USA which was established last year, and Jos de Blok has spoken around the world about how even the most complex of homecare structures can be simplified to become autonomous nursing teams.

In the UK it has been looked into by the Royal College of Nursing, The King’s Fund, the Scottish Government and the Chair of Public Health Wales. Public World Consulting organised a recent event with the Royal College of Nursing and the United Kingdom Homecare Association to explore the model. Public World Consulting is also working with Guy’s and St Thomas’s NHS Foundation Trust and Buurtzorg to test the model.

Over to the experts…

We have a very complex, but also very fragile homecare market. Could the Buurtzorg approach to autonomous homecare work here? Could it be the answer to England’s homecare situation? Would our levels of regulation and compulsory training impact on its success? Is such a drastic change to the system possible to implement? Or is it worth trying as the sector is facing ‘catastrophic collapse’?

An attitude shift is needed

Buurtzorg offers a fascinating model for joined-up health and social care. There are certainly lessons from this model which could be implemented here. Buurtzorg boasts impressively low operating costs, with minimal bureaucracy and excellent use of IT. Its success also seems to come from the use of small-scale teams of non-hierarchical, self-directing registered nurses, whose professional development is well-supported. The shrinking pool of registered nurses is well-documented, and increasingly a well-trained homecare workforce could be future district nurses.

There has been lots of interest in Buurtzorg in the UK, but few attempts to put it into practice. I think there are three interlinked issues to overcome: money, training and trust. The costs of developing homecare workers with similar training and skills afforded by up to three years of nurse training are unlikely to be met by the State in a grossly underfunded system. Nurse education also equips people to become accountable individuals, recognised through a professional register. A move which Government (in England) has repeatedly ruled-out for social care workers on grounds of cost.

The vast majority of cash-strapped councils continue to commission homecare prescriptively, with care purchased in minutes at extremely low prices. This is where trust comes in. Employers must equip staff to take on significant autonomy, while councils must learn to trust their providers to deliver reabling services and allow flexibility for the right care to be delivered for individuals, whose needs change regularly. An attitude shift is needed to deliver this model successfully. It might even be unrealistic to look to underfunded councils or CCGs to drive this model.

It may well come from providers to the self-funded market, where prices allow greater risk-taking and innovation.

Colin Angel Policy and Campaigns Director, UKHCA

There are fundamental barriers

This model is clearly an effective combination of elements which deliver successful outcomes for both the workforce and those receiving services. However, there are some fundamental barriers when considering its transfer to the UK.

Our regulatory, commissioning and funding framework provides a very different backdrop. Developments in integration, co-location, professional training and more trusting partnerships amongst services would be required. Trust issues and funding fears drive barriers between central and local governments, the NHS and providers. We only have to look at the Better Care Fund rollout to see the challenges.

Buurtzorg relies on essential components: informal networks of neighbourhood resources, high staff ratios of qualified (and professionalised) staff, integration of medical and support services and flat rate ‘per hour’ payments. Mainly, things we want to achieve here are involvement of family and community, seamless integrated services and a widely accepted fair price for care.

But our society is fragmented, our system has a diminishing workforce with little support to professionalise, not enough nurses to deliver essential clinical care, a lack of investment and continuing absence of robust private insurance models to support this type of service. Most importantly, we have dangerously undermined that vital bond between the frontline staff and the person receiving care.

It is unsurprising that the model is so successful, it seems simple: co-operation between essential service elements to give holistic care with autonomy and trust given to the frontline professionals. Would it work here? There are glimmers of similarity in the development of some clinically-led social care teams and with nods towards proper outcome-based commissioning but we have some way to go.

Raina Summerson Chief Executive, Agincare Group

I believe it is worth trying

Buurtzorg: the concept and the way it works is undoubtedly fascinating. It immediately reminds me of Nurse Fleet on her bicycle in the village where I grew up, where she was the district nurse, midwife and health visitor. By being highly-trained, accessible and resourceful she was able to be completely flexible in the work she did, solving complex problems for all age groups and varying her routine to accommodate changing demands on her time.

But Buurtzorg is not a case for turning the clock back to a nostalgically constructed community. It is a contemporary and vibrant model recognising diversity of need and, importantly, seems well-supported by IT. Reducing bureaucracy is important for nurses, but they still need to keep good records to satisfy the adage that ‘if it’s not written down, it hasn’t been done’. There is something to learn from Buurtzorg which doesn’t have the administrative demands of a system based on commissioning and inspection regimes.

A personal approach to care is very attractive and one that is based on meaningful relationships sounds very satisfying for both the client and the nurse. And, crucially, such relationships are based on trust. This is key to Jos de Blok’s creation of Buurtzorg, in which the nurses work with no management structures and are self-organised. In this model, nurses can exercise a great deal of autonomy and many of our current district nurses already do: they are co-ordinators of care, they won’t say ‘it’s not my job’ – they might not do the job, but they readily get it done by someone appropriate – and many are prescribers. So there are no impediments when it comes to nurse regulation or nurse training, in fact the freedoms nurses have craved for years are now available to support this model. And I believe it is worth trying.

David Foster* Head of the Nursing, Midwifery and Allied Health Professions Policy Unit, Department of Health

*These views are personal and professional and do not convey Department of Health or Government policy.

 

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