Buurtzorg and Self-Management
Author: Simon Duffy
Recently I was lucky enough to spend a couple of days meeting people from Buurtzorg, a fascinating organisation that was founded in the Netherlands in 2007. Buurtzorg means ‘Neighbourhood Care’ and it now supports more than 10,000 nurses to provide support in 900 small local teams. The idea has spread rapidly and there are now over 25 countries experimenting with Buurtzorg’s approach, some with great success.
One of the founders of Buurtzorg and its current CEO/Finance Director/Personnel Director has won several awards for his work, including the RSA’s Prince Albert Medal; and most recently the Ideas Into Practice Award. He joked that it was interesting to get an award for management when his primary innovation is to take out all managers - and it is for this seemingly wildly and radical idea that Buurtzorg are best know:
We don’t need managers because nurses (or other professionals) can form self-managing teams that improve quality, morale, efficiency and prevention.
Of course this rather simplifies the true nature of the innovation. The beauty of the approach lies in the subtle interplay of freedom for professionals, continuity and flexibility of support for people and the use of a clear framework of minimal rules and systems that enable people to primarily focus on providing high quality care, preventing problems and strengthening community support.
One example of this smart simplicity are the four critical metrics applied by Buurtzorg:
- Are people happy?
- Are staff happy?
- How is staff sickness?
- Are people working within the budget?
The job of the ‘back office’ is to provide structures that support self-management and ensure that people are asked to do no more administration than is strictly necessary. The other important function of the Buurtzorg organisation is to protect teams from disruptive external bureaucracy and undue regulatory control. As Buurtzorg has grown it has been able to have significant policy impact in the Netherlands - changing the culture and helping other organisations to develop the same principles.
Will it work here?
At the seminar I met The Guardian journalist David Brindle who said he was rather skeptical:
“Could this really work in our hierarchical NHS?”
But - as Jos de Blok said - self-management isn’t really a wild and radical idea. It is how many professionals used to work in the past. He also revealed that his own 26 year-old son had just started working as a District Nurse with Buurtzorg, at exactly the same age as he himself had begun as a District Nurse in the 1980s. Moreover, at the beginning of his career, Job de Blok felt that trust, flexibility and cooperation were normal. But in too many places today these values have been corrupted and eroded by the management hierarchy, and the culture of distrust, regulation and control on which it feeds. His hope for his own son is that he will be able to learn how to be a nurse from within a renewed culture of cooperation and freedom, and that he will never have to suffer the mind-numbing bureaucracy that has blighted the last 30 years.
In a recent article for the Centre, David Zigmond, one of the Centre’s Fellows, argues that in the past the NHS also used to trust professionals to get on with their work, to collaborate and to perform, without all the dispiriting bureaucracy. It is not the UK’s class-based or elitist society that is the problem; in fact the growth in bureaucracy really began in Thatcher’s Britain (Zigmond, 2019).
It may seem a strange to think that Thatcher’s neoliberal philosophy has increased bureaucracy - but this paradox can be explained. If you fear or despise the welfare state, if you do not trust civil servants or professionals, if you want to create commercial opportunities for yourself or for your political allies then it makes perfect sense to impose burdens and controls upon the welfare state:
It is almost as if - in order to undermine the welfare state - those who hate it - must wrap it in the bureaucracy that they themselves claim to despise.
Neoliberalism claims to value freedom, but more fundamentally it is about promoting the meritocratic control of an elite group over the wider population - supposedly for our own good. This approach entitles politicians and their allies to dictate to professionals (and the rest of us) how we must work and what we must prioritise. This is not just a UK trend: the same trend can be found in Australia, the USA, Canada and New Zealand. In fact John O’Brien calls this ‘cogworld’ and (for all the seeming differences) the US experience of ‘managed care’ exactly mirrors the UK experience of purchasers, providers, contracts, commissioning, procurement and regulation (O’Brien, 2015).
Liberalism is not really about freedom for all - it is really about increased power and control for those who shape and control society.
Possibly this change is also more than ideological. I suspect that it is also linked to important economic and demographic changes. The growth in management roles was perhaps a natural overspill from the growing post-war middle class who sought to create more white collar jobs for themselves to occupy. At a time of economic growth this was natural and it is perhaps easy to invent solutions to problems that also created opportunities for increasing your own income and status. Meritocracy has many happy bedfellows.
But I suspect we are now reaching the end of a natural 40 year arc and the wheels are beginning to fall off the crazy market-bureaucracy:
- Market failure - Privatised services are going bankrupt, merging or taking over others. It is no longer possible to squeeze profit out of the system using the current methods.
- Technological change - Software is killing white collar jobs; there is almost no information that can’t be shared immediately - in a user-friendly form - with people at the frontline.
- New generation - The demographic shift in power has closed down traditional routes to career and money to the younger generation, although they are now better-educated than the generations that actually control money and opportunity. So some amongst the young are starting to looking for meaning and autonomy outside the old paternalistic career models.
- New ideals - More of us are starting to reclaim our citizenship, to demand equality and the right to make decisions together in our own places. The price of elitism is getting higher - which tends to lead to extremism and intolerance - is starting to appear too great and people are looking for a more hopeful and democratic future.
The conditions for change are here now, but the path forward is harder to discern.
Lessons from UK pilots
In the UK it is Buurtzorg Britain and Ireland, a member of Citizen Network, who are leading Buurtzorg’s development work and in the events I attended people described some of the early progress and also some of the challenges ahead. There is now work going on in Kent, Essex, Cambridgeshire and at Guy’s and St Thomas’ hospitals, in order to develop self-managed teams.
But as a Northerner I do wonder why it’s not happening in the home of municipal socialism. Surely Buurtzorg should be thriving in Sheffield, Barnsley, Manchester, Bolton, Newcastle and Leeds?
Participants from pilots sites explored the early successes and the challenges. Tania Eber (from Buurtzorg Britain & Ireland) interviewed Karen and Lauren to explore the practical impact of implementing Buurtzorg principles within a pilot in Medway:
The most striking innovation was the significant increase in continuity of care and the increased influence and authority of the sick or disabled person over their own support. Reducing external management and controls seems to have increased the opportunity for nurses to offer more flexible and holistic care, coproduced with the person and their family. There is always a named nurse, and that nurse can maintain a real and meaningful relationship with the person. This leads to a stronger relationship between the nurse and person, and this enables the person to have greater involvement and control over their own treatment plan.
The nurses themselves talked about the increased mental and physical health which results from being able to do your job properly and to work without undue stress. Non-qualified staff feel like they also have a valid voice and that professional boundaries have been reduced. In the past, when you struggled you went to see your manager. Now you go to a fellow team member or discuss things with the whole team. This also means that the team has a much better understanding of each other’s needs and the needs of the people they serve. This improves the quality of support when team members do have to cover for the named nurse.
Leadership roles still exist - but they are shared and rotated around the team. Interestingly even data collection improves. Reducing the fire-fighting and the super-quick visit means that staff can spend time asking the questions that let them gather the data they need.
Fundamentally the increased professional authority granted to nurses enables more humanity; people can be flexible and do things that previously they would not be allowed to do. As Brendan Martin (Buurtzorg Britain & Ireland) argued, many of the resources we need to increase humanity and quality in the nursing and social care are actually locked within the wasteful bureaucratic and over-managed systems which currently binds people.
“Everybody says we need more people; but we are doing things in ways that waste people’s time and doesn’t focus on enabling things to be done without people, or by working better with the person, the family or the community.”
However, Jo Maybin Fellow of The Kings Fund explored the piloting of Buurtzorg in West Suffolk. Here the piloting was not successful. The process created many additional stresses. People were put off by creating new self-managed structures, organising systems for themselves and they were not secure in their faith that this way of working would be sustained. It seemed here that the pilot had confused ‘self-management’ with ‘anything goes’. They had ignored the important details and structures that make the innovation successful.
Sadly this kind of poor ‘knock-off’ implementation is all too familiar to me from my time running In Control, during the development of personal budgets. People need to think more deeply about the structures, incentives and messages which a new system creates. Buzzwords are not enough.
This also suggests that there may be important lessons for implementation:
- Good infrastructure - There needs to be a replicable infrastructure that can take away unnecessary or distracting work. There is nothing wrong with some fixed structures that enable people to focus on the things that really matter to them in their professional work.
- Commitment - In a hierarchical system people may not trust that a shift in power is permanent and this then may make it much harder to invest themselves in the process. Ideally piloting needs to be part of a positive ongoing process with an established a mission and a confident new direction that helps people have faith in the process.
- Universality - Start with the people who are working in the system now. Don’t treat the innovation as if it requires new people, with new skills. We need to trust and support the existing workforce. If things are not working don’t blame them - instead ask why the system is not really supporting them in the right way. As Jos de Blok said: “Don’t make training in self-management too big.”
- Free space - It is very hard to make these changes within existing structures and even compromises can waste of energy. People need a free organisational space and new back office systems that they can rely on and improve over time. Simply tweaking the current system or merging it with the current infrastructure may create horrible and unsolvable problems further down the road. - “Throwaway the protocols!”
I was struck particularly by this observation by Jos de Blok which, I think indicates the kind of challenge we will face:
“We don’t give freedom; to give freedom assumes that the organisation is hierarchical and that you have the power to give or take away freedom. Instead we must start with professional ethics. The question is how do we serve people and enable people to live up to their own professional responsibilities and to help them avoid everything that is not necessary to that work.”
In other words, it is not about making professionals ‘decide everything for themselves’. Instead it is about creating a platform for people to do things that they really need to do as they see fit.
Innovation with integrity
It was a real pleasure to see the folk involved with Buurtzorg explore the issue of how to implement the idea in the UK in a way that will both respect its integrity but which can also adapt to the challenges of a different country. The reality is that bureaucracies do not die a natural death. They are staffed by people who need to defend their job roles and defend their mental models and they will usually have significantly more power than the professionals who are seeking self-management for themselves or their colleagues.
I suspect that Buurtzorg will have significantly more success than I did when I began the development of personal budgets in 2003. By 2009 I was forced to watch central government badly botch the implementation of the idea by shifting control to individuals and agencies who had no commitment, understanding or serious intent to make the innovation a success. The bureaucracy - with its meritocratic mindset - is not neutral - it has its own agenda. It is naïve to assume that government policies, laws or programmes will ‘make change real’.
In the end - realising that I had been seriously outmanoeuvred - I was forced to resign from In Control - the organisation that I had set up and led. It was a bitter blow. In this respect, Buurtzorg has great strengths that might help it stay immune to these problems:
Its thinking is rooted in a living-breathing reality in the Netherlands; this will be protected from UK policy changes.
There has already been serious consideration of the success factors for self-management and Jos de Blok and his allies will be free to observe and comment without any punishment.
But if it was me I would be thinking about how Buurtzorg could create a deeper sense of membership for the people, organisations and statutory bodies who are interested in learning with it. As Jos de Blok noted, making helpful positive systemic change becomes much easier when your numeric strength increases. A membership community can also cooperate in creating helpful systems and adaptions to suit the UK or local circumstances. For instance, in its early days In Control really benefited from:
- A membership programme for local authorities (at its peak there were over 100 members from a possible 150).
- Working with local government officers to develop and share models of good practice
- Counting progress on numbers of people receiving personal budgets
- Developing our own data, research and publications
The combination of these methods provided a powerful platform for influencing policy and for supporting positive change. What was deathly was to enable Government to own, control and standardise the innovation. This killed the innovation process and the development of personal budgets in the UK has not yet recovered from the initial spurt of apparent Governmental enthusiasm. As Buurtzorg knows very well - the innovation is not the original idea, it is the process of ongoing change necessary to realise that idea.
How do we protect the integrity of a good idea?
It is very easy for us to misunderstand, half understand or bastardise any social innovation. Moreover, as an idea starts to gain some attention and becomes somewhat sexy, there is also an incentive for people or organisations to ‘steal’ the idea (or perhaps just key words associated with that idea) and this can then lead to poor implementation and it may eventually even pollute the original innovation or its reputation. It is for this reason that I established the Centre for Welfare Reform and its Fellowship programme. I still believe that we need to work hard at sharing social innovations, but we must also protect the integrity of the social innovation by connecting and supporting those who are really working on it.
Buurtzorg is the future for public services. Or to be more accurate - it is part of the future. It represents the best form for the delivery of public services and I see no reason why many of its principles could not be extended from nursing to social work, social care, education, housing and many other community services.
However, implementing innovation is not easy, and implementing innovation amidst the current chaos of UK politics is something else altogether. I think it will be very important to establish a strategy for implementation which both protects the integrity of the idea, while also building and managing the momentum of that idea. A way in which people could join Buurtzorg might be helpful.
I think more attention could be given to the principles of human rights and self-directed support. Given the outcomes people experience it seems to me that there would be many potential allies for Buurtzorg from within the Independent Living Movement and those wanting to see the rights of older people or people with complex needs respected. This feels like an underdeveloped area. In particular I think there could be an interesting collaboration between Buurtzorg and the work to advance the use of Individual Service Funds as a more manageable alternative to Direct Payments.
Buurtzorg is about citizenship. The citizenship of the professional - trusted to work within a framework of professional ethics and the citizenship of the people they serve - empowered to live a life of meaning and contribution. I think it would be very productive to explore the way in which Citizen Network could support and advance the work of Buurtzorg.
O'Brien J (2015) Surviving Cogworld? Madison: Developmental Disabilities Network.
Zigmond D (2019) NHS Reform: Money Can't Buy Love. Sheffield: Centre for Welfare Reform.
The publisher is the Centre for Welfare Reform.
Buurtzorg and Self-Management © Simon Duffy 2020.
All Rights Reserved. No part of this paper may be reproduced in any form without permission from the publisher except for the quotation of brief passages in reviews.