Aspects of the Buurtzorg model are in stark contrast to standard provision in England where ‘health’ and ‘social care’ are provided by two entirely separate systems. People requiring care at home are often seen by multiple staff members on a given day and may not see the same care worker or nurse again. The care that is provided is stipulated by strict protocols (for nursing) and limited by tight time restrictions (for social care, and increasingly nursing too). Staff in both systems usually work in strongly hierarchical management structures. These constraints undermine the ability of health and care staff to mobilise the full extent of their skills and motivation to support and care for the people they serve. So, could the Buurtzorg model work within this context?
In 2017 a group of NHS and local government organisations in West Suffolk, who had joined forces in a project to support older people to live independently at home, initiated a test-and-learn of the Buurtzorg model. They recruited a team of nurses and assistant practitioners to provide health and social care to people in line with the principles of the Buurtzorg model. The Fund has been working with this team to support them to learn about their experiences as they go along.
Here are five things we have observed about trying to implement the Buurtzorg model in England.
Ask not how you can implement the model, ask what the model can do for you
The challenge of implementing an entire care model in a new setting is that the impact of implementation is not predictable. A significant part of how things turn out is down to the people involved (and their attitudes, behaviours, values) and what else is going on in the local context (from the state of organisational relationships to national workforce crises). There is plenty of research that demonstrates that doing the ‘same’ thing in a new place will not look the same or produce the same outcomes as the original. And it may generate plenty of problems to boot.
It makes more sense, rather than implementing the model wholesale, to start from a position of clarity about what the change is trying to achieve, and to ask which aspects of a model such as Buurtzorg might help to achieve that. What seemed most powerful and inspiring to staff and patients in these early days of the West Suffolk test-and-learn was nursing team members having the time to really listen to patients/clients, and the resources and a mandate to act on what they learnt to provide that person with tailored support (themes we’ve heard elsewhere in our work on the Wigan Deal and mental health outcomes).
Develop infrastructure early
In the Netherlands, new Buurtzorg teams inherit already-established user-friendly information management systems, expert back-office support, a strong online peer network and expert organisational development support via a Buurtzorg coach. In West Suffolk, managers were admirably ambitious and counter-cultural in devolving as many decisions as possible to the new frontline nursing team. From the test location, through IT systems, to referral criteria, the team (with support) were in the driving seat. However, by doing the infrastructure development work themselves, nurses had to wait before they could get on with what they were really motivated by: directly providing excellent holistic care. We observed that more infrastructure development could be done in advance by management teams without losing too much of the spirit of the model.
Cultivate the ‘how’ of working as a non-hierarchical team
‘Hierarchy’ is written into the DNA of nursing, the NHS and social care sectors (and British society more broadly). Learning to work in a non-hierarchical way requires just that, learning. Teams need extensive support and time to develop and practise new ways of working together, fathoming out issues such as: how will we make decisions? How will we manage disagreements? How will we draw on and nurture expertise and specialisation without introducing a management hierarchy by stealth?
Working in this very different way, while developing a new type of service and capturing and acting on learning along the way, requires a huge amount from team members. To be able to learn, and to offer up innovative ideas, team members need to feel safe to make themselves vulnerable to others in the group without fear of negative consequences (however informal). For at least the first year of testing a model like this, developing ways of working and nurturing trust among colleagues are the most crucial points of focus.
Clarify roles and responsibilities, on repeat
Shifting to self-managed teams is a long and complex journey. Some colleagues need to let go of power and responsibility, while others need to step up. And they need to do this together, in a co-ordinated and evolving dance. There are bound to be toes trodden on, full-on collisions and unplanned gaps on the dancefloor. Absolutely critical throughout this is that people speak to each other continually about which responsibilities sit with which role. Don’t assume a shared understanding: work for it.
Take a performance break, and learn
The West Suffolk site was lucky to benefit from (and worked hard to nurture) support among senior leaders, who were effective in providing the team with a ‘heatshield’ from the wider performance demands of the system. But there was a tension between a desire to learn and discover what this model could really do for care; and a (at least perceived) need to prove its impact, particularly in reducing demand for acute services. The former tells you to slow down and move at the pace of the work, and the latter pushes for quick evolutions to a bigger scale in an effort to show effect, to the detriment of establishing something truly effective and sustainable.
Protect new ways of working from system pressures as much as you can. And system leaders need to take seriously the extent of the space and time (at least 5-10 years) required to cultivate genuinely new ways of working and to appreciate that the benefits of such innovations may show up in a range of ways not captured by emergency admission rates.
The full report of our work is available here (Agenda item 10).
A very useful blog Jo, which notes some key historical differences. I think it is true that Jos De Blok who founded Buurtzorg was inspired by district nursing teams in the UK when establishing his model. They had an established method of working as autonomous teams. My experience is that the power of this way of working is each team and organisation will need to develop different ways of working together. There are core principles and structures, but how they operate can flex to the needs of the team and most importantly to the needs of people who receive care. As the article points out, we already know that the ability to flex a model and make it our own is the key to any successful change initiative. As Rogers says “ we own what we create”. In this situation, if the objective is to welcome the whole person to work and to provide truly person-centred care, then of course each team will be different.
It was an interesting approach to offer the West Suffolk team the opportunity to develop infrastructure. In other places this has not been considered an option at all and organisations have either developed a firewall to protect them from core organisational practices or have dealt with the organisational culture and structure the best way they can. The latter, one of the reasons why many pilots of this type of working in the NHS have been unsuccessful. One aspect that I think is not covered by the article is the wider organisational commitment to change. We need to acknowledge that there are interests within our organisations that see these changes as a threat. I write more about them here https://www.linkedin.com/pulse/nhs-antibodies-kill-innovation-jane-pigh…
I have always been impressed by the ability of staff to step up and work with this approach. Many of us remember when social workers and nurses were expected to make decisions and practice based on ethics, supported by good reflective supervision not by rote. A move back into this messy space, where we can build relationships, make a real difference and live our values is a strong motivation to work through the challenges of working in this way. It is not for everyone, in the same way lots of staff left when the work moved to become bureaucratic and hierarchical, I expect a different kind of staff will be attracted back if organisations make this move.
I am grateful to see the recognition in this article of the timescales here. I agree. I think at least 5 years will be needed for any large organisation to make this move and embed a new culture. The tension between what we know will deliver a long-term advantage and the need to make quick (especially budget focused) wins is an agenda that plays out across the health and care system. For any organisation planning or starting out, these are the foundations that I have found to be helpful and I think are echoed in the article here https://www.linkedin.com/pulse/part-3-reinventing-health-care-fifteen-f….