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Going Dutch in West Suffolk: learning from the Buurtzorg model of care


Writing about Why the Dutch are different, Ben Coates describes how distinctive cultural practices of directness, tolerance and co-operation in the Netherlands are (at least partly) rooted in a history that required different communities to work together to establish and maintain drainage systems to rescue these lowlands from the sea.

So perhaps it is not surprising that this is the nation that has cultivated a model of health and social care provision in which professionals work collaboratively in non-hierarchical teams to provide holistic care.

The Buurtzorg model of care, developed by a social enterprise in the Netherlands in 2006, involves small teams of nursing staff providing a range of personal, social and clinical care to people in their own homes in a particular neighbourhood. There’s an emphasis on one or two staff working with each individual and their informal carers to access all the resources available in their social networks and neighbourhood to support them to be more independent. The nursing teams have a flat management structure, working in ‘non-hierarchical self-managed' teams. This means they make all the clinical and operational decisions themselves. They can access support from a coach, whose focus is on enabling the team to learn to work constructively together, and a central back office.

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 on our website.