I was watching the Florence Nightingale Conference 2016 remotely last week and I was delighted to see Jos de Blok., the CEO of Buurtzorg on the platform describing the evolution of Buurtzorg neighbourhood nursing service – he never fails to impress and his charismatic leadership shines through his presentations. As a Florence Nightingale Scholar I was privileged to actually visit Buurtzorg and go out on visits with a nurse and I have blogged about that experience here.
What struck me again last week was the question I keep getting asked – ‘Why can’t we do it like Buurtzorg here in England?’
When we visited the Netherlands I remember someone asking Jos what, in his opinion, was the biggest challenge in the UK to implementing a similar model to Buurtzorg. His response? ‘You are a brownfield site.’
Brownfield is a term used in urban planning to describe land previously used for industrial purposes or some commercial uses. Such land may have been contaminated with hazardous waste or pollution or is feared to be so.
For those of you who are unsure what his meaning was the term brownfield site is used in planning terms to refer to a site that has already been developed, in contrast to a greenfield site where there is no existing development.
The same terms are also used in software development and deployment, where the presence of existing systems makes the transfer across to a new system more complex; there are legacy systems to consider and potentially old networks, boxes and wires to deal with moving from old to new.
When Jos set up Buurtzorg he didn’t have to worry about any of those things. He was able to start small and build and set up everything from new. He was able to learn and test the approach as he went along and could make decisions about how fast to develop without dealing with a concern about maintaining a nursing service to existing patients.
So the answer to the question ‘Why can’t we do it like Buurtzorg here in England?’ is a complex one. But here are some of the potential answers:
- We have an existing service to maintain to patients, uninterrupted and maintaining safety – the shift from here to there is seen as too risky;
- We have an organisational framework where there would be some people whose roles would no longer be required (similar to old boxes and wires). Middle managers don’t exist at Buurtzorg at all;
- The Buurtzorg model requires executives to cede power to frontline staff and to stop many of the management processes that underpin the way we currently work;
- It requires high trust and bravery from organisational leaders and commissioners – tearing up existing boxes and wires;
- It requires nurses to stop seeing the hierarchy as the way to be promoted and to focus on increasing satisfaction through self-development of clinical interests;
- The Buurtzorg model does not really have specialist roles and nursing seems to have increasingly become specialised in the last decades; Is nursing up for that?
- Meeting regulatory requirements would be possible in the Buurtzorg model through the use of technology. But who would dare to have an organisation with such a small amount of checking and performance managing?
Just a few of my thoughts. If I had the power though, I would have a go. The experience of visiting with the nurse I spent time with was unforgettable and reinforced for me the reasons why I went in to nursing in the first place – as Jos would say ‘doing what is normal’ and what is ‘common sense’.
You can watch Jos talk about Humanity above Bureaucracy here. Listen to why he says he started Buurtzorg!
anniecoops 
So, if there is too much risk in changing from one system to the other, what we need is to run parallel systems so they can be compared. Is there an agency out there that will fund a starter team of 6 Buurtzorg Nurses to kick things off?
Great post Annie,
The ‘brownfield site’ analogy is spot on.
Where we start from is hugely inflential in how fast and how far we can move in another direction.
Huge ‘leaps’ and the Grand Transfornmations so often spoken about aren’t really feasible.
The point about starting small, testing and evolving is so right.
The Idea of a Minimum Viable Product is used in the IT industry.
I’ve been looking for an example elsewhere, I think I’ve found it here in your description of Buurtzog
Thanks
Chris
Last time I checked, it sounded like there were a number of Buurtzorg pilots gearing up across the UK. That was a few months back – I need to find out where things are now.
I was even talking to someone I didn’t know while waiting for the photocopier at work earlier today – turned out she works most of the time for a CCG, and there’s strong interest there in trying the Buurtzorg approach. This felt like a good sign!
But the challenge of changing the pre-existing NHS culture on ‘brownfield’ sites could certainly be a big one…
Here are various Buurtzorg news stories etc, from a website I co-founded last year: http://www.enliveningedge.org/tag/buurtzorg/
Matthew
Thanks everyone for your replies. For me there is something ‘pure’ about Buurtzorg. While I was there it was clear that the blueprint for each team was simple and applied consistently.
In the UK I hear about pilots but most are a corruption of Buurtzorg principles. They are more like shared governance, which is good in its own way but not what Jos has done. I am unconvinced that anyone can do what Jos did here in the UK. We can reduce management, implement various versions of shared governance but we can’t do this!
By the way I’m also a big shared governance fan. I have been to magnet hospitals. They stand out! X
I think this is a beautiful example of how hard it is to transfer policy and practice from one system to another. Starting conditions matter, history matters, relationships matter and often we pretend they don’t.
It would be lovely to think we could roll out business models like red carpets. But we can’t. Instead we can just encourage people to learn from what they see and act and decide differently in how they intervene to develop their own systems.
There will be some test and learns of the Buurtzorg model in the UK this year. Annie’s blog points to some of the reasons why it takes time from learning about Buurtzorg and starting a test and learn.
I first met Annie just over a year ago at a Transforming Community Nursing in London Conference where a Buurtzorg nurse spoke. Two of the nurses who first heard about Buurtzorg then are now leading test and learn Buurtzorg projects in their trusts. These tests will start small with one or more teams of around 6 nurses.
Our approach (Public World is Buurtzorg’s UK partner) is by encouraging sites to start as close as possible to the Buurtzorg model and then learn from the test if anything needs adapting to the UK / local context. This means being prepared to start a test without knowing the answer to some of the questions Annie raised.
A Buurtzorg team is based around a small geographical area and provides holistic care instead of purely medical care leaving personal care to unqualified home care workers. Therefore another reason these tests take time to start is gain a common understanding of the Buurtzorg model across the local system.
This is now happening in a growing number of places.
I will finish by pointing to Amstelring and Zorgaccent which you may not have heard of but they could be more useful examples in our context than Buurtzorg. They were both ‘brownfield sites’, existing community nursing organisations in the Netherlands operating in the time and task manner. They and others have successfully transitioned to adopting the Buurtzorg model. The message from Erik Verboom, Director of Home Care at Zorgaccent who now has over 60 teams of nurses directly reporting to him and no managers in between, is be brave and take the leap, it has put pleasure back into the life of a professional and gives the client pleasure too in the way they are treated.
Annie – lets talk soon.
http://www.publicworld.co.uk/the-blog/
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Thanks for great reply James. Can’t wait to see the pilots in flight properly. Let me know if I can help. A x
‘Why can’t we do it like Buurtzorg?...
Great comments and insights here. To avoid the perfect becoming the enemy of the good-enough we are working on small local Buurtzorg initiatives around the country. Yes, they are often adaptations of the Buurtzorg model, but local context is important; a key reason why in NL Buurtzorg teams have the freedom and mission to device their own solutions. If you’d like to follow our progress, check our website: http://www.buurtzorg.org. uk