No managers, no bureaucracy: how the Netherlands improved care for less

But can the "neighbourhood care" model work in other countries?

Alice* used to wait in her London home for a string of district nurses to visit and change the dressings on her leg ulcers. Discouraged by her lessened mobility, she became a shut-in, waiting passively at home for the arrival of her caregivers.

But then her care was transferred to a new pilot project. She was assigned a single nurse whose job was to get to know her well. Through unrushed conversation, the new nurse learned that Alice had once helped plant a commemorative tree for a friend who passed away. The nurse persuaded Alice to take her to see the tree. Regular outings followed. The renewed mobility cured Alice’s leg ulcers and within a few months she was discharged from nursing care.

Home nursing reformers say examples like this point to the need to correct the wrong path onto which district nursing has strayed. From the 1980s, a number of governments introduced sweeping reforms of home health care aimed at increasing efficiency and reducing costs. Yet in most cases, the results were not what had been promised. According to many analysts, quality of care took a downward plunge, while costs have continued to soar.

But an innovative approach that began 12 years ago in Holland is revolutionising home care in that country and has spread, so far, to two dozen others. Buurtzorg (Dutch for “neighborhood care”) has done away with most administration and management jobs and is instead run by self-managing teams of nurses.

The result, according to a number of evaluations and studies, is improved care and greater satisfaction among both patients and care workers. Buurtzorg has won half the home healthcare market in Holland. But it is encountering obstacles in some other countries, and it remains to be seen whether attempts to establish Buurtzorg affiliates outside the Netherlands will be successful.

First coffee, then care

In place of the array of caregivers who typically serve the elderly and infirm in their homes — nurses, home care aides, therapists, cleaners and so on — the Buurtzorg nurses themselves are responsible for providing all the care for their clients.

They can spend as much time as they need with each patient, taking a comprehensive approach. They develop close relationships with their patients, and can tap into family or community networks to improve the quality of patients’ lives. The organisation’s slogan is “humanity over bureaucracy”.

“It’s first coffee, then care”

When a Buurtzorg nurse visits a new client, she or he will typically sit down with the person to talk about their history, strengths, and interests (did they practice a sport or have a hobby, were they involved with a religious community or organisation, do they have skills they could share with others?), as well as their life goals.

“It’s first coffee, then care,” said Brendan Martin, managing director of Buurtzorg Britain and Ireland.

Although fully trained nurses cost more than other caregivers, the Buurtzorg approach ends up requiring substantially fewer total contact hours with caregivers, often resulting in overall savings.

Buurtzog was founded by Jos de Blok, a veteran home care nurse.

De Blok described a 1993 Dutch reform that introduced more rules and additional layers of management to home care as “ a disaster” for nurses and clients alike. Elderly patients got visits from a confusing array of caregivers — up to 40 in a month — resulting in fragmented and often ineffective treatment. Costs skyrocketed, and quality went down.

“The care organizations looked more like factories,” De Blok said. So in 2006, along with several colleagues, he founded Buurtzorg as a non-profit home nursing organization. “Our idea was to show that elderly care could be done much better based on trust and self-organisation.”

Starting in 2007 with one team of four nurses in the small Dutch city of Almelo, Buurtzorg has grown continuously and today employs 10,000 nurses in 850 community-based teams — half of the country’s community nurses. The organisation also employs 4,000 social workers who work in their own teams. De Blok said that his organisation grew by 10% last year.

Low admin costs

Buurtzorg employs only 45 back-office staff, who take care of payroll and invoicing. Administrative costs account for only 8% of the budget, compared to up to 25% for other home care organisations.

It operates as a social enterprise. Although a non-profit, the organisation is commercially self-sustaining with surplus revenues going into training, community events and other activities. The organisation had a turnover of 400million euros ($455million) in 2017 and served 100,000 patients.

Besides de Blok and his wife, there are no managers, leaving the nursing teams — 10–12 nurses caring for 50–60 patients in a given neighbourhood — to organise their work as they see fit.

The Dutch Ministry of Health, Welfare, and Sport was sufficiently impressed by the potential of the new model that within two years of Buurtzog’s launch it changed its reimbursement rules. Previously service providers had to bill separately for some twenty different categories of care but now they could bill for a single all-encompassing category labeled “community health”.

A 2009 Ernst and Young study found that Buurtzorg’s patients required care for less time, regained autonomy quicker, had fewer emergency hospital admissions, and shorter lengths-of-stays after admission.

Obstacles overseas

Buurtzorg is currently supporting efforts in 24 countries to replicate its model. The largest projects are in east Asia, with hundreds of nurses and other health workers involved in China, Japan and India.

In Europe, Buurtzorg Britain & Ireland, established in early 2017, provides consulting and other support to some 20 existing home care organizations interested in adopting the model. Martin told Apolitical that it has turned out harder than anticipated. “In all cases, the biggest challenge is not getting frontline staff to operate in an independent way but changing back office systems to support them well,” he said.

While consulting with existing organizations will continue, his group is switching its focus to creating new Buurtzorg-inspired home care organizations from scratch.

“There may be some reluctance from senior managers of district nursing as Buurtzorg would do them out of a job”

A study published this spring in BMJ Open, an online peer reviewed medical journal, evaluated the first pilot, set up in a low-income neighbourhood of London in autumn 2016. It found that many patients preferred Buurtzog “ to previous experiences of district nursing”.

Fiona Ross, a professor of health care research at Kingston University London, and one of the study’s authors, told Apolitical that the UK’s health funding system and the attitudes of some senior health care managers appear to be the biggest obstacles slowing the model’s wider adoption. “There may be some reluctance from senior managers of district nursing as Buurtzorg would do them out of a job,” she said.

Last year a small initiative named Buurtzorg USA, based in Minnesota, closed after it was unable to grow beyond four nurses and 25 patients in five years. “We had success delivering care,” said Michelle Muenich, an American nurse who directed the company. “The problems were financial,” namely securing payment from the two large government-funded health care programs, Medicaid and Medicare.

Meanwhile, Buurtzorg’s de Blok said a shortage of nurses is the biggest problem the organization faces in Holland, even as it has begun training nurses itself. “It is a barrier but also an opportunity,” he said. “The focus on prevention becomes more important. When we do that we need a smaller workforce.”

For supporters of Buurtzorg, the movement represents the best hope of allowing nurses to return to their profession’s central goal—caring for patients—by freeing caregivers from the straightjacket of bureaucracy. — Burton Bollag

*Alice is not the patient’s real name

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