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= Community Nursing organization in the Netherlands



Mark Thompson:

"The Buurtzorg community nursing organisation has a back office of 30 people to support 7,000 frontline nurses. It has almost no middle management – no HR, legal, estates, comms, finance, IT, procurement and so on. An audit firm reported that 40% fewer hours of care are required by the organisation’s patients, and its nurses have 60% less absenteeism and a 33% lower turnover than other nursing organisations.

This organisation has been able to provide a radical increase in frontline services, of much better quality, with greater satisfaction for both patients and carers – and for much less money. No one in the UK has been able to do this.

Now for the interesting numbers. The audit firm suggests that Holland could achieve savings of €2bn each year if all of its nursing organisations achieved similar results. Grossed up for the UK, that’s almost £6bn saved, every year. Just in community nursing.

If we were to follow a similar, back-of-envelope approach across the UK’s public services, what sort of numbers could we release and redirect to the frontline? There are around 5.3 million UK public sector workers, 1.1 million of them in public administration. If we add 400,000 for the NHS, we get 1.5 million non-frontline public sector workers, at a cost of £36bn (assuming an average salary of £24,000). The Dutch model has a ratio of back office to frontline workers of 30 to 7000." (http://www.theguardian.com/public-leaders-network/2015/feb/12/uk-voters-cut-public-services-amazon-spotify-uber)


Anna Betz interviews the co-founder, Jos de Blok:

  • Anna: So you started in late 2005 and early 2006 with friends. When was it that the government or ministries became really supportive?

Jos: That was in 2007. At that time we had 3 locations, and in May or June we were on television for the first time. One of the political parties said ‘We want to make a report’ and after that in August 2007 the minister of health joined one of our nurses in the teams in the neighbourhood. Together with a nurse he went to visit patients, which was followed by a roundtable meeting with various ministers and nurses.

Nurses talked about their feelings, their profession, the difference between the way they worked before and how they work now. As ministers they were actually very authentic. They understood very well what the difference was and how nurses were struggling in the old system and how they could just do the right things in this new environment.

  • Anna: What governance and decision-making models do you use in Buurtzorg?

Jos: The way things are working is based on some logical guidelines. So we say in community healthcare, there will be the daily routines based on the care for the patients. These routines are quite logical. Of course the way things work out can be a little bit different but they are based on the standards of good quality care. Our aim is to deliver the best possible care. So we have to define what that is.

In decision-making we choose the consensus model. Everyone in the team has to agree with a certain decision. Of course there have been some challenges.

We learnt a lot of things and developed trainings. I worked together with some friends who did coaching, and I ran a coaching agency myself. Based on our experience, we wrote articles on our web about topics that came up. For example, how to deal with conflict, how to have an effective meeting, or how to divide roles.

Every time when there were some issues, we thought it would be good to talk about them, and we wrote an article about it. It also meant that every team, whether they were just starting as a new team or already had been running, could have a training on the different topics that came up for them as a team. At that point, we developed two half-day trainings.

  • Anna: Did that training help to bring everyone to a similar level of understanding and make consensus-based decision-making more effective?

Jos: That was one of our struggles. There were teams who did have that problem, and there were teams who had a good and effective way to work with consensus. Teams who struggled with it were advised to have a training on decision-making, for example.

Whenever you meet a challenge or problem, this is an opportunity to learn and find out how to deal with it. Maybe you need to book a training or coaching session or both.

The key is that training or coaching should be available as and when you need it. The central organisation always supported teams and individuals to book training and coaching sessions as and when they needed them. The development of the role of the coach was very important in that. By the end of 2007, we had our first coaches who were always available when a team or individual was struggling. We always advise everyone to ask for support, and coaches would always offer whatever kind of support was needed. We didn’t have guidelines or structures to say “When you have this, you should do this.” (http://www.enliveningedge.org/features/jos-de-blok-founder-buurtzorg-speaks-journey/)


Mark Thompson:

"I am raising the long-term possibility of a bold reconfiguration of our public sector, away from management and back to serving the public. My speculative numbers suggest that the election choice of “more taxes or fewer services” may be a confected nonsense that masks a deep-seated political and bureaucratic reluctance to entertain a reform of our own public sector along similar lines to that achieved by Buurtzorg. The electoral truth is that the Victorian-era plumbing of our public services is irreparably broken, and that no matter how much money we pour in at the top, or how much we cut services, we won’t solve the problem. We should distrust anyone who says they can.

So why do I think this fundamental reconfiguration of our public services might be possible? Well, the sorts of emerging business models that we’re all familiar with (leaving aside the issue of whether these companies pay enough tax: remember, we’re talking about keeping the money within the public sector) such as Spotify, eBay, Airbnb, Rightmove, Uber and Amazon, all broker new, direct, relationships between people, services and things. They also improve as they go by harvesting data, to ensure they’re always giving people what they want.

All of these organisational models succeed by enabling providers of services and products to connect with consumers in a much more direct, flexible, and cost-effective way. Importantly, although clever digital technology mediates this relationship, it doesn’t need to replace it: think of sites that allow people to choose their taxi driver – or their next date – in a much less haphazard way that puts the consumer, not the provider, in control.

It is worth bearing in mind that all of these new models have been vigorously resisted by incumbent organisational structuresthat in effect extract rent from brokering this relationship. We need to think about how the politics of modernising our public services along these lines might play out. Although all savings would remain in the public sector, by radically redirecting public money away from bureaucracy to face-to-face services there will inevitably winners and losers.

Doctors, nurses, teachers, home visitors, librarians will be winners. We’re told we must learn to live with fewer of these people, but we could actually have more if we sorted out our organisational model. The other big winners are, of course, the customers: everybody who consumes public services.

Long term, the losers will be the legions of workers in hierarchical organisational structures – private or public sector – who, like the record company executives in the 1990s, play a less important part in post-bureaucratic organising.

Of course, our public services are different from the likes of Amazon or eBay. They’re often the last safety net protecting the welfare of citizens – but are also a monopoly in which those citizens lack a choice. Public organisations therefore need careful regulation to ensure public money is spent fairly and wisely – and this will require valuable non-frontline roles. Nonetheless, my point remains: if progressive taxation and cuts are unable to safeguard our current public service model, it must be time to consider some of the newer ways of organising that which we all take for granted in our daily lives." (http://www.theguardian.com/public-leaders-network/2015/feb/12/uk-voters-cut-public-services-amazon-spotify-uber)

More Information

Pat Conaty writes: "This six minute video by Buurtzorg’s founder, Jos de Blok shows how they revolutionised social care and community nursing in the Netherlands by using platforms like Uber has done but not to rack rent taxi drivers for Wall Street hedge funds but to secure the savings for higher pay and higher care quality. They began with community nursing in 2007 (today 10,000 jobs and 850 teams and workers are the managers), then moved on to home care (4000 jobs), now moving on to mental health, midwives, youth work and other care fields. John just think what this could do for advancing economic democracy and social co-operatives? Buurtzorg (which means Neighbourhood Care in Dutch) is a commons co-op way forward in embryo I think." (email January 2017)