The Dutch model of Buurtzorg Care provides an alternative model of care across health and social care, could we learn from this tried and tested model?
The provision of care for older people is a case in point. The organisational culture of some providers in our current system leave some older people neglected and without support where surviving the ‘system’ takes precedence over ‘thriving’, and often leads to unnecessary hospital admissions through poor levels of support at home. This is not about lack of resources but the poor allocation of resources.
As a social work practitioner I saw at first hand how good quality home care could reduce admissions to hospital. Good quality care at home can reduce, or even prevent, carer breakdown. It can support good nutrition which is essential to optimise both physical and mental health, for example by reducing UTI’s (urinary track infections) one of the core reasons I found for many avoidable admissions to hospital.
Avoidable and unnecessary admissions are incredibly detrimental to older people, and especially for those whose lives are touched by dementia, not to mention extremely costly. Decisions re admissions are not taken lightly, however, GP’s are often faced with the dilemma of admitting someone with dementia to hospital because that is the only option, not the best option. Any savings made on reducing the cost of unnecessary admissions to hospital would, I’m pretty sure, more than cover any cost incurred in reconfiguring care services provided at home.
We know care provision in the future is going to have to cope with growing numbers, so we need a system that is sustainable. The notion of sustainability in this context could draw on the ecology movement, where sustainability is defined as “development that meets the needs of current generations without compromising the ability of future generations to meet their needs”. This captures two important issues facing care today, the need to support those currently requiring care without compromising the future of the care system to accommodate a growing number of users within budgetary constraints. At first glance the two may appear irreconcilable, however, by building on the drive for personalisation and person-centred dementia care, alongside reshaping organisational ‘cultures’ new concepts and models are able to evolve which can contribute to developing relationship based complete care.
Complete Care: a model in practice – Buurtzorg Nederland
Providing a new form of service provision able to incorporate the principles of relationship based care and capability, along with notions of ethical practice and sustainability will require a re-organisation of the way in which we currently use resources to deliver care at home. Research from KMPG International (2012) highlights how Buurtzorg Nederland might provide a blue print for such a model.
The founder of Buurtzorg Nederland, Jos de Blok a district nurse, became frustrated with the way traditional services were focused on policy, targets and administration rather than on care and compassion. So he decided to develop his own model where his role as a nurse regained its explicit social value to the community he worked with. Buurtzorg was founded 10 years ago and started with an initial team of four. The system that evolved deploys teams of up to 12 nurses, who are responsible for between 40 and 60 people within a particular area. There are now around 900 teams in the Netherlands, supported by no more than 50 administrators and 20 trainers.
In the Netherlands, the financing and delivery of care in the community is highly fragmented with various tasks – such as washing the patient, serving meals and putting on elastic compressions – paid through different reimbursement schemes and, more often than not, executed by different professionals. As a result, patient care tends to lack coordination, making it difficult for the care providers to respond appropriately to changing patient conditions, which in turn leads to compromised continuity of care and low patient satisfaction.
At the same time, many home care service providers have cut costs by fine-tuning the minimum skill level required to accomplish each task. Dutch home care also tends to be focused on responding to patients’ current problems rather than preventing deterioration, meaning that interventions are generally added on only once the patient’s condition has already worsened.
To respond to these challenges, the home care organization Buurtzorg (meaning neighbourhood care) was created to focus on increasing patient value. Essentially, the program empowers nurses to deliver all the care that patients need. And while this has meant higher costs per hour, the result has been fewer hours in total. Indeed, by changing the model of care, Buurtzorg has accomplished a 50 percent reduction in hours of care, improved quality of care and raised work satisfaction for their employees.
How it led to productivity improvement
One of the keys to the program’s success is that Buurtzorg’s home care nurses organize their work themselves. Moreover, rather than executing fixed tasks and leaving, they use their professional expertise to solve the patient’s problem by making the most of their clients’ existing capabilities, resources and environment to help the patient become more self-sufficient, visits focus on the person not the task. Simply put, even though Buurtzorg professionals’ visits are not time limited the aim is to make themselves superfluous as soon as possible, versus other providers who tend to execute tasks without truly focusing on the patient’s overall capability.
Buurtzorg uses small self-steering teams (with a maximum of 12 nurses) who attend to an area of approximately 15,000 inhabitants and work together to ensure continuity of care. As a result, the professionals build durable relationships with their community, which further strengthens their ability to find local solutions for patients’ problems. Although the teams are independent and self-steering, they are supported by a centralized service organization which provides management information to both the team and the organizations’ leadership in order to minimize local overhead and maximize the professional’s face-to-face time with patients. Every team is responsible for its own clientele and is in close contact with those who use services, their families and doctors. Teams are also responsible for their own financial results.
In just two years, more than 2,000 nurses have joined the program despite the increasingly tight labour market for nurses in the Netherlands. Indeed, by 2011 Buurtzorg employed 4,000 nurses and nurse assistants working in over 380 autonomous teams.
Preliminary results show that Buurtzorg‘s patients consume just 40 percent of the care that they are entitled to and half of the patients receive care for less than three months. As a result, patient satisfaction scores are 30 percent above the national average and the number of costly episodes requiring unplanned interventions has dropped.
I spoke with Jos de Blok a couple years ago, and in the years since it’s inception he is as enthusiastic as ever and rightly proud of the difference his teams are making to the lives of those who require support in the community, as well as the professionals delivering care. Surely these would be good outcomes for us all?
One issue is funding: the Dutch model is tailored to payments by health insurance companies, not a state healthcare system like the NHS or means-tested social care. I’m no advocate of privatisation, I believe models such as this could be utilised within a National Health and Social Care Service, which is publicly funded, to provide sustainability for the future by reinvesting profit into the system, rather than giving it to shareholders and bonuses for CEO’s and the like.
It is suggested another potential issue is the scrapping of hierarchies and specialisms within the nursing teams: a Buurtzorg nurse might administer wound care, but may also help someone to wash or get dressed. I feel the segmentation of care needs is dehumanising as individuals become defined by a series of tasks, rather than the person they are. If I undertook wound care, would I really mind also washing and dressing that person, no I would not, I would see it as part of caring for that person. So I do not see a problem with this.
Some might see a third challenge, in that the model requires management to back off and allow their teams considerable latitude, with much less performance monitoring than has become the norm in, for instance, the UK. Bureaucracy is reduced to a minimum.
Many professionals in the current system would see this as a positive!
Government has to change its focus on the continued privatisation and marketisation of care as a commodity to be bought, sold and traded.
How we design and deliver ‘Care’ tells us something about us as a society, the constant focus on profit disfigures us all.