First coffee, then care. This is the simple mantra of a model of nursing that has been transforming older people’s care in the Netherlands, and is now starting to have an impact in the UK.
The mantra sums up what’s at the heart of the Buurtzorg Model of care. ‘It means finding out about the whole person, what matters to them, and what their goals are,’ says Brendan Martin, managing director of international social enterprise Public World, which also trades as Buurtzorg Britain and Ireland.
This February’s new White Paper proposals for health and social care could be a means to further enable the Buurtzorg Model of Working in England. ‘We hope the paper’s emphasis on place-based integration will create more favourable conditions for experimenting with joint commissioning at neighbourhood level, through Primary Care Networks (PCNs) within Integrated Care Systems (ICSs),’ says Mr Martin.
However, he points out that ‘the existence of those institutional arrangements in itself will solve nothing – it all depends on how local leaders decide together to use the scope and space those arrangements catalyse’.
Mr Martin learned of the Dutch Buurtzorg Model of care after his own experience of looking after ageing parents had shown him that ‘the best efforts of district nurses and home care workers were undermined by the time-and-task and command-and-control systems in which they work’.
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‘Drawing on both personal and professional experience, I imagined a future of self-managed neighbourhood home care teams’. After some international research he then discovered that ‘Buurtzorg were showing how it could be done’, he says.
The model was first developed in the Netherlands in 2005 by experienced district nurse and care home manager Jos de Blok and a small group of collaborators. ‘They wanted to re-find the humanity in nursing and to reconnect nurses to the people they are caring for,’ says Jo Maybin, policy fellow at the King’s Fund, where she leads research and analysis projects on contemporary English health policy.
The Buurtzorg model – which is Dutch for ‘neighbourhood care’ – has two defining characteristics, Ms Maybin explains. The first is its holistic approach to care, in which nurses and nursing assistants, working in small teams, provide a wide range of personal, social and clinical care to a small number of clients.
Continuity of care, integrated needs assessment and supporting client independence - including through informal and community-based networks of support - are all described as key features of the model. ‘Nursing team members have a target to spend 60% of their time on direct client care, in an effort to prioritise ‘humanity over bureaucracy’, says Ms Maybin.
She says there is no equivalent ‘target’ for UK community nurses, but points out that according to the 2019 NHS Community Benchmarking Dataset district nurses spent 60% of their time in patient-facing activities.
Maybin says the second central feature of the model is its flat organisational structure, where team members report to each other. ‘Small, non-hierarchical, self-managing teams of nurses and nursing assistants make their own operational and clinical decisions, with functional support - but no oversight or direction - from a small central office,’ she says.
Developmental support is provided by Buurtzorg coaches [see case study]. In the Netherlands, teams are responsible for recruitment, organising and delivering care, determining whether to take new clients on, and managing their own performance. The central office is responsible for a range of administrative functions, including salary payments, sales contracts, IT support, and accounting.
By 2014, the model had grown to become ‘the largest and most successful provider of neighbourhood nursing in the Netherlands’, says Mr Martin.
He attributes its success to the care it provides, but also that it ‘enables nurses and other care professionals to really use their training and commitment to build relationships and work out how best to support somebody to look after themselves’.
Inspired by the model, in 2015 Mr Martin accepted an invitation from Buurtzorg to become its partner, and Buurtzorg Britain and Ireland was established as an approved Buurtzorg partner to provide learning and development support and advisory services about the Buurtzorg approach, especially to NHS and social care organisations.
Although the health and social care systems differ from the Netherlands, Buurtzorg Britain and Ireland sees the challenges in the UK and Ireland as being ‘remarkably similar to those Buurtzorg was founded to overcome: ever increasing demand, spiralling costs, fragmented care models, inadequate outcomes and disillusioned staff teams’.
To date, this social enterprise has already supported the development of teams in Kent, Suffolk Cheshire and Cambridgeshire, as well as in four London boroughs and three areas of Scotland, both urban and rural.
Guy’s and St Thomas’ was the first NHS organisation in England to implement key elements of the approach in 2018. The Trust commissioned an independent report led by Professor Vari Drennan MBE from the Faculty of Health, Social Care and Education, run jointly by Kingston University and St George’s University of London, to assess the impact of the scheme. Professor Drennan and her team found the new approach had real benefits for both those giving and receiving care.
Professor Drennan says this model of community home nursing ‘empowers nurses to be able to have a real impact on patients’ lives’.
‘Having more time to spend with those they care for allows these nurses to build relationships that enable them to understand and address the health issues most important to patients. They are then able to put in place joined up packages of care tailored specifically for each individual that help keep people in their own homes for as long as possible, rather than having to go in to hospital’.
While the Buurtzorg model is predicated on nurses spending time to get to know their patients, time is something community nursing teams say they’re short of. To square this circle, the Buurtzorg business case is that ‘by enabling nurses and other caregivers to build the relationships needed with their clients to support more self-management of care and mobilise family, neighbourhood and community supports, fewer hours of professional input will be required’, says Mr Martin.
‘So it is a question of supporting the initial investment of more time on the basis that overall, and before long, more time will be saved. That means investing in the transition by putting a protective shield around the teams working in the new way and gradually making that the norm.
‘This requires some initial financial investment, but the financial return can be seen quite quickly. That initial investment need not be that much if this approach is phased in, but it will be important,’ he says.
Buurtzorg nurses organise their own workload, both individually and collectively. ‘Obviously, the nature of care demand is that it is not entirely predictable, but teams are able to manage peaks and troughs and the unexpected because they manage their own rosters and flex as they need to as much as they can,’ says Mr Martin.
He says the fact that teams manage their own caseload and rosters also means they can balance in terms of acuity and generalist or specialist needs. ‘Many Buurtzorg nurses have specialist skills but they work as generalists with that specialist expertise available across the team as needed.’
Ms Drennan’s evaluation report of progress at Guy’s and St Thomas’s NHS Foundation Trust, states that ‘The neighbourhood nursing team members described their high level of job satisfaction and very positive experience of the collaborative ways of working within the team’.
However, in common with Buurtzorg Britain and Ireland’s experience of supporting change there and elsewhere, the scheme also raised challenging issues. ‘The frustrations the Neighbourhood Nursing team reported were particularly focused on interfaces with administrative departments and IT issues…There was an on-going tension described as to whether a self-managing team was fully understood, recognised and allowed to function within a very large, multi-layered, organisation,’ the evaluation report finds.
Another example of Buurtzorg model in action in England was when 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 ran a test-and-learn of this approach in 2017-2018.
A single team of nursing staff was recruited and given the freedom and responsibility to set-up a service following the Buurtzorg model. They were supported by a clinical lead and a coach.
The team commissioned The King’s Fund and their local HealthWatch organisation to help them capture learning from staff, patient/client and carer experiences of the test.
The team set-up an office in a GP practice and provided health and social care support to older people living in and around a rural village who the GP practice and district nursing service identified as likely to benefit from their support. At the end of the trial the team members joined existing local services and local managers started to develop a self-management development plan for integrated neighbourhood teams in the area. Ms Maybin says the Buurtzorg method could work as a collaborative approach but that it cannot be regarded as a ‘better’ approach to current common practice because of the limited evidence.
Nursing staff in this test-and-learn found that they were able to ‘reconnect with patients and their carers’, says Ms Maybin. ‘They were able to take the time to get to know them, listen to them, and work with them to meet their needs, without being constrained by narrow protocols about the types of care or support they could provide,’ she says.
This approach was enabled by the staff having ‘very small case-loads because they were just establishing the service, and they were given a clear mandate to start with person, and build support for them on the basis of those conversations’, says Ms Maybin.
The self-management aspect of the test was the most challenging for the nursing team. ‘They were keen to focus on care rather than management tasks, and the test revealed how much experience, training and support was required to shift to this very different way of working.
‘More broadly the model focuses on nursing-only teams, when the direction of travel in the UK is to have integrated teams bringing different professional skill and perspectives together to collaborate in supporting patients and clients,’ says Ms Maybin.
Overall, what these and other adaptations of the model in Britain have shown, says Mr Martin, is that ‘if you give an opportunity to care professionals to work with greater freedom and responsibility in self-managed teams they thrive’.
Investing in the time to build relationships with patients, rather than being task focussed, results in better recovery, examples show. This preventative and holistic approach makes for ‘better care for patients and better working lives for healthcare professionals’, says Mr Martin.
While Buurtzorg has developed as a model for district nurses, Mr Martin believes the approach ‘does strengthen the professional status of nursing in all community settings, including practice nurses’.
‘Enabling practice nurses to work in the Buurtzorg way and make the kind of relationships with community nurses and AHPs that they need, would be likely to improve primary care and reduce pressure on GPs,’ he says.
Despite the model’s successes and potential, Mr Martin says that ‘NHS organisations have yet to grow this approach to any substantial scale because there are so many structural and cultural obstacles’.
‘NHS organisations are very hierarchical with many layers of management and administration. But what frontline professionals really need is highly responsive and agile back offices that support them, and a shift from ‘command and control’ from organisations to their being dedicated to serving these professionals – so that means quite radical change,’ he says.
Mr Martin explains Buurtzorg was created because ‘the Dutch system had the same issues of hierarchy, fragmentation and waste that we have now’.
‘Buurtzorg has grown to be the leading provider of Dutch home care - with around 100,000 clients per year - and has influenced wider change in the country’s system. So there has been significant change, but much of the system remains as it was,’ he says.
Buurtzorg’s self-managed teams have neither hierarchy nor managers, but they are supported by coaches and administrators. ‘There’s no management layers at all, and there’s a back office of 50 people providing IT and other services to the teams.
‘It’s a culture of serving and supporting and of doing what is needed and not what isn’t is crucial,’ he says.
He says that during COVID-19, particularly early in the pandemic, ‘there was a sudden surge of demand from teams for support – information, advice, PPE - and the back office was able to respond very fast by bringing in some extra expertise and forming a crisis team, which continues its work but now with less demand’.
In the five years Buurtzorg Britain and Ireland has been supporting NHS organisations to learn from the model, they are ‘really rising to the challenge, which gives us a lot of optimism’, says Mr Martin.
And this year, Buurtzorg and Mr Martin are creating Buurtzorg Care UK as a provider of health and care services, working with public partners, as a social enterprise in Britain. ‘We will employ our own nurses and care workers, provide our own coaching to them and establish our own back office to support them,’ says Mr Martin.
He explains the organisation is working to find partners, particularly in the context of PCNs and ICSs, ‘who will enable and support us to start small and show what we can do’.
‘Buurtzorg Nederland is prepared to invest in the associated start-up costs, although we would hope our local partners will also contribute to that. And we would love to hear from anyone in ICSs and PCNs to explore possibilities.’
The move will give more nurses the opportunity to adopt the Buurtzorg way of ‘first coffee then care’. As Mr Martin says: ‘Nurses want to be able to build relationships and take a really holistic approach to supporting someone to recover and care for themselves. If they have that opportunity they enjoy their working life more. Nurses who work the Buurtzorg way say ‘this is the way I was always hoping to work and why I went into nursing in the first place’.
Buurtzorg is keen to hear from nurses and other care providers, and from NHS, local government and other public and charitable organisations, who would like to take part in this venture. You can contact them via firstname.lastname@example.org