Lessons From Going Dutch - The Challenges Of Implementing Buurtzorg In The UK

Consistently in the top ten for patient satisfaction, better clinical outcomes, Employer of the Year awards, AND proven to be cheaper to run. No wonder that many National Health Service organisations and local authorities in the UK were interested in finding out how Dutch community care provider Buurtzorg does it, and how their model can be adopted here. After all, Buurtzorg was created in response to challenges in community health and social care that are very similar to those facing the UK today, including poor outcomes for patients and service users, overstretched and disillusioned staff with resulting problems with vacancies and retention, and a constant pressure on budgets.

Over the past few years, I have supported various organisations in the UK, each with their own ambitions and expectations, who wanted to explore and adopt the Buurtzorg model. And with some success. We have seen teams of nurses and homecare workers thrive as self-managed teams. And we have seen patients flourish under their care and make remarkable progress.

Nevertheless, full take-up of the model has not quite happened (yet), and many promising teams have been absorbed back into their wider organisations. More successful pilots have at best continued, but without fully scaling up throughout the wider organisation. What could be the reason(s) behind this and what are the implications for organisations who, inspired by Buurtzorg and other self-managing organisations, aspire to become – more – self-managing too?

I have come to a number of reflections regarding the challenges involved in replicating the successes of the model.

Challenge 1: Is there a paradox in following a good example?

When you study the inspiring journeys of self-managing organisations such as Buurtzorg, Semco, and many others, what stands out is the their clarity of purpose (‘what they stand for’) and how they have translated that – over time – into their way of working.

All of these rebel organisations started out with the conviction that a different way of working would result in better products and services as well as a better working environment for staff. HOW they would achieve that, none could have predicted at the outset.

This willingness to embark on a journey without a clear end-point, but with a clear sense of how that journey of discovery should be conducted and what the destination should feel (rather than look) like, is what these organisations generally have in common. There are many lessons to draw from the similarities and differences in the solutions that these organisations have come up with, but the most important lesson for me is about the process they were willing to go through to find those solutions.

Is there a risk, therefore, that the models and solutions of the Buurtzorgs and Semcos of this world won’t ‘stick’, if you don’t go through a similar process yourself? That the real magic comes from the process of working out what way of working serves your purpose best? In other words: is the transformation more in the journey than in the destination?

If that is the case, there is a risk that being inspired by one such example and wanting to replicate its model because of its great outcomes, will divert your transformation process away from your own journey and into the path of ‘implementing’ your source of inspiration into an environment which isn’t quite suited or quite ready for it.

Challenge 2: How to lead while not knowing where you’re heading?

“The biggest barrier to change - believe it or not - is you, the leader” says Aaron Dignan in his book ‘Brave New Work’. My clients in the UK have generally been sizable public sector organisations with several thousand employees, budgets of up to hundreds of £millions, and incorporating divisions delivering wide-ranging services. In these organisations the senior management teams are accustomed to leading change from afar. Senior buy-in and support is most often translated into signing off on the required transformation budget and appointing a delegate to the newly formed Steering Committee.

This is no criticism of these organisations or of their leaders! They have many priorities to balance, an overflowing diary and other parts of the organisation that require their attention. And this is how their organisations have always ‘done change’ and with some success.

However, on occasions like these this will not be enough. When introducing concepts of self-management the fundamental premises most organisations have been built on need to be re-set and challenged. Lots of certainties become uncertainties. People will look at the leadership for permission, for attention, for feedback. And most of all they look for a sign of how serious the leaders are about this. So, if you act the same, demand the same performance measures, ‘do change’ in the same way as usual, people are likely to see this as another minor change. Or worse still, as a fad. As something that will pass.

Self-management is about unleashing the intrinsic motivation of people for the benefit of the organisation and its customers. That requires clarity of purpose, autonomy and a thirst for learning. If you want self-management to stand a chance of succeeding, you – the leader - will have to change your behaviours, your language and your leadership style accordingly. You have to be prepared to experiment, to let go, to trust, to support, to make mistakes, to be patient. In short, you must create safety in the organisation to allow for the change to take shape.

“But how – I hear you ask – do I approach this? I am more used to leading our organisation from A to B. This self-management concept sounds very different, and it pushes me out of my comfort zone.“

And that is of course correct. This is a ‘you don’t know what you don’t know’ moment, in a way. It is for this reason that I believe that leadership should invest significant time and energy in two things, when considering concepts of self-management:

• Exploring successful examples such as Buurtzorg and others, but with a focus on learning from their journey and the leadership lessons that flow from that, as much as on the technicalities of the solutions these organisations have arrived at.
• Thinking through, and working through with the rest of the organisation, what the primary purpose of your organisation really is all about, and what therefore your design principles will be for a more self-managed future version. What will this new organisation look and feel like? How will customers experience the difference? What issues will it resolve?

This should then lead to either your ‘aha moment’ and generate the confidence and energy to commit yourself to this journey of transformation. Or – perhaps – it leads to the realisation that this is not for you and your organisation after all.

Challenge 3: The dual paradigm issue

In my work with health and care organisations in the UK we typically focused initially on the creation of a small number of self-managing teams of care professionals, supported by a coach, very much in line with the successful Buurtzorg model. We tried to create a bubble where different rules of engagement applied: nurses would make their own planning, choose their own office, recruit new colleagues, order new materials etc, without any manager’s involvement. To delineate this bubble from the standing organisation, an important role was identified for the ‘heatshield’ person, typically someone with some seniority and credibility in the organisation and the ability to navigate both sides of the divide between the bubble and the standing organisation.

As various independent evaluations have shown [1], most of those pioneer teams – after a period of settling in - functioned really rather well and achieved results not dissimilar to Buurtzorg itself: very happy patients, better clinical outcomes, and higher levels of engagement and retention amongst the care professionals.

Where teams (and projects in general) continued to struggle, was the interaction with the wider organisation. Despite the heatshield, getting the organisations to support the teams in line with their needs as well as their – admittedly unusual – rules of engagement, appeared beyond their capability. Examples include the inability for teams to order medical devices or IT equipment ‘because there is no manager sign-off’, interventions by the middle managers undermining trust in the teams, and the imposition of standards and processes that teams believed undermined their autonomy.

Although these could be considered to be learning moments that would get resolved over time, most organisations ultimately decided not to proceed before this could be proven. It calls into question whether large organisations such as these, whose leadership have a vast organisation to oversee, and whose central functions provide support to a wide array of services, are able to accommodate a unit which has its own – very different – rules, culture and way of working.

I fear that organisations that work on the basis of a paradigm of control, hierarchy and administrative oversight cannot also – and at the same time – operate on a self-management paradigm based on trust, devolvement and support. Just like your iPhone is unable to run an Android app, these paradigms function like separate operating systems of which the core components and assumptions are attuned to one way of working only.

Therefore, I now believe that a hard separation will be required in order to be successful. For instance, through spinning out the service in question into a separate entity [2]. Creating a separate entity would provide the best opportunity to re-set the operating system for the self-managed organisation and would allow support functions and technical infrastructure to be fully attuned to the needs of the frontline. It would offer the chance to create the right culture and behaviours without the legacy organisation holding it back. There is no reason why this entity could not be (co-)owned by the original service, thereby retaining its link to its public sector roots. In fact, it could operate much in the same way as many large commercial corporations that create small start-up subsidiaries to rediscover their innovation mojo.

Challenge 4: Can self-management be done at scale?

It will come as no surprise that the jury is still out on whether self-managed models can grow to scale in the UK health and care sector. There is of course good evidence that self-managed organisations can be of a substantial size: Buurtzorg itself has more than 14,000 employees in the Netherlands. White-goods producer Haier in China has circa 80,000 employees. Are they the exceptions that confirm the rule? I believe it will be a matter of time until more self-managed organisations will grow to substantial size. But more importantly, I expect that self-managed organisations are less obsessed with growth than they are with purpose. If clients can be served better and employees are more fulfilled through smaller entities, I believe this is a more likely route taken.

It is one thing to create a self-managed organisation from scratch, but surely there is a limit on size when transforming an existing organisation?

Again, the limits of what is possible are still to be found. General McChrystal’s achievement as described in ‘Team of Teams’ shows you can even transform the US armed forces in the middle of a war, if the purpose is clear and the approach is supported consistently from the top. Buurtzorg, too, supported various successful transformations in the Netherlands of organisations of up to 2,000 staff.

Turning inspiration into transformation

If you are considering bringing aspects of self-management to your organisation, you could be forgiven for being a bit confused by now. Successful self-managed organisations are great to learn from but we shouldn’t copy them. Starting small is advisable, but it involves the entire organisation. Senior management’s leadership is essential, but they should not lead. This advice is as clear as the UK government’s on Covid-19…

My conclusions after three years of working with organisations who were in your position once, is that – ultimately – your best approach depends on your own situation and ambition:

• If you are after a full transformation of your organisation, you should manage it as such. That does not mean you shouldn’t start small, but you should be in a position to lead it from the top. (General McChrystal wouldn’t have had a hope to succeed if he had been Sergeant McChrystal instead). But lead in a manner congruent with the characteristics you are hoping to bring out in your organisation.
• If you embark on this journey you will need the conditions to see it through: can you create the safe space for the organisation to learn and evolve, can you bring the patience, do you really trust your staff to do the right thing, do you have the resources? Fundamentally: do you really believe that this is the right response to the challenges coming at you from an increasingly complex world?
• For the concept of self-management to work your organisation needs to find and ‘own’ the solution it comes up with. By that I mean ‘embrace’, ‘believe in it’. That can only be achieved by designing, experimenting, learning, adjusting and finding out what works as you go along. By all means, be inspired by other organisations that have gone before you and borrow, copy and build on what others have found to work well. But don’t copy a model wholesale and expect it to work for you.
• If you are part of a much larger organisation and are at risk of being dominated by its legacy structure, culture and processes, consider creating a separate entity for your self-managed service. Only then are you likely to be able to escape the gravity pull of the mothership and create the right environment where all components move in the same direction.

Having seen a wave of entrepreneurial and creative solutions emerge around the world in the first half of 2020, and with so many more people now realising that there are better ways to organise work, I am convinced that in due course we will see inspirational and unique, self-managed organisations emerge in the UK too. And some might even have pronounceable names.

Footnotes:

[1] See for instance the following articles and reports:

• The Guy’s and St Thomas’ NHS Foundation Trust Neighbourhood Nursing Team Test and Learn project of an adapted Buurtzorg model: An early view, Vari M Drennan MBE, Fiona Ross CBE, Mary Saunders and Peter West, Centre for Health & Social Care Research, Joint Faculty of Kingston University & St. George’s University of London, 2017
• Neighbourhood Cares Pilot, Cambridgeshire County Council, 2019
• Transforming community nursing services in the UK; lessons from a participatory evaluation of the implementation of a new community nursing model in East London based on the principles of the Dutch Buurtzorg model, Lalani et al. BMC Health Services Research, 2019
• Going Dutch in West Suffolk: learning from the Buurtzorg model of care, Jo Maybin, King’s Fund, 2019

[2] Between 2010 and 2016, many social enterprises were created out of public sector services that wanted to become more entrepreneurial, nimble and responsive to their customers’ needs. With a high level of employee involvement (often through employee ownership and other ways of ensuring staff are involved in key decisions) these spin-outs have since proven that state services can be provided very well through alternative structures. The wave of public sector spin-outs created in that period have mostly been a success, and some have grown many times over. For example in 2019, spin-out Sirona Care & Health CIC won a £1bn contract to deliver community care services in the Bristol region, the largest community contract ever awarded in the UK.

Paul Jansen was COO at Buurtzorg Britain & Ireland between 2018 and 2020. He built a reputation for introducing the concept of self-management to many organisations in the UK, predominantly in health and care providers, social enterprises and other entrepreneurial organisations. Since 2005 he has led and created several social enterprises. You can read his blogs here