Lessons From Going Dutch - The Challenges Of Implementing Buurtzorg In The UK
Despite its hard-to-pronounce name, Buurtzorg has attracted plenty of interest from UK health and care organisations over the years. Yet even for the most committed it has – thus far – proven to be difficult to fully adopt the model. I believe there are four crucial challenges at play which must be addressed in order for the sector to benefit from the model’s great promise.
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.
Buurtzorg has attracted plenty of interest from UK health and care organisations over the years. Yet even for the most committed it has – thus far – proven to be difficult to fully adopt the model.
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 , 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.
Lessons From Going Dutch - The Challenges Of Implementing Buurtzorg In The UK
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 . 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.
 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
 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
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This is a great article and what we have found ourselves in trying to create a self managed team. The two points that jump out for me are:
"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."
"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."
Thank You for sharing your thoughts and experiences, Paul.
I work in the german automotive sector and do experience the same challenges in building self-managed teams, giving them the power to take decisions, building their own structures and align with our overall purpose.
However, the biggest challenge for us are the processes and rules of the legacy organisation. From budget to timelines, everything comes from the top and needs alignment with 2-3 managers. That is frustrating for all those team mates, that build the bridle between legacy organisation and self-managed organisation.
I can 100% follow your conclusion. A real transformation of the hierarchical organisation with around 45.000 employees will not succeed. Motivated by your post, I will suggest to build a separate entity for our product or at least move it to our "innovation" entity with a more modern mindset.
Paul this is a great piece. Particularly aligned with your first challenge. There is a mountain starting to pile up around failed attempts to copy spotify, Haier or the many other examples of organizations that created fit-for-purpose operating models for themselves. Organizing around principles or the desired outcome at a high level (vs. specific pieces of org "architecture") is key. Who would have thought that the successes of a music sharing service or health services provider wouldn't apply at scale for a global bank in the first attempt :-)
Thank you for these excellent reflections! Super useful insights, addressing the same queries and paradoxes that have arisen repeatedly regarding potential "teal conversions" among my local meetup group. I've added a link to this article from my ever-expanding Teal Resources page (https://treegroup.info/teal-resources/).
Paul thanks so much for these excellent and I imagine hard won insights. I will be sharing your story. This might interest you and perhaps others. We found an ‘emergent’ approach to change requires of leaders exactly the kind of discipline you describe. Research shows it’s the quickest and most effective approach in complex contexts:
Paul, have you seen John Seddon's recent article / podcast on these very same issues? https://www.patreon.com/posts/38490316
I'm sure you'll disagree with some of the things he says, but you both make a some similar and important points.
Real change and improvement is emergent, coming from the learning experienced as you go along. A lot of transformation attempts fail by people trying to work towards a pre-determined model or plan, which completely ignore each organisation's unique context and the complex and dynamic environment they sit in.
The other point is that change isn't going to happen or be sustainable if leadership or management practices don't change - starting from the top! Too often people make the mistake of implementing new structures or processes, but without changing the way they lead or manage. Even if there is a short-term improvement, neglecting this rarely if ever leads to it being sustainable.
In a complex word, there is no room for best practices, not even for good practices.
Rather, communities of practice sharing, and sharing again... giving birth through unexpected emergence to new practices at a higher level of complexity. So, no scaling up, rather crystallization leading to new spaces through emergence.
Paul, thank you for sharing your thoughts and experiences in such a well-written way. Coincidentally I just published a (LinkedIn) article on Buurtzorg, titled
"The outrageous success of “Buurtzorg” is easy to explain and hard to replicate — and there is still plenty of (spectacular) potential!"
If you have a chance to read it that would be great. It may make it clearer as to why I happen to disagree with the provided explanations behind the challenges you come across (the challenges are still there, of course).
The LinkedIn article can be found here: https://www.linkedin.com/pulse/outrageous-success-buurtzorg-easy-explain-hard-still-jorn
How are work outcomes affected by the treatment of those who do it? I have been exploring this question for ~50 years. In that time, one comment stuck with me more than any other. It was made in 1998 when I interviewed a group of men in Indianapolis who had redesigned most of the US city’s waste collection and disposal operations. “We are no longer expected to park our brains at the door when we come to work.”
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