Reinventing The NHS: Removing The Shackles Of Bureaucracy

- 6 min read

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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They were not managers or people with words like ‘service design’ or ‘organisation development’ in their titles. They were the guys who got out there every day among the muck and the rats to clear up after their 200,000 fellow citizens. And it was precisely because they did the work that they knew, at a level of detail no-one else could match, what was needed to do it better and more cheaply. (Full story)

Simply listening to them properly, providing some training in activity-based cost analysis, and trusting their ability to produce solutions, the city’s mayor was able to raise the quality and cut the cost of a service he had intended to outsource.

Indeed, having planned to privatise everything, he ended up with more in-house operations than he started with. He also won a Harvard’s John F. Kennedy School of Government award for Innovations in American Government.

In the decade after visiting Indianapolis, I had many similar encounters with ‘frontline’ workers and community activists across every continent. But by 2009 I was back where I grew up in south London attending to my mother’s growing need for care.

Improving community nursing

At that stage I knew little about community nursing and adult social care services in England, but by the time my mum died in 2011, I had learnt enough to decide I’d dedicate the rest of my career to improving them.

Some wonderful women from all over the world were my mother’s care workers and companions in her last years. I saw that in the main they were caring, compassionate, kind and trustworthy. But their ability to exercise those qualities as well as they could was undermined by the same organisational and systemic failings that had prevented the Indianapolis binmen from keeping their city clean efficiently.

The intrinsic motivation and tacit knowledge of ‘frontline’ workers was being systematically wasted – and, worse, degraded – by the way their relationships with the people they cared for was replaced by commodified ‘time and task’, and enforced by ‘command and control’.

I knew there was a better way because, not only in Indianapolis but in many places around the world, and across sectors, I had seen what could happen when working people had more control over how to achieve the purpose they shared with their employers.

So, as my professional knowledge converged with my personal experience around my mum’s care, I was sure that community nursing and home care were crying out for the creativity, humanity and productivity gains that self-managed neighbourhood teams could produce.

Looking around for inspiration, I soon discovered Buurtzorg. Founder Jos de Blok was kind enough to not only invite me to visit him, his colleagues and his nursing teams, but to support my ambitions for Britain.

Buurtzorg Britain & Ireland

An early opportunity presented in 2015. My social enterprise, Public World, was commissioned by Guy’s and St Thomas’s National Health Service Foundation Trust (GSTT) in south London to support a change programme in its community services. Jos and his colleagues generously supported that work and it led to a partnership, now called Buurtzorg Britain & Ireland.

Since then, we have worked in some 40 health, care and social housing settings over the last five years. Beginning with GSTT, and responding to growing demand from many others, we decided to support those organisations by drawing upon Buurtzorg’s experience to make their own changes, inspired as they were by Buurtzorg’s extraordinary success.

Many people told us we’d never succeed because hierarchical bureaucracies would thwart us. But we didn’t believe learning could come from simply accepting such generalisations – we wanted to grapple with the challenges in an open-minded and granular way.

Others told us you can’t ‘lift and shift’ a successful model from one context to another, and we knew that too. Again, it was only by working alongside people in these organisations that we could learn what needed to change to make it work in Britain.

Dedicated NHS professionals

Above all, we were motivated by two beliefs: firstly, that Britain’s NHS and social care systems are populated by dedicated professionals many of whom are desperate for change; and, secondly, that they would be our teachers at least as much as we’d be theirs.

We have yet to grow any of this work to the scale we would like in Britain, although we are making strong progress in organisations where senior leaders understand and commit to the changes needed to support self-managed team work effectively.

So it could be said that we have failed, but I believe that way of looking at it is part of the problem. A fundamental lesson of Buurtzorg’s own success is that knowledge is the emergent product of continuous learning from doing.

As my compatriot the playwright Samuel Beckett put it: “Ever tried? Ever failed? No matter. Try again. Fail again. Fail better.”

Our efforts have supported hundreds of nurses and care workers to begin working with greater freedom and responsibility in more person-centred and community-based ways, with inspiring and tangible results for clients and their own job satisfaction, as independent evaluations have shown. (Case studies)

We haven’t turned their organisations into Buurtzorg. (We have never wanted to. If Buurtzorg wants to set up in Britain it will – watch this space!)

Buurtzorg itself didn’t start with a model but with clear purpose and principles, and that is where any organisation aspiring to apply the lessons of its success has to start too.

We will continue to support them the best we can – every day we learn how to do that better -- while also contributing to the growth of what I believe is an unstoppable movement for change in how we care for each other and work together.

Who wants to park their brains at their workplace door?

The less any of us have to do that, the more fun we’ll all have – and the better we will solve the great social and environmental challenges that not only undermine our happiness but threaten our very survival.

This is a guest post from Brendan Martin, Managing Director at Buurtzorg Britain & Ireland, a partnership with Jos de Blok to support Buurtzorg-inspired change in health and care in Britain. For more information on Brendan and the company, check out his rebel page.

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