As we move ever closer to an aged care crisis in this country, one pioneering European may have already cracked it: Care given by caregivers, and nothing else in the way.
It is the definition of craziness: try something, fail at it, then try the same thing again expecting another outcome. And again, again and again, being surprised every time that it doesn’t work. A good example of this is the care of the elderly and people with long-term (mental) illnesses.
Everywhere in the world, the 1980s were the turning point in how countries dealt with people who needed continuing help. We started to “rationalise” it, building ever-bigger facilities or “hubs”, where managers and not health care staff decided what was good for patients and clients. Assisting people in their own homes became more and more rare. And unfortunately, most of those managers were more interested in the structure of the care than its content. They started implementing management plans, running the services like hierarchical, bureaucratic institutions where filling out forms and ticking boxes was more important than both patients and health workers. The consequences were disastrous: punters unhappy with harried, ever-changing carers, stressed out and suicidal nurses and doctors and costs that were spiralling out of control. Still, we kept doing it. In fact, trying to respond to the pressure of a baby-boom generation getting old and growing mental health problems, most countries tried to manage their way out of the mess. Despite what was staring them in the face, they tried to solve the problems of management with more management. And so the difficulties got bigger and the costs so large that nobody knew what the future would hold.
In 2006, Jos de Blok was a manager in a large care institution in The Netherlands. What made him different from his colleagues, though, was that he had started his career as a district nurse. So he knew what was needed to do the job right. And managers, he kept saying, was not it. Out of the 16 administrators in his own organisation, at least 14 could be missed without any negative consequences, he wrote improvement plan after improvement plan. “Funnily enough, that didn’t get a lot of applause,” he now says ironically. So De Blok decided to put his money where he mouth was. He left his job and started Buurtzorg (Neighbourhood Care). The concept was, as all good ideas are, brilliant in its simplicity. Community care would be delivered by the people who knew how to do that: well educated, well trained, motivated district nurses, working with GPs and other carers in a neighbourhood. They were going to run their own show, in small regional teams. They would decide who to care for, for how much time, how often and where. When the need was larger than the care they could offer, they hired their own colleagues. That meant no waiting lists for anything. They also got a budget for training and, if necessary and only if they requested it, a temporary coach. There would be a small back office, mostly to organise the finances, but no managers. The nurses would keep in touch with each other through a Facebook-type website, where they could swap ideas and come up with solutions to problems. Because there would be no managers, there would be money to pay the nurses more than they would get elsewhere, and hire the best and brightest.
The current system can’t survive. Anything is better than having to fit into a hierarchical machine that doesn’t allow you to do your job, doesn’t trust you and delivers bad outcomes. Millennials are opting to work for themselves. They want their lives to mean something.
It seemed like a ridiculous plan. No managers? Give people the freedom to run their jobs the way they saw fit? Surely not! Yet, 10 years later, Buurtzorg has a yearly turnover of €400 million (about $600 million AUD), employs 14,000 nurses in 900 teams and 4,000 care workers in social care. Together they take care of almost 100,000 patients. Apart from delivering home help, there are also Buurtzorg homes, for people who have been in hospital but can’t go home yet. Additionally, you’ve got Buurtzorg Young, for teenagers, Buurtzorg T, which specialises in mental health, Buurtzorg Kraam for new mothers and hospices run by Buurtzorg. It seems to be a concept that works for everybody. This year, Buurtzorg was named employer of the year for the fifth time running. Because nurses organise themselves, they feel trusted, in charge and less stressed. The consequence is that almost 80% of all registered nurses in The Netherlands now work for Buurtzorg. Because they like the concept, they are leaving other health care providers in droves. Patients are happy too, relieved that they get personal carers instead of a long line of strangers at their bedside. And these are people who know their region and the other assistance available there, and make themselves responsible for care, not management of a problem. Lastly, because hardly any money is being spent on bureaucracy, it has proven possible to do all this “more” for less money and within the current health care budgets, paid for by government and insurers. Jos de Blok:
“We’ve got about 8% overhead, against 25% of most other organisations in Holland. We did some calculations lately and found that every year between 20 and 30% of the health care budget of the country is being spent on things or people who don’t contribute anything. That is about 30 billion dollars. Imagine what you could do for that kind of money!”
According to De Blok, it is inevitable that in the future more organisations will transform themselves to work according to what he calls the Buurtzorg model. The big problem in the world today, he thinks, is that all kinds of businesses and institutions spend more money on bureaucracy and management than the thing they have been tasked to do. Health care is one, but the same goes for education, the civil service and most corporations. They are top-heavy, while very little money and effort goes to the actual work. That isn’t just expensive and silly, it also breeds frustration, anger and burnout. Teachers who can’t teach, policemen who can’t police, civil servants who can’t help the public.
“The current system simply can’t survive. Look at young people: they are leaving those kinds of work environments in their thousands. You spend a lot of your waking hours doing your job and people want that time to be as pleasant as possible. That is why a lot of millennials are opting to work for themselves. Anything is better than having to fit into a hierarchical machine that is no fun to work in, doesn’t allow you to do your job, doesn’t trust you and delivers bad outcomes. They want their lives to mean something. At the moment there is an epidemic of millennials with burnout and stress. Their work literally makes them sick. I think that in 25 years we will wonder why on earth we put up with this crap.”
We have to understand, De Blok says, that de Buurtzorg model is not just about people having control over their jobs or getting rid of managers and bureaucracy – although that is very important. It has to work as a business too and cannot be used as a measure to cut costs. The IT that connects employees is vital as well, because it ties everybody and everything together. But most importantly this “movement” is about changing the culture, focusing on dialog, trust and mutuality instead of top-down edicts. Realising that it is about the quality of the work, not about the structure of the organisation. Care, or anything else for that matter, is not a product, but an experience. We are talking about human beings and community here, not statistics. Managers have often no on-the-ground experience, thus don’t know what they are talking about. If you cut them, and useless meetings, out of the system and focus on content, you can solve any problem. In fact, “managing” people prevents them from coming up with solutions. If you take the manager out of the equation, you give people back their capacity to think creatively themselves.
In the last couple of years, Jos de Blok has been approached by people from international banks, educational organisations, civil services and all manner of commercial enterprises. He is a regular visitor at the offices of ministers all over the world, and, despite (or maybe because of) his heavily accented English, a rising YouTube and TEDx star. The Buurtzorg model has been adopted or is being looked at by health care corporations in Japan, China, Korea, Taiwan, India, Germany, the UK, Sweden, Italy, Spain, France, Switzerland, Austria, Canada and the US. There are even tentative conversations with Australia, although De Blok doesn’t want to say with whom. Nevertheless, he says, we are in the middle of a “revolution” that will change the face of the planet. Not bad from a boy from rural Holland.
But better for us, workers and patients alike.