Early
in March, several AQuA staff and members embarked on an exciting study trip to
the Netherlands, to learn more about the Buurtzorg health and care system.
In our latest blog blog from our Buurtzorg Diaries series, members from the Manchester locality
share their thoughts from the trip.
“Buurtzorg
feels right and fits well’ – SC, district nurse, Manchester
This blog is not an attempt to present
a complete picture of either Buurtzorg or Amstelring as organisations – but
rather to share a few ‘take home’ messages of a group of clinicians and
managers who went to see Buurtzorg self-managed teams in action (March 2018),
and to learn from Amstelring (who changed into an organisation with
self-managed teams).
By sharing our learning and thoughts we hope to build a
collaboration of the willing who are prepared to lead by example and work in a
way that really values people, trusts them to ‘do the right thing’ and enables
them to build trust with the clients with whom they work – so here goes!
Be under no illusion – the client really is front and centre in
both organisation and all they do – as Buurtzorg’s model makes clear.
The person needing
support
The focus is on continuity
of care and developing the strong bond between patient and member of staff. Total patient holistic care was highly valued
and the clients we met were clearly impressed with the staff working with them
who knew them all well. W
We were also impressed that the staff made choices, sometimes, not
to complete tasks but to simply listen / talk when it was more appropriate to
do so; which built a culture of trust. The only
protocols in the organisations were clinical; all others were removed in
favour of simple goals and simplicity itself.
Informal networks
Teams are based, and
often live, in the community in which they work. Highly
visible, they are often based in previous shop premises on the high street and
people walk in from the street to seek access to the team. With small areas to
cover, the team are also seen out and about on their bicycles; spending very
little time commuting between visits.
Clients had access to
all their care records via iPads in the home,
as did their carers where they wanted them to.
All clients / carers could message staff via this route, as well as
phone their team out of hours if necessary; although calls to teams were
extremely rare – teams citing rates of one or two calls at night a year.
Buurtzorg team
Our reflection is that the current system in which we work in the
UK is based on distrust rather than trust - rules are made for the 3% who don't
do a good job rather than the 97% who do.
The small teams in Buurtzorg who share responsibility for management / planning roles within their
team, seem to encourage people to ‘step up’ and hold both themselves, and each
other, to account; whereas in the UK it feels more as though by making many
people responsible, no one is responsible.
In Buurtzorg teams spring into life when a group of nurses
collectively decide that they want to work together. Within the organisational
infrastructure that Buurzorg provides, they operate as self-managed teams (almost individual ‘franchises’) with
high levels of individual and mutual accountability. Teams rotate roles,
operating with a framework of activities that prioritise the quality of the
relationship with the customer, productive client facing time and longer term
prevention.
The clinicians within our team saw true autonomy for the nurses who they felt were both personally and
professionally more enriched and had more job satisfaction. Simplicity was key
to their approach but this didn’t prevent a clear, open and safe approach to
governance.
The willingness of the
organisations to cede control of the teams stood out, as did the complete
lack of traditional management structures and the simple systems for enabling
the teams themselves to manage poor performance amongst themselves.
The access to coaching support seems to be highly valued if
infrequently required. Interesting to note that, of four coaches originally
appointed by Amstelring, only two were ultimately successful in their roles; 2
of the 3 managers were unable to make the transition to coaches.
All staff reported that team
size was crucial; 5 staff minimum to provide safe capacity but no more than
12 in total, with 8-12 cited as the ‘magic number’. Any attempt to go over 12 had led to a
breakdown in team functionality.
Staff as customers and
client
Experienced staff were highly valued. Working on the assumption
that in fact the staff are also customers of Amstelring (since happy staff
provide safe and efficient care), the focus of the ‘back office’ function comes
to be ‘delighting’ employees.
Support services should be just that - a back office function -
and not an industry in itself. The net effect of this is that the back office teams constantly focus on
‘keeping it simple’ when providing support, removing obstacles, acting as a
firewall to prevent bureaucracy creeping into the work of the clinical teams,
and always, always, taking steps out of processes and working to simplify.
The single IT system helps, as does an approach which, for
example, allows staff to notify the office of contract hours changes by email,
text, letter or phone; whatever is easiest. Teams work in a flexible way which was valued
as a two way deal; good for clients, good for staff.
Leadership was pivotal in ensuring that the organisations took actions which embodied
their visions; demonstrating to the workforce, through action, their commitment. For example, the teams at Amstelring were
charged with interviewing and appointing the coaches from the existing managers
that applied. Even allowing for this, only 2 of the 4 coaches ended up being
right for the job (2 previous managers could not make the transition).
Amstelring were demonstrating the value they place on good
coaching ("we would rather have no coach than a bad coach") and interesting
that the decision to delegate this process to the self-managed teams was
considered deeply symbolic and consistent with their vision.
There was a sustained and
deliberate focus on the future – where you want to be / get to – rather than
dwelling on the past, as well as a belief in the power of shaping the wider
system / world to be better - "this is our alternative to what you think
you need” rather than just saying that what existed wasn’t good enough.
Formal network
Referral processes were simple and referrals to other teams
appeared minimal. The principle of the team was to act as generalists,
recruiting specialist help if and when needed.
Integrated care, not integrated
teams, was the order of the day.
Conclusion
Inspiring, motivating, challenging and
‘do-able’, the lessons from Buurtzorg and Amstelring are timely for systems who
really want to make a difference to the quality of peoples’ lives – clients,
staff and communities. If these ideas
are of interest to you and / or you would like to find out more or become
involved in work in Manchester please contact one of the team via peta.stross@mft.nhs.uk or siobhan.reading@srft.nhs.uk
