Tuesday, March 20, 2018

Buurtzorg Diaries - Integrated Care, Not Integrated Teams - Manchester


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 

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