Is integration missing the point of care?

Merged authorities, pooled budgets and multi-disciplinary teams can all make sense, but in and of themselves they solve nothing. To take seriously the idea of ‘person-centered care’ is to enable the persons at the point of care — the caregiver as well as their client— to craft solutions together. That certainly requires organisational change - but within organisations rather than between them.

Professionals do not always know what is best for the people they care for, and the decline of deference to them is healthy. But people needing care require expert and honest support in making realistic choices, and that means enabling professionals and their clients to build trust. Investment in that relationship, and in strengthening and mobilising the social networks that can help sustain quality of life at home, is fundamental. It is the core role of the Dutch Buurtzorg caregiver, of whom there are now more than 10,000, in more than 850 self-managed teams, only a decade after four nurses founded the first one.

In partnership with Buurtzorg Nederland, and with the support of the RSA, my social enterprise Public World is launching Buurtzorg UK to adapt and apply their model here. We are working with several health and social care commissioners and providers in England, talking to more in Scotland and recently took a study visit to the Netherlands. The aim is to enable self-managed teams of caregivers to serve their neighbourhood clients in a holistic way, removing the arbitrary barrier between health care and social care. That wall has been cemented by the industrialised model of district nursing and home care in which timed tasks are allocated to the cheapest possible worker. It is obvious that ‘time and task’ has undermined care quality. Less obviously, it hasn’t cut costs as intended — on the contrary, it has added them.

In the Netherlands, Buurtzorg has greatly improved care quality — academic, survey and anecdotal evidence all show that. It has also improved jobs — winning Dutch Employer of the Year four times in the last five years proves that. Crucially, it has also cut costs, because that early investment in the care relationship leads to less dependence over time, while the absence of unnecessary management functions cuts overheads.

When Buurtzorg asked us to be their UK partner a year ago we knew there would be plenty of challenges ahead, and now we have a clearer picture of what they are. Our understanding of the institutional and regulatory barriers has improved, and we are finding ways around, over or through them in the test and learn exercises we are co-designing with our clients. But the most fundamental change required is in mindsets, in the habits of thought that have grown over the years in which bureaucracy has been reinforced by the very structural and managerial reforms that were supposed to sweep it out of the way.

Among the millions of words, thousands of pages and hundreds of recommendations of the Francis Report into the Mid Staffs hospital scandal three years ago, one paragraph stood out for me. It states that frontline staff working in "strong and stable organisations" must be allowed the "freedom and responsibility" to put the patient first all the time. That is what we are aiming for in Buurtzorg UK, but unlike our Dutch partner — a social enterprise that provides care within the insurance-funded system there — our role is to support existing NHS and social care organisations to apply the lessons of its success.

We start by facilitating conversations within and between them in a local area, to explore how the Buurtzorg approach could apply to their circumstances and support their aims. Then we co-design ’Test & Learn’ exercises — we don’t call them pilots because the point is not to take or leave a final product but to create adaptive solutions — and support their implementation. The aim is not only to support doing, learning and scaling in each locality but to share insights between them so that we grow knowledge right across the system. We are drawing on Buurtzorg’s own experience of supporting change in other Dutch care organisations. They are supposedly competitors, but Buurtzorg’s founders always aimed to change the whole system, and so do we.

Our approach is closely aligned with the RSA’s, in that we are driving system change by unleashing the power to create that is stifled within hierarchical compartmentalised organisations. The RSA has supported us with a Catalyst Grant, the only external funding we have received other than the consultancy and training fees to fund our work with the clients that commission us. It’s a challenging business model but it enables us to serve our clients with integrity while exercising our duty of care to the 10,000 nurses who have entrusted their good name to us.

We are building a community of practice to drive fundamental change — and we invite you to join us. We’re looking for people who can help us in many ways, from deploying their professional skills to help change at the frontline to building a wider movement for truly person-centred care.

For more information please email enquiries@publicworld.co.uk

Brendan Martin FRSA is founder and MD of Public World, which has set up Buurtzorg UK in partnership with Buurtzorg Nederland.