Buurtzorg: the Dutch model of neighbourhood care that is going global

Innovative nursing model cuts bureaucracy and gives nurses more freedom and time with clients

The Guardian, David Brindle, 9 May 2017

New Dutch homecare model insists nurses spend more than half of their time
in direct contact with the people they support. Photograph: Fred Froese/Getty

The Dutch may be renowned for tulips and Edam cheese, but these days it’s their innovative district nursing and homecare model that is exciting global interest. Buurtzorg, which translates as “neighbourhood care”, is seen by its many enthusiasts as a key part of the solution to challenges facing healthcare systems across the world.

From Aberdeen to Shanghai, the Buurtzorg approach is being seized on by policy-makers as a means of enabling people with care needs to live independently with much less formal support. Potential cost savings of up to 40% have been calculated.

At the same time, the model is said to be hugely popular with the nursing teams who run it because it frees them from management control and unleashes their entrepreneurial creativity. And it is very simple.

Buurtzorg was founded 10 years ago by a 56-year-old nurse, Jos de Blok, and started with an initial team of four. The system that evolved deploys teams of up to 12 nurses, who are responsible for between 40 and 60 people within a particular area. There are now around 900 teams in the Netherlands, supported by no more than 50 administrators and 20 trainers.

The principle underpinning the model is that the nurse acts as a “health coach” for the individual and their family, emphasising preventive health measures but also delivering necessary care themselves or calling on others to do so. The golden rule is that nurses must spend 61% of their time in direct contact with the people they support.

An evaluation by consultancy KPMG in 2012 found that although the care might be costlier per hour than under a traditional approach, it was of higher quality and better appreciated by those in receipt. Crucially, only half as much care was typically required.

“What I see in a lot of countries is that systems are increasingly complicated and frustrations are becoming worse and worse,” says de Blok. “I want to show that it’s easy to change.”

De Blok will be talking change at the 25th annual European Social Services Conference in Malta at the end of June, organised by the European Social Network. In some cases, he will be preaching to the converted: Buurtzorg is being trialled in the UK and Sweden, with Germany and Austria soon to follow, as well as in the US, Japan, China, Taiwan and South Korea.

But others at the conference will need convincing that the model can be transplanted into other health systems and nursing cultures as easily as he suggests.

One issue is funding: the Dutch model is tailored to payments by health insurance companies, not a state healthcare system like the NHS or means-tested social care. Another is the scrapping of hierarchies and specialisms within the nursing teams: a Buurtzorg nurse might administer wound care, but may also help someone to wash or get dressed.

A third challenge is that the model requires management to back off and allow their teams considerable latitude, with much less performance monitoring than has become the norm in, for instance, the UK. Bureaucracy is reduced to a minimum.

 “We have tried to prevent it becoming a meetings structure,” says de Blok, describing how his teams are encouraged to think freely in finding answers to people’s care needs, drawing on other professionals and volunteers. “The autonomy is better when [the teams] build their own networks to solve problems.”

The Buurtzorg approach has even been extended to what in the UK would be recognised as home help, after the organisation stepped in to rescue a failing Dutch provider two years ago. By cutting its overheads dramatically, the provider has not only been saved but has expanded by more than 60% to 4,000 employees.

It is significant, therefore, that one of the most advanced UK Buurtzorg pilots is being run by Cornerstone, a Scottish homecare charity, while others closer to the original nursing concept are developing at sites including Aberdeen, Angus, Dumfries and Galloway, and Borders.

In England, the model has been taken up by the Guy’s and St Thomas’s NHS foundation trust in south London as well as integrated health and care services in Tower Hamlets, east London, and in west Suffolk. Active interest has come from Kent and Cheshire West, among others, and 300 people recently attended the first presentation in Wales by Public World, a consultancy working with Buurtzorg.

De Blok insists he is relaxed about the model being adapted to suit local circumstances. Buurtzorg is a non-profit organisation – though it makes a surplus for reinvestment – and it does not seek to franchise the model under licence.

“I’m not interested in money,” de Blok says. “I see so many people searching for a new way of doing things in all the places I visit. It’s all about creating something different from the bottom up.”

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Dutch flag carrier KLM to cut management by 25%, boost efficiency

DutchNews, October 1, 2015

Dutch airline KLM is poised to cut a quarter of its managerial jobs and support functions, broadcaster Nos says, after acquiring a copy of the reorganisation plan. 

The document states that KLM is too complex, too slow and too expensive. The company is too hierarchical, has too many managers and ‘has lost sight of its customers’. Slashing costs will involve ‘flipping all the switches’, Nos says. 

According to KLM, this means 25% of managers will lose their jobs and those who remain will have bigger departments to deal with. In addition, support, HR and communications departments, can be streamlined and made more efficient. 

The job cuts should lead to savings of €40m a year, Nos says. 

The plan was sent to the airline’s works council on July 8 and it has reacted positively, Nos says. 

The reorganisation has been on the cards for some time. A spokesman told the broadcaster that the changes would make KLM more future-proof but declined to say how many jobs will actually be lost.

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Fewer managers but more of them are women

DutchNews, September 22, 2015

While the number of people in work has risen, the number of managers has dropped by 8%, from 531,000 to 490,000. 

The figures, released on Tuesday by the central statistics office CBS, show that although female managers are still in the minority, their number has risen from 24% of managers to 26%. 

The number of people working in Dutch companies and organisations in a management position has also risen: from one in 15 to one in 17. 

The majority of job losses at management level were in the insurance and financial services sectors.

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Zappos is going holacratic: no job titles, no managers, no hierarchy

Quartz, Aimee Groth, December 30, 2013

In September, Zappos got a new home, now the company is about to
get an internal makeover. Aimee Groth

Zappos is known for its zany corporate culture. The company’s Q4 “All Hands” meeting in November was aptly-themed “Gone Wild”: one female employee voluntarily climbed into a case filled with tarantulas to win a $250 gift card. The event opened with a Lion King performance put on by employees at the Smith Center in downtown Las Vegas and closed with an after party at the museum next door. Focusing on company culture and customer service is how CEO Tony Hsieh built Zappos into a billion-dollar online retailer. While he’s not getting rid of those priorities, Hsieh is laying the groundwork for a major reorganization. 

During the 4-hour meeting, Hsieh talked about how Zappos’ traditional organizational structure is being replaced with Holacracy, a radical “self-governing” operating system where there are no job titles and no managers. The term Holacracy is derived from the Greek word holon, which means a whole that’s part of a greater whole. Instead of a top-down hierarchy, there’s a flatter “holarchy” that distributes power more evenly. The company will be made up of different circles—there will be around 400 circles at Zappos once the rollout is complete in December 2014—and employees can have any number of roles within those circles. This way, there’s no hiding under titles; radical transparency is the goal.

Hsieh told the crowd on that rainy November afternoon, “Darwin said that it’s not the fastest or strongest that survive. It’s the ones most adaptive to change.”

Last fall, while exploring ways to scale Zappos without letting bureaucracy set in, Hsieh met Brian Robertson, the founder of the management consultancy HolacracyOne.

“Zappos’ focus on core values and culture has done a remarkably good job of getting around the limits of a conventional corporate structure,” says Robertson, who created the company in 2007 after using Holacracy to run a software company that he founded. “Leaders that already understand the limits of conventional structures are the ones that are attracted to Holacracy.”

CEOs who sign on to Holacracy agree to cede some level of power. The advantage is that they get to view their company through an entirely different lens. But it’s an adjustment for both leaders and employees. Zappos, which has 1,500 employees, will be the largest company to date to implement Holacracy.

“We’re classically trained to think of ‘work’ in the traditional paradigm,” says John Bunch, who, along with Alexis Gonzales-Black, is leading the transition to Holacracy at Zappos. “One of the core principles is people taking personal accountability for their work. It’s not leaderless. There are certainly people who hold a bigger scope of purpose for the organization than others. What it does do is distribute leadership into each role. Everybody is expected to lead and be an entrepreneur in their own roles, and Holacracy empowers them to do so.”

In its highest-functioning form, he says, the system is “politics-free, quickly evolving to define and operate the purpose of the organization, responding to market and real-world conditions in real time. It’s creating a structure in which people have flexibility to pursue what they’re passionate about.”

Twitter Co-Founder Ev Williams is one of the system’s early adopters; he uses Holacracy to run his publishing platform Medium, which has around 50 employees. Jason Stirman, whose roles include head of people operations and product designer at Medium, says that one of the best things about Holacracy is that it facilitates autonomy. “Ev isn’t the CEO of Medium to have another title for his Twitter bio. He wants the company to operate at the highest level possible, and he recognizes that all the power consolidated at top is great for people who are hungry but it can be a total bottleneck. There are decisions he wants to make and the rest can be absorbed in other areas of the organization.”

Still, Holacracy can feel unnatural, especially at first. Meetings are designed to rapidly process tensions. The focus is on the work, not the people. “It’s not a very human-centric model for things,” says Stirman. “For example, if you’re a junior designer, Holacracy says that you should bring up everything in this forum, but it can be difficult to ask for feedback or mentorship, especially when you’re new.”

Robertson says that Holacracy is meant to address structural issues, and that leaders will respond to the human element in different ways. Medium has created mentorship circles, and Zappos has similar plans. Williams and Hsieh both “have a high capacity to see the complex systems at play in their organizations,” says Robertson. “It’s not linear or a matter of just following the logical argument; it’s seeing the cloud of interconnections and influences, beyond just cause and effect thinking.”

At the Zappos “All Hands” meeting Hsieh said that at most companies, “there’s the org chart on paper, and then the one that is exactly how the company operates for real, and then there’s the org chart that it would like to have in order to operate more efficiently. … [With Holacracy] the idea is to process tensions so that the three org charts are pretty close together.”

Hsieh’s plans for Zappos are part of an even more ambitious undertaking. He’s currently investing $350 million of his own fortune to transform downtown Las Vegas, where  Zappos’ is now headquartered, into an improved holarchical system. For Hsieh, work, play and everything else are already a series of overlapping circles.

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Who Needs Bosses? Not Game Company Valve

ABC News, by Alan Farnham, April 25, 2012

Software developer Valve Corp in Bellevue, WA, has 300 employees
and not one manager or boss. (Value Corp)

Video game and software developer Valve Corp, in Bellevue, Wash., has 300 employees--but not a single manager. How to they do that? What's it like to work in a boss-free zone? And what other companies share Valve's approach to non-management?

Valve's website proclaims: "We've been boss-free since 1996. Imagine working with super smart, super talented colleagues in a free-wheeling, innovative environment—no bosses, no middle management, no bureaucracy," just highly motivated peers coming together to make "cool stuff" without anybody "telling them what to do."

It would be wrong to say that up until this week Valve kept its no-boss policy a secret, or that its happy peers toiled in obscurity. The company gets plenty of attention, acknowledgement and feedback from customers, suppliers and reviewers for the best-selling games it makes.

But a few days ago, Valve allowed its unique and quirky employee handbook to be posted onthe Internet -- and since then, the phones have been ringing off the hook.

The calls aren't coming from would-be game buyers. They're coming from doctors and lawyers, clerks and car mechanics asking either "Can I go to work for you? Boy, I hate my boss" or "Can you teach our organization how to do what you do--get by boss-free?"

All of this attention, says Valve's Greg Coomer, has come as something of a shock. "Surprising," he calls it. "We've been hearing from people well outside our usual audience, from the UK, even from the public sector."

As its handbook makes clear, Valve's approach isn't for everyone. The U.S. Army, for instance, is never going to embrace no-boss-ism. Nor, probably, says management expert and business author Geoffrey Colvin, could FedEx--or any other business that employs tens of thousands and has to function like a Swiss watch, day after day, with precision and predictability.

Coomer agrees. "We know we're unique," he says. But he adds, "We wouldn't advise others against trying it. We're very interested to see others applying it to their organizations."

He says it's taken Valve every day since its founding in 1996 to make its system work. But work it does, judging by results. The company is to video game distribution what Apple's iTunes is to music. Its best-selling games series include Half-Life, Counter-Strike, Left 4 Dead, and Portal. In 2010 privately-held Valve announced it had in excess of 30 million active user accounts.

"Welcome to Flatland," says the handbook, referring to Valve's non-hierarchy. It goes on to explain that hierarchies are great for maintaining predictability and repeatability, but maybe not so good for an entertainment company trying to manage some of the most "innovative, talented people on Earth." Telling people like that "to sit at a desk and do what they're told obliterates 99 percent of their value."

Employees get to vote on their assignments. If they hear of a project they want to join, they literally vote with their feet and with their desks, which all have wheels. They unplug their computers, push back from the wall, and wheel themselves to whatever new project they want to join.

There's a system for reviewing their work and for assigning blame and praise. There's a system for tweaking compensation. But it all plays out without what most long-suffering office schlubs would consider top-down authority. For a full (and vastly entertaining) description of how Valve accomplishes this trick, see their handbook.

The closest Valve gets to having bosses are people called Team Leads. Says the handbook, "Often, someone will emerge as the 'lead' for a project. This person's role is not a traditional managerial one." They serve as clearinghouses of information, "keeping the whole project in their head at once, so that people can use them a s a resource." When the project disappears, so does the Team Lead.

Is it possible to get fired? You bet, and Valve employees certainly have been, says Coomer. But the reason has never been for an honest screw-up. Valve from time to time has hired people who, by temperament, found it frustrating or impossible to work within so gossamer a structure.

He freely allows that not having bosses has its downside. The handbook, in fact, has a section headed "What is Valve Not Good At?" Number 1 on the list: helping new people find their way. After that comes: mentoring people, disseminating information internally, and missing out on hiring people of talent who simply need to work within a more traditional structure.

Management expert Colvin, author of "Management Strategies for Difficult Times," says he can think of only two other companies that do business the Valve way: Fabric innovator W.L. Gore, where, he says, not only is the organization flat but people's business cards list no title (just their name, phone n email).

"This is the company where somebody once said, 'To see if you're a leader, call a meeting and see if anybody comes.'" And the other boss-less company? A Brazilian outfit called Semco.

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