A first attempt at a systematic overview of the public record in English on Buurtzorg Nederland (Part A — Buurtzorg’s performance)

Introduction

Buurtzorg Nederland, a district nursing and home care organisation in the Netherlands, has recently gained prominence amongst the UK health and social care community. The NHS Confederation, the Royal College of Nursing, the King’s Fund and the RSA have all expressed their interest in Buurtzorg by inviting its CEO and founder, Jos de Blok, to present Buurtzorg’s way of community nursing to UK audiences. This interest in Buurtzorg has culminated into an array of pilot projects (at different stages of preparation and implementation) in London, the East of England and Scotland inspired by Buurtzorg’s approach. Buurtzorg Nederland’s prominence rests on its record of success along an impressive range of performance indicators and on its distinctive and counter-normative (as far as the UK is concerned) organisational and operational model.

The purpose of this paper

Yet despite this rising prominence and the recent direction of scare resources into pilot projects, I have not been able to find a comprehensive and concise summary of the available public documentation on Buurtzorg in the English language. This paper aims to address this gap. I hope that by bringing together and summarising the available sources of information on Buurtzorg in a clear, concise and structured document this paper will reduce the search costs faced by health and social care professionals in their effort to familiarise themselves with Buurtzorg. Secondly, this paper aims to contribute to attempts to bring structure and clarity in the public discussion on Buurtzorg which is currently dispersed along conference presentations and interviews by Jos de Blok and other Buurtzorg spokespeople, blogged accounts of study visits, consultancy involvement, announcements of pilots, workshop and conference materials, books, and professional journal publications. Thirdly, this paper aims to be of use to the professionals involved in decisions on the implementation and evaluation of services inspired by Buurtzorg particularly by helping them in benchmarking and evaluating the outcomes of pilot projects. Finally, this paper aims to contribute to a further flourishing of the literature and documentation on Buurtzorg in the English language.

The structure of this paper

The first section of this paper summarises the public record on Buurtzorg’s performance while the second section summarises Buurtzorg’s operational model. The array of performance indicators presented in the first section come under the following headings: a) health and social care outcomes for patients; b) cost implications of these outcomes for the health and social care economy; c) patient satisfaction; d) employee outcomes operationalised as employee satisfaction, sickness absence rate, turnover rate, recruitment, retention and remuneration; e) business performance operationalised as scaling, revenue, profitability, productivity, efficiency, economy, expansion in different services, international expansion, adoption of the Buurtzorg operational model by competitors and pubic image of the organisation.

The second section on Buurtzorg’s operational model describes the main elements of Buurtzorg i.e. the self-managing home care teams and the framework of supports and constraints they operate in, the regional coaches, the BuurtzorgWeb (the organisational intra-net) and the role of the directors. This section finishes with accounts of a set of self-managing processes (decision-making, team meetings, rostering, peer coaching, dealing with the need for specialisation and expertise in teams of generalist nurses, forced dismissals).

Part A — Buurtzorg’s performance

In summary, Buurtzorg Nederland is depicted as an organisation that is significantly more lean, efficient, and productive than the average while at the same time engendering significantly better than average health and social care outcomes for its clients and also better than average outcomes for its employees. Buurtzorg appears to transcend the usual trade-offs in health and social care: it is cost efficient and yet the ratio of nurses to clients is purposely kept low in the interest of care continuity; it generates a healthy surplus even though it employs a significantly larger than average number of highly-qualified staff remunerated at a higher than average level; it achieves higher than average employee productivity figures without centralised systems of employee control; it achieves higher than average quality of care at a cost level that is below the industry average.

My review of the English-language record on the performance of Buurtzorg shows that the record on the health and social care outcomes for Buurtzorg patients and the cost implications for the health and social care economy in the Netherlands relies almost entirely on the two following studies which are not available in English as far as I can tell:

KPMG (Jan 2015) The Added Value of Buurtzorg Relative to Other Providers of Home Care: A Quantitative Analysis of Home Care in the Netherlands in 2013 [in Dutch] / KPMG-Plexus. De toegevoegde waarde van Buurtzorg t.o.v. andere aanbieders van thuiszorg. Eeen kwantiatieve analyse van thuiszorg in Nederland anno 2013. 2015]

Ernst & Young (2009) Maatschaappelijke business case Buurtzorg. Reportby Ernest & Young. [online] Available at: http://www.transitiepraktijk.nl/files/maatschappelijke%20business%20case%20buurtzorg.pdf [Accessed: 4 August 2016]

With regards to the first one, Gray et al. (2015: 4) explain that it was commissioned by the Dutch Ministry of Health, Welfare and Sport “to compare Buurtzorg’s performance with that of peer organisations” on account of the “increasing prominence” of Buurtzorg and the criticism that its rapid growth was the outcome of ‘cherry-picking’. With regards to the second one, Monsen and de Blok (2013a) explain that Ernst & Young (2009) reported on a structured cost and outcome analysis of Buurtzorg, as part of a Dutch Ministry of Health program, in which Buurtzorg was compared with other home care organizations.

These two reports are referenced very heavily in the English-language record on Buurtzorg. In the absence of English translations, their contents are made available to us primarily through Gray et al. (2015), Alders (2015), Laloux (2014) [these authors or members of their research teams speak Dutch] and presentations, speeches and articles by Jos de Blok the co-founder, co-director and public spokesperson for Buurtzorg. On the face of things, they appear to be reports conducted by large, multi-national consultancies, independent of Buurtzorg and commissioned by a Dutch Ministry as part of its regulatory and monitoring duties and so the possibility of bias in favour of Buurtzorg appears minimised. The KPMG (2015) report in particular includes findings that do not reflect well on Buurtzorg performance so this offer further grounds not to doubt its objectivity. The documents that reference these reports however are completely silent on the methodologies and research practices that produced the reported results. As a consequence, it is impossible to assess and evaluate these results when parameters such as data selection, inclusion and analysis are unknown. Translating these reports in English would certainly help in building the evidence and documentation record on Buurtzorg Nederland and would contribute to the discussions in the UK on implementing similar approaches to district nursing and home care.

A third source of information on patient outcomes is the following article in a KPMG International publication:

KPMG International. (2012) Buurtzorg empowered nurses focus on patient value. pp. 20–23 In KPMG (2012) Value walks: Successful habits for improving workforce motivation and productivity. (http://www.kpmg.com/global/en/issuesandinsights) Available at: http://www.publicworld.co.uk/wp-content/uploads/2015/10/kpmg-buurtzorg.pdf [Accessed 29 July 2016]

Unfortunately, the article does not give details of the evidence supporting the claims made. It is suggested that data were made available by Buurtzorg and analysed by KPMG.

Patient outcomes (health and social care)

The documented health and social care outcomes for Buurtzorg clients relative to other home care organisations in the Netherlands are summarised in Table 1 below.

Table 1: Patient outcomes (health and social care)

The studies referred to above seem to concur that Buurtzorg is economical and effective in its deployment of home care hours. Patients’ needs appear to be met with markedly less hours of home care per patient year (50–55% less) relative to the industry average. Buurtzorg appears to use only 40% of the prescribed home care hours for a client (against an industry average of 70%). These hours of home care are delivered over a significantly shorter time period (5.5 months against 7.5 months for the industry average) with one publication suggesting that 50% of patients receive care for less than 3 months. The Ernst & Young (2009) report is cited as also indicating that patients improve faster, experience fewer episodes required unplanned interventions, are less likely to be admitted to Emergency Departments and when they are admitted they are more likely to have a shorter hospital stay. KPMG (2015) however reports that on average Buurtzorg patients move into nursing home care at a lower age than the patients of other organisations.

Above, I am offering a possible description of the evidence record. There is a debate to be had as to whether the results of the two studies undertaken as such different points (2009 and 2013) in the organisation’s development can be combined into a single portrayal of organisational effectiveness.

Cost implications of patient outcomes for the health and social care economy

The cost implications of patient outcomes for the health and social care economy are summarised in Table 2 below.

Table 2: Cost implications of patient outcomes for the health and social care economy

The case-mix adjusted costs of Buurtzorg per patient-year in 2013 were at the 38th percentile of Dutch home care providers (62% of providers had higher costs while 37% of providers had lower costs). ‘Case-mix adjusted’ means that differences between the group of Buurtzorg patients and that of other providers were controlled for in the calculation of the cost figures. The specific variables controlled for were: “age, gender, zip code, socioeconomic status and ‘pharmaceutical cost group’ as a proxy for high-cost conditions including COPD/severe asthma, depression, diabetes (I and II), cardiac disorders, HIV/AIDS, cancer, kidney disorders, Parkinson, psychosis/Alzheimer’s, addiction, rheumatism and transplants” and “differences in travel time” between patients (Gray et al. 2015: 8). Adjusting for the patient case-mix was “aimed at minimising the possibility that cost differences were the result of patient selection either by Buurtzorg or other providers” (Gray et al. 2015: 4). The lower case-mix adjusted costs cannot accounted for by personnel costs per hour as these are higher in Buurtzorg relative to the average — €54.47 against €48.74; a difference of 12% (Gray et al. 2015).

Buurtzorg’s non-adjusted average home-care costs are lower than the Dutch average: €6,248 vs. €7,995, a difference of 34%. de Blok (2011: 84) claims that “ if we compare Buurtzorg with other organizations, the various patient groups are divided differently […] Buurtzorg handles many complex care situations with patients who leave the hospital, terminally ill patients and patients with comorbidity problems”. Further, in a Public World/Royal College of Nursing stakeholder seminar in the UK in July 2015 he claimed that about 50% of Buurtzorg’s clients have some form of dementia (RCN 2015). If it is the case that Buurtzorg patients have higher care needs than average then the non-adjusted cost difference may understate the economy achieved by Buurtzorg relative to other organisations. de Blok (2011: 83) claims that the report by Ernst & Young (2009) showed that “costs per patient were half that of other homecare organisations”. A reduction of home care costs by 30–40% is also claimed by de Blok (2013, 2015). Given that we do not have in English the details of how these costs were calculated it is impossible to offer any opinion on their comparability.

The KPMG (2015) study looked at follow-up costs to the health and social care system for the four quarters after the first quarter of home care.

The follow-up costs of nursing home care were below average. Alders (2015) states that 38% of the other organisations had higher costs. Burtzorg’s patients at follow-up incurred an average of €2,029 against €2,730 for other organisations (a difference of 34%). This is despite the patient outcome reported above that the clients of Buurtzorg were admitted to nursing homes at a lower age than average.

The follow-up costs for ‘curative’ (physician and hospital) costs for home-care patients were higher than average for Buurtzorg patients. Buurtzorg patients incurred average cost of €7,787 against costs of €5,187 for other organisations (a difference of about 50%). Alders (2015: 59) notes that the ‘curative’ costs “include all hospital costs, which included some costs that are unrelated to the quality of the nursing by care organisations”.

According to Alders (2015: 59), “[t]he total ‘follow-up’ costs — the costs of hospitalisations, Primary Care Physicians (PCPs), and nursing home care […] — were relatively higher [for Buurtzorg] than those of other home-care organisations — €9,334 a year vs. €7,959” and that 72% of home-care organisations had lower follow-up costs .

Adding up all costs to the health and social care economy and adjusting them for case-mix differences places Buurtzorg just below the national average at the 49th percentile of Dutch home-care providers. Buurtzorg’s total incurred costs were €15,357 against €15,856 for other organisations (a 3% difference).

However, Alders (2015:59) notes that there are limitations to the KPMG (2015) study in that “factors like regional differences and problems with activities of daily living (ADL) were not taken into account for adjustment of the case-mix”.

According to Laloux (2014: 66), the Ernst & Young (2009) study claimed that “[t]he savings for the Dutch social security system are considerable — Ernst & Young estimates that close to 2 billion would be saved in the Netherlands every year if all home care organisations achieved Buurtzorg’s results”. This is the same study that found that Buurtzorg’s patients were less frequently admitted (by 1/3) to hospital and the average hospital stay was shorter.

Patient reported satisfaction

The main source of evidence on this indicator is the Consumer Quality Index. According to Alders’s (2015) account, home care organisations in the Netherlands are invited to participate in the exercise of calculating the Consumer Quality Index (CQ-Index) which is carried out by accredited agencies biennially on behalf of the Dutch Ministry of Health. The Index aims to capture consumers’ views on the following indicators of quality: 1) experienced treatment, 2) physical care, 3) staff quality, 4) information, 5) participation; 6) the Net Promoter Score (NPS) which according to Gray et al. (2015: 8) is “the percentage who would recommend the organization to a friend minus the percentage who would not do so”. Before the 2015 reforms to the long-term care system, the organisation commissioning community nursing care in a Dutch region (the ‘Zorgkantoor’) would take into account the CQ-Index in its negotiations with individual providers on the volume and price of home care to be purchased.

Table 3 below summarises the available record in English on Buurtzorg’s performance with regards to patient satisfaction.

Table 3: Client satisfaction for Buurtzorg clients

Sources: (a) NIVEL (the Netherlands Institute for Health Services Research, www.nivel.nl/en) is the organisation which carried out the CQ-i surveys. It is referenced as having published its results in 2008 or 2009. If measurements are carried out biennially as claimed by Alders (2015) then one of these dates must be wrong. (b). The reference given in European Commission (2014) is: Buurtzorg (2012). Jaarekening 2012. Stichting Buurtzorg Nederland. (c ) Same as above: Buurtzorg (2013). Jaarekening 2013. Stichting Buurtzorg Nederland.

Once again without detailed knowledge of the methodologies, materials, and results of these consumer surveys it is impossible to draw any firm conclusions. However, it is apparent that in terms of patient satisfaction Buurtzorg ranks very highly in the time period between 2008 and 2013.

Employee outcomes

Work satisfaction and alignment with the values of the organisation

The main source of evidence for this indicator are the Best Employer Awards carried out by the Dutch organisation Effectory. Effectory according to Gray et al (2015: 8) is “an international organization that conducts employee surveys to help organizations use employee engagement to improve organizational performance”. The European Commission (2014) report explains that the title of ‘Best Employer’ is awarded on the basis of independent employee surveys among at least 300 employees in each organisation . According to the Knowledge Bank Workplace Innovation website (www.workplaceinnovation.org), Effectory operates through self-managing teams itself. I have not been able to locate a copy of the survey forms used. In their absence is hard to contextualise the content of Table 4a below which summarises the retrieved evidence record.

Table 4a: Indicators of employee satisfaction and engagement at Buurtzorg

Staff turnover, sickness absence, workforce recruitment and retention

The only independent study cited as a source of figures for these indicators is Ernst & Young (2009). Presumably, the only source of this information can only be Buurtzorg and a range of authors report the figures provided by Buurtzorg. Table 4b below summarises the evidence record on these indicators.

Table 4b: Indicators of employee well-being at Buurtzorg

Business performance

The growth of Buurtzorg appears nothing sort of explosive. According to a report by the European Commission (204: 362): “For five years in a row (2009- 2013), Buurtzorg Nederland has received the Golden Gazelle Award of the Dutch Financieele Dagblad (Financial Jounal) for being the fastest growing big company in the East of the Netherlands (FD, 2013)” The source cited in the report is: Financieel Dagblad (2013). FD Gazellen 2013. http://fd.nl/events/fdgazellen/442262- 1311/fd-gazellen-2013-arends-techniek-grootste-groeier-in-noord-nederland. Table 5 below summarises Buurtzorg’s growth between 2007 and 2016 in terms of home care employees, teams, clients, back-office staff, coaches, revenue, and profit.

Table 5: Growth, between 2007 and 2016 in home care employees, home care teams, clients, back-office staff, coaches, revenue and profit

1) de Blok (2011); 2) European Commission (2014: 358); 3) Nandram (2015); 4) Kreitzer et al. (2015); 5) RSA Replay: Humanity above bureaucracy. (2014); 6) Jos de Blok l Organisation without management l Meaning (2015); 7) Morsen & de Blok (2013); 8) de Blok (2015); 9) KPMG (2012); 10) Royal College of Nursing (RCN) (2015); b) Figure by Jos de Blok at a Public World/RCN stakeholder seminar in July 2015; 11) Laloux (2014); 12) Health and Social Care Academy (2016); 13) Sprinks (2014); 14) Alders (2015); According to Alders(2015): €217million is 4–5% of the Dutch home-care market (nursing, personal care and assistance); 15) de Blok (2013)

Financial indicators

Table 6 below summarises a range of financial indicators for Buurtzorg.

Table 6: Financial indicators for Buurtzorg reported in the English literature

(a): Dalen, Annemarie van, Uit de schaduw van het zorgsysteem, Hoe Buurtzorg Nederland zorg organiseert (Out of the shade of the care system, How Buurtzorg Nederland organises care) , 2010, Den Haag, Boom Lemma uitgevers

Table 7: Financial structure of a typical Buurtzorg team according to Ernst & Young 2009 as cited in European Commission (2014: 357)

Employee qualifications of Buurtzorg home care teams

Table 8 below summarises the evidence record on the educational level of home care team members at Buurtzorg Nederland.

Table 8: Employee qualifications of Buurtzorg home care teams

Sources: 1) de Blok (2011); 2) de Blok (November 2013); 3) Health and Social Care Academy (2016); 4) RSA Replay: Humanity above bureaucracy. (2014); 5) Gray et al. (2015: 7); 6) Royal College of Nursing (RCN) (August 2015); 7) Monsen & de Blok (2013a)

There is variation in the numbers which is understandable. A lot of these numbers are taken from speeches or notes or other material whose primary purpose are to make broader points than to be pin-point accurate. However, they have been collated here to contribute to the emerging depiction of Buurtzorg in English-language materials.

Expansion in other areas of service delivery in the Netherlands

More recently Buurtzorg has expanded into an array of related services (European Commission 2014: 356). These are:

According to the European Commission (2014 — Annex 5: 358) case study, in response to the continuous and increasing interest in the Buurtzorg operational model from a range of organisations from within health and social care and from other fields (e.g. education) from within the Netherlands and internationally, in 2011, Buurtzorg Nederland, Ecare Services and the Institution for Cooperation Issues (IVS) created “Buurtzorg Advice to better serve interested organisations”.

Buurtzorg Services (https://buurtzorgservices.com/) was recently launched to make the BuurtzorgWeb available to other organisations.

Influencing other organisations in the Netherlands and internationally

Buurtzorg has supported two other home-care providers in the Netherlands, Zorgaccent and Amsterling to transition to self-managing teams (NHS European Office 2016; Nandram 2015b).

In Belgium two non-for-profit home care organisations have also transitioned to the Buurtzorg model: Wit-Gele Kruis Oost-Vlaanderen and Wit-Gele Kruis Vlaams-Brabant. They are described in a report by the European Commission (2014; see case reports 5.2 and 5.3).

Buurtzorg-inspired services have also been established in Sweden, the USA (http://www.buurtzorgusa.org/), China (https://buurtzorgservices.com/expansion-in-china/) and other countries.

Pilots in the UK

The model is being considered in areas of London (e.g Tower Hamlets see: http://www.pcc-cic.org.uk/article/buurtzorg-and-tower-hamlets-integrated-provider-partnership). Public World Consultancy is reported to be collaborating with Guy’s and St Thomas’ NHS Foundation Trust in London (see: http://www.publicworld.co.uk/ project/buurtzorg/; http://senscot.net/view_art.php?viewid=21586) and with health and social care commissioners in West Suffolk (see: http://www.eelga.gov.uk/innovation-programme/buurtzorg.aspx)

Conclusion

Buurtzorg Nederland’s achievements are celebrated widely with the exception perhaps of the reservations raised by Dutch trade unions. However, in the absence of systematic documentation, the reverbating echo-chamber of social media and web pages makes it very difficult to identify the sources of evidence and the bases of the opinions and views expressed. The spectrum of Buurtzorg’s achievements from economic and financial efficiency to patient satisfaction and employee loyalty has attracted a range of interested organisations in the UK with very different priorities. They are likely to be advancing radically different versions of Buurtzorg. Buurtzorg Nederland spokespeople have been clear about the beliefs and motivation that have driven the organisation. Adopters in the UK have been more reticent leaving the basis of their expressed interest on Buurtzorg ambiguous.

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