Antonia: I really like the Buurzorg case study – it’s quite radical in that it unseats the notion of highly split up working and instead makes a single person responsible for all aspects of the care role with the cared for person. Instead of the patient having lots of small visits of different people looking at different aspects of their care you have one highly skilled person, in this case a nurse, who is actually doing multiple tasks. The team element of it is great because it’s the way they set up work which is thoughtful in the sense that, for example they develop twelve people into a team and develop them to work in a specific geographical location. You’ve immediately got a bunch of people who are able to support each other in the community and then you’ve also got all of those practical problems – people being on holiday or timetable – then there’s good interchange within the group. It makes lots of sense. When we’re talking about efficiency savings we should be thinking about better service at less cost. Really impressive.
Clive: It brings responsibility back to the individual – not just responsibility but control as well because that individual is making clinical judgements and judgements about the whole person. The essential element is that the patient is allowed to influence their care and the individual carer can take responsibility for quality and moderate what is happening without reference to someone else. Where costs go up is when things get kicked up the hierarchy for someone else to judge, by some strange rationale that someone remote is in a better position to judge than the person on the ground. The carers get a lot more deal job satisfaction which is directly linked to patient outcomes. Rather than being told from above what targets and procedures they have to do or limited by a silo mentality.
Antonia: There is a paradox in the NHS. That by splitting up the work task into smaller bits you get a lower quality service and lower productivity. The other side of that though is the importance of having people who have joined a profession – people who joined to be a nurse, a mental health specialist – people who have a deep knowledge of their area and now in order to provide whole person care for example in cancer teams, then you want to have a bunch of specialists on a single task. You don’t want silo mentality but you do want people with the ability to bring together different expertise.
Clive: So that’s where you need to build that into the work situation. People need collective and reflective time to look at the quality of the service. When we see the small but dreadful cases of the Bristol infirmary, there was no reflective time, no analysis of how did we do. You’re right its a paradox but its also about creating a system where people recognise that there is a prescribed system for care but can also adapt it based on their own intelligence and will.
Antonia: There is the opportunity through Better Care Together to do some radical thinking in healthcare and cooperation between different agencies. But often it’s turned into programme management – lots of well trained project managers and meetings reviewing Gantt charts and actions – we’ve now lost the philosophy of people finding out how to do things better together.
Clive: It’s not just a method, it’s a philosophy. It was against Taylorism and Fordism and it said, look, you take the responsibility back to the individuals. Forget the supervisors – they just cost you money and breathe down people’s necks – just give people the opportunity to get things right the first time. It’s a common cycle in the academic literature – plan-do-check-action – very simple. It’s a continual cycle that if you can, you get individuals, teams and managers to adopt.
To hear the full conversation with Antonia Maclean and Clive Morton go to www.survivingworkinhealth.org
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