Going Dutch

New 24/7 health targets have focussed our search for the holy grail of efficiency in care. Our attention has now turned to Buurzorg, a Dutch social care company, that claims to provide a radical model for high quality social care at 65% of the going rate. It does this by getting rid of administrators and letting carers organise their own work.   Set up 6 years ago, Buurtzorg now employs 7000 frontline staff, representing 60% of Dutch community nurses with just 30 managers on its books. The costs per hour are higher but patients need 30-40% less contact time every month. Nurses work in teams of 10 each serving a particular community and working reactively to patient needs. They work closely with local GPs and local services and see themselves as having a key social function identifying and building relationships within the community. Not only are patients happier but so are staff with 60% less staff absenteeism and 33% lower turnover.  Never have 1980s nursing management techniques been so en vogue.  This model of care is in stark contrast to the UK where 160,000 social carers earn less than the minimum wage and social care job vacancies are higher than any other sector. In policy terms we’ve had a sharp wake-up call with targets set as high as 40% cuts in public spending. This is going to have a profound effect on social care in the UK.  Courtesy of reports by the Resolution Foundation and the meticulous work of Shereen Hussein  we now know more about these often invisible workers. Here’s what an anonymous domiciliary carer had to say.   “It’s another 10 minute drive to my next client, Mrs. T. I assumed given the time (12.30 – 12.45pm) this was a lunch call but it is actually a medication prompt. It could have been a nice easy call, but it turns out the last carer was late so she didn’t take morning medication until 11am. I have to remove some of her meds and refuse to give them as the time frame is too short and could put her at risk of overdose. I again call the on-call team to inform them of the situation (a call I make from my mobile phone for which I pay the bill). Mrs. T’s was supposed to be a 15 minute call but what with reading the care plan and discussing with the on-call team it takes 25 minutes, 10 of which I won’t get paid for.”Most of the people who currently work as carers are the real deal. Women, middle aged, many of whom worked for the public sector and still remember what professional ethics and standards look like. Currently 50% of private providers come from the not-for-profit sector www.nationalcareforum.org.uk/, many of which were set up during privatization. Within the next decade most of these carers will retire and with them goes our heritage of how to manage social care, old school.  Different institutional models A pragmatic attention to efficiency and cost savings through technology and clinical practice is attractive  but the Dutch model comes from a very different institutional setting.  Comparative Employment Relations, sometimes called the Varieties of Capitalism model, offers us a theoretical framework for understanding how and why work is organised differently in different countries. Within this perspective, the UK and Netherlands, despite both being capitalist systems are profoundly different in their approach to providing social care. Two institutional factors really stand out.  The first is that Dutch institutions are framed within a political culture of social democracy and based on strong egalitarian principles. The Dutch & Nordic countries have a shared emphasis on equality, reflected in the lack of pay differentials and a dominant workplace culture of flat leadership. To maintain this equality, the Netherlands has one of the strongest welfare systems in the world.  The second institutional factor relates to employment relations. Although wages by UK standards are moderate, Dutch workers are compensated by a generous ‘social wage’ including high unemployment benefits, labour protections and social security benefits.  These differences are seen most clearly if we look at flexible work in health and social care sectors. Unlike the UK’s often brutal neo-liberal model of high flexibility and insecurity, the Dutch model specifically tries to balance the demand for flexible working with the security needed by flexible workers - in the EU called ‘flexicurity’.  The Dutch system protects carers from falling into in-work poverty and de-skilling by having higher protections and investment in skills development. This security includes a higher percentage of flexible workers that are represented by Dutch trade unions, including new unions designed specifically for self-employed workers.  These two factors - an egalitarian social welfare system and robust labour protections - put the Dutch model of care in stark contrast to ours. Can we go Dutch?With a £22 billion efficiency challenge  and ‘restructuring fatigue’ within health and social care, its tempting to go for a technical solution to a political problem. Cut the 48% of non-clinical staff in the NHS and voila we’re in Keukenhof?  There’s nothing wrong with importing new management ideas - we did it in the 1980s with Japanese production methods - but to do this successfully we have to understand the institutional systems within which they can work.  Cutting bureaucracy is only one part of the socio-political equation, because the Buurtzorg model is one of workplace autonomy and democratic leadership where decision making and setting targets is decentralised to clinical teams. The UK and Netherlands’ profoundly different institutional settings mean that to do this successfully would require an enormous shift in both the UK’s employment relations and workplace cultures.  The Dutch model at its best offers us is a relational model of care where consistency of care, community relations and being responsive to individual needs provides the necessary framework for this important emotional job of work. Most of the people receiving social care are over the age of 85 years making social care the most important social project of any society. All of us deserve a model of care which gives people enough time to know our names and listen to our stories, whether we’re the carer or the cared for.  This blog was produced for theconversation.com for our column Battles on the NHS frontline: Stories from the vanguard of health and social care. Please help us build up a picture of what is happening in health and social care by sending us your Stories from the Frontline here.