Have you heard of Buurtzorg. No? Me neither, until I started reading a fascinating new book by Jaideep Prabhu.
This is, however, not a review of that book – ‘How Should a Government Be?’. I’ll do that another time (and in the meantime you might want to get hold of it and read it – there will be a test).
So, back to Buurtzorg. It might sound like something from Star Trek, but actually it’s an innovative Dutch social care organisation.
The basic idea is simple. Buurtzorg organises adult social care workers into small, community-based, self-managed teams. About a dozen nurses work together to look after elderly people at home, with clients usually only seeing one or two nurses who service all their social care needs.
Buurtzorg backs up these self-managed teams with no middle management. Instead, it provides a highly efficient web-based IT system for casework and a very light back-office function.
Teams had high degrees of autonomy to decide things like where their offices should be and how they should be furnished and decorated, within a budget.
And although Buurtzorg issues standardised general guidance, these teams are free to innovate with clients and other providers. The focus is the client, and moreover facilitating the elderly people to help themselves as much as possible.
This is an extreme version of what internationally renowned organisational theorist Henry Mintzberg calls “professional bureaucracies”. ‘Bureaucracies’ because there are rules, but ‘professional’ because the rules are not top-down imposed standards, but bottom-up evolved ways of working driven by the professionals who do the work.
Buurtzorg is both expensive and cheap. It is expensive because the hourly rate of the Buurtzorg nurses to do what are sometimes menial tasks compares unfavourably with lower-paid care assistants doing the same chores.
But it is cheaper than supposedly more efficient systems for two reasons. Firstly, with no middle-management and only minimal back-office functions it focuses resources on providing care. Secondly, the type of care provision – more personal and holistic – produces far better outcomes, and hence lower long-term costs.
Health and social care in the UK have gone in the opposite direction to Buurtzorg for decades. It now resembles much more what Mintzberg calls machine bureaucracies. These are much more like the traditional idea of a rule-bound, rigidly hierarchical, bureaucracy described in the work of Max Weber.
Work is organised not by professionals, but by rules and hierarchies of middle-managers, supported by large back-office functions like finance, IT, HR, etc. Tasks are divided and sub-divided and allocated through numerous divisions of labour.
The result may appear to be superficially more efficient, but often in reality it costs more and produces worse outcomes. The most extreme version of this can probably be seen in the US health-care system, where every task is specified and costed and accounted for. The result is the USA spends almost twice as much on healthcare as any other OECD country, for much poorer outcomes.
And for patients and clients the experience can be truly awful. They are seen by multiple workers, none of whom they know or who know them. Rushing in to provide a single specific task in the shortest time possible, health and care workers have little chance for human contact and support.
As an aside I should mention that this is what has also happened to UK Universities. In my three decades in the higher education sector there has been a decisive shift from ‘professional’ to ‘machine’ bureaucracy. Courses have been standardised and unitised, ‘support services’ and middle-managements have burgeoned, and every more complex and onerous rules-based systems imposed.
Ironically, many of these changes have been driven by ideas that came to be known as the “New Public Management” – the essence of which was supposedly importing management ideas and practices from the private sector to the public.
Often these ideas were very selectively chosen from a diverse set of private sector organisational and management practices, and largely tried to import practices from what were private-sector ‘machine bureaucratic’ manufacturing organisations into public-sector human services organisations – like health and education – where they were at best clunky, at worst toxic.
What Jaideep Prabhu’s book shows is that actually some of the most successful private companies today are likely to be more similar to Buurtzorg than a highly-specialised factory production line popularised by Henry Ford. This is the lesson that the public sector should now be taking on board.