Many people have now interviewed Jos de Blok of Buurtzorg. I first met Jos at Meaning Conference in Brighton, where he was one of the most informative and entertaining speakers on the day about the challenges and successes of using self-management as part of his organisational set-up to support his mission to change an entire system. As there are so few organisations who are as established (10 years into the business) he had to be part of The Purposeful Enterprise Summit.
What did you see happening in the home care industry before you set up Buurtzorg that was so radically wrong?
A development which started in the 90s in Holland, which was centred in a change made by political choices at that time, which made homelier very fragmented. The organisations and healthcare providers were delivering activities, and didn’t question any more whether they were good solutions for the people who needed them. People were depending on providers who didn’t do the right things – they were just selling activities and were paid by the hours they worked, so they just worked more hours but didn’t care about the quality of the service they provided.
One activity was delivered by a higher education nurse and some by a lower qualified nurse. Sometimes 40-50 different people would come to the house to treat one person. Costs went up, care went down, care workers and nurses saw that their daily practice didn’t lead to good solutions for patients. Patients had to deal with too many different care workers and nurses. Care workers and nurses couldn’t do the work they thought they should do. Cost development doubled in 10 years because of the way they organised it.
Was there a moment or over a period of time where you decided you just had to do something about it or was it a gradual decision?
In 1993/94 I was a community health nurse. I told my colleagues – I was doing a lot of study at the time – I was developing new policies. I became a manager. I felt as a manager, I would only be satisfied if we can get the real things back we saw as district nurses, as community healthcare nurses, providing service as it should be. I thought at first I could attain a position as a manager or director and could change things. I felt it became more and more difficult. The organisation was following the system not critiquing it. I was critiquing the system but became more and more isolated by my colleagues over 10 years. But I know how the system works, I know how healthcare works, and then I felt in 2005/6 I was ready to create something new.
What was the process and thinking you went through to decide how you would create it?
I am a very practical person and didn’t focus on purpose and mission. It’s important to have but it’s more internalised because of the things I did. We discussed as friends how we could use new ways of dealing with knowledge and information, how to build a network, how to organise, how to connect with the old principles. That was what we were doing. Together with different strengths and different skills, we created a new concept that would be consistent with our client-centred way of working in everything we were doing. We were focused not only on the empowerment of nurses but also of patients. It took 1 – 1.5 years. We felt we had a concept that was very scalable, and that could also create a transition in healthcare.
During that transition period, how did you test the concept?
We started n 2006. There were other organisations that were interested in trying to test the concept. One of them was the biggest healthcare provider in Holland at that moment. They wanted to change and wanted to use the concept to accelerate the change. We had 6 or 7 organisations who were testing the concept. But for us it wasn’t just about healthcare, it was also about the organisational structure. Then we had a problem as the existing organistions didn’t want to change structures, they wanted to remain based on the existing paradigm. So we reached a conclusion at the end of 2006 we decided to create our own tests. We had already created a Foundation, and we decided it would experiment with 10-12 locations and show that it was possible to do it in a new environment.
What measure did you take to create the kind of culture you wanted to have in your experiments? What particular things did you set out to do?
We tried to avoid all traditional management theories. We said we would just focus on the craftsmanship and talk to the nurses, asking them what they needed to do their work as best as they could. We did the same with IT. What do you need to be supported in your daily work? We described things in a very practical way, looking at what was necessary rather than what was useful. Then we had to arrange all the legal matters, and ensure we followed regulations in a very practical way. it was very dialogue based, we had a lot of meetings with nurses examining what was normal in their daily practice. In this way we started to understand what kind of coaching and support teams needed when they had problems.
Do you support them with both personal and business coaching?
My idea was to create an environment where people could show their entrepreneurial behaviour and they would do it. Community nursing is a very entrepreneurial professional, in that they are good at finding great solutions. Maybe not experienced at running businesses, but experienced at finding solutions to problems. We created a very simple business model, earnings and cost structure. So that everyone understood how it worked, and everyone knew what they got paid for. Previously the complexity in the payment system was enormous. In our system the nurses know what is needed to be financially sustainable, and everyone takes responsibility for the results.
Then you have the standards for healthcare, and if you are a trained nurse, you know what those are. So we trust people to use the protocols that exist to deliver the best possible care. The third part was how to deal with the team dynamics. As there is no leader and no manager, you have to find a way to deal with all sorts of decisions and problems collectively. We looked at how to define roles in teams so that the power is not concentrated by one or two people. We had ideas and we shared them with the teams, and by sharing them we created a standard way of building those teams.
When you launched were you taken by surprise by how fast the organisation grew?
It was not a surprise. We looked at different scenarios. We made a 5 year plan. The fist year which was experimental. Succeed and we cover our costs, then it could scale. Every team to start costs 20,000. It takes time to start, get the patients and then you are effective.
The €2million to grow the company came from organic growth, we didn’t want to have investors. We wanted to be independent, we wanted patients to be independent and nurses to be independent. We can make our own choices.
You were quite rebellious at school. Do people need inmate characteristics to succeed as self-managed businesses?
I think so. It’s a combination of characteristics that are needed. You have to have an overview on the different perspectives, it’s also the financial parts. Before I became a nurse I studied economics, I was very good at creating financial plans. At 8 and 9 years old I calculated everything in my head. The way I want to make things simple was always there. When people want to make things complicated, my response is why would you do that?
My values are to create environments where people can make their own decisions. It creates more happiness. If you can take the financial system be supportive to doing that, you create a different organisation. All the financial departments in traditional businesses dominate all the other departments and it should be the other way around.
You have to have some optimism, I have always been optimistic about what is possible. There are many solutions to any problem, so focus on the solutions but not the problems. And if you ask people to give their views, you create common responsibility where everyone is thinking about how to make things happen.
How is Buurtzorg growing internationally?
We got a lot of interest from other countries about what we were doing. I had some international experience. We had questions from Sweden, the US etc which helped us toldemonstrate that if we have very different cultures but we can show that the model can work there, we can show that it is based on Universal values. You have to find out in every country, how to deal with the systemic issues and cultures. But more or less, it was by coincidence.
Are there other opportunities to shift to a completely different model within the healthcare industry?
I didn’t focus on home care, I was trying to change health care. What I wanted to show was that if you create health communities and focus on prevention, you have another way of dealing with problems. My idea from the start was that we had to create another infrastructure in the community which could lead to a change in healthcare in the community. For example 50% of patients in hospital don’t need to be in hospital. So I’m now discussing how to accelerate the flow of patients back from hospital to home. And how to stop them from having to go in in the first place. So the focus should be about creating environments where people don’t have to go to hospitals unless absolutely necessary. Also for other fields in healthcare such as psychiatric care should be dealt with in the community. If you put people in institutions, they won’t get better. You should deal with problems in the place they exist. If you have to deal with children, you have to deal with their families. You have to create in the community infrastructure and knowledge so that people are supporting in a way they can handle their problems.
WE have new innovations in all these different fields so at the end I want to change all healthcare.
If someone from a different industry came to you for a different model to deal with a social or environmental issue, what would be your key advice?
Banks, schools, police all ask me these questions. You have to go back to what your service is, and what your values are and what you want to provide. If you look at schools, are we supporting young people to become good people. Are we giving them the skills they face in daily life or are we focusing on the pattern we have created? With banks, what should be the service, what’s the value for society? The 2008 crisis was based on a development where the focus on earning money and profits was the main and most important focus. If you now look at banks, they have to think about their contribution to society. That’s where I start. It’s then about purpose, what the people in the bank think about what they’re doing day by day. How do they feel and what would be a better way to work.
Going back to purpose and what the individual employee thinks. Thinking about ethical things. Is it ethical or is it pushed by old models like shareholder value? If you want to build your organisation on different paradigm you have to change you culture, leadership, lots of different things.
Is it possible to go from bolt-on purpose to in-built purpose or do we have to start again with completely new organisations?
I think it should be a combination of both. I advise an organistion to start with small experiments within the business. See them as a new organisation from which they can learn. A green field experiment, saying this is what we want to be, this is what we are. How can we use this experiment to understand how we could change our organisation? Sometimes within 2 years, this can activate change, especially if the CEO is convinced there could be change. In Holland there are many sectors where people are taking this as a new paradigm and it’s getting more and more mainstream.
How do you see leadership changing in the future? What will be the model of leadership?
I always had problems with leadership questions. I think you see so many leadership programmes in the UK. I don’t think it’s about leadership. If it’s about leadership it should be about co-operative leadership. Integrating Simplification talks about a leadership style, where leaders were expected to support people in society. We connect leadership too much with management. If you have a role and position you have a responsibility to use it to support people. In my opinion leadership should be about creating environments where people can show their own leadership. Professor Nonaka talks about distributed leadership. He talks about practical wisdom. If we want to create more knowledge and healthier, happier people, people should make their own decisions.
What’s in the future for Buurtzorg?
We want to change social care. We have to get together with the Unions, government. People see tat Buurtzorg works, so they wonder if we can apply the model to social care. Health insurers are focusing on cost-reduction rather than health improvement. We have gone to building a template bottom up, so we’ve said who wants to support this idea. If people step forward, we will create something. We have a lot of discussion about what our healthcare system should bein the future and looking at how we can make breakthroughs in the current system. The minister of health wrote a book called The Alternative Healthcare, an we’re talking to her about ideas.
Then we have our international work to connect people who are interested in this work, so we will have a network of people who understand how to change systems. I don’t know where it will lead, but in 10 years time we will see.