Battles on the NHS frontline

Battles on the NHS frontline

What the Netherlands can teach the NHS about cutting cost but not quality

Doing things differently. Care by Shutterstock

The social care sector recently underwent a serious reality check. A chronically underfunded system is “turning good people into bad carers”, claimed Andrea Sutcliffe, the Care Quality Commission’s social care chief, following news that 150 complaints about elderly care are raised every day. In the same week the government announced it would delay the introduction of “limited liability” - the cap on the costs an individual must pay for their care for a further four years, kicking the crisis in social care funding into the safety of the next election.

But as financial cuts bite, the private Dutch company, Buurtzorg, claims to have the answer for doing more with less in social care. It offers a radical model for high-quality social care at 65% of the going rate by cutting the number of administrators and letting carers organise their own work.

Set up six years ago, Buurtzorg now employs over 7,000 frontline staff, representing 60% of Dutch community nurses – with just 30 managers on its books. Staff costs per hour are higher but patients need 30% to 40% less contact time every month, the company claims, because care is directly responsive, changing on a day-to-day basis depending on what the patient needs.

Nurses work in teams of ten, each serving a particular community and working closely with local GPs and services. They see themselves as having a key social function of identifying and building relationships within the community. Buurtzorg says that not only are patients happier but so are staff – it has 60% lower staff absenteeism and 33% lower turnover than the sector average.

Could be the UK – but it isn’t. Dutch house by Shutterstock

Buurtzorg’s Dutch 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.

Most of the people who currently work as carers, whether public or private, are female ex-public sector workers over the age of 45. Half of private care providers [come from the not-for-profit sector](www.nationalcareforum.org.uk/](http://www.nationalcareforum.org.uk/) and tend to have a memory of public service. Within the next decade most of these carers will retire and with them goes our heritage of how to manage social care the old-school way.

Essential differences

The UK and the Netherlands, despite both being European 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 and Nordic countries have a shared emphasis on equality, reflected in the lack of pay differentials and a dominant workplace culture of flat leadership which is non-hierarchical and emphasises democratic practices. To maintain 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 workers, something the EU calls “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.

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 we’re in Amsterdam.

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.

This column looks at the reality of our health and care systems from the perspective of those working to deliver services. Please send us your anonymous stories from the frontline.