From Extra Time (Camilla Cavendish, 2019) pp173-8
The Power of Dutch Kindness
I’m climbing the stairs of an apartment block in Den Haag, the Netherlands, with Nurse Josie. It’s a cold March day and the low-lying clouds are Vermeer grey. Josie, a sturdy lady in her fifties with a wide, teddy-bear face, is puffing a bit as we head for the third floor. But what worries me is that panting behind us are Josie’s two Border Terriers. I cannot imagine any home-care service in England allowing a nurse to take two small, hairy dogs to a client visit. What about hygiene? Josie is telling me about the old lady, Berit, who we are going to visit. Berit has early-stage dementia and can get agitated. Apparently, she is looking forward to trying out her English on me, as she used to work In a souvenir shop. I nod, but I’m less concerned about my lack of Dutch than the dogs scampering at our heels. Is this really good idea?
When we reach the third floor and the door opens, I realise that the dogs are our secret weapon. Berit, 93, stooped and pouting in a yellow fleece and bare feet, initially looks uncertain. Then she sees the dogs and smiles. The terriers have obviously been here before, they rush in and roll ecstatically on the carpet. Once I’ve been introduced, sipped coffee and exchanged jokes about the Tower of London, Josie hands Berit a plastic bag full of dog treats. Berit rises slowly to her feet, concentrating hard and fishing about in the bag with long, pale fingers. She carefully selects two treats of identical size as the little dogs sit at her feet, tails wagging expectantly. When they take the treats, her face breaks into a huge smile.
This is what happens when you put humanity before bureaucracy. This is Buurtzorg, a Dutch model of care which lets nurses not some remote, cost-cutting manager decide what is right for each of their patients. Not everyone likes dogs; Josie’s stay obediently in the car on many visits, but she knows that they make Berit happy, calm and more willing to let Josie in. As Berit shows me photos of her trip to London in 1978, I can see out of the corner of my eye that Josie is quietly checking the fridge and dishes to see if Berit has remembered to eat. Her dementia is making her forgetful but also angry. Last week, she started shouting at cars when she was trying to cross the road to the local shop. Her son Bruno is worried; he can only visit at weekends. Josie logs Berit’s mood on the Buurtzorg app which Bruno can see, on the iPad which Buurtzorg issues to all its nurses.
Buurtzorg issues iPads, but few commands. Unlike every other care service I’ve ever encountered, there are no tick sheets or timetables. Nurses work in local teams of no more than 12, and are expected to assess clients, organise their own schedules and even find their own office space: Josie’s team operates from two small rooms at the foot of a concrete block containing four chairs, two desks, a filing cabinet and a dog bed. They don’t need anything bigger, they tell me, because they want to be out visiting people, not sitting at computers typing reports.
Head office pays the team’s rent, sorts out the payroll and handles IT. But it’s tiny: only 50 people at HQ support 10,000 Buurtzorg purses and care assistants. As a result, its overheads are about 8 per cent, compared with 25 per cent for comparable organisations. The money saved is used to employ more nurses, because Buurtzorg is non-profit.
It’s hard to explain how revolutionary this is. In so many counties, systems have become dehumanised, hedged about with rules and regulations. Compassion has been downgraded in favour of risk assessments. And no one has time to care.
Buurtzorg was founded in 2007 by a male nurse, Jos de Blok, who had become disillusioned with the Dutch health service. ‘Healthcare and community care were defined as production,’ he says. ‘We defined ten different products: nursing, nursing care extra, guidance extra – for commissioners that’s the way they buy care – so many hours of this and so many hours of that. The resulting relationship between patients and nurses, he has said, ‘was really disturbing’.
A well-spoken man in his sixties with greying temples, de Blok started his first team with just three colleagues, aiming to restore meaningful relationships between staff and patients. His philosophy is to ‘keep things simple’, so ‘you don’t need so many people to control all these things’. And to remove hierarchies. ‘We haven’t had one management meeting since we started,’ he says. ‘My old job was only about meetings. Now we have time to solve the problems.’ And it’s working. Today, Buurtzorg serves 70,000 patients across the Netherlands. Nurses have come out of retirement to join it, so enthusiastic are they about the philosophy.
Back in Berit’s flat, the Tower of London photographs have been put aside and I’m now drowning under an album of her 1980 trip to Berlin. Josie has decided not to apply the cream for Berit’s psoriasis until tomorrow, because to undress her now would disrupt a conversation which she is enjoying. Berit is a wonderfully forceful character. telling me stories of the past in a halting mixture of Dutch and English but she sometimes loses her thread, her shoulders stoop and her bare feet look painfully warped on the thick carpet.
It’s time for the next appointment. “You’re leaving the dogs here?” I ask Josie as we say our goodbyes. ‘Yes,’ she says confidently, ‘I’ll collect them later. You can see the light in her eyes, can’t you?’ she whispers proudly, catching my scepticism. And I can. Giving Berit the companionship and responsibility of these little dogs is undoubtedly part of what keeps her going.
As I drive around with Josie the rest of the morning, I am struck by three things. First, the continuity of care. In every home we visit there is a booklet with pictures of the only three team members a client will ever see, who are responsible for their care. Second, the emphasis on self-reliance and family networks. Josie and her colleagues are proactive about seeking out friends and family, keeping them informed and getting them involved..
Third, no team member sees any task as beneath them. In the UK, we parcel activities into ‘professional’ tasks, like giving medication, done by registered nurses, and ‘basic’ tasks, like helping someone shower, done by care staff. But Josie loves doing it all. She tells me she joined Buurtzorg to connect with patients again. ‘I’m going back to my roots, working with people,’ she says, with a joyful look. “We take care of everything – we’ll make a sandwich for a client if that’s what they need.’ ,
In the UK, I long ago came to the view that our obsessive allocation of tasks to the cheapest member of staff is a false economy. A monstrous bureaucracy is required to oversee it and no one has time to build an actual relationship. This often means that patients deteriorate faster and require more and more help. For the good of patients, we need to start focusing on outcomes, not costs. And we might even; paradoxically, save money.
Buurtzorg seems to prove my theory about efficiency. Despite often paying qualified nurses to do all tasks, which means that the service costs more per hour than comparable agencies, Buurtzorg ends up costing almost 40 per cent less overall, according to the consultancy EY.* This is because staff need to put in fewer hours with each patient. And that, in turn, is a result of trust. Josie and her colleagues encourage patients to manage their own conditions and they’re good at getting relatives involved to help with that. Patients don’t panic and call head office endlessly, because they know Josie is coming back. Buurtzorg, in that sense, is creating neighbourhoods – which, as we have already seen, can improve health.
Josie gives the impression that she has all the time in the world on her visits, but during my morning with her I realise that she is flexing skilfully. We spend only ten minutes with one elderly lady who needs compression socks putting on, but it feels longer, as Josie and the lady are chatting all the while. ‘The clients have the feeling that I’ll take five or ten minutes extra when they need it, she says. ‘They have the knowledge that we’ll be there when they need it,
Client satisfaction rates for Buurtzorg are higher than for any comparable healthcare organisation in Holland. In fact, Buurtzorg may be making even greater savings for the state, by reducing demand for other services. ‘Buurtzorg are my family, says Anita, a middle-aged lady we meet who is recovering from lung cancer. ‘I can tell Josie things I don’t want even my sister to know. The hospital doctor asked, did I want to see a counsellor? But I don’t know them. Why would I talk to them? I talk to Josie.’
Treating people as human, building proper relationships and paying those who have a vocation, for what I would call the ‘craftsmanship’ of nursing, may sound like common sense. But in today’s world, it’s radical.
The problem is most acute in Japan, where the dwindling population has left the government predicting 380,000 care staff vacancies by 2025. To replace and augment human carers, the Japan, government is now investing heavily in technological solutions
The Robots Are Coming
In Aichi province, central Japan, a loudspeaker blares down the street. It’s asking if anyone has seen an 85-year-old lady wearing , bright pink shirt. ‘If you see her, please report to the police station’, barks the tinny voice.
Originally put in place to warn of typhoons and earthquakes, Japan’s public warning system is now frequently commandeered to search for elderly people with dementia. Mrs Ahote, the lady with the pink shirt, is one of almost 16,000 who go missing each year in Japan. Last year, about 500 of those met with fatal accidents.
At the Shintomi nursing home in Tokyo, Director Yukari Sekiguchi foresees a world in which everyone will have to be monitored electronically, because there are no longer enough children to keep an eye on parents.
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