Caring for complex patients in the community requires a radical change

Jordi Varela

Editor

The pandemic has highlighted the need to protect, even more, if possible, people suffering from clinical complexities and some of them, in addition, family, economic or social difficulties. For this reason, some primary care centres have set up nursing teams to more proactively care for the most vulnerable patients. These groups of nurses have taken the initiative and now organize their tasks, most of them at home, in an autonomous way, according to a fine balance between coordination and effectiveness. The historical medical-nurse binomial of primary care, then, is beginning to show cracks that give way to advanced organizational models with more nursing skills.

Are Spanish primary care nurses ready to do a Buurtzorg?

Buurtzorg, the Dutch model of community nursing, much discussed in this blog, starts from the idea that to efficiently care for people with complex social and health needs at home, the best thing that can be done is to give nurses a degree of autonomy high enough for them to be able to take responsibility for the overall individualized care plan of each person they serve. Therefore, everything would indicate that the nurses of some Spanish primary care teams are one step away from doing a Buurtzorg, but given the radical nature of the Dutch model, would it be viable? Most likely not, but to lend a hand to innovative nurses, I think it's worth paying attention to what Paul Jansen says in a post on Corporate Rebels, in which he discusses the difficulties (and challenges) of implementing Buurtzorg in the United Kingdom.

The lessons learned from the British Buurtzorg

Paul Jansen states that in an attempt to implement the Dutch model in the UK, innovative nurses have had to face four challenges, which are becoming very difficult in an environment as rigid as the NHS:

1. Models can inspire, as is the case, but if they are simply copied, the process fails to be genuine and many professionals end up being more aware of the loss of the status quo than of the new model.
2. Changing the NHS traditional controlling leadership for Buurtzorgian coaching creates unease for some professionals.
3. Interactions with the "parent" organization (the NHS) can be toxic, especially due to comparative grievances.
4. Buurtzorgs are generated locally and are difficult to scale in a highly bureaucratic environment, which encourages its naysayers.

How to overcome barriers?

Reading the “Corporate Rebels” analyst, the fable of John Kotter's penguins came to mind, remember? When the penguins, after a complex and tense process, decide to leave the iceberg where they have lived since ancient times and explore a new one, the whole colony ends up leaping. They don't leave anyone on the old iceberg. Kotter's fable warns us that in primary care, organizational models of the last century, more individualistic, should not coexist with others of the current century, more multidisciplinary and, therefore, more adapted to the care of complex patients in the community environment.

Paul Jansen, in the style of Kotter, says that if you want to imitate Buurtzorg, the whole system must make a radical change. The challenge of caring for the sick, the elderly, and the frail in their community environment is too great to test small inventions (remember Sara Kreindler's research). I thought it appropriate to take note of four recommendations that emerge from Jansen's post.

1. Even if it starts in small formats, health care systems must be clear that the empowerment of nurses to autonomously manage the individualized plans of dependent people is a change that will transform the health and social care system.
2. To start projects, safe (and protected) spaces must be created, where you can innovate, learn and evolve with your solutions. We must therefore rely on the most innovative teams, have patience and offer them the essential resources, aiming to obtain results in the medium and long term.
3. The Buurtzorgian spin-offs that arise from this process must not necessarily copy a stereotyped model but must be organized with the capabilities of each of the team's professionals in mind and the warmth and effectiveness of their services.
4. These new groups must achieve an internal climate that allows them to learn with trial-and-error techniques.

Despite the initial euphoria, the Buurtzorg model shows that it’s stuck in an overly bureaucratic and controlling NHS, making it clear that offering full competence to groups of nurses to manage the individualized care plans of dependent people is not a matter of four pilot tests, but a movement that, sooner or later, will end up changing the whole system.

After a first essential question about whether the primary care nurses in Spain are ready to do a Buurtzorg, throughout the article has emerged another question that has probably been asked before: is our health and social care system willing to take the step towards a warmer, more integrated and more effective home services?