What happened
Mixed outcomes. Buurtzorg grew substantially and attracted favorable patient and staff assessments. A historical KPMG comparison found relatively low adjusted home-care costs but roughly average total healthcare costs. Lower spending within the nursing service therefore did not translate into an equivalent reduction across all care, and the contribution of team autonomy remains difficult to separate from nursing expertise and patient differences.
- Teams carried responsibilities normally assigned to managers, with coaches and a central office supplying support. Buurtzorg: scaling up an organization with hundreds of self-managing teams but no middle managers
- Adjusted home-care expenditure was below the comparison average, while total healthcare expenditure was around average. Home Care by Self-Governing Nursing Teams: The Netherlands’ Buurtzorg Model
- Qualified nurses coordinated relatively separable local services, reducing the need for every daily decision to pass through a central office. Buurtzorg: scaling up an organization with hundreds of self-managing teams but no middle managers
What might explain it
Plausible
Local decision rights may reduce handoffs between the person who knows a patient and the person authorizing care. Buurtzorg: scaling up an organization with hundreds of self-managing teams but no middle managers
Alternative explanation: Professional selection, nursing skill, or continuity of staffing could account for benefits without the entire governance model.
Supported in case
Shared administrative support may be as important as team autonomy to keeping coordination manageable. Buurtzorg: scaling up an organization with hundreds of self-managing teams but no middle managers
Alternative explanation: A different service with heavy cross-team dependencies may need more centralized scheduling and integration.
Understanding the outcome
Functional substitutes for hierarchy
Managerial functions still need owners when managerial positions disappear. Buurtzorg: scaling up an organization with hundreds of self-managing teams but no middle managers
Services with tightly interdependent teams may require more central integration than local home-nursing teams do.
Questions to take into practice
- List the work performed by managers before deciding which positions to remove.
- Measure total costs and patient outcomes, not just the budget line that the new team controls.
What remains uncertain
- How much of the cost difference reflected the patients served, staffing continuity, or nursing expertise rather than decision rights?
- The workload of coaches, teams that struggled, and care supplied informally by relatives may change the apparent balance of costs and benefits.