Leaderless Leadership

Jos de Blok

CEO & Founder, Buurtzorg


When he is on the road spreading the word about his leadership philosophy Jos de Blok has a favourite party piece. “Put your hands up,” says the Dutchman (who is always dressed in black) to his audience, “If you like having a boss.” Nobody ever raises their hand. “Now put your hand up if you are a boss…” Never fails to get a laugh.


He doesn’t dismiss the value of those who manage others but just thinks the system is fruitless. “Of course, there are good bosses out there in the world of work, but they aren’t good because they are a boss, they are good because in general they are a good person. Good people could be even more useful and effective to us all if they weren’t bosses. When you take management out from an organisation you see nobody is waiting for you to manage.”


De Blok, 58, is king of the leaderless organisation movement, and his outfit Buurtzorg (meaning “neighbourhood care”) is its poster child. The 12-year-old not-for-profit is a network of over 14,000 nurses and care workers organised into smaller autonomous teams of up to 12 members who work together to meet their patients’ needs. There are no bosses or leaders.


Within each neighbourhood, the independent teams of nurses are responsible for the complete care delivery to their 40-60 patients. These nurse teams have complete autonomy to carry out their work as they see fit – no targets, no allocated time slots per patient, no tick-box care. The twelve are wholly responsible for the well-being of their patients and they share patient solutions, results and experiences with one another. A specialized digital platform facilitates this communication, linking not only nurses within a team but also to other nurses in the wider network. The ground rule is that nurses must spend 61% of their time in direct contact with the people they support.



There are no “useless” and expensive managerial layers and bureaucratic processes of the sort that de Blok was part of and rebelled against when he worked as the Innovation Director for a traditional care supplier. Although Buurtzorg requires higher costs per hour – 40% of the nurses are degree level qualified, (the other 60% are registered nurses and nurse assistants, split 50/50) – all are well rewarded, as the model overall requires fewer hours in the long run. A 2012 KPMG study showed that Buurtzorg has accomplished a “50 percent reduction in hours of care, improved quality of care, and raised work satisfaction for their employees”. Furthermore, such a transformation in system ultimately resulted in a reduction of per-patient costs, between 20-30 percent according to Ernst and Young. Little wonder that it has already spread to the UK and 23 other countries worldwide.


So where did this anti-boss thing emerge from? “Well, I had problems with
authority at school,” he muses. “Also, with my father. Power structures caused me problems – I always saw the injustice in them. I think from an early age I believed we’d all be better off without hierarchical structures.”


“Trust people, don’t control them.’ This sort of anarchy – because that is what it is in the proper sense of the word – will make many health managers very nervous. They will be anxious about a loss of quality and control, but Buurtzorg says the group does that. Each nurse sees the results of the work of colleagues. Problems are observed and dealt with early by peers.


Think about the value of tacit knowledge, experience, intuition, evidence – all that has been lost in the pursuit of endless efficiency.


It may be an organisation ostensibly without leaders – “humanity over
bureaucracy” – but it isn’t without management. Indeed, it’s very carefully and
precisely managed – but this authority is distributed downwards. One factor
that isn’t widely publicised is that Buurtzorg’s workforce is 97% female. He says he doesn’t draw any particular conclusions from this besides noting that district nursing has always traditionally been a woman’s job but also adds, “Well women are better at organising than men. Just look around you. I think women are more focused on continuity and sharing. They work out how to survive together.” He acknowledges that when (rarely) men do join his community nursing teams, it doesn’t tend to go well if they try to dominate.


He believes it’s not just the sexes who look at and do things differently. Also,
the generations. Millennials and the young have a completely different outlook
than today’s older folk. “It’s the over 50s who have been brought up on the
management paradigm that only leadership can lead to efficiency and success,” he says. “The young understand better that there are more organic and natural ways of organising. All that silly MBA talk. To think people, build their whole lives on that…”


So, what about his own status? (A word he detests) How much does he earn? And, after all, he is responsible for Buurtzorg – the buck stops with him. His business card just has his name on it – no title. “I couldn’t put CEO on it. I’m a nurse. I do earn the most in the organisation and everyone knows what I make  but I’m the lowest paid CEO in Holland.”


Buurtzorg is highly successful financially but de Blok briskly contends that isn’t the point. Money is simply a by-product of doing the job well and getting the best outcomes for patients. It turned over 415 million euros in 2018. And what of his advice for the NHS? (The UK’s former health secretary Matt Hancock expressed interest in de Blok’s methods not least because they might reduce bills).


“You were the best in the world at primary care,” says de Blok. “But you may need to start rebuilding from basic principles. It’s too much top down at the moment and the structure is immensely complex. How did you let it get so complicated? Centralized power means complexity and that means cost which exacerbates the problem. All your money goes on admin. I’d have a look at Cuba. And think about craftsmanship again. Think about the value of tacit knowledge, experience, intuition, evidence – all that has been lost in the pursuit of endless efficiency.”


One complicating issue for the UK issue is funding: the Dutch model is tailored
to payments by health insurance companies, not a state healthcare system like the NHS or means-tested social care.


And the answer to the many people who want to know how to make their
organisations like Buurtzorg? “Well, it can be introduced at any time, at any
moment. But you must want it and know what’s needed to do it. It’ll take a year
to get traditional behaviours out of your system.”


Workers – and organisations – of the world unite: you have nothing to lose but
your leaders and a world to win.


Jos de Blok is CEO and Founder of Buurtzorg