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If we're going to talk about how to "scale care" and how not to, then Buurtzorg has to be mentioned[0][1]. It's a Dutch home-care company that was started by nu

If we're going to talk about how to "scale care" and how not to, then Buurtzorg has to be mentioned[0][1]. It's a Dutch home-care company that was started by nurses who basically got frustrated that managers got in the way of them doing their job. It operates by having a flat organization working with small teams of highly trained nurses, and trusting them to make the right decisions. The result is a low-cost provider of high-quality health-care. So when the author says care "doesn't scale", they obviously mean "you need a one-to-one ratio of caretakers", which I fully agree with. But what they're also accidentally doing in the process is explaining why creating bigger teams with bigger hierarchies and structures does not appear to increase the efficiency of care. Some projects do need big teams with hierarchies - even in healthcare. Effectively responding to a pandemic comes to mind. I suspect it's when the core problem to tackle most naturally breaks down like a tree - a hierarchy then mirrors the way the problem breaks down. For some projects, like general homecare, the efficiency sweet spot is a flat structure of autonomous individual teams, because it doesn't scale beyond those teams anyway. And just like the author concludes, I find that there's something comforting about that. [0] https://en.wikipedia.org/wiki/Buurtzorg_Nederland https://en.wikipedia.org/wiki/Buurtzorg_Nederland [1] https://www.youtube.com/watch?v=SSoWtXvqsgg https://www.youtube.com/watch?v=SSoWtXvqsgg

cassepipe 2y ago
Thanks for elaborating further what we mean by "scaling". Couldn't it be said that when organization acquire ranks, it is to solve coordination problems that arise with scale but that in this case, there isn't much that is solved by more organization ?
- vanderZwan 2y ago
  That sounds about right. If you watched the video then you also will notice that the further up the management chain we go, the more abstract the goals become compared to the most concrete ones that the nurses are dealing with. One could say that if most care work starts and ends with those concrete individualized issues, the cost of handling (or worse, prioritizing) abstract goals is far greater than the benefits that they add. Compare that to the pandemic response example I gave: that is the kind of challenge where there are concrete problems at individual, city-wide, national and international scale to tackle, and they're all interconnected too. So plenty of those coordination problems you mentioned.
- rachofsunshine 2y ago
  There's also a different kind of coordination problem. The incentives of an organization - or at least of a corporation - are to make money and to continue to exist and to enrich and empower the people who control it. But employees' incentives are usually pretty different. Nurses usually get into nursing because they, at least to some extent, want to help people. Engineers get into engineering because they, at least to some extent, want to build something really good. Teachers get into teaching because they want kids to learn. And so on. If you're the principal of a school, and your goal is for a teacher to teach, you don't have a coordination problem. Most teachers want to do that. But if your goal is for teachers to maximize standardized test scores, or to minimize the number of frustrated parent calls, etc, you do have a coordination problem, because your goals are misaligned with your employees'. If you're the CEO of a tech company, and your goal is for your engineers to build good software, you don't have a coordination problem. Your engineers want to do that. But if your goal is to maximize conversions, or to ship faster, or to raise money, etc., you do have a coordination problem. If you run a hospital, and your goal is for your nurses to care for patients, you don't have a coordination problem. But if your goal is to maximize profits, then you do. It's usually these kinds of coordination problems that managers are, effectively, in charge of enforcing. Their job is not to help individual employees achieve individual employees' collective goals, it's to make employees feel (sometimes truthfully) like their goals are aligned with the organizational goals, or to use the threat of loss of income or work to force them into line.
  - nine_zeros 2y ago
    This is the most insightful comment about organizational dysfunction and misaligned incentives. What you have described is astute and 100% accurate. Please make a blog post or something and share it around.
    - walterbell 2y ago
      Possibly relevant: "Institutions try to preserve the problem to which they are the solution", https://news.ycombinator.com/item?id=39491863 https://news.ycombinator.com/item?id=39491863
  - 2y ago
kartoffelsaft 2y ago
Honestly sounds like that's Conway's law, but in reverse. Instead of a project's setup mirroring it's organization, the organization mirrors what they see as the ideal project setup. That's something that I wish more teams were willing to recognize as the best approach; Conway's law isn't necessarily something to be worked around, it's a tool.
bumby 2y ago
Your reply seems focused on size, but this line caught my attention: >trusting them to make the right decisions. I'm wondering if trust isn't the real issue. For example, wouldn't a large high-trust organization be able to provide good care? Or is there something intrinsic to scale (e.g. diffusion of responsibility) that makes "high-trust" and "large organization" incompatible?
- vegetablepotpie 2y ago
  Not OP, but orgs that scale usually rely on metrics. It's metrics that are easier to measure, not the one that measure system performance (i.e. lines of code written per day, points closed per sprint) that get selected. Then management lampoon workers for not meeting those metrics (they need to prove their doing something, and can't lose control), regardless of how the system is performing. So trust erodes.
  - ToucanLoucan 2y ago
    I honestly think most orgs would leap forward considerably (with some pain) by doing a severe reduction in middle management, basically making them prove why they are actually providing value, and removing them if they aren't. Tons and tons of middle managers do absolutely FUCK ALL in terms of delivering product, meeting goals, and serving customers.
    - bumby 2y ago
      I generally dislike middle-management as much as the next IC, but I think these types of arguments tend to ignore latent or low-probability risks. You see this all the time in discussions about quality or safety metrics. By definition, if those teams are doing a good job you won't see many quality or safety issues, which leads people to believe they are doing "FUCK ALL" and provide little benefit. Only in hindsight, after a low-probability but high risk event happens, does getting rid of them seem like a bad idea.
    - taneq 2y ago
      You’ve never worked in middle management, have you? Just because they do largely ‘soft stuff’, mediating between different departments, teams and layers of the organisation, and (hopefully) running interference so that their team can focus unimpeded on the actual fun part of the job, doesn’t render their contribution null and void. I’ve dealt with bad upper management, bad project management, bad clients, bad suppliers, but only rarely bad middle management. (And no, I’ve never worked in middle management although at times I’ve been some of the other categories above. :P )
Aeolun 2y ago
To be fair, Buurtzorg doesn’t scale either, as they’re perpetually short staffed.
- consp 2y ago
  The other companies are also shortstaffed, all healthcare is at the moment, and the bureaucracy layers just keeps humming along ... Buurtzorg is however cheaper, and since you cannot scale the actual care that counts.
  - vanderZwan 2y ago
    Yes, and the actual nurses also have more job satisfaction and their patients are happier too, so the quality also improves. The main explanation given for that is that compared to solutions that require a lot of time spent on administrative work, these nurses get to focus on the actual care work, and have more personal time with the patients, meaning a bond of trust can be established. Which is also an important aspect in the scaling trade-off I'd say.
    - evolve2k 2y ago
      Imagine if we had an openly adoptable Buurtzorg model along side open source software used for adminstration. With the power resting with the carers the non-care admin work could be collectively automated through the open source model.
      - reallycare_mark 2y ago
        I'm actually working on the software part of that, in the UK. It isn't open source yet (mostly because we can't afford the level of comfort we need about data security, given that this is very sensitive data) but that remains the intention. But even with open-source software, there will still be the issue of how highly regulated the care industry is. There are significant variations even within the UK, and indeed, there are even inconsistencies between inspectors of the same regulator. But below the level at which regulation kicks in, care work is—for some people—the most rewarding (not financially!) type of work and arguably will be one of the last professions to be replaced by AI (though there is plenty of work on robots).
myworkinisgood 2y ago
Training is the high-cost missing from the equation of "low-cost" High quality training doesn't scale.
- vanderZwan 2y ago
  Doesn't scale compared to what, though? Because if the comparison point is the more typical modern care-work organization where tasks are divided into a fine-grained categories of "high skill" and "low skill" work, outsourcing the "low skill" tasks to the low-trained workers as an attempt to save costs, then Buurtzorg shows that that approach is not a net savings. Because Buurtzorg has been shown to have lower costs and higher job satisfaction than its competitors, and the reasons are quite obvious too: the hierarchical outsourcing solution adds extra communiciation costs, administration costs, and similar organizational overhead. On top of that patients are in a situation where they see many different unfamiliar care workers briefly, meaning they do not get to form a bond of trust with any one of them. That is a pretty heavy costs that I don't even know how to categorize.

cassepipe 2y ago

Thanks for elaborating further what we mean by "scaling". Couldn't it be said that when organization acquire ranks, it is to solve coordination problems that arise with scale but that in this case, there isn't much that is solved by more organization ?

vanderZwan 2y ago
That sounds about right. If you watched the video then you also will notice that the further up the management chain we go, the more abstract the goals become compared to the most concrete ones that the nurses are dealing with. One could say that if most care work starts and ends with those concrete individualized issues, the cost of handling (or worse, prioritizing) abstract goals is far greater than the benefits that they add. Compare that to the pandemic response example I gave: that is the kind of challenge where there are concrete problems at individual, city-wide, national and international scale to tackle, and they're all interconnected too. So plenty of those coordination problems you mentioned.
rachofsunshine 2y ago
There's also a different kind of coordination problem. The incentives of an organization - or at least of a corporation - are to make money and to continue to exist and to enrich and empower the people who control it. But employees' incentives are usually pretty different. Nurses usually get into nursing because they, at least to some extent, want to help people. Engineers get into engineering because they, at least to some extent, want to build something really good. Teachers get into teaching because they want kids to learn. And so on. If you're the principal of a school, and your goal is for a teacher to teach, you don't have a coordination problem. Most teachers want to do that. But if your goal is for teachers to maximize standardized test scores, or to minimize the number of frustrated parent calls, etc, you do have a coordination problem, because your goals are misaligned with your employees'. If you're the CEO of a tech company, and your goal is for your engineers to build good software, you don't have a coordination problem. Your engineers want to do that. But if your goal is to maximize conversions, or to ship faster, or to raise money, etc., you do have a coordination problem. If you run a hospital, and your goal is for your nurses to care for patients, you don't have a coordination problem. But if your goal is to maximize profits, then you do. It's usually these kinds of coordination problems that managers are, effectively, in charge of enforcing. Their job is not to help individual employees achieve individual employees' collective goals, it's to make employees feel (sometimes truthfully) like their goals are aligned with the organizational goals, or to use the threat of loss of income or work to force them into line.
- nine_zeros 2y ago
  This is the most insightful comment about organizational dysfunction and misaligned incentives. What you have described is astute and 100% accurate. Please make a blog post or something and share it around.
  - walterbell 2y ago
    Possibly relevant: "Institutions try to preserve the problem to which they are the solution", https://news.ycombinator.com/item?id=39491863 https://news.ycombinator.com/item?id=39491863
- 2y ago

kartoffelsaft 2y ago

Honestly sounds like that's Conway's law, but in reverse. Instead of a project's setup mirroring it's organization, the organization mirrors what they see as the ideal project setup. That's something that I wish more teams were willing to recognize as the best approach; Conway's law isn't necessarily something to be worked around, it's a tool.

bumby 2y ago

Your reply seems focused on size, but this line caught my attention: >trusting them to make the right decisions. I'm wondering if trust isn't the real issue. For example, wouldn't a large high-trust organization be able to provide good care? Or is there something intrinsic to scale (e.g. diffusion of responsibility) that makes "high-trust" and "large organization" incompatible?

vegetablepotpie 2y ago
Not OP, but orgs that scale usually rely on metrics. It's metrics that are easier to measure, not the one that measure system performance (i.e. lines of code written per day, points closed per sprint) that get selected. Then management lampoon workers for not meeting those metrics (they need to prove their doing something, and can't lose control), regardless of how the system is performing. So trust erodes.
- ToucanLoucan 2y ago
  I honestly think most orgs would leap forward considerably (with some pain) by doing a severe reduction in middle management, basically making them prove why they are actually providing value, and removing them if they aren't. Tons and tons of middle managers do absolutely FUCK ALL in terms of delivering product, meeting goals, and serving customers.
  - bumby 2y ago
    I generally dislike middle-management as much as the next IC, but I think these types of arguments tend to ignore latent or low-probability risks. You see this all the time in discussions about quality or safety metrics. By definition, if those teams are doing a good job you won't see many quality or safety issues, which leads people to believe they are doing "FUCK ALL" and provide little benefit. Only in hindsight, after a low-probability but high risk event happens, does getting rid of them seem like a bad idea.
  - taneq 2y ago
    You’ve never worked in middle management, have you? Just because they do largely ‘soft stuff’, mediating between different departments, teams and layers of the organisation, and (hopefully) running interference so that their team can focus unimpeded on the actual fun part of the job, doesn’t render their contribution null and void. I’ve dealt with bad upper management, bad project management, bad clients, bad suppliers, but only rarely bad middle management. (And no, I’ve never worked in middle management although at times I’ve been some of the other categories above. :P )

Aeolun 2y ago

To be fair, Buurtzorg doesn’t scale either, as they’re perpetually short staffed.

consp 2y ago
The other companies are also shortstaffed, all healthcare is at the moment, and the bureaucracy layers just keeps humming along ... Buurtzorg is however cheaper, and since you cannot scale the actual care that counts.
- vanderZwan 2y ago
  Yes, and the actual nurses also have more job satisfaction and their patients are happier too, so the quality also improves. The main explanation given for that is that compared to solutions that require a lot of time spent on administrative work, these nurses get to focus on the actual care work, and have more personal time with the patients, meaning a bond of trust can be established. Which is also an important aspect in the scaling trade-off I'd say.
  - evolve2k 2y ago
    Imagine if we had an openly adoptable Buurtzorg model along side open source software used for adminstration. With the power resting with the carers the non-care admin work could be collectively automated through the open source model.
    - reallycare_mark 2y ago
      I'm actually working on the software part of that, in the UK. It isn't open source yet (mostly because we can't afford the level of comfort we need about data security, given that this is very sensitive data) but that remains the intention. But even with open-source software, there will still be the issue of how highly regulated the care industry is. There are significant variations even within the UK, and indeed, there are even inconsistencies between inspectors of the same regulator. But below the level at which regulation kicks in, care work is—for some people—the most rewarding (not financially!) type of work and arguably will be one of the last professions to be replaced by AI (though there is plenty of work on robots).

myworkinisgood 2y ago

Training is the high-cost missing from the equation of "low-cost" High quality training doesn't scale.

vanderZwan 2y ago
Doesn't scale compared to what, though? Because if the comparison point is the more typical modern care-work organization where tasks are divided into a fine-grained categories of "high skill" and "low skill" work, outsourcing the "low skill" tasks to the low-trained workers as an attempt to save costs, then Buurtzorg shows that that approach is not a net savings. Because Buurtzorg has been shown to have lower costs and higher job satisfaction than its competitors, and the reasons are quite obvious too: the hierarchical outsourcing solution adds extra communiciation costs, administration costs, and similar organizational overhead. On top of that patients are in a situation where they see many different unfamiliar care workers briefly, meaning they do not get to form a bond of trust with any one of them. That is a pretty heavy costs that I don't even know how to categorize.