Democratic Management
in Primary Healthcare:
Implementing the
Learning Organization
Zoë-Jane Playdon
Kent, Surrey and Sussex
Department of Postgraduate Medical
and Dental Education
University of London
Contents
Introduction:The idea of Democratic Management1
1.The idea of Fairfield7
2.Principles and processes of Democratic Management14
3.Working together, creating the system42
4.Democratic Management in action57
5.Return to Fairfield72
6.Implementing the Learning Organization88
Appendix: The research approach110
References115
List of figures
1.Opening Workshop15
2.Team Building and Action Planning43
3.Stages in the development of a Learning Organization89
4.The Learning Organization and Democratic Management109
Indexi-iv
for Catherine
No happy employer ever frightened his employees.
A. S. Neill (1962)
Introduction
The idea of Democratic Management
This report describes a system of management democracy, its principles, and the processes used in its implementation. It does so by working from a particular, real-life example, in the form of a long-term case study of the Fairfield Centre, and using that as a basis for establishing general principles and processes. This is a qualitative management study, therefore, which begins with the lived experience of those in the front line of the NHS, to develop processes which really work in the practical day-to-day delivery of high quality healthcare. In line with this methodology, and to enable readers to see behind the scenes into the real working of the system, the voices of participants are used as far as possible, and the account follows the chronological development of Fairfield itself.
Fairfield
The Fairfield Centre is a primary healthcare centre, a single building which houses all of the professionals employed to take care of the first-line healthcare needs of the local community. So, doctors, midwives, health visitors, community nurses, physiotherapists, occupational therapists and other healthcare professionals are all to be found under the same roof. It opened on 1st April 1996 and is located in the socially disadvantaged Charlton area of the London Borough of Greenwich, home of the Cutty Sark, the meridian line and the millennium project.
It is not the only healthcare centre where the professions are housed together: there are many others, in London and in towns and cities across the country. Fairfield is organizationally similar to these other primary healthcare centres in that, like them, it combines several different employers. Its doctors are a practice of five General Practitioners, ‘GP Principals’ as they are known, who operate as a National Health Service (NHS) funded, self-employed partnership. They are the employers of twenty secretarial, clerical and technical staff who provide support to all of the healthcare professionals in the Centre. Finally, the community healthcare staff who share the Centre are employed by the Greenwich Healthcare NHS Trust.
What makes Fairfield different from other primary healthcare centres, though, is the way in which it works. It is run using a democratic management system, a system in which decisions are taken at a meeting of everyone who works there. Everyone has one vote and no vote counts for more than any other - the doctors’ no more than the midwives’, the receptionists’ as much as the practice manager’s, the caretaker’s as equal to all of his colleagues. This does not mean that Fairfield can do as it pleases: its work is still subject to UK law and NHS regulations, of course, while the democratic meeting itself, decides what areas it will discuss and vote on, and what are left outside its remit.
Democratic management
Democratic behaviour in organizations is not a new idea. There is a large literature on experiments in industrial democracy and in participative management, that have been carried out for over a generation, especially in the Scandinavian countries. However, as Heller (1983, xxxv) points out in his review of this area, both these experiments and the literature which records them are of an uneven quality and of a controversial nature:
Democratic behaviour in organizations has many facets, with several academic disciplines working in the area… Moreover, practical contributions have been made by management, trade unions and by experiments in industrial and other organizations, such as hospitals and schools.
Such diversity has meant that studies have been published in hundreds of books and journals in many specialities, and, of course, in many countries…Because many topics within our chosen field have become quite popular, shoddy and superficial material has proliferated . . . Furthermore, since our subject is controversial and often overtly political, the task of attempting an overview and broad perspective is formidable.
Further, it appears that achieving the perceived benefits of democratic behaviour in organizations has proved to be difficult. In particular, for example, two well-known experiments in this area, those carried out at the Kalmar plant of Volvo cars and General Foods’s Gaines Pet Food plant at Topeka, Kansas, have had controversial results. Although initially hailed as a success, with its problems being attributed to ‘inherent difficulties in the motor car market’ (Jenkins 1978) Volvo’s replacement of the assembly line by self-managing teams of workers was also criticised (Hauck 1979) as ‘primarily a public relations stunt’. Nevertheless, it has also been claimed (The Myths of Volvo, 1983) that ‘twenty percent higher productivity than projected was achieved at the plant’.
In the self-managing teams which assumed responsibility for large segments of the production process at Topeka, one study (Walton 1977) found ‘high levels of worker participation, freedom to communicate, minimization of status distinction, human dignity, commitment and individual self-esteem’. However, as a later study (Whitsett and Yorks, 1983) pointed out, ‘the Topeka System did not become integrated into the overall organization’ and a further study (Mroczkowski and Champagne, 1984) reported that ‘General Mills has not implemented it in its other plants’.
Further, there are three fundamental problems with the literature of organizational democracy which inhibit its practical use by managers. First, there are no agreed definitions for the terms ‘organizational democracy’ and ‘participation’, which are thus used in very different ways by different writers. As Crouch (1983, xliii) says of ‘organizational democracy’:
The fact that the term ‘organizational democracy’ covers such a broad range of techniques creates problems for its study . . . do we count advisory consultative committees, co-determination, extended collective bargaining, works councils, employee stock ownership, kibbutzim, counter-cultural co-operative collectives, Yugoslav work organizations, work reform and quality of working life experiments, and Russian citizen inspectors?
and Warner (1984, 5) confirms:
The origins of an idea, such as organizational democracy, are both complex and demanding. No two writers would agree on a common view. . . . Organizational democracy is a catch-all term, often divided into industrial democracy, worker participation, self-management and so on, perhaps encompassing voluntary associations and governmental forms.
Similarly, Dachler (1978, 17) comments about the term ‘participation’:
The international literature on participation in decision-making, industrial democracy, power equalization, worker management, democratic leadership, and similar topic issues is diffuse in meaning and purposes, involves frequent contradictions, harbors a plethora of undefined terms, is plagued by ambiguous theoretical underpinnings, and provides a few useful statements for the policy makers.
The second fundamental problem is that the language used in accounts of ‘organizational democracy’ and ‘participation’ is opaque. It takes terms such as ‘democracy’ and ‘empowerment’ at face value, and in doing so, discourages managers or workers from analysing the basic assumptions which underlie its thinking. If an organization wishes to change in some fundamental way, then it needs to be able to understand every aspect of that change, all of its implications, before it can be accepted. As Rizvi and Lingard (1996, viii-ix) point out, looking at the literature from the point of view of worker empowerment, its commitment appears only to be skin-deep, since it uses:
vocabulary suggestive of a commitment to democracy. Words like ‘collaboration’, ‘participation’, ‘devolution’ and ‘empowerment’ are used to indicate a partnership between the manager and the workers - between capital and labour . . . [it] is inherently contradictory because, while it preaches organizational democracy and empowerment, it does not really permit workers to question some of the fundamental assumptions underlying the new business capitalism.
The third fundamental problem is the limitations of the research approaches that have been used to produce the literature of organizational democracy and participation. The scale of discussion tends to be large - whole countries, for example - rather than the small-scale, in-depth case studies in which managers might find a reflection of parts, at least, of their own organizations. Further, there is a strong tendency to make brief comparisons and contrasts with other large units - other countries, or other industries - without subjecting these to any detailed analysis. So, managers are unable to see the points of convergence and divergence between the examples discussed and their own lived experience. Finally, the research methodologies employed are generally positivist ones – large scale questionnaires, literature reviews and quantitative data translated into abstract models - rather than humanistic ones, exploring in detail the lived experience of individuals in complex, changing circumstances. This is a particularly noticeable absence since, as King, Streufert & Fiedler (1978, xv) point out, for managers to gain insights into the daily realities of organizational environments, what is required are processes which ‘so many recommend but so few actually undertake: a field study utilizing a data-gathering technique not restricted to a survey’.
In spite of these difficulties, discussion about democratic behaviour in organizations continues, both in popular and professional standard texts on human resource and organizational management (Senge 1990; Duke 1992). That interest, combined with mixed reports about success, has created a sense of democratic management as something which is potentially attainable but perpetually elusive, a kind of ‘Holy Grail’ of management which has yet to be found.
The learning organization
During the last decade, many of the ideas experimented with under the heading of ‘democratic management’ have also been mustered under the title of ‘the learning organization’. This has been in response to a broad consensus that skills and knowledge are an increasingly important source of competitive advantage. Global competition has increased, so that competitive advantage arises from offering high-quality, customised services, rather than price alone. At the same time, there has been a contraction of the product life cycle, so that new products have a shorter time in the marketplace and companies are continually having to learn to do new things. As well, technological advances mean that there is a huge and sustained shift towards ‘knowledge-intensive industries’ and ‘knowledge workers’.
Reflecting on these circumstances, Keep & Rainbird (2000) indicate that the only viable response for organizations is to seek long-term competitive advantage by utilising the skills and knowledge of their employees. This cannot be done by using the models and processes of training and personnel management that were effective a generation ago. Instead, there has to be a step change, a movement from a state where there are just individuals within an organization learning things, to a stage where the central organizational goal is systemic learning. A learning organization is characterised by fairness, openness, and flexibility, and by making ethical considerations important in its general business management. Its key features include (Keep & Rainbird 2000, 176):
- people come first and a concern for society’s welfare and betterment
- the organization represents a way of life to be cherished because of its values
- learning is at the centre of activities
- the organization is instructing and controlling itself by means of a total involvement in the community
- the organization is judged by the extent to which the people who make it up control and teach the organization how to learn, rather than vice-versa
Instead of managers being ‘policemen and women, spies, controllers, dispensers of reward and punishment, sources of wisdom and expertise, order givers and arbitrators between competing claims’, in the learning organization they are ‘teacher, coach, mentor, facilitator, resource controller and “servant” of the team’ (Keep & Rainbird 2000, 184). Other commentators have typified the change as being ‘a movement from employee compliance to employee commitment . . . organizational performance is improved when “perfunctory co-operation” is replaced by “consummate co-operation”, i.e. when employees stop merely fulfilling the basic formal contractual requirements and start showing mutual loyalty and commitment to the enterprise and its goals’ (Mabey, Salaman & Storey 1998, 38). Part of the requirement for a learning organization, therefore, is a foregrounding of social relationships and personal identification within the organization, and a recognition of the importance of autonomy in working life.
Equally, however, the problems associated with achieving learning organizations are many. Organizationally, the existing systems of human resource management present in most organizationswork directly against progress of that sort, since job design and internal relationships mean that both management and employees have an interest in ‘minimizing their part of the exchange and maximizing the contribution of the other side’ (Mabey, Salaman & Storey 1998, 40). The reality of organizational life tends to be a generally low level of autonomy, especially for employees in non-managerial roles, with managers wondering how they will maintain their own status and pay vis-à-vis the rest of the workforce, if they do become facilitators and support their ex-subordinates to develop as the major source of the organization’s competitive advantage (Keep & Rainbird 2000, 184). At the heart of the dilemma lies the issue of power. An organization of autonomous knowledge workers needs fewer managers, and it requires commitment to the employee in order to gain employee commitment. The ‘command and control’ model of ‘do it because I say so’ is not available, and it is not clear that all existing managers, recruited to operate to that old model, have the attitudes and abilities to operate to a negotiated agenda or to recognise the specialist expertise of those whom they manage.
Implementing a learning organization is made more difficult still since, as Keep & Rainbird point out (2000, 178), the bulk of the literature in this area concentrates on prescriptive definitions and theoretical models: ‘broadly based, in-depth, longitudinal research of how the concepts and models play out in real life organizations is in very short supply, and even detailed case studies are few in number’.
Summerhill (i)
Bringing together these ideas of democracy and of learning into a management context, the system in operation at the Fairfield Centre, is based primarily not on a management model, but on an educational one: democratic education at A. S. Neill’s famous radical school, Summerhill. At Summerhill, a particular kind of organizational democracy has been operating successfully for almost eighty years since its founding in 1921, informed by particular principles – ‘freedom not license’, ‘self-regulation’, for example – which anticipate values inherent in current ideas of learning organizations and ethical business practice. It is these ideas which were applied to the primary health context to create the form of democratic management through which Fairfield has been operating for the last six years.
It is, of course, a very specific context - a particular group of individuals in a precise location – but the circumstances which they faced six years ago are those which many healthcare organizations will face, as they reorganize to become Primary Care Trusts (PCTs) and to meet the requirements of the NHS Plan and the modernisation process accompanying that (Department of Health 2000, 2001). Further, the nature of primary healthcare is such that its management methods have a high level of transferability into other organizational bases. An obvious candidate is a particular multiprofessional specialty or directorate in an NHS Trust, but there are other, equally important ones too. The first is small to medium sized enterprises [SMEs], since, essentially, primary healthcare centres are set up on a similar base to commercial SMEs. In terms of size, therefore, as well as other features of SMEs – such as having an owner-manager, valuing close links with a local community, and supplying a very specific target market – working in and running a primary healthcare centre is more like running a SME than it is being a Chief Executive of a large NHS Trust. Second, healthcare provision is made on the basis of a group of experts bringing their expertise together. So, for other ‘knowledge workers’ too, in education, law, consultancy, creative arts and public administration, the organizational and interpersonal dynamics of Fairfield should resonate at many points with their own working circumstances.
To summarise, the literature of management science records considerable difficulties in implementing both democratic behaviour in organizations, and learning organizations, and in the literature of both there is a paucity of in-depth, long-term case studies, detailing processes, problems and solutions, from which managers may gain a ‘fly-on-the-wall’ view. Nevertheless, the achievement of the learning organization continues to be presented as a major strategic objective for management, and thus is in danger of becoming another unreachable Grail. Given these difficulties, experienced and discussed by management studies, over a period of thirty years, it seemed important to write the story of Fairfield and thereby to illuminate the twin questions:
- what does democratic management look like in action?
- how may a learning organization be created in practice?
A note on the text
This research was produced initially as a piece of management consultancy for Fairfield, then written up in collaboration with Henley Management College, as part of the regional development role of the National Health Service Executive’s Postgraduate Deanery for Kent, Surrey and Sussex, at the University of London. An account of the research methodology employed is provided in the Appendix.
The original, full-length research is lodged at Henley Management College, and their kind permission to use it in a shortened form here, is gratefully acknowledged. In the fuller version, data are presented rather differently, many more quotations are provided to substantiate the various points made, and the discussion summarized here in the last chapter works from many more sources to make its points. In this account, however, the data cited have been reduced to illustrative quotations from the people at Fairfield, and arguments have been summarized, to provide a more accessible read. All of the speakers are cited simply as ‘S’, with the exception of the Chair and Secretary of Meetings, who are cited as ‘C’ and ‘Sec’ respectively, and the author, who is cited as ‘ZJ.’ Fieldnotes are cited as ‘Fn.’ If no attribution is given for a quotation, its provenance may be either audio tapes or written fieldnotes.