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Dido Harding, NHS Improvement: “I’m shocked at the lack of basic people management skills in the NHS”

BMJ 2018; 361 doi: (Published 18 June 2018) Cite this as: BMJ 2018;361:k2657
  1. Tom Moberly, UK editor, The BMJ
  1. tmoberly{at}

Better leadership training in the NHS would increase staff engagement and tackle bullying, the chair of the NHS trust regulator tells Tom Moberly

Since she joined watchdog NHS Improvement as chair in October 2017, Dido Harding has been struck by the ways in which the health service falls short in the treatment of its staff. “I am quite shocked at the lack of some of the basics of people management that I would expect to see,” she says.

“That’s not to say that there are not pockets of complete brilliance—of course. there are. I’ve seen examples of some of the best people management and leadership I’ve ever seen. But it is unbelievably inconsistent.”

Harding joined NHS Improvement, which regulates NHS trusts in England, after a string of senior jobs in the private sector, most recently as chief executive of telecoms company Talk Talk. Speaking at the Health Foundation annual event in London on 22 May, she says that, coming into the NHS as an outsider, she can’t get her head around the prevalence of bullying among health service staff.

“It’s awful,” she says. “The percentage of staff saying that they have been a victim of or have witnessed bullying is three, four, fivefold more than you would see in other organisations.”

The high levels of bullying seen in the health service arise, she believes, from shortcomings in management skills across the NHS. “I suspect it’s a real indication of an immaturity in the whole system in what good management looks like,” she says. “Good management isn’t soft and fluffy—good management is about giving or having honest adult conversations. Bad management can often be interpreted as bullying.”

Low engagement

Data on bullying in the NHS are collected as part of the NHS staff survey. But Harding points out that, even before you start looking in detail at people’s answers to these questions, the low overall response rates reveal a problem with staff engagement across the NHS.

“Best practice in the private sector for a staff survey is that at least 90% of your workforce fill it in,” she says. “There isn't a single organisation in the NHS that has 90% of its staff who have ever filled in a staff survey. People will say, when they’re at 65%, ‘This is amazing.’”

Employers need to see such poor response rates as a warning sign, she argues. “It’s the first indicator of how engaged your workforce is,” she says. “If they’re not even going to fill in a form telling you how they feel, they have already told you they’re not very engaged. We’re light years away from best practice on that.”

She believes that, to increase staff engagement, managers need to create an environment in which staff feel that their contribution is valued. “If you look at any study that has been done in the health sector—or in any other sector—about what determines whether you are engaged at work, it is how your line manager treats you,” she says. “It’s almost never how much you are paid, or how much money the organisation as a whole has got. It’s ‘Do I feel valued as a human being?’”

One way in which NHS Improvement believes it can drive up staff engagement is by using the influence it has on senior appointments in the health service. “The most powerful lever we use is people,” Harding says, “in the leadership culture that we inspire and encourage, and the people decisions that we take either directly by appointing chairs or [less directly] by sitting on appointment panels for chief executives or medical directors. It is the most powerful lever that we can pull, and we don’t pull it in anything like as structured and thought through [way] as we could, and we fully intend to.”

Leadership overlooked

Since starting at NHS Improvement, Harding has seen that, although everyone knows the important purpose of the NHS as a whole, individual line managers often fail to show their teams why their part of the service has an important purpose in itself.

“If you are in a team with a manager who shows they care about you, who can describe your part in the enormous jigsaw puzzle that the NHS is, and that can help you really feel valued and included, you feel your part has a real purpose,” she says. “All of those are the things that individual leaders can do.”

NHS Improvement should have a big role in supporting the development of leadership and management skills across the health service, she argues. “We should be thinking about how we plan and develop talent at the most senior level,” she says. “I'd like to see us develop a fully fledged approach to managing senior people in the NHS.”

The importance of developing leadership and management skills has so far tended to be overlooked, she believes. In her view, the NHS too often underestimates not only the opportunities that improvements in leadership and management skills offer but also the work involved in honing those skills.

“It’s much easier to teach doctors and nurses to be great managers and leaders than it is to teach me to be a doctor or a nurse,” she says. “Nonetheless, it’s a skill that needs to be taught and honed and practised—we are never too good at it to not practise.”

Improving NHS Improvement

Although her organisation is seeking to raise standards across the NHS, Harding is open about the fact that NHS Improvement is “far from perfect” when it comes to its track record on improving itself.

“The harshest criticism I've heard of NHS Improvement is that we aren’t much of a learning organisation ourselves, and I take that quite to heart,” she says. “We have a huge amount of work to do to change the way we lead and manage our own teams, let alone how we then try to role model the right behaviour for the sector as a whole.”

Poor alignment between NHS Improvement, which regulates trusts in England, and NHS England, which commissions health services, does not help the situation, she acknowledges.

“On a good day the NHS Improvement team and the NHS England team will ask a trust or an STP [sustainability and transformation partnership] roughly the same question in slightly different ways and ask them to fill in separate forms,” she says. “On a bad day, they ask the same organisation to do directly contradictory things, and unfortunately there are quite a lot of bad days.”

She says that the two organisations should be collaborating more closely to improve patient outcomes. “Together with NHS England we set, broadly, the rules of the game, the financial incentives and the non-financial incentives,” she says. “We need to make sure, together with NHS England, that we’re setting them to get the outcomes that we want.”

Dido’s big idea: a national volunteering scheme

Harding is trying to set up a volunteering scheme for all staff in NHS Improvement. “I want to find a way to get everyone in NHS Improvement to spend at least a couple of days helping on the front line in January,” she says. “Helping could be making cups of tea or running errands around the hospital, just being human and available.”

“I'm trying to improve the culture of NHS Improvement,” she explains. “I'm absolutely certain that seeing is believing and that the way we change the culture throughout the NHS, as leaders and managers, is by seeing it in the way that our patients see it.”

Career history

  • 1985-88: University of Oxford—studied politics, philosophy, and economics (PPE)

  • 1990-92: Studied MBA at Harvard Business School

  • 1992-2010: Roles at McKinsey, Thomas Cook, Woolworths, Tesco, and Sainsbury’s

  • 2010-17: Chief executive of TalkTalk Telecom

  • 2014: Appointed to the House of Lords (Baroness Harding of Winscombe)

  • 2014-present: Non-executive director and chair of remuneration committee, Bank of England

  • 2017: Chair of NHS Improvement

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