Dido Harding, NHS Improvement: “I’m shocked at the lack of basic people management skills in the NHS”
BMJ 2018; 361 doi: https://doi.org/10.1136/bmj.k2657 (Published 18 June 2018) Cite this as: BMJ 2018;361:k2657All rapid responses
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I am shocked that Baroness Harding is shocked at “the lack of basic people management skills in the NHS."
It was not ever thus. I say this having served in the NHS from 1960, till I retired - with the exception of about seven years when I served in local government.
Baroness Harding must know (family lore) that the commander has to have the confidence of his men. Only then will they “go over the top”, in the face of a hail of bullets. The juniors will gladly slave away for a consultant who foregoes his round of golf (even in Trumpian links) if they know that he has slept in the intensive care unit while the registrar goes to his (her) wedding.
Baroness Harding will also know that the official lines of accountability sometimes break down and the chief does not know the mess made by the accountants. She will do well to seek unofficial briefings - from staff as well as patients.
A little matter of staff shortages. Anyone who has read the newspapers will know that “Health Chiefs” are continuously declaring that we are in crisis. Yet, instead of handing in their resignations and letting the Secretary of State recruit new miracle makers, they go back and squeeze the staff till their pips squeeze. Any wonder that morale is down?
Baroness Harding is not in supreme command. She is a staff officer of a sort. She could make unannounced visits (surprise inspections like those made by the Inspector General of Hospitals, in His Majesty’s empire and colonies, long ago).
Competing interests: No competing interests
Dido Harding puts her finger on the NHS's generally poor and sometimes atrocious management skills. Of course, with the Brexit chaos we're currently witnessing, it could be said that management generally in the UK is seriously wanting. But as far as the NHS goes, those of us working at the coal face realise that frequently even the most basic tenets of management aren't followed. For example, when a skilled employee leaves, whether doctor, nurse paramedic, unhappy junior manager or porter, there is generally no honest exit questionnaire. And if an organisation doesn't know whay its employees are leaving, then how can it improve? Even regular staff surveys, which I have semi-regularly been asked to complete, have questioned designed in such a way as to promote falsely positive responses. Or offer no free text opportunities for participants to express individual views. The NHS suffers a big problem not confined to healthcare, but a national one, and that's the increasing tendency to window-dressing. All manner of leaflets, reports and publications, together with their pretty pictures, try to put 'spin' on every aspect of our work. Where is the room for the kind of brutal honesty that should be the start point for change for the better?
Dido Harding doesn't really offer any suggestions herself, despite her valid observations. Let me make one . . . . . the NHS, employing over a million people, is more than big enough to justify its own dedicated free-standing university. There are precedents for this in the USA. Such a university could offer, amongst a wider diet, top class courses in management, both abbreviated and intensive. All managers could pass through such an institution, and those at the clinical coal-face could also be required to attend shorter courses. Not only would this drive up standards, but it would ensure a common high quality approach and most likely easily pay for itself.
Let's DO something instead of simply wringing our hands.
Competing interests: No competing interests
The efforts of Dido Harding are appreciated in highlighting this problem and emphasizing the need to address it. It’s all about leadership and managing people, and, although everyone recognizes it and so much has been done to identify it as a priority in healthcare service delivery, in reality this is frequently not reflected both effectively and consistently in healthcare organizations (1). Bullying, whether real or perceived, is a failure of leadership and can arise where staff in a pressurized work environment perceive themselves working to separate agendas. This erodes trust and leads to disengagement, ergo poor response in staff surveys. Unfortunately accusations of bullying are not uncommon and best approached when they arise by tackling them initially in an informal manner. Where necessary the officer responsible to resolve such cases whether from the human resource department or other healthcare services is required to do a full assessment of the situation and remedy it through informal discussion with the parties to arrive at a constructive and healthy solution (2). Prevention is better and clearly needs effective leadership.
Both induction and mandatory training of managers must include effective communication with staff and how to avoid unnecessarily upsetting them. The clinical governance reporting mechanism of incidents of perceived bullying need to be taken as seriously as other clinical governance incidents and must be dealt with promptly and objectively. There is a perception by some staff that in such incidents, organizations appear to take the side of the manager as the latter is part of the management structure. The more objective and fairer these incidents are managed the more are these perceptions dispelled.
Finally, senior management going all the way to the Board of Directors should lead by example. They need to show constant presence on the ground and at the clinical interface, and the more they interact with an understanding, caring and courteous approach with all staff the more they set examples as to how leaders/managers communicate and deal with staff. After all one of the key objectives of every healthcare organization is asserting the fact that its staff are its biggest asset and to do its absolute best to make them happy in the workplace and maintain a spirit of high morale (3).
1. https://www.kingsfund.org.uk/blog/2018/02/priorities-nhs-2018-19-and-beyond
2. https://www.nhs.uk/conditions/stress-anxiety-depression/bullying-at-work/
3. http://nhsproviders.org/media/1057/we-need-to-talk-about-boards-boards-l...
Competing interests: No competing interests
Dido Harding’s approach on the issue of the lack of basic people management skills in the NHS is both insightful and timely.
Her observations are reflected in the results of 2017 NHS staff survey, which demonstrated endemic bullying and harassment in the health service, with 24 per cent of all NHS staff reporting that they have experienced bullying in some way.
The causes of staff bullying in the NHS include poor awareness of sound management skills; limited management training opportunities; balancing management responsibilities with ever increasing clinical demands; the desire to exercise power and control. The hierarchical organisational structure and culture in the NHS conducts itself to such malpractice.
However, the very notion of ‘managing’ people, so deeply embedded in the language of business, is problematic. We manage non-human resources but we lead, direct, motivate, develop, coach people. We learn and grow with people. We don’t manage them and people will defy being reduced to mere organisational resources. We engage people by giving them purposeful work, giving them autonomy on how they do their work and enabling them to develop a sense of mastery in what they do. People engagement is of prime importance in the caring professions which themselves are an organisational risk factor for compassion fatigue and burnout.
Bad management and in its extreme form bullying, has profound physical and psychological effects on those affected by it. It is a major cause of work dissatisfaction, disengagement and embitterment and may lead to presenteeism, increased sickness absence, lost productivity, recruitment and retention problems. Work relationships are identified by the Health and Safety Executive as one of the six management standards that help identify and manage areas of job design which can cause stress.
What can be done? Dido Harding offers the answer, by advocating the development of leadership and management skills across the health service. This also represents an effective employer primary prevention strategy for workplace bullying, which alongside increased awareness, robust procedures, improved reporting, hotspot identification and the offer of support to those affected, will produce long-term tangible and intangible benefits to NHS organisations. But workers also play an important role in identifying and reporting incidents. Employers should involve workers, their representatives and other stakeholders such as health and safety, human resource and occupational health professionals in promoting and delivering a positive culture of trust and growth.
Competing interests: No competing interests
We also wait for a better culture of the NHS. Locum doctors who come over to the UK just for a short period of time, say, 2-4 weeks or months, are not given respect or management skills, support or supervision. The GMC is also not engaging. Foreign doctors are facing local demands and bureaucracy, contribute to the 'culture of shortage of staff', not appreciated. This makes life hard and stressful. Locum doctors who keep working in their countries who hold an active licence need to go for local Appraisals and Revalidation and need to pay money to the foreign country. Doctors from the EU countries. We lack the dialogue instead of ticking the boxes of "job done". Doctors are dealing with alive human beings, so human values are very much needed to be considered as priority, as well as communication skills, competence, and medical qualifications.
Competing interests: No competing interests
Re: Profile of Dido Harding - some alternative facts
The profile of Dido Harding, Baroness Harding of Winscombe, does not explain why she was appointed to be Chair of NHS Improvement when she has no experience of working in the NHS and was heavily criticised for her previous role as Chief Executive of TalkTalk.
According to the profile her big idea is “a national volunteering scheme for NHS Improvement’s staff”. Volunteering is doing extra service without gain. Some staff may find volunteering more difficult than this racehorse owner who was reported to have earned £6.8 million in a recent year. She is paid £63,000 per year for her part-time role at NHS Improvement. I made a Freedom of Information request and was told that she does not have a job description or set hours of employment. When the job was advertised it was for “two or three days per week”, but NHS Improvement will not say how many days Dido Harding works.
There are two other life peers on the Board of NHS Improvement. Lord Darzi is a doctor. Lord Carter is not. It would be useful to know what relevant experience he brings to NHS Improvement.
It would be good if we could be confident that those with national roles are appointed purely on the basis of relevant ability and experience, rather than status or social standing. Also, it would be better if journal profiles of healthcare leaders provided more than a PR opportunity for the individual.
Competing interests: No competing interests