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Speaking up to drive change

Posted by NHS National Guardian Sep 26, 2019 Posted in Blogs

To provide the highest quality compassionate care to patients, NHS workers need to feel valued, supported and free to speak up. The learning and improvement that speaking up can provide is a key factor in driving change in the NHS.

The role of the National Guardian for the NHS was a key recommendation made by Sir Robert Francis’ Freedom to Speak Up Review, that was published in response to the Mid-Staffordshire scandal.

I took up that post in October 2016 and have overseen the start of a culture change in the NHS that is embedding the principle that speaking up should become business as usual.

Since it was established, my office has overseen the rollout of Freedom to Speak Up Guardians in every trust in England, as well as guardians in other parts of the healthcare sector.

Trusts have been providing data for two years now, which has shown more and more speaking up by NHS workers. In total there were over 7,000 cases brought to guardians in the first year and over 11,000 in the second year. Nearly half of the cases in the first year were related to bullying and harassment and a third of cases related to patient safety. We have shown that high performing trusts have better speaking up cultures, as perceived by Freedom to Speak up Guardians.

The early success of Freedom to Speak Up in secondary care has led to the expansion of the remit of the office recently to include primary care, with in-roads also made into guardians in the independent sector and national bodies.

We have recently recruited to new regional posts with a real focus on integration. We have learnt some valuable lessons from the rollout of Freedom to Speak Up in trusts and recognise that models of working in other parts of the health sector are going to have their own challenges and we need to find different ways of ensuring workers feel confident to speak up.

Confidence is a key word in relation to speaking up, as it is essential workers believe that speaking up will make a difference and their voice will be heard if they are to approach a guardian. So how do we persuade an NHS worker speaking up is the right thing to do for them and the organisation they work for?

Well, partly it is about the guardian role itself and making a real effort to explain what it is and how it can help workers who may not want to speak up via existing routes, such as HR, staff side or their line manager.

Speaking up is a relational exercise and Freedom to Speak Up will only work if listening up occurs and it is embraced by the organisation as whole. Only by welcoming feedback and walking the walk when it comes to acting on the information from speaking up will confidence be instilled in the rest of the workforce and encourage others to speak up too.

My office is an independent, non-statutory body, not a regulator, so our whole approach is about working with organisations to make Freedom to Speak Up effective. Leadership is absolutely key to making a success of Freedom to Speak Up, so we aim to engage hearts and minds, rather than impose conditions.

That said, there are contractual obligations that apply to organisations that are subject to the Standard NHS Contract, and Freedom to Speak Up is part of the Well Led Domain of CQC inspections. There is also a lot more emphasis on speaking up in all walks of life and I believe this is having an effect too.

Workers rightly feel they have the right to speak up. Organisations that do not embrace this and see speaking up as a gift to inform learning, are increasingly out of step with the way of the world.

I’m proud we have made such significant steps in health and while the catalyst for change was tragic, what Freedom to Speak Up has done is set a new way of working in motion. I’m pleased to see that picking up speed and making a difference and I am optimistic it will continue to permeate into every part of health.

Last October, we launched the first ever Speak Up Month. At a national level this saw an event take place at the House of Commons and supportive messages come from the Secretary of State, the Chief Executives of NHS England, NHS Improvement and the CQC, amongst many others in the form of short films and statements published on Twitter.

At a local level, guardians put on over 100 special events and launched a variety of publicity campaigns that included the widespread reference of the campaign hashtag – #speakuptome – used over 5,000 times during the month. Cases of speaking up jumped from 2,600 in the second quarter, to 3.600 cases in the third quarter (when Speak Up Month took place).

I myself travelled over 2,000 miles around the country over the course of the month visiting various trust events. This year I will similarly be out and about, and I am looking forward to seeing health organisations celebrate how they encourage their workers to speak up.

I hope those of you that engage in the campaign directly, or via Talk Health and Care, can help raise the profile of speaking up and promote this important issue. By making speaking up business as usual we can all improve patient safety and the wellbeing of workers.

Dr Henrietta Hughes, National Guardian for the NHS


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This post was edited on Sep 30, 2019 by NHS National Guardian


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Comments (4)

Minh Alexander says... 11 months ago

The Freedom To Speak Up project was created with no evidence base:

It is badly designed and is fatally flawed, such that it is wholly ineffective at

- protecting individual whistleblowers and ensuring redress of any harm suffered

- ensuring the investigation and proper resolution of whistleblowers' concerns

This is a summary of the problems and risks facing NHS staff who whistleblow and who may be forced to rely on the Freedom To Speak Up apparatus:

The National Guardian's exclusion criteria are excessive and exclude all whistleblowers engaged in any active processes. The National Guardian's Office has confirmed that this includes Employment Tribunal litigation, so whistleblowers may be excluded from case review by the National Guardian for years, which is very unsafe for patients affected by the cases in question.


Moreover, the National Guardian has applied exclusion criteria that do not feature in her official published exlcusion criteria:

Even where case review is undertaken, there is no redress for harmed whistleblowers and partly because of the National Guardian's lack of any statutory powers, little evidence of robust follow through and enforcement:

Both the National Guardian and the government continue to resist proper examination and accountability for the proper handling of NHS whistleblowers' concerns:

Until this is addressed, and UK whistleblowing law is reformed to provide genuine protection for both whistleblowers and the public, all else is mere theatre of distraction & noise.

Morganth says... 11 months ago

The Freedom to Speak out Guardians do a brilliant job, when the Trust they work will allow them to.

Unfortunately, the Trust I work for will only allow a Guardian in for a year, on secondment, doing the job whilst they also do their other job, and will only allow senior managers to apply. Not very comforting to staff who want to speak out or to anyone who really could make a difference in this role. Disappointing that it is just a façade of a role.

 And when it comes to speaking out, the Trust I work for does nothing, just pays it lip-service, takes weeks to come back to you and then tells you there is nothing they can do. I know of a lot of people this has happened to. Such a pity, when this could be such a brilliant way for people to be heard. Its a shame it has been hi-jacked by senior managers too afraid to allow any serious complaints get through for fear of being seen as incompetent.

It is disappointing that there isn't enough money in Central Government to pay for a Guardian in each Trust, totally separate and independent so they cannot be manipulated. But I have thought long and hard about this, and there is a way to do it if each Trust has to pay the wages of one person to the National Guardian Office, who then ensure that they pay for a Guardian independently of the Trust they work in.  The Guardians would all then work for the National Guardian Office and all it would take would be the time of one secretary to manage and monitor it all. It would solve the problem with compliance but also with independence.

I would love to be involved in this and have applied to be a Guardian twice in this Trust and once in the Trust I worked in before but not even had an interview in either due to being a low banding. I would so love to do a job that would make such a difference to people, instead of the role being judged on how well you can present to the Senior Management Team.

NHS National Guardian says... 11 months ago

Thank you for your comments Minh - always pleased to listen and while we don't always agree I value your contribution to the discussion. Just as when you were part of our Advisory Working Group and when we supported you to run your Whistleblower-led event about PIDA Reform, you have always been open and honest and we need to value that above all else.

Morganth - I am pleased to hear some of your comments and obviously disturbed to hear others. But what you point out is absolutely right - FTSU must work at an organisational level to be effective and truly bring about positive change. I don't believe the experience at your trust is typical throughout the country, but you are right to raise the issue as a concern. Thank you for doing so and by all means email me at if you require further support and feedback.

Minh Alexander says... 10 months ago

Hi Henrietta,

I think whistleblowers would feel more valued if the NGO's engagement process resulted in more staff-centric action. We of course thanked you and your team for the use of a venue for our whistleblower led event. It would be valuable if one day you would agree with the vast majority of seasoned whistleblowers who have been seriously failed by current UK whistleblowing law, and the majority of legal specialists in this area, and support urgent reform of unfit UK whistleblowing law. The law of course not only fails whistleblowers and their families, leaving many ruined and with broken health, but most importantly it fails patients because it does not compel anyone to investigate whistleblowers' concerns. As I am sure you will be aware, the Department of Health and Social Care is currently doing its best not to answer my urging of the last year to change the Care Quality Commission's regulations to ensure that the Commission investigates individual whistleblowers' concerns where necessary. I think you could make a real difference by speaking up and intervening on this issue. BW Minh

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