NHS Voices blogs

Having the freedom to speak up

Looking at the freedom to speak up guardians two years after their establishment.
Judith Graham

17 July 2018

Two years on from the introduction of freedom to speak up (FTSU) guardians, what has been their impact on the NHS and what challenges do they face? Mental Health Network board member Dr Judith Graham, a regional FTSU guardian lead, considers the issues.

The Freedom to Speak Up (FTSU) concept was introduced by Sir Robert Francis following a 2015 review into ‘whistleblowing’ processes within the NHS. It incorporates whistleblowing but extends well beyond, aiming at developing cultures where safety concerns are identified and addressed at an early stage before people feel the need to ‘blow the whistle’.

FTSU has three components: improving and protecting patient safety; improving and supporting staff experience; and visually leading and promoting learning cultures that embrace continual improvement.

But what impact has it made? And what are some of the challenges?

FTSU approaches were introduced into the NHS Standard Contract in September 2016, and since then, there has been demonstrable impact at trust, regional and national levels.

For the last 12 months, the National Guardian’s Office has captured overall data and the results of the first year demonstrate that:

  • 6,768 cases have been raised to Freedom to Speak Up Guardians (1,259 anonymously)
  • 2,163 of these cases included an element of patient safety / quality of care
  • 3,069 included elements of bullying and harassment
  • 356 related to incidents where the person speaking up may have suffered some form of detriment.

Alongside this quantitative data gathering, FTSU guardians at trust level analyse intelligence from concerns raised and integrate the feedback into other internal safety processes. The contribution this makes to a trust’s safety culture is demonstrated through its quality review processes and safety barometers.

The presence of FTSU guardians and adherence to FTSU principles is expanding, in line with the way care provision has diversified. Many private providers of NHS services now have FTSU guardians. And NHS England, NHS Improvement and the Care Quality Commission have also introduced guardians within their teams. Speaking up processes are also being introduced in primary care, to teams including general practice, community pharmacy, dentistry and ophthalmology.


But the introduction of FTSU has not been without difficulties.

Support has – in the main – been positive, but concerns have been raised about the FTSU guardian, advocate and ambassador roles and processes, with critique centring on who may be perceived as best suited, skilled or experienced to provide FTSU guardianship, and the role and resource diversity for FTSU across the provider community.

And developing a FTSU culture in the multi-provider mental healthcare landscape is challenging, requiring systemic approaches to integration and enhanced collaboration to improve safety, rather than merely introducing individual guardians within organisations.

This systemic factor must be considered alongside worker feedback and behaviour detailed in data including the NHS Staff Survey, which shows a general decline in response rates and engagement scores for a number of trusts, which is suggestive of a decrease in workplace wellbeing.

The movement towards ‘leaner’ leadership approaches with increased focus on financial efficiency is suggested by some researchers as a threat to FTSU cultural development, due to the creation of competing priorities that may distract from patient-focused care. Unintended ‘lean’ consequences include the reduction in number, visibility or presence of leaders, which may also inadvertently affect the availability of time or support that is afforded to workers to discuss concerns.

As organisations and guardians that champion FTSU approaches, we have a responsibility to provide evidence to convince doubters – with proof that cultural change will enhance safety.

Workplace wellbeing

Publications including Surviving or Thriving? and Employee Engagement, Sickness Absence and Agency Spend in NHS Trusts have shown the importance of workplace wellbeing, highlighting the links between wellbeing and safety cultures, a core tenet of the FTSU concept.

Cultures where leaders demonstrate high emotional intelligence and compassionate leadership cognisant of individual and systemic wellbeing tend to integrate and embrace FTSU processes more easily. Being more aware of, and championing these styles of leadership is advocated to meet the patient safety and workforce challenges ahead, which are intensified if staff wellbeing is low.

Within my own and many trusts, FTSU guardians work closely with health and wellbeing coordinators and occupational health services to engage with wellbeing support, to support staff engagement and healthy workforce cultures that underpin speak-up processes.

Achieving a just culture

In the year in which the NHS turn 70, it is agreed that one of the key contributing factors by which we will achieve outstanding patient safety is through a consistent culture where it is safe to raise concerns, supporting the notions of candour and transparency.

It is a test of our compassion and cohesion as a provider community not only for how we support safe ‘speak up’ cultures, but also how we support fragile organisations which struggle with this or are recovering after an incident.

Mental health organisations and services specialise in support for traumatised individuals, making them uniquely placed to understand and respond supportively to the reflection and recovery from traumatic circumstances that effect individual staff or patients, their systems and provider community.

It will always be a challenge to balance the need to reflect, apologise and learn from events, while also authentically celebrating those who ‘speak up. But we must strive for this in order to achieve a just culture.

Dr Judith Graham is deputy director for organisational learning, advanced nurse consultant and psychotherapist at Rotherham Doncaster and South Humber NHS Foundation Trust. She is also freedom to speak up guardian and chair of Yorkshire and Humber Guardians Network. Judith is a member of the Mental Health Network board.