Guidance for NHS trusts and foundation trusts: assessing the well-led key question
Freedom to speak up
We foster a positive culture where people feel that they can speak up and that their voice will be heard.
What does good look like:
The trust has a culture of speaking up. All staff at all levels within the trust are equally encouraged and empowered to speak up. They feel safe to speak up without fear of detriment, that is without experiencing disadvantageous and/or demeaning treatment as a result.
All staff are confident that their voices will be heard. Managers across the trust feel confident to listen and act when someone speaks up and improvements happen as a result. These are communicated back to those who raise matters. Leaders are seen to promote Freedom to Speak Up through actively demonstrating positive behaviours. Appropriate training and support is available to equip freedom to speak up leads to actively support the Freedom to Speak Up Guardian.
The trust’s policies and procedures positively support this process.
Further detail and context:
Speaking up is about anything that gets in the way of providing good care
When things are good, but could be better, workers should feel able to say something and should expect their suggestions to be listened to equitably and used as a potential opportunity for improvement. Equally, when things go wrong, organisations need to make sure lessons are learned, and things are improved. This involves all workers being equally supported to speak up so that potential harm or discrimination is prevented or eradicated.
Speaking up may take many forms. This can include:
- a quick discussion with a line manager
- speaking with human resources or the patient safety team
- making a suggestion for improvement
- raising a matter with a Freedom to Speak Up Guardian
- telling a regulator about a matter.
The act of speaking up encompasses activities such as ‘raising concerns’, ‘reporting incidents’ ‘suggesting improvements’ and ‘whistleblowing’. There is a consistent feedback loop to the member staff involved.
Good practice
Freedom to Speak Up Guardians provide an additional route for workers to speak up. They complement, and do not replace existing channels such as line management, human resources, patient safety teams or incident reporting systems. Guardians make sure that people who speak up to them are empowered, treated equitably, and thanked. They also make sure the organisation responds to the issues and gives feedback on actions taken to the person speaking up. Freedom to Speak Up Guardians also work throughout the organisation to identify ways to improve the speaking up culture. This includes reporting to leaders in their organisation on the barriers to speaking up (to include discrimination) and themes to encourage equity of voice, learning and improvement. A good speaking up culture ensures that guardians are present and accessible across a diverse range of staff networks to enable all groups to feel comfortable in speaking up.
To establish an effective speaking up and reporting culture, the leadership of the organisation needs to make a clear commitment. This must include:
- leaders being role models of behaviour
- creating cultures that support speaking up
- implementing robust and effective arrangements to support speaking up, which everybody is aware of.
This should include giving Freedom to Speak Up Guardians enough time, resources and support to fulfil all aspects of the universal job description and meet the needs of workers in their organisation. It also means establishing assurance about the culture and arrangements for speaking up. This includes having multiple routes for speaking up that may not exclusively involve guardians, and a plan to improve it. Speaking up also has an important role as part of safety and improvement cultures, and it is important that leaders use speaking up to identify learning for improvement and to inform supporting plans.
National policies
The National Guardian’s Office provides resources and examples of good practice, policies and processes, and legal obligations that set out how to manage speaking up cases. This includes those raised with a Freedom to Speak Up Guardian, line manager or other route.
Providers appoint one or more Freedom to Speak Up Guardians. The National Guardian’s Office provides training, support and guidance to Freedom to Speak Up Guardians about their role. It reviews speaking up in health care to identify learning and encourage improvement. The National Guardian’s Office has also developed training with NHS England to help learners understand their vital role in a healthy speaking up culture that protects patient safety and enhances the experience of workers.
NHS England’s national speak up policy provides the minimum standard for local freedom to speak up policies across the NHS. This enables those who work in the NHS to know how to speak up and what will happen when they do.
NHS England and the National Guardian’s Office have also published guidance and a Freedom to speak up reflection and planning tool. Providers were required adopt the policy and undertake the reflection and planning tool by 31 January 2024.
Best practice / guidance
NHS England
NHS England and National Guardian’s Office
The guide for the NHS on freedom to speak up
Freedom to Speak Up: A Reflection and Planning Tool
Freedom to Speak Up Support Scheme
Developing inclusive and accessible Freedom to Speak Up arrangements
Listening to workers: A speak up review of Ambulance Trusts
National Guardian’s Office (support for Freedom to speak up guardians)
Find Your Freedom to Speak Up Guardian (Directory)
National Guardian’s Office Guidance (to support guardians in their role)
National guidelines on Freedom to Speak Up training in the health sector in England
National Guardian’s Office Freedom to Speak Up training
Link to regulations
Regulation 10: Dignity and respect
Regulation 12: Safe care and treatment
Regulation 17: Good governance
May also consider Regulation 9: Person-centred care