At the end of 2023, MP Maria Caulfield laid the 2022/23 Freedom to Speak Up annual report before Parliament (National Guardian's Office, 2023). Although she recognised some excellent examples of practice, Caulfield shared concerns about health and care leadership. These concerns follow the Messenger review, an independent review commissioned by the Department of Health and Social Care (DHSC), to examine the leadership of health and social care organisations. It found a lack of consistency in leadership support for speaking up, noting:
‘In the NHS, we sensed a lack of psychological safety to speak up and listen, despite the excellent progress made since the Francis Report. We would observe that the Freedom to Speak Up initiative can be narrowly perceived through the lens of whistleblowing rather than also organisational improvement, and we would encourage a broader perspective.’
Caulfield stated that it was chilling to think of the harm that might have been prevented and/or the lives that might have been saved if colleagues had felt able to raise concerns, or had been listened to and appropriate action taken swiftly when they did. She specifically cited reports from the Lucy Letby case, and those by Donna Ockenden and Bill Kirkup, and the inquiry into University Hospitals Birmingham. She stated that these show why Freedom to Speak Up has never been more important.
The report shared some concerning data, including (National Guardian's Office, 2023):
- The Freedom to Speak Up sub-score has declined from 6.5 in 2021 to 6.4 in the 2023 NHS Staff Survey. This fall equates to a 1.5% change - around 9000 staff feeling less comfortable to speak up
- The Speak Up review into ambulance trusts identified the need for the Care Quality Commission, England's health and social care regulator, to treat workers' voices on a par with those of patients
- The review shared that there was disappointment that, following an earlier commitment by the Government, Freedom to Speak Up in Adult Social Care is not being taken forward at this stage.
In terms of sharing the reasons why people spoke up – against the categories required by the National Guardians Office across all healthcare organisations in the country:
- 30% of cases were reported to have an element of ‘inappropriate attitudes or behaviours’
- A further 22% of cases were reported to have an element of ‘bullying or harassment’
- 27% of cases had an element of ‘worker safety or wellbeing’
- 19% had an element of ‘patient safety or quality of patient care’.
It was reported that there is an evolving network of local Freedom to Speak Up guardian (FTSUG) roles – with just 200 guardians in NHS trusts in 2017 to now more than 1000 guardians in a wider range of organisations. However, the survey of FTSUGs revealed the impact that insufficient protected time and the skills required to execute the role has had on individuals – the report concluded that clinical supervision and support were essential.
When attending a panel at a leadership event several weeks ago, I was asked what was one of the most important pieces of learning a leader needs – my answer was the ability to support a culture of transparency and enable colleagues to raise concerns and speak up.
The Nursing and Midwifery Council (NMC) Code (2018) includes the expectation that registrants will escalate concerns professionally, and recently published an animation to support the message (NMC, 2023). I suspect future versions of the Code will be more specific in relation to our collective responsibilities at every level to enable raising concerns and freedom to speak up. My strong view is that it is all our responsibility to enable cultures where openness supports patient and staff safety. I previously wrote about the work that the Welsh government has recently published in relation to this area (Foster, 2023) and would also signpost to the NHS England e-learning platform (https://portal.e-lfh.org.uk) where there are training sections to support understanding the vital role of Freedom to Speak Up and the support available to encourage a healthy speaking-up culture for the benefit of patients and workers. The training is divided into three parts:
- Speak up
- Listen up
- Follow up.
I will conclude with a quote from the National Guardian for the NHS cited in this year's annual report:
‘If we can get the culture right, benefits will follow, including improving patient safety, innovation for improvement, retaining workers and making the NHS a great place to work.’