Organisation objective

• Governance

Executive summary

Board members are asked to note and discuss progress made by the National Guardian’s Office and priorities for this financial year.

Background

1. The National Guardian’s Office was set up in October 2016 as part of recommendations from the Francis Freedom to Speak Up Review (2015). Dr Hughes stepped down from her role as National Guardian in September 2021 and Dr Jayne Chidgey-Clark was appointed and commenced the role in December 2021.

2. The office leads, trains and supports a network of Freedom to Speak Up Guardians in England and conducts speaking up reviews to identify learning and support improvement of the speaking up culture of the healthcare sector. The National Guardian’s Office also provides challenge and learning to the healthcare system as part of its remit.

3. Progress continues to be made to improve the speak up culture across a range of organisations, systems, and processes across the health sector. Since the National Guardian Office last update to the Board on 18 May 2023, there are now 1231 Freedom to Speak Up Guardians [as of May 2024] supporting thousands of organisations across the healthcare sector, who have handled over 133,000 speak up cases to date [as of March 2024], allowing workers to speak up who might otherwise not be heard.

4. The National Guardian lays an annual report before Parliament each year, and reports to the Boards of its funding partners a minimum of annually. The NGO’s Annual Report 2022/2023 was laid on 16 November 2023. The Annual Report can be found here. The report shares intelligence and learning collated by the National Guardian’s Office.

5. The report also features case studies from across England and different healthcare providers, sharing the experiences of people who have spoken up and the difference Freedom to Speak Up guardians are making.

6. The National Guardian will bring the 2023/2024 annual report to NHSE Board later in the year. This report provides highlights of progress and priorities for this year.

Funding

7. Last year a memorandum of understanding was agreed for 2023 – 2026 between CQC, Department of Health and Social Care and NHSE. For the next three years the National Guardian’s Office’s budget has been reduced by 5% to £1.58m.  A business plan has been developed based on the reduced budget.

Governance

8. The National Guardian’s Office’s Accountability and Liaison Board meets four times a year. In accordance with the CQC/DHSC Framework Agreement on an annual basis the Office reports to CQC’s Audit and Risk Committee, CQC’s Board and NHSE’s Board.

Strategy

9. In July 2024, the National Guardian’s Office announced the refreshed strategy for the work of the organisation. Improving workplace cultures is at the forefront of our strategy. We are aiming to achieve a sustainable and lasting cultural shift that improves workers experience as well as patient and worker safety. 

10. Our ambition for our 3–5-year vision is to ensure workers are confident to speak up. Safety is the minimum standard, what we seek is to build confidence which comes through workers feeling not only encouraged to speak up, but that it will be welcomed and listened to, and action taken when they do.

11. The National Guardian’s Office has set out its six strategic goals to achieve the National Guardian’s vision, improving existing services as well as making some step changes to drive further change across the system. These are: 

• continuing to improve resources and offer to Freedom to Speak Up guardians 
• developing additional support and guidance for organisational leaders 
• using the National Guardian’s independent voice to champion Freedom to Speak Up and challenge the healthcare system by raising awareness of issues which affect workers’ confidence to speak up
• using the insight gathered by the National Guardian’s Office to drive recommendations to improve speak up measures and culture, for example through Speak Up Reviews, and challenging organisations to do better 
• improving partnership working with key organisations to deliver change 
• improving the organisational maturity and internal infrastructure of the National Guardian’s Office to support these ambitions

12. The Office is working on several initiatives to support the delivery of the strategy. Oversight of progress is reported to the National Guardian’s Office Accountability and Liaison Board on a quarterly basis.

Highlights of progress since May 2023 report

13. Freedom to Speak Up Guardian network. There are now over 1231 trained Freedom to Speak Up Guardians in the National Guardian Office’s network and included on the published directory. The variety of organisations represented has also expanded with Freedom to Speak Up Guardians being appointed in:

• NHS trusts and foundation trusts
• primary care providers including GP practices, dentistry, optometry, and pharmacy services
• independent providers of healthcare including hospices and diagnostic services
• arm’s length bodies, national organisations, and regulators

14. Organisations in other sectors, including education and financial services, have also sought to learn from and implement the Freedom to Speak Up Guardian model. The National Guardian’s Office hosts a pan sector speak up group to support cross industry learning.

15. We have continued to collect anonymised data about the speaking up cases raised with Freedom to Speak Up Guardians. This information shows that:

• the number of cases raised through the Freedom to Speak Guardian route has increased by 27%. In 2023/24, 32,167 cases were raised with Freedom to Speak Up Guardians. In comparison, 25,209 cases were brought to Freedom to Speak Up Guardians in 2022/23
• workers were speaking up to their Freedom to Speak Up Guardians about various issues, including worker safety and wellbeing, patient safety, bullying and harassment and other inappropriate attitudes and behaviours
• the percentage of cases raised with Freedom to Speak Up Guardians in which detriment is reported remained at 4.0% for both 2022/23 and 2023/24

16. We continue to work with NHSE and other stakeholders to improve understanding of the speaking up landscape in healthcare, including through the NHS Staff Survey and the pilot Bank Survey. The key findings from the 2023 NHS Staff Survey are:

• clinical practice questions are showing signs of decline with ‘I would feel secure raising concerns about unsafe clinical practice’ now being at a five-year low. 71.3% of respondents said they felt safe to speak up about unsafe clinical practice and 56.8% thought that their organisation would address such concerns
• questions about ‘any’ concerns have stabilised and are starting to show improvements. 62.3% of respondents said they felt safe to speak up about anything and 50.1% thought that their organisation would address such concerns
• overall the Freedom to Speak Up (or Raising Concerns) sub-score (calculated from the four Speak Up questions) is stable, with marginal improvement from 6.44 in 2022 to 6.46 in 2023

Speak Up Reviews

Ambulance Trusts

17. In 2022/23 the National Guardian’s Office implemented a new approach to Case Reviews called Speak Up Reviews. Speak up reviews seek to identify learning, recognise innovation, and support improvement, and, ultimately, improve the experience of workers, patients, and the public. Whereas case reviews were typically triggered by individual referrals, speak up reviews seek to give as many workers as possible a voice in what we decide to review by looking at a range of indicators to inform those decisions.

18. Our inaugural Speak Up review into NHS ambulance trusts in England was published in February 2023. We proposed this review in response to consistent findings that, despite their inspection ratings, the speaking up culture in NHS Ambulance Trusts tended to be more challenged compared to other trust types.

19. The report made four recommendations, which if actioned in full would be reflected in improved speaking up culture within the next three years:

• review broader cultural matters in ambulance trusts
• make speaking up in ambulance trusts business as usual
• effectively regulate, inspect and support the improvement of speaking up culture in ambulance trusts
• implement the Freedom to Speak Up Guardian role in accordance with national guidance to meet the needs of workers

20. Following the publication of our report, we set up a steering group involving stakeholders to oversee the implementation of the recommendations. During this time, the NGO, ambulance trusts, and system partners have taken various steps to realise the recommendations. Among other things, the National Guardian has delivered development sessions to boards in most of the ambulance trusts, with the remainder scheduled to be undertaken this year.

21. The government accepted our recommendation for an independent cultural review of ambulance trusts. The review, commissioned by NHS England and carried out by Siobhan Melia, was published in February 2024. The review acknowledged the problems mentioned within the NGO’s Speak Up Review report and developed pragmatic solutions for improvement. Specifically, the review identified six key recommendations to improve the culture, with actions for NHS England, ICBs, and ambulance trusts. NHS England accepted the recommendations and held the inaugural culture review delivery board on the 16th of April, focusing on implementing the recommendations over two years with a wide range of stakeholders.

22. NGO will publish a report in August, providing a one-year update on the progress made towards the recommendations outlined in our review.

Overseas-Trained workers

23. In March 2024/25, the National Guardian’s Office announced its second Speak Up review, looking into the experience of Overseas-Trained Workers. The aims of the review are to:

• enhance the understanding of the Speak Up culture among overseas-trained workers in the NHS
• identify and address barriers that prevent these workers from speaking up
• recognise and disseminate examples of good practice in supporting an open and safe environment for speaking up
• develop actionable recommendations to improve policies and practices, fostering a more inclusive and supportive Speak Up culture

24. Stage 1 of the review, which involved a comprehensive review of existing information and literature in this field, is complete and we are now moving to Stage 2 (‘fieldwork’), which consists of engagement with workers, guardians, and other stakeholders.

25. It is envisaged that the review will be published before the end of 2024.

Working with our Partners

Speak Up Partnership Group: 

26. The National Guardian’s Office leads the Speak Up Partnership Group, which comprises several national bodies. Its purpose is to improve the consistency and quality of responses to workers speaking up to national bodies, which we know can be poor and inconsistent. The group works through agreed principles that define good practice in this area, sharing knowledge, challenges, and approaches to improvement with members seeking to enhance their approach to receiving and acting on matters raised by workers.

27. We are collaborating with members to produce a booklet showcasing good practices under each of the 12 Speak Up principles, which will be published later in 2024.

28. The next phase will involve discussions with members about the group’s future direction. It is envisaged that the group will continue to operate by sharing and learning from lived experiences, supporting members in further developing their Speak Up practices.

Arm’s Length Bodies Safety Recommendations Collaboration Group:

29. The National Guardian’s Office is a member of the Recommendations Collaboration group, Chaired by HSSIB. The purpose of the group is to improve efficiencies across the Arm’s length bodies (ALBs) through collaboration and to support the health and care system by improving the quality of patient safety recommendations.

Perinatal Culture and Leadership Steering Group: 

30. The National Guardian’s Office is a member of the Perinatal Culture and Leadership Steering Group which is made up of healthcare leaders from across the ‘perinatal’ landscape. The Office has been in discussion with members regarding where Freedom to Speak up could be embedded across several member initiatives regarding worker voice, team cultures, ways of working, protocols, policies and procedures.

National Quality Board: 

31. The National Guardian’s Office is a member of NHSE’s National Quality Board. In April 2024 the National Guardian presented an update of the Office’s revised strategy and work programme.

Escalation routes:

32. In December 2023 National Guardian’s Office co-chaired three workshops with NHSE, to explore the existing mechanisms for escalating concerns/speaking up in extreme cases where there is evidence of intentional, or criminal intent to cause harm. Following the three workshops the group agreed an action plan which is being taken forward by NHSE and CQC.

Thirlwall:

33. The National Guardian’s Office submitted evidence to the Thirlwall Inquiry in February 2024.

Health and Social Care Select Committee: 

34. Expert Panel: Evaluation of the Government’s progress on meeting patient safety

• the National Guardian’s Office together with the Department of Health and Social Care, NHSE and NHS Resolution submitted a response to the questions laid out by the committee
• following the publication of the findings and recommendations from the Expert Panel in February 2024 the National Guardian’s Office has written to the Department of Health and Social Care outlining work the Office could undertake to further support implementation of recommendations related to patient safety

35. Inquiry into NHS leadership, performance, and patient safety

• the National Guardian’s Office submitted a response to the questions laid out by the committee
• in May the National Guardian was invited and attended the second panel of the committee giving evidence into NHS leadership, performance, and patient safety
• following her attendance the National Guardian sent the committee further information ahead of the committee’s pause due to the pre-election period

Primary medical services and integrated care systems

36. We continue to work closely with NHSE, CQC and other organisations to develop and embed speak up routes, including how Freedom to Speak Up Guardian roles can be implemented effectively in primary medical services and integrated care system settings. The National Guardian’s Office established a quarterly ICB roundtable discussion to support with the implementation of the Guardian role across ICS’s. To further support this work in April 2024 National Guardian’s Office established a Primary Medical Service Guardian Network and appointed a network chair.  The inaugural meeting will be held in July 2024. 

Adult Social Care

37. The National Guardian’s Office have recently written to the Department of Health and Social Care asking for Ministers to reconsider undertaking a pilot into implementing the guardian role in social care. Introducing the role into social care would bring a level of parity and support integration across the health and social care sector in terms of worker voice.

Guardian Support

Training: 

38. The Freedom to Speak Up Guardian role is complex, and their work is constantly evolving. The National Guardian’s Office have developed an annual Refresher module to support guardians’ learning and development needs on changes and updates to the Freedom to Speak Up landscape. For 2024/25, the Office launched Equity, Diversity, Inclusion and Belonging for its refresher module. It has been well received and has become part of every new guardian’s foundation training from 2024/25.  To date 273 have completed the training with a further 186 in progress.

39. On launching the module, guardians are given an eight-month completion period. Failure to complete the training within this timeframe will result in the NGO notifying CQC and NHSE of non-compliance.  We will also reach out to the organisation to ensure the guardians are getting the support they need to fulfil the requirements.  Non-compliance may result in the guardian being removed from the directory.

Guardian development:

40. The National Guardian’s Office is undertaking a review of the Guardian Universal Job Description. The current universal job description for Freedom to Speak Up Guardians was written as such so that the principles can be applied to a Freedom to Speak Up Guardian role in any organisation. Speaking Up Case Reviews identified recommendations for the job description to be reviewed in view of ring-fenced time and for the role to be properly resourced with additional feedback from Guardian surveys also identifying a lack of ringfenced time for the role. Feedback from Freedom to Speak Up guardians suggests that the current job description is no longer fit for purpose and clarity over role expectations is needed.

41. At the time of writing this report, initial engagement and feedback has been sought from Freedom to Speak Up network chairs and mentors and a further two guardian focus groups were held. Information from these engagement sessions will be analysed so that a decision can be made on; what guardians want, what guardians need and what we are able to produce to best support them, their leaders, and their organisations.  Next steps include a refresh of the universal job description by March 2025 and a review of the coproduced Freedom to Speak Up Guidance with NHSE by Autumn 2025.

Communications and engagement

42. The theme of October 2023’s Speak Up Month was Breaking Barriers to Speaking Up. The aim was to highlight through numerous initiatives the barriers to speaking up and by raising awareness of the barriers to speaking up, and encourage barriers to be addressed, fostering an inclusive environment that encourages speaking up, listening up and following up.

43. The impact of the month can be seen in the 25% increase of visitors to the ‘Find My Guardian’ page on the NGO website (October 23: 23,941 compared to September 23). This is also reflected in the increased number of cases brought to guardians in Q3 2023.

44. The theme for our seventh Speak Up Month in 2024 will focus on listening and the important part we can all play in listening to one another and fostering psychological safety.

45. Case studies showcasing good practice, blogs from leaders and stakeholders and 100 Voices stories from workers who have spoken up have been published on our website. These are also shared in our monthly newsletter for stakeholders, which is received by nearly 3,000 people who have signed up via our website.

46. We continue to support Freedom to Speak Up guardians with communications resources to help them in their role and our fortnightly bulletins share information across the Freedom to Speak Up Guardian network. We produce a programme of webinars throughout the year which complements our annual conference for Freedom to Speak Up guardians. In March we held a hybrid conference in Birmingham for which over 750 people registered – 451 attended virtually and 300 in person and more are able to watch the sessions as they are available on our YouTube channel.

Engagements:

47. ICB Roundtable – following the joint publication of ICB guidance by NHS England and the National Guardian’s Office in 2023, the Office has established a quarterly ICB roundtable to discuss with guardians their successes and challenges in implementing speaking up across ICS’s. To date there have been two meetings focused on the sharing of information and models.

48. Guardian engagement – A discussion took place with Guardians who are either working in or moving towards a ‘group’ model to discuss whether bespoke guidance would be beneficial to them. A further discussion is planned for the Autumn.

49. Pan Sector network: All sectors have much to learn from one another about how to embed a culture where people feel they can speak up about anything which gets in the way of them doing their job.

50. For these reasons, the National Guardian’s Office set up the Pan Sector Network to enable cross-sector sharing and learning. Since the last Board meeting, the network have met to discuss: speaking up in command and control environments and fostering a speak up culture which supports workers from overseas.

Media engagements:

51. The National Guardian has taken part in a number of media engagements, including, BBC Today programme and BBC network news, the iNews, Nursing Times, The Independent, The Guardian and Nursing Standard.

52. In addition, there have been articles by the National Guardian in the following journals: GP Nursing Journal; Hospice UK and NHS Employers. We are continuing to develop our communications and engagement in addition to the above, including responses to media enquiries and support of NGO reviews, reports and guidance, and stakeholder engagement.

Conclusion and next steps

53. Over the past year the healthcare sector has seen several events such as the Countess of Chester, the Ockenden Review and inquiries into University Hospitals Birmingham demonstrating how important it is to improve the speak up culture in health and why it is so essential for patient safety and worker wellbeing.

54. We know the best organisations embrace speaking up because it is the right thing to do, for worker engagement, for inclusion, for learning and improvement, and ultimately, for patient safety and high quality services. The continuing feedback from the NHS Staff Survey along with the data guardians submit, and such high profile cases shows the imperative that the NHS, collectively and every single organisation delivering NHS care, really seek to listen to all their workers and to act appropriately on what they hear. Leadership to improve culture has to be at the heart of improvements and NHSE has a key role and we look forward to continuing to work closely with you.

55. We know there are inconsistences in implementation of the Freedom to Speak Up Guardian role and we have identified a number of areas as part of our strategy where we can support organisations to better implement and embed guardians. We seek ongoing NHSE support and are working closely with the NHSE Freedom to Speak Up team in this area.

56. ICBs have been asked to improve access to Freedom to Speak Up Guardians for primary medical workers. The staff survey and feedback from existing guardians working in the primary care space demonstrate significant challenges to successful implementation of the role and improving speak up culture in the small business model. We continue to work with NHSE and ICBs as a priority in this area.

57. All of the key areas identified in this progress report continue to be priorities for 2023/24. Our work programme and business plan will include a focus on:

Continuing support and development for Freedom to Speak Up Guardians, including:

• review of the Universal Job Description
• develop dedicated speak up materials for:
  • leaders – Non-Executive Directors and Executives
  • champions

Speak Up reviews:

• further development of Speak Up reviews including planning, governance, and evaluation
• further develop priority list of healthcare sector areas where a speak up review would be beneficial to identify learning and improvements
• work with, and input into work of, other patient safety organisations to share learning across the system

Work with NHSE and CQC supporting implementation of the new Universal Freedom to Speak Up policy and guidance. Including:

• work to support NHSE in developing the role of Integrated Care Systems and Boards in speak up culture
• work with the regulators to clarify external escalation routes and support wider communication with guardians about available routes for workers
• develop further CQC Inspector speaking up training to support with Well Led inspections
• work with NHSE and CQC on increasing compliance with Freedom to Speak Up policy and guidance

Strengthening National Guardian Office infrastructure, including:

• implementing a new enquiries and management system to support more secure records management and increase efficiencies within the office such as the recording of support calls and general enquiries
• enhancing the functionality of the National Guardian’s Office website including implementing a greater search facility

Publication reference:  Public Board paper (BM/24/30(Pu))