Last reviewed 26 April 2023

The NHS Staff Survey results for 2022 have come out and the relatively new questions about raising concerns in organisations showed declines on all measures across all types of trust, both regarding confidence in raising concerns about clinical safety and about speaking up more generally. Knowing how to identify and tackle any barriers facing staff at this stage should help managers understand the strengths within their own organisation and work out the most relevant priorities when embedding a Freedom to Speak Up (FTSU) culture for the future.

NHS staff are now less confident to speak up

NHS organisations are expected to show that they value staff who have the courage to raise concerns, and that they support FTSU guardians to fulfil their role. We know that it is not easy to raise concerning issues at work, so NHS England (NHSE) and the National Guardian’s Office (NGO) are working through 2023 to understand more about how speaking up can be successfully embedded in organisations and systems.

The first step is to assess current progress. However, the “sub-score” for raising concerns declined from 6.5 in 2021 to 6.4 in 2022. These results, published in March, were based on responses to the NHS Staff Survey questions.

  • I would feel secure raising concerns about unsafe clinical practice.

  • I am confident that my organisation would address my concern.

  • I feel safe to speak up about anything that concerns me in this organisation.

  • If I spoke up about something that concerned me I am confident my organisation would address my concern.

The greatest deterioration was in the percentage of staff who would feel secure raising concerns about unsafe clinical practice which, having improved between 2019 and 2021, declined by 3.1 percentage points from 75.0% to 71.9%. This revealed a return to 2019 levels.

Commenting on the results, FTSU National Guardian Dr Jayne Chidgey-Clark said it was disappointing that the results “reflect a decrease in workers’ confidence to speak up, and especially concerning that this includes about clinical matters…These survey results must be a wake up call to leaders at all levels that Freedom to Speak Up is not just a ‘nice to have’–it is essential for safe services.”

The results of the survey should focus minds; if no one is speaking out managers should start asking a few questions. Could it be that staff believe nothing will change if they do speak up? Do they think they will be branded a “troublemaker” or fear reprisals from colleagues or managers, or are they frightened of a career nosedive? Do they lack trust in their FTSU guardian, lack confidence that their senior team will take them seriously, or did they get an inadequate response after speaking up before?

NHS England’s Eight Principles

Dr Chidgey-Clark reinforced how “fostering a culture where speaking up is supported, and actions taken as a result, is the responsibility of each and every one of us; whether you are a government minister, a regulator, a board member or senior leader; whether you work in a department, in a team, on a ward, or in a GP practice.”

To help managers to achieve this, NHS England (NHSE) published its Freedom to Speak Up (FTSU) Guide, setting out eight principles fundamental to creating an environment where this can happen.

  1. Value speaking up.

  2. Be a role model for speaking up and set a healthy FTSU culture.

  3. Make sure staff know how to speak up and feel safe and encouraged to do so.

  4. When someone speaks up, thank them, listen up and follow up.

  5. Use speaking up as an opportunity to learn and improve.

  6. Support FTSU guardians to fulfil their role in a way that meets workers' needs and NGO requirements alike.

  7. Identify and tackle barriers to speaking up.

  8. Know the strengths and weaknesses of the organisation's speaking-up culture and take action to continually improve.

Principle Seven: Identify and tackle barriers to speaking up

With indications that staff still appear to be experiencing barriers to speaking up, Principle Seven is particularly relevant to organisations that want to halt a steady decline in staff confidence in the system.

A case study relating to this Principle within a primary care network (PCN) was published by NHSE last month. It looked at a PCN that launched a nine-month FTSU pilot programme staffed by two fully-trained FTSU guardians. Not one member of staff in the GP practices contacted their guardian with concerns during the first two months of the pilot, despite extensive efforts to prepare them. The managing partner explained the concept of FTSU and its benefits to staff, and guardians attended online meetings to introduce themselves and explain the FTSU pilot but no responses were received.

FTSU guardians and the personal touch

The guardians felt that taking the trouble to visit the GP practices in the pilot could give people more confidence to speak up. With the intention of creating a more personal connection, and with the agreement of the managing partner, the FTSU guardians attended the five GP practices in the third month of the pilot, spending two hours on sites at a routine staff meeting and offering a drop-in session. At four of the sites, practice managers displayed posters and sent an email to all staff to publicise the event in advance.

In the staff meeting, guardians spoke more extensively about their role, explaining who they were as individuals and what could be spoken up about. They made it clear that they were not employees of the GP practice but that they were employed by what was then their clinical commissioning group. After the meeting, the guardians held a drop-in session to answer one-to-one questions. During these conversations the door of the room was shut and people’s privacy assured.


Ten staff spoke up from four of the GP practices in the month after the face-to-face sessions. Among matters raised were issues to do with working practices and employment matters.


The guardians drew up an interim report for the partners, with a response paper sent to all staff by email. This pilot was extended by three more months and the guardians ensured that staff who spoke up were also given personal feedback.

Points of learning

It is essential that confidentiality is respected, and that identifying details of individual cases are not shared outside the bounds of the FTSU guardian’s agreement with the person they are supporting. Establishing this, the guardians then identified five main reasons why staff came to them with their concerns.

  1. Visible support from the practice manager.

  2. Knowing the guardians were not employed by the GP practice.

  3. Meeting with people face-to-face, enabling guardians to convey authenticity and commitment to listening and acting on concerns.

  4. Providing staff with a confidential, safe space to speak to the guardians.

  5. Knowing partners are aware that concerns raised must be considered and feedback must be given to staff raising concerns.

The local Health Education England (HEE) training hub that helped set up the pilot commissioned an independent evaluation of the programme. The guardians are meeting GP partners and the managing partner to discuss possible future FTSU arrangements, taking into consideration the training hub’s work to establish arrangements for all primary care staff in the integrated care system.

Conclusions on self-reflection

Self-reflection helps organisations to understand their progress in developing effective, person-centred speaking-up processes, and can help demonstrate their achievements during oversight activities. NHSE’s Reflection and Planning Tool was designed with this in mind; a useful resource to help senior FTSU leads identify their own strengths, strengths in the leadership team and the organisation, and to highlight gaps against the Eight Principles that need prioritising and tackling.