Last reviewed 29 July 2022

NHS England (NHSE) published its new and updated Freedom to Speak Up Policy at the end of June, presenting an opportunity for organisations to review and refresh their Freedom to Speak Up (FTSU) arrangements, which apply to all primary care, secondary care and Integrated Care Systems (ICSs) in England. Organisations providing these NHS healthcare services are required to adopt the national policy as a minimum standard to help normalise “speaking up” and to ensure all matters raised by staff are captured and considered appropriately. Christine Grey investigates.


The National Guardian’s Office (NGO) and the role of FTSU guardians were created in response to recommendations made in Sir Robert Francis QC’s report, The Freedom to Speak Up, which was published in 2015.

The NGO has published the FTSU Index since 2019 and leads, trains and supports the network of FTSU guardians throughout the healthcare sector; it also describes and shares good practice and reviews the way that “speaking up” is being handled. The NGO uses the term "speaking up" rather than “whistleblowing” to reflect the desire for healthcare staff to raise ideas for improvement in an organisation as well as concerns. The term is defined as "anything that gets in the way of patient care, or that affects your working life”.

The importance of a “speaking up” culture

Building a more open culture in which learning and improvement are encouraged can lead to safer care and improved patient experience. Viewpoints from staff can act as an early warning that a policy, process or decision should be improved, and a speaking-up culture supports better staff satisfaction and performance. It is not always easy to engender this type of culture, especially in organisations where leaders are defensive or do not welcome change. Effective, person-centred processes are therefore essential to support the development of a healthy “speaking up” culture.

Freedom to Speak Up Guardian Survey 2021

Highlights of this survey, published at the end of March this year, contained warning signs that more must be done to support the development of a speaking-up culture in healthcare amid the continued pressure from the pandemic.

The report said local and national leaders need to do more to listen, act and support, with findings revealing the following.

  • The proportion of FTSU guardians who reported a positive culture of “speaking up” in their organisation dropped by five percentage points to 62.8% on the previous year.

  • There was a drop by nine percentage points in the proportion of guardians who said their senior leaders support workers to speak up, falling to 71%.

  • 10% of respondents said that their senior leaders do not understand the role of FTSU guardians.

Following these results, Dr Jayne Chidgey-Clark, who was announced as the third National Guardian for FTSU on 11 November 2021, urged all leaders to prompt a conversation with their FTSU guardians, who “can be a significant source of support for leaders as an important additional route for speaking up” and can “support them with the themes of what workers are speaking up about — whether those are patient safety concerns, ideas for improvement, or issues affecting their work or wellbeing”.

Primary care

Sir Robert Francis’ review identified harrowing experiences of NHS staff who had spoken up, with a large number of responses coming from people working in primary care. It also highlighted the unique challenges primary care staff face, such as individuals feeling particularly isolated.

  • Many work in “small independent units” where it is harder to raise confidential or anonymous concerns.

  • There is a sense of greater risk to employment if concerns are raised about someone who may be a direct employer.

  • In ancillary and non-clinical roles, there are likely to be fewer options for raising concerns externally (as they may not have access to a professional body or union).

Within the primary care workforce, there were certain groups (including temporary staff, locums and students) that were particularly vulnerable because they were often in practices for short periods of time.

Separate Freedom to Speak Up guidance

Based on this, the report recommended that primary care be addressed separately, and after consultation with the sector in May 2016, Freedom to Speak Up in Primary Care was produced by NHSE, detailing principles and actions to support the raising of concerns by staff. The new guidance says it is especially important that everyone working in primary care, including temporary staff, has access to someone outside of their line management chain who they can raise a concern with or who can offer advice and support.

It provides a set of principles that underpin best practice and ensure that FTSU expectations for the wider NHS are applied equally in primary care. All NHS primary care providers should work to ensure:

  • it is safe to speak up

  • staff have the confidence to speak up

  • concerns are investigated

  • speaking up makes a difference

  • concerns are well received.

Concerns should be raised within the primary care organisation and, if necessary, with an external body like NHSE. Employees who wish to make a protected disclosure relating to the delivery of primary medical, dental, ophthalmic and pharmaceutical services in England can do so via NHSE, which is a “prescribed organisation” — this means individuals who have made a qualifying disclosure with NHSE are protected from detrimental treatment or victimisation from their employers.

New FTSU guidance

The NHSE’s new national FTSU policy includes learning from previous versions drawn up for primary care and NHS trusts, ensuring a consistent approach for all NHS staff, from GP practice staff to hospital workers, and signposts to a wider variety of support. Other changes include an update to the NHS Staff Survey, in line with the NHS’s People Plan, to include some questions that were in the FTSU Index.

For this reason, the NGO will no longer be publishing its FTSU Index separately but will continue to work with NHSE on the “speaking up” questions in the NHS Staff Survey. Last year’s staff survey included a new question about whether staff “feel safe to speak up about anything that concerns them in their organisation”. This year’s survey contains a new follow-up question, “If I spoke up about something that concerned me, I am confident my organisation would address my concern.”

Together with the NGO, NHSE has also published new and updated FTSU guidance to help organisations develop their speaking-up culture. It aims to:

  • build a culture that is responsive to feedback from staff

  • ensure an organisation focuses on learning, to continuously improve quality of care and experience of staff and patients

  • improve staff survey scores and other staff experience metrics

  • demonstrate to regulators the work done to develop “speaking up” arrangements.

Dr Chidgey-Clark said: “The new guidance we have developed in collaboration with NHSE will help leaders throughout the sector turn that policy into a healthy and supportive Speak Up, Listen Up, Follow Up culture.”

The regulator’s approach

Advice from the Care Quality Commission (CQC) says speaking up is a professional obligation for some staff members, including doctors, nurses and allied health professionals, but that this is only part of the equation: “Listening well when someone speaks up is key.” The CQC expects that all staff feel comfortable about raising concerns and are confident that their concerns will be acted on appropriately — a sentiment echoed in its key line of enquiry W3: “Is there a culture of high-quality, sustainable care?”

Looking to the future

National Association of Primary Care Chief Operating Officer Sally Kitt recently described her aspiration, in a guest blog for the NGO, that all parts of the health and care system gain a voice and speak openly: “This will foster an environment where healthy challenge and debate can take place and where care can be provided by a happy, engaged workforce that will improve the outcomes for our communities and the future of the NHS.”

Organisations should adopt the new national FTSU policy by the end of January 2024, which is also when all NHS trust boards will be expected to show results of their organisation’s assessment of its FTSU arrangements against the revised guidance.

In December 2021, the Department of Health and Social Care announced plans to look at ways in which FTSU guardians could be introduced in the social care sector.

Further information