GP mythbuster 87: Freedom to Speak Up

Freedom to Speak Up is about encouraging a positive culture where people feel they can speak up, their voices will be heard, and their concerns and suggestions acted on with no retribution.

Speaking up can be about anything that affects care for patients or the working life for colleagues. It includes:

• learning lessons from complaints and when things have gone wrong
• feeling able to speak up to prevent potential harm
• being able to make suggestions as an opportunity to improve.

Speaking up can improve the quality of care for people and can benefit colleagues in the workplace. It is a professional obligation for some members of staff including doctors, nurses and allied health professionals.

It is vital to listen well when someone speaks up. All staff should feel safe and comfortable to raise concerns and be assured that their concerns will be considered and acted on appropriately. Listening well enables staff to do this.

Most speaking up happens through conversations with supervisors and line managers where challenges are raised and resolved quickly.

Sir Robert Francis published an independent review of Freedom to Speak Up. This sets out the principles and actions that aim to create the right conditions for NHS staff to speak up.

There are 5 elements to managing the Freedom to Speak Up process:

• recognising something is wrong
• speaking up
• thanking the person who raises the concern
• undertaking the necessary actions to remedy
• providing support to the member of staff throughout the process.

The Freedom to speak up policy for the NHS focuses on the importance of arrangements for inclusive and consistent speaking up and driving learning through listening.

See guidance on developing freedom to speak up arrangements in the NHS.

GP providers

There are some unique challenges to speaking up in primary care. Some staff can feel particularly isolated because they work in smaller practices or they fear a risk to their employment if they are raising concerns about someone who may be their direct employer.

There are different models to support primary care organisations in developing their speaking up arrangements in general practice. These include providing Freedom to Speak Up:

• within an organisation, such as a GP practice, GP federation or primary care network
• within local medical committees or at an integrated care system-wide level.

See Exploring Freedom to Speak Up in Primary Care and Integrated Settings for more details.

You can use the Guide for the NHS on freedom to speak up and the reflection and planning tool. This will help identify strengths in the practice, leadership team and organisation, and any gaps that need work.

See the guide for leaders in the NHS and organisations delivering NHS services, which provides further information and recommendations for further reading.

These tools can help to deliver the NHS promise for workers by ensuring they have a voice that counts.

NHS staff

NHS England’s National speak up policy gives you information on how to speak up and what will happen when you do.

You can also speak up externally through NHS England and through our give feedback on care form if you have a concern about a service you work for.

We will use what people tell us along with other information from the service itself or from our own evidence about a service to understand a concern about the quality of care.

See the Speaking Up support scheme and Freedom to Speak Up e-learning for NHS staff.

The work of Freedom to Speak Up Guardians

Any organisation can appoint a Freedom to Speak up Guardian. They are appointed locally by their organisation according to local policies, following a fair and open appointment process.

All organisations that provide services under the NHS Standard Contract are required to appoint a Freedom to Speak Up Guardian. Although not compulsory, the National Guardian's Office expects primary care provider organisations, health and care leadership organisations and regulators to appoint Freedom to Speak Up Guardians. GP practices can work with other practices in the area or with other stakeholders, their primary care network or integrated care board to achieve this.

Each NHS primary care provider should have systems to ensure that staff know who is the named individual as the Freedom to Speak Up Guardian. The guardian should be independent of the line management chain or GP partnership. The Guardian can then make sure that policies are implemented, and that staff know who to contact if they have a concern.

See the NHS England new measures to support whistleblowers in primary care.

Freedom to Speak Up Guardians support workers to speak up when they feel they are unable to do so. Their role should be independent and impartial, and they should abide by the guidance from the National Guardian's Office. Guardians should work proactively to support their organisation to tackle barriers to speaking up and should take into account the needs of workers in their organisation.

The National Guardian’s Office also expects health and care leadership organisations and regulators to appoint Freedom to Speak Up Guardians.

The Freedom to Speak Up Guardian will:

• understand and promote their organisation’s speaking-up culture to enable speaking-up processes and strategies to work well
• work in partnership with senior leadership, but maintain their ability to challenge poor practice and act where quality of services and worker experience do not meet expected standards
• respond to members of staff who want to speak up, and manage each case
• examine and address any barriers to speaking up
• make sure there is appropriate training on how to speak up
• produce regular reports for the senior team or board, where needed.

The freedom to Speak up Guardian must fulfil their national requirements. See the National Guardian's Office job description for competencies, requirements and details of what is expected from the role.

When we inspect

We use these Regulations when we assess whether the practice is safe, effective, caring, responsive, and well-led:

Regulation 12 (Safe care and treatment)

Regulation 13 (Safeguarding service users from abuse and improper treatment)

Regulation 16 (Receiving and acting on complaints)

Regulation 17 (Good Governance)

Regulation 20 (Duty of Candour)

There are no specific regulations governing a practice's freedom to speak up arrangements. However, if you can’t show us evidence when we ask for it, you may risk breaching the overarching regulations.

We may not look at every regulation at every assessment. If there are concerns about the speaking up process, we will check certain areas, for example:

• how you develop a positive culture where people feel they can speak up and that their voice will be heard
• the support, processes and strategies to make staff aware of Freedom to Speak up policies, encourage them to speak up, and to respond to their feedback and concerns
• how you listen, evaluate, escalate and respond to individual concerns and trends reported by the Freedom to Speak up Guardian
• how matters raised by staff and the Freedom to Speak up Guardian drive learning and improvement in the service
• how you evaluate and monitor arrangements and processes to highlight organisational barriers to success.