October is Speak Up Month, a time to raise awareness about the NHS “Speak Up / Listen Up” goals, and to highlight the important role that Freedom to Speak Up Guardians play in the NHS.

What is speaking up?

Speaking up is simply sharing something that’s causing you problems while you’re trying to do your job. People often mistakenly think it’s simply whistleblowing, but it’s much broader than that. Speaking up might include raising a grievance, making a complaint, making a disclosure, whistleblowing, making a qualifying disclosure, raising a concern or making a suggestion for improvement.

The speaking up message is that employees should feel free to raise issues to a safe and neutral person, they should feel heard, and they should know that someone is doing something about what they’ve shared. The Speak Up / Listen Up culture the NHS wants to develop is one where, as a practice, we’re grateful when staff raise matters with us that might result in a change or improvement – indeed, we should see this as a gift and not a problem.

Is speaking up promoted in your practice? Do you have a Freedom to Speak Up policy? Do you have a Freedom to Speak Up guardian in your practice? Or an external company that people can go to?

Whether this is a completely new concept to you or something you think your practice does well, this month we’re reminded of the importance of having a strong Speak Up / Listen Up culture in our practices and PCNs.

Why do we need a Freedom to Speak Up policy?

Since the Sir Robert Francis QC report in 2017, having a named Freedom to Speak Up guardian has been a requirement of all NHS Trusts.

In primary care, the compulsory requirements haven’t been as onerous. We need to have a policy in place and we need to be working to make our employees feel able to speak up if there’s something getting in the way of their ability to do their job, but we’re not currently obligated to have a formal registered FTSU guardian employed or to have enlisted an external liaison company to act as a guardian for the practice – yet!

Change is in the air, though, and new requirements around FTSU are coming soon.

Also, recent CQC inspections have given primary care facilities lower grades when there hasn’t been an appropriate Freedom to Speak Up guardian in place. The way the CQC describe it (since the latest update in November 2022) suggests that practices may be considered non-compliant if they fail to have a suitable speaking up system in place. So, if you haven’t thought about it yet, now is a good time to consider your practice’s Speak Up culture.

What is a Freedom to Speak Up guardian?

A Freedom to Speak Up guardian is a neutral and qualified person who’s completed training with the National Guardian’s Office and works, in ring-fenced time, to the national job description. They should not be a member of the management team and they should be able to demonstrate neutrality. This isn’t easy in primary care!

The guardian must:

• Be suitably qualified, certified by the National Guardian’s Office
• Not be an existing part of the management team
• Be available to all staff (so there needs to be provision made for the guardian if they’re also an employee at the organisation)
• Have ring-fenced time for their guardian duties (which includes producing internal reports, external reports for the National Guardian’s Office, meeting employees and keeping up to date with national training)
• Be neutral and unconflicted
• Be of a suitable character and equipped with the skills required to handle sensitive conversations with wisdom

Practices and PCNs are encouraged to team up and share their Speaking Up provision in order to have someone in place who meets the above criteria. This can be a good approach and can make it more affordable. There are one or two external FTSU guardian services that you can contact now if you don’t currently have something in place, or you can wait for the ICB to begin working with you to support creating the primary care FTSU provisions in your area.

What’s coming up?

NHS England has tasked all ICBs with ensuring that their own ICB staff have access to routes for speaking up, including Freedom to Speak Up guardian(s) and associated arrangements, by 30th January 2024.

ICBs are expected to adopt the new national policy and use the guide and improvement tool to map the plan for the next three years.

ICBs are also tasked with working on Freedom to Speak Up for primary care workers by March 2024. The NHS guidance to ICBs says:

“ICBs have been instructed to think about primary care workers across the ICS having access to routes for speaking up, including access to a Freedom to Speak Up guardian(s) who is registered with and trained by the National Guardian’s Office.

There are relatively very few trained and registered Freedom to Speak Up guardians that support primary care workers. Even where guardians are in place, levels of speaking up (both reported and not reported to the National Guardian’s Office) remain extremely low.”

What challenges do we face in primary care with FTSU?

Primary care organisations are typically unable to provide a genuinely neutral person to act as a Freedom to Speak Up guardian in their own organisations due to the size of the organisation.

A guardian should be neutral and ideally not involved in other parts of the organisation in order to remain neutral and not have real or perceived relationships or biases. Currently, many practices either do nothing at all or give the title to a member of staff to “tick a box” but don’t ring-fence time or training for the individual to carry out the role as described in the universal job description, nor do they have a mechanism in place for receiving feedback and suggestions and actually listening to what’s being said. And, to be fair, primary care has been overstretched and underfunded for such a long time, it’s a wonder anyone has managed to get this in place at all! If you’re one of the PMs who has managed to get a FTSU policy and guardian in place, go you!

There hasn’t been as much noise about FTSU in primary care as there could have been, and many practices either have no idea this is something they should be doing or simply don’t consider it to be important in the frenetic world of general practice. Given the origins of the requirements, and the well-known difficulties we have in the NHS around staff wellbeing and retention, and some of the explosive headlines of the past few months, it’s important to have a real, intentional, dedicated and proactive guardian protecting your employees’ freedom to speak up.

Resources

Freedom to speak up policy and procedure [PLUS]

The NHS has produced a template for new national policy.

The National Guardian’s Office has a library of useful information and case studies.

Signal Speak Up is a national FTSU guardian service for primary care based in Essex.

Howbeck Healthcare supports the North Staffordshire GP Federation, South Cheshire and Vale Royal GP Alliance, East Staffordshire Primary Care Partnership, and the Mercian GP Network with FTSU guardians.

The Freedom to Speak Up review, by Sir Robert Francis, is the foundation of the Freedom to Speak Up guardian’s and the National Guardian’s role.