Make it easier for staff to be heard

Creating a speaking-up culture is not easy, but it is essential for patient safety, quality of care and the well-being of staff, says the Independent Healthcare Providers Network’s Dawn Hodgkins.

One of the most notable and consistent themes in any significant patient safety failure is that in nearly all cases there were warning signs or concerns.

But, for whatever reason, people who could and perhaps should have raised those concerns didn’t, meaning that issues remained unresolved. 

To avoid repeating these failures, providers across the entire healthcare system need to pay attention to and implement the learning from these reports, including the importance of creating a speaking-up culture.

In recent years, one of the very welcome developments we have seen has been the introduction and embedding of Freedom To Speak Up (FTSU) guardians. 

FTSU guardians support workers to speak up when they feel that they are unable to do so by other ways. They ensure that people who speak up are thanked, that the issues they raise are responded to and make sure that the person speaking up receives feedback on the actions taken. 

Independent of management

Guardians also work proactively to support their organisation to tackle barriers to speaking up and, crucially, they are independent from any organisation’s management structure, meaning that they should be able to ‘hold a mirror up’, often supporting anonymous colleagues who have flagged concerns in this way. 

There are now more than 1,000 guardians in NHS primary and secondary care and independent sector organisations, national bodies and elsewhere who ensure workers can speak up about anything which has an impact on their ability to do their job or that affects care for patients. 

All organisations that provide services under the NHS Standard Contract are required to appoint one or more Freedom To Speak Up Guardians to fulfil the role set out in and otherwise comply with the requirements of National Guard­ian’s Office Guidance.

This includes, but is not limited to, NHS trusts and private hospitals that provide services to the NHS. However, any organisation can appoint a guardian.

Recent data from the National Guardian showed a record 25,382 cases raised last year (1 April 2022 to 31 March 2023) – that’s a 25% increase from 2021-22. 


Inappropriate attitudes and behaviours

There are some interesting observations to make about the types of cases which are being raised. 

While there is a significant number which are related to patient safety and quality specifically (just under 20%), far more cases are being brought forward around bullying or harassment (22%), and in a new category ‘inappropriate attitudes and behaviours’.  

This new category has been introduced to broaden the understanding of behavioural cases that do not fall within the bullying or harassment category and it represents 30% – so that’s nearly a third of all cases being raised. 

The kinds of behaviours include things like disrespectful attitudes, lack of compassion, micro-aggressions, micromanagement, gossiping, aggressive communication styles, rudeness and unprofessional behaviour; in person and over digital communications. 

FTSU guardians also reported initiatives that have been launched to address the issue, such as cultural reviews, civility saves lives training, behaviour charters and the introduction of kindness and respect champions within teams, but it is clear this is a significant issue which will need continued attention. 

Sector under-representation

In fact, the latest survey found that independent providers make up 21% of organisations, with 24% of guardians, but are only reporting 3% of cases. 

Conversely, NHS trusts, where admittedly this has been introduced for longer, make up 34% of organisations and 39% of guardians, but account for 92% of all cases!

It could be – and I very much hope this is the case – that this is because in some respects the culture in the independent sector is good. I know that many organisations have worked really hard on developing a culture of respect and civility within their teams. 

It may also be a factor that the elective services environment is naturally different from the acute and emergency pathways, as well as mental health. 

So while it is difficult to compare, it probably also suggests there is some under-representation of speaking-up cases in the independent sector. 

This could be due to a number of reasons as noted above, but we need to remain alert to the fact that it could be due to other factors, including a lack of awareness of the Freedom to Speak Up process, a fear of reprisal or a belief that speaking up won’t make a difference.

More to be done

Whatever the reasons, it is clear that more can always be done to create a culture of openness and trust in the independent healthcare sector. This will require a concerted effort from all stakeholders, including leaders, managers, and staff.

I know that different organisations have rightly taken different approaches to FTSU, depending on their unique size, scale, geographical and clinical factors. However, there are some common things that we can all be doing:

 Appoint a Freedom to Speak Up Guardian – or guardians. This is an independent and impartial individual who is there to support staff who want to speak up about concerns they have;

 Provide training and resources to your staff on speaking up. This will help them to understand their rights and responsibilities and how to raise concerns effectively;

 Create a culture where staff feel comfortable raising concerns. This means being open to feedback, listening to concerns and taking action to address them;

 Celebrate staff who speak up. This will show that you value their contributions and that you are committed to creating a speaking up culture.

Support essential

It is also important to recognise the challenges facing our guardians. They are often faced with difficult and sensitive issues and they may have to challenge the status quo. 

Dealing with distressing cases can affect mental health. The role can be lonely and isolating, with limited support from managers. This can be stressful, and so having the right support to do their job effectively is essential.

Forty-four per cent (44%) of respondents stated that the role had reduced their health and wellbeing, either somewhat or greatly – that’s actually better than last year’s 49%, but it’s still nearly half.  

However, conversely, it was really encouraging to see that 26% of the respondents reported an improvement in their health and well-being due to the FTSU role – that just shows that, for some, working in this role is a rewarding and positive experience if we can get it right.

So what does good support look like?

Provide them with training and resources. This will help them to understand their role and responsibilities, and how to deal with difficult situations.

Give them access to senior leaders. This will ensure that they have the support they need to raise concerns and make a difference.

Create a culture where they are respected and valued. This will help them to feel confident in their role and to do their job effectively.

Protect their time to carry out the role properly. To perform this role properly takes time – make sure colleagues are supported by carving out proper time to commit to it fully.

Creating a speaking-up culture is not easy, but it is essential for patient safety, quality of care and the well-being of staff. By taking these actions, we can help to ensure that the independent healthcare sector is a safe and supportive place for everyone who works here.

Dawn Hodgkins (right) is director of regulation at the Independent Healthcare Providers Network (IHPN)