Anita Day, Vice Chair, Worcestershire Acute Hospitals NHS Trust, and Freedom to Speak Up Board Lead

Many of us are familiar with Freedom to Speak Up. We understand its importance to patient safety and outcomes; both in terms of the care which patients experience directly, but also as regards the environment in which our colleagues work and the impact of poor behaviour on staff retention and quality of care.

But I am still struck by the difficulties which many trusts face in truly embedding the Freedom to Speak Up culture. Whilst the reasons for this vary, in my view there are certain critical success factors which improve a trust’s likelihood of success.

Does the Board really care?

Too many trusts have a Freedom to Speak Up Guardian because they have to, not because they actually understand why it is essential, and this can lead to insufficient resource being allocated and/or inadequate Board-level scrutiny. Having a non-executive director (NED) Board Lead for Freedom to Speak Up does not remove the responsibility for all Board members to monitor their organisation’s culture, but it does allow greater focus.

In my view, the Board Lead should undergo the same training as all Freedom to Speak Up Champions and wear the lanyard or badge with pride when on-site. They should, where possible, attend meetings with the Freedom to Speak Up Champion network in their organisation. This means that they hear first-hand some of the matters which are being raised by people on the ground, and also demonstrate visible leadership commitment.

At People & Culture Committee meetings, and at Board level, their greater understanding of any issues helps to focus debate and is particularly helpful in ensuring that intelligence from multiple data sources (e.g., National Staff Survey, Friends & Family Test, WRES, WDES, staff networks, patient & volunteer liaison services etc) is triangulated so that trends and emerging issues can be highlighted at the earliest opportunity.

The Freedom to Speak Up NED also has an important role in supporting the Freedom to Speak Up Guardian personally. The guardian is not an easy role, and even the most experienced guardian may require someone with whom to share ideas in a confidential space; and, at times, the NED may even provide an element of restorative clinical supervision to help the guardian process difficult conversations.

What’s a good number?

One of the hardest things about Freedom to Speak Up is knowing when you are doing it right. In the case of the level of resource that an organisation needs to ensure proper coverage, it’s difficult to judge. Most organisations have one guardian and a network of champions embedded across the trust. This model can work well, but it is important to ensure that you have good coverage. Do your champions represent all divisions, all job roles and bands (not just core clinical but students, junior doctors, temporary staff, porters, housekeeping, mortuary, etc.), those staff groups with
protected characteristics, volunteers? Are the champions well integrated – and perhaps even merged – with other cultural and staff network ambassadors in the organisation? Experience tells us that:

  1. Workers who are drawn to these roles are probably involved in other initiatives too, so use them to deepen and broaden coverage.
  2. Workers often feel more comfortable raising matters to other staff members who can relate to their experience, so the range and diversity of Freedom to Speak Up Champions is critical.

The other problem is knowing when you are seeing the ‘right’ number of matters being raised. Lots of concerns might suggest a poor culture; but it might also suggest an environment where people feel confident speaking up. Conversely, a small number of matters being raised might suggest a wonderful culture with few issues; but it might also indicate an environment where people feel fearful to speak up. Triangulation of data from multiple sources and trend analysis is key to understanding what the speaking up data is telling you. The other ‘tell-tale’ indicator is the number of matters being raised anonymously; if the proportion or number is rising, that might indicate an increase in anxiety or fear of retribution among workers.

Our biggest enemy is complacency

Just because you don’t think you have a problem with your Freedom to Speak Up culture today, that does not mean that you won’t have next month or next year. In my view, trusts need to be continually on the look-out for potential issues to emerge e.g., every time you reconfigure a ward or service, get a significant intake of workers or students or experience a global pandemic! The key is to be pro-active. Don’t assume that all your workers understand Freedom to Speak Up, and the importance of speaking up. Work with your champions to identify and eliminate barriers to speaking up, e.g., an online portal which colleagues can access from home on their phones might be easier than having to schedule a call or write an email during worktime. Make a point of increasing Freedom to Speak Up visibility in areas of unusually high or low reporting. And don’t just sit back and wait for matters to be raised sometimes the most serious issues may require encouragement to be surfaced.

In my view, Freedom to Speak Up is one of the most important tools we have to raise standards of patient care and improve the work experience of our colleagues. As we say at Worcestershire Acute, it’s all about ‘Putting Patients First’.

This featured as a guest blog in our July newsletter. You can download a copy here.