It has been an immense privilege to serve as the National Guardian for the NHS for the past five years and lead the Freedom to Speak Up social movement.  At the start this was unchartered territory – there was no equivalent in other sectors or other countries and we needed to fan the spark into a flame.

In those first days, our task was focussed on building the national network of Freedom to Speak Up Guardians in Trusts. At the end of my first 100 days in post, I reported that 200 Trusts had recruited Freedom to Speak Up Guardians. Now we have over 700 guardians in more than 400 organisations. The network has spread beyond Trusts and into primary care, independent providers, hospices and national bodies.

Freedom to Speak Up arose from the tragedies at Mid Staffs where an atmosphere of fear and futility pervaded. As Sir Robert Francis QC identified, fear about the consequences of speaking up and lack of confidence that concerns would be addressed were deep seated issues in the NHS. The 2015 National NHS staff survey highlighted that only 68% of staff felt secure in raising any concerns regarding clinical practice and only 56% of staff had confidence that their organisation would address their concerns if they were raised. This is starting to improve and  our latest FTSU Index Report (which brings uses these measures as an indicator)  showed that the FTSU Index has risen 3.7 percentage points nationally from 75.5% in 2015 to 79.2% in 2020.

I am humbled by the courage of workers who speak up in unsupportive organisations. Their passion and commitment to their patients and colleagues, their bravery to raise issues in the face of these barriers, inspires me and my NGO colleagues every day. Over 50,000 cases have been raised with guardians; that’s 50,000 opportunities for learning and improvement for the benefit of colleagues and patients.

I am so grateful for the work which Freedom to Speak Up Guardians do in supporting workers in their organisations.  You should be rightly proud of the difference you have made in these five years.

The Freedom to Speak Up Guardian role is complex. It requires empathy to listen to workers and impartiality and courage to speak truth to power. Upholding these values can be a challenge in an unsupportive environment. This is why, in the NGO’s Strategic Framework, empowering Freedom to Speak Up Guardians to deliver their best for the workers they support is one of the NGO’s priorities. Professionalising this important role with training, resources and standards will ensure Guardians have the skills they need to affect the improvements needed in speaking up cultures.


We have seen a new generation of leaders leading with compassion through the pandemic.  Without this role modelling, I believe we would not have seen the innovation, collaboration and team resilience we needed to take us out of the darkest days of the past 18 months.  The embracing of technological innovations, the collaboration to develop effective vaccines and roll out immunisation, the clinical innovations which improved the outcomes for seriously ill patients – none of this would have been possible without fostering psychologically safe workplaces. As Amy Edmondson writes in The Fearless Organisation “If leaders want to unleash individual and collective talent, they must foster a psychologically safe climate where employees feel free to contribute ideas, share information, and report mistakes.”

The pandemic has also provided stark lessons in the inequalities and biases of our health system – for example fit testing for PPE; pathways for admittance to hospital; oximeters which give false readings on darker skin. Listening and acting can also help to tackle prejudice and inequalities by providing opportunities to listen, learn and act.

With the hope that the vaccine brings, we need a working environment which fosters high performance and collaboration to manage the needs of patients whose treatment was put on hold as we dealt with the crisis, something I am acutely aware of as a GP.

Being able to speak up safely is an essential element of psychological safety; but it needs to be part of a listen up and follow up culture – one where leaders at all levels listen and commit to taking appropriate actions. Just as the network of guardians has grown and welcomed members from across the healthcare sector, this is reflected in the way that the NHS is also evolving to welcome more partnership working.

Working in partnership

The National Guardian’s Office welcomes the opportunity to work in partnership across the healthcare system to make this ambition a reality. I am proud of the work we have done together – developing guidance for providers and organisations on Freedom to Speak Up; Non-disclosure and settlement agreements;  the Education and Training Guide and guidance for guardians; and Freedom to Speak Up E-learning available for all workers and managers. The inclusion of Freedom to Speak Up in the standard NHS Contract and the Well Led domain of CQC inspections and the contribution of speaking up data to the Model Health System highlights for me how Freedom to Speak Up is becoming embedded into the very fabric of how the NHS works and what the sector values.

There is more which needs to be done, and the office will continue working together with national bodies so that there is a consistent develop a consistent and supportive response when workers speak up.

As the Integrated Care Systems develop, I would like to issue a call to action to the new Chairs of the Integrated Care Boards. As you establish new ways of working together, think about how you will ensure that psychological safety is hard wired into your system.  One of the lessons we have learnt from working through the pandemic together is that when we collaborate  and break down barriers, whether they be geographical, hierarchical or professional, it can make a positive difference to the welfare of workers and the outcomes of patients. Responding to feedback from service users and families and the ideas and concerns of NHS workers will support the Speak Up, Listen Up, Follow up culture that the NHS needs.

Thousands have undertaken our Speak Up, Listen Up e-learning course. If you lead an organisation, do you know how many of your workforce have? Have you completed the training and made your Speak Up Pledge?

After five years I can see a measurable difference although there is still a huge amount that needs to be done. Now, with hundreds of Freedom to Speak Up Guardians, supporting tens of thousands to speak up, the flame is burning brightly and lights the path to speaking up being business as usual in the NHS.

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