Workers feeling confident to speak up – and trusting that senior leaders will listen and act on their concerns, feedback, and suggestions – is business-critical for any organisation. In healthcare, it can quite literally be a matter of life and death, with patient safety at stake.
The NHS Staff Survey, one of the largest workforce surveys globally, provides crucial insight into this issue. This year’s results indicate a plateau in confidence – with some small improvements in certain areas but persistent challenges elsewhere.
For system leaders, regulators, and healthcare providers, this is a moment for reflection. If workers lose trust that speaking up leads to action, the risk is not just disengagement – it is a culture of silence that threatens safety and sustainability.
In light of what these figures show, the National Guardian’s Office is calling for the role of the Freedom to Speak Up Guardian to be strengthened and standardised, greater accountability for leaders and organisations, and the embedding of a culture of listening and action across the entire NHS.
Progress is uneven – some gains, but overall lack of progress
The Freedom to Speak Up sub-score in the 2024 NHS Staff Survey remains virtually unchanged at 6.45 compared to 6.46 in 2023.
While this suggests stability, it also highlights a lack of progress and risks a slide backwards into disengagement and silence.
However, some groups of workers and sectors have seen improvements.
Where improvements have happened:
- Ambulance trusts have shown slight gains in confidence, following a sector-wide review and targeted interventions.
- Minority ethnic staff has seen a steady increase in confidence that their organisations will act, rising from 54.5% in 2023 to 55.2% in 2024.
- Internationally recruited workers report higher trust in organisational action than UK recruits – a key finding as we prepare to publish our review of overseas-trained workers’ speaking-up experiences.
Where progress has stalled
Across the system, confidence levels have not increased, and in some areas, they are declining.
- Workers who are part of the Wider Healthcare Team shows a steady decline in trust that their organisation will act on concerns – falling from 59.9% in 2021 to just 53.5% in 2024.
- Longer-serving staff report lower confidence in speaking up than newer employees, raising concerns about disengagement over time.
- White staff have seen a consistent decline in trust that their organisation will act on concerns.
These trends reinforce a wider issue: while targeted efforts in some areas have led to improvement, the overall speaking-up culture remains stagnant. Without renewed attention, there is a risk of further decline.
The action gap: a barrier to progress
While some staff feel able to raise concerns, many do not trust that those concerns will lead to change. This action gap remains a key challenge for the system.
- 71.5% of staff feel safe raising concerns about unsafe clinical practices (unchanged from 2023). Yet only 56.8% believe their organisation will act on patient safety concerns.
- 61.8% feel safe raising concerns about anything in their organisation (slightly down from 62.3% in 2023), but fewer than half (49.5%) trust their organisation to act on concerns more generally.
A speak up culture without action risks creating disillusionment, distrust, and disengagement. This trust gap is critical. Workers may still be speaking up, but confidence in follow-through is eroding. If concerns are consistently met with actual or perceived inaction, many workers will stop speaking up altogether.
Leaders must move beyond encouraging staff to speak up – they must demonstrate that speaking up leads to meaningful change.
The need for renewed focus on speaking up
Progress on speaking up may have plateaued, but the need for it remains as critical as ever – especially for patient safety. Without a culture where concerns are heard and acted upon, risks go unnoticed, and harm can follow.
Much changed since Sir Robert Francis QC’s report The Freedom to Speak Up, which created the role of the National Guardian, following the Mid Staffordshire scandal. But as memories fade, so too can the urgency for action. It is essential that speaking up remains a priority, with renewed focus and attention to ensure concerns lead to real change.
As we reflect on this year’s NHS Staff Survey, we are calling for three key changes to ensure improvements in speaking up:
- Embedding a culture of listening and action
Creating more avenues for workers to speak up is essential but insufficient – we need a stronger focus on listening and responding. This is central to the NGO’s strategic framework, launched last year.
A consistent, structured approach across the system is needed to ensure concerns are taken seriously and lead to action. This includes:
- Clear, standardised processes so that leaders at all levels understand and fulfil their responsibility to act.
- Training that goes beyond awareness – equipping leaders with the skills and accountability to respond effectively.
System-wide bodies, including the Department of Health and Social Care, professional and system regulators, must ensure that concerns are handled effectively including concerns raised with them.
- Greater accountability for leaders and organisations
There must be stronger accountability for both individual leaders and organisations as legal entities, ensuring that concerns are taken seriously, and workers are protected from victimisation. This means:
- Leaders must be held responsible for fostering a culture where staff feel safe to speak up and see their concerns addressed.
- Organisations must be accountable for how they handle concerns – not just encouraging speaking up but demonstrating that concerns lead to meaningful action.
- System-wide oversight must be strengthened, ensuring that when concerns are raised, there is clear follow-through and consequences for inaction.
If proposed reforms, such as the regulation of NHS managers and the creation of a legal duty to investigate concerns, can support these goals, they would be a welcome development.
- Strengthening and standardising the guardian role
There must be greater consistency in how the Freedom to Speak Up guardian role is implemented across organisations. This includes:
- Ensuring guardians have sufficient time and resources to carry out their duties effectively.
- Safeguarding their impartiality, recognising that whichever model organisations use to appoint a guardian – whether directly employed or contracted – presents potential challenges in maintaining impartiality and trust.
We welcome the opportunity to work with government, regulators, healthcare leaders, and other stakeholders to ensure that speaking up remains a priority and leads to meaningful change.