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The role of regulators in encouraging a Speak Up culture

‘See it Say it. Sorted’ – you usually hear this if you are taking any kind of public transport and it applies to being vigilant – keeping a look out for unusual behaviour that could put people at risk. However, you could also apply this principle to speaking up and raising concerns in a health/care setting – concerns which, if ignored, could also put people at risk. In his blog, Russell Parkinson explains that without positive and supportive organisational cultures and good leaders, staff can ‘see it’; they can ‘say it’, but it might not always get ‘sorted’.


On 1 April 2017 a new legal duty came into force which required all prescribed bodies to publish an annual report on the whistleblowing disclosures made to them by workers. In September 2018, the health professional regulators published their first joint report on whistleblowing disclosures made to them. A year later the Authority organised a seminar bringing the regulators together to discuss the work they have been doing to strengthen arrangements to encourage a Speak Up culture.

Russell Parkinson came along to the seminar in his role as Head of Office, National Freedom to Speak up Guardian for the NHS. In his guest blog, Russell outlines the progress made by the Freedom to Speak up Guardians, but also underlines that for Speaking Up to be effective, there needs to be supportive organisational cultures with good leaders.

Encouraging a culture which supports freedom to speak up

The Interim People Plan aims to ‘to grow the NHS’s workforce, support and develop NHS leaders and make our NHS the best place to work’. The plan says that in addition to recruiting extra staff, much more needs to be done to improve staff retention and transform ways of working. Secretary of State Matt Hancock MP has said that ‘we need …. a more supportive culture to make that plan a reality’. A positive speaking up environment where workers feel valued and listened to is fundamental to developing a supportive culture. 

If it is the role of regulators to protect patients, service users and the public, then it stands to reason that they also have a role to play in encouraging a supportive culture for those they regulate.

The events at Mid Staffs and Gosport War Memorial Hospital serve as reminders of the harm that can occur to patients when a Speak Up culture does not exist. Following the publication of the Francis Freedom to Speak Up Review in 2015, Trusts and Foundation Trusts in England have appointed Freedom to Speak Up Guardians. The network has now grown to over 1,000 guardians, champions and ambassadors in NHS trusts and FTs, independent sector providers, national bodies and primary care organisations. Thousands of cases have been brought to Freedom to Speak Up Guardians since April 2017.

The National Guardian’s Office supports this network of Guardians through training, disseminating good practice, undertaking case reviews, and providing challenge and works across the system to tackle barriers to speaking up.

What is a ‘healthy workplace culture’ and how do you measure it?

The saying ‘what gets measured, gets done’ was never truer than when faced with an inspection from a regulator. But culture is a difficult thing to measure, despite its acknowledged importance. A healthy culture is hard to define in concrete terms, it seems vague and difficult to pin down. Culture by its very nature is what happens when nobody’s looking – so measuring it seems impossible. Yet there are some indicators which can give an insight into what a Speak Up culture looks like.

In the National Guardian’s Office Freedom to Speak Up Guardian Surveys, we showed that guardians in organisations rated Outstanding by the Care Quality Commission were more positive in their perceptions of the speaking up culture. We wanted to understand how other NHS workers perceived speaking up in their organisations, so we have created a single measure from four questions from the 2018 NHS Staff Survey. 

The questions ask how workers feel their organisation treats staff who are involved in an error, near miss or incidents; whether they are encouraged to report these; if they would know how to report unsafe clinical practice; and if they would feel secure raising concerns about it.

By bringing these four questions together into a ‘Freedom to Speak Up (FTSU) index’ and comparing them with CQC overall and Well-Led inspection results, we are able to see a correlation between workers’ perception of a supportive Speak Up culture and organisations which are managed well. For regulators, this is potentially a lead indicator which can be viewed together with other information about safety, workforce and culture. 

The regulators’ role

Regulators also have a role to play in offering safe spaces for workers to speak up, when other internal routes may not have been successful. But it is not enough to listen to what workers have to say, it is also important to ensure that action is taken as a result. Sending the message that regulators are listening will also help focus leaders’ minds that their workers voices are important. Leaders will be held accountable if they fail to promote an open and learning culture.

Creating the right workplace environment

We also need to model this behaviour in our own workplaces. We all have a responsibility to encourage an environment where candour and feedback are business as usual. A supportive Speak Up culture is one where all of us should be able speak up about anything. Where we can share ideas, seek advice, offer feedback, challenge decisions or raise concerns without fear of repercussions.

A positive speaking up culture is often associated with higher performing organisations. It is a reflection in how psychologically safe people feel, that they are able to speak up, feedback, and work together to innovate and perform effectively.

Workers are the eyes and ears of an organisation and they should be listened to when considering patient safety and experience. The best leaders understand how important this is. These leaders create an inclusive speaking up culture where everyone’s insight and expertise is valued, and all workers are empowered to speak up and contribute to improvements in patient care.

Ultimately, speaking up protects patient safety and improves the lives of NHS workers. For regulators, whose role it is to bring peace of mind to the public, it is important to show that those they are regulating are listening and learning.

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Please note the views expressed in these blogs are those of the individual bloggers and do not necessarily reflect those of the Professional Standards Authority.