Uncovering, creating or constructing problems? Enacting a new role to support staff who raise concerns about quality and safety in the English NHS

Why it matters

Healthcare staff are an important source of information about quality and safety problems. And recent incidents at UK hospitals have shown what can happen when staff don’t voice their concerns.

A 2015 report about speaking up in the NHS following the disaster at Mid Staffordshire concluded that staff knew about the hospital’s safety issues but were reluctant to come forward. To avoid repeating the mistakes of “Mid Staffs”, the report recommended creating a new role at NHS trusts in England to support staff in raising concerns. The “Freedom to Speak Up Guardian” would be an expert in all things related to speaking up and an impartial source of advice.

The role was unprecedented in the UK and internationally. And when it was first implemented in 2016, there was little guidance from government on how Guardians should be appointed, and what their specific responsibilities should be.

This study is the first exploration of how Freedom to Speak Up Guardians have fared thus far. It critically examines the new role while considering broader issues around “employee voice.”

Our approach

To look more closely at Freedom to Speak Up Guardians, we conducted 51 interviews with clinicians, administrators, and others involved in implementing the role. This includes the Guardians themselves, policymakers, and representatives from regulatory bodies and third-sector organisations.

Interviews were conducted between July 2017 and January 2018 as part of a wider mixed-methods research study.

What we found

• Freedom to Speak Up Guardians showed potential to help support employee voice, but their work was challenged by a lack of role definition.
• NHS managers often wanted to keep the Guardian role focused on clear-cut quality and safety problems, in part so that it didn’t interfere with existing channels for speaking up.
• Guardians found it difficult to limit their work to these kinds of problems. The concerns they heard were less easy to pin down or relate to specific aspects of quality and safety, and were sometimes symptoms of larger, more complex issues.
• The experience of Freedom to Speak Up Guardians underscores that voicing concerns in healthcare is far more complex than the traditional view of “whistleblowing.”
• The greatest benefit of the Guardians may be their potential to work with colleagues to help identify and think through less clear-cut issues and determine what to do with them.

Related content from our open-access series, Elements of Improving Quality and Safety in Healthcare