Speaking up protects patients and workers, but is only effective if leaders listen up and follow up. As leaders, you set the tone from the top. You role model compassionate and inclusive leadership and articulate your organisation's values so they are meaningful and lived by everyone. In practice this means continuous improvement, learning and sharing with others to provide high-quality care.
In the pandemic, speaking up has never been more important. Senior leaders need to be aware that power can silence truth and that senior people are more likely to believe that speaking up in their organisation is easy to do. So, how can board members assure themselves that theirs is a positive speak up culture?
There is no single measure of culture, but the acid test is the impact this has on your patients and the views of workers.
National Guardian for the NHS
There is no single measure of culture, but the acid test is the impact this has on your patients and the views of workers. For NHS trusts we have developed the Freedom to Speak Up (FTSU) index, a metric drawn from four questions in the NHS annual staff survey, on whether staff feel knowledgeable, encouraged and supported to raise concerns and if they agree they would be treated fairly if involved in an error, near miss or incident. Since the introduction of FTSU guardians in 2015, following the Francis Freedom to Speak Up review, the FTSU index has improved and risen nationally from 76% in 2015 to 79% in 2019.
Data will give you insights but your role is to look behind the numbers, to join the dots. Where are the culture hotspots? Do workers feel supported and listened to? Are negative behaviours impacting on patient care? Your FTSU guardian can help you, by sharing themes and working proactively to tackle barriers to speaking up. Their insights can provide you with an early warning system of where the stresses and strains are within your organisation, before problems become crises, and lives are lost.
I am often asked "How do we know when we've got it right?". Sometimes boards can appear defensive, or that they only want to hear good news. If few people are speaking up should you feel confident that all is well or does this indicate a deeper problem of fear and mistrust which should give the board cause to dig deeper? Triangulate your data – staff survey results, sick days, grievances and silence. Together with qualitative data from your FTSU up guardian, you will get a sense of where the issues lie.
This is a whole board approach, not just for the non-executive director who is the lead for FTSU, or as an agenda item for the audit committee. Together with NHS Improvement, we published Guidance for boards of NHS trusts. This guidance can be applied by anyone who sets the strategy or culture of their organisation – whether trustees, governors of integrated care systems or board members of national bodies, or independent health providers.
As leaders I encourage you to do all three parts of the training, role modelling the right behaviours which will be seen and emulated by your workforce.
National Guardian for the NHS
Speaking up arrangements can only be effective if listening up and following up occurs. We recently launched a new FTSU e-learning package, in association with Health Education England. The first module – Speak up – is for all workers. The second module, Listen up, for managers, focuses on listening and understanding the barriers to speaking up. A final module, Follow up, for senior leaders will be launched later in the year to support the development of FTSU as part of the strategic vision for organisations and systems. As leaders I encourage you to do all three parts of the training, role modelling the right behaviours which will be seen and emulated by your workforce.
FTSU works when guardians are supported and listened to by their leaders. They amplify the voices of your workers, especially those who may not be often heard.
For those board members who embrace the challenge to continually learn and improve, I would encourage you to talk to leaders in organisations with high FTSU index scores, to learn how FTSU can contribute not just to your own organisation, but to the health system as whole. By asking the question "how can we do better?", together we can make speaking up business as usual in the NHS.
The latest FTSU Index will be published at the end of May and available from and available from the National Guardian website.
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