Our NHS People

Creating a Speaking-up Culture

Creating good speaking up cultures

The NHS People Plan included a commitment to empowering all our NHS people to have a voice, as well as supporting leaders and managers to foster strong speaking up cultures. In this video series, our Director of Leadership & Lifelong Learning, Jacqueline Davies, chairs a panel discussion on how we can create these cultures, why they are so important and what role leaders must play. It also looks at how one trust has done this successfully. The panel includes:

  • Dr Henrietta Hughes OBE, National Guardian for the NHS
  • Dr Ronke Akerele, Director of Culture Transformation at NHS England and NHS Improvement
  • Jane Tomkinson, Chief Executive at Liverpool Heart & Chest Hospital NHS Foundation Trust.

Expectations of senior leaders when it comes to speaking up are clearly set out in the Guidance for Boards. You can also find lots of useful resources to help support your speaking up arrangements on the National Guardian’s Office website.

The importance of staff voice and the beneficial role it plays within organisations

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00:01 Jacqueline: I’m delighted today to introduce you to our three guest speakers, talking about Freedom to Speak Up (FTSU). 

Now I know that many of you listening to this will be experienced in freedom to speak up. We’re not just going to talk about the value of a freedom to speak up scheme, we’re going to talk about the things that executive senior leaders, chief executives need to know about how you create schemes which create cultures, and how you make cultures that take FTSU and make it successful in a sustainable way. And I want to start by introducing Henrietta Hughes.

00:34 Henrietta: Well, hello Jacqueline and thank you so much for inviting me to this. This is a time when we want all leaders at every level to recognise the value of the speaking up culture, this is a really great opportunity for leaders at all levels to think about not only the alternative route that their FTSU Guardian provides, but how to really raise the game. Speaking up saves lives.

I’m a GP, and I know this from personal experience that when people aren’t able to speak up about things, it can lead to serious harm. And we’ve seen that during the pandemic, that people want to speak up about patient safety matters, about behaviours and about bullying and harassment — but also about their own safety, about the safety of their colleagues, in terms of PPE, risk assessments, and also in terms of the availability and of the testing they’ve been experiencing.

And we know that there are FTSU Guardians in many organisations across the NHS, nearly 600, and what’s been fantastic is that Guardians have created an alternative channel where people can speak up about all these different matters, knowing that they’ll be thanked, listened to, that their concerns will be escalated and that they’ll get the outcome of the actions that have been taken. But to really raise the game and embed this so that it’s a culture, leaders at all levels need to emulate those behaviours so that wherever anyone speaks up, whoever they speak up to, and whatever they speak up about, they’ll get that same, high quality result. In that way, the fears that people have about getting repercussions or being victimised from raising matters that they’re concerned about will be eliminated — because people will start having a good experience every time they speak up.

02:22 Jacqueline: Thank you, and I think there’s probably not a person listening to this who wouldn’t listen to that and say, we need that, we need more of that. But I’m thinking of it now from a chief executive’s perspective, and thinking that many chief executives that I know will say ‘I want that Henrietta, but actually I don’t often hear this, I don’t hear that I need to do more of this, these are the things I exactly want to hear, but I don’t hear it’. How do I go about sort of setting this up and how do I make this sustainable?’. I just wanted to introduce Jane Tomkinson from Liverpool Heart and Chest. So Jane, how long have you been chief executive there, and tell us a little bit more about your journey to making you know, what we just heard Henrietta describe come to life.


03:07 Jane: Well, firstly can I thank you all for inviting me to join this panel of experts today, I feel a bit of a fraud in the company of people who are such role models for speaking up. I’ve been Chief Executive of Liverpool Heart and Chest for seven years now, and FTSU has been a real journey for us, but a journey that didn’t just start with the production of the Francis report. It was a journey that had been ongoing for many years whereby we recognised that if our primary aims were about having the safest care for patients, the best experience for patients — but actually the best place to work for staff.


We needed a culture where colleagues felt safe to speak out, because in organisations where you feel safe to speak out, you can share ideas and concerns, but you can also share good ideas and learning and improvement. Our speaking out is always about improving, and improving things for staff and for patients, and anyone that has any dealings with Liverpool Heart and Chest. I think over more recent years the focus of FTSU has become different.

It’s just actually the way we do things round here, it’s the norm and it’s socialised very frequently, so when we discuss this at the board or at our monthly team brief or when we have our quarterly FTSU summits or inclusion events, people look forward to them as an opportunity to get involved. That hasn’t happened overnight, and I think building the trust has been a real journey for us. I think picking up Henrietta’s point, if you feel you’ll speak up and be shot down, or there will be any form of retribution, you won’t do it again and what’s more, you’ll tell people it was awful. And that sort of pushes issues inwards, when actually bringing to the fore is the way that we would improve things consistently for our patients and for our staff. So for me and everybody else that works for the Liverpool Heart and Chest, this is just another essential tool in creating that culture of excellence and openness.  

05:24 Jacqueline: Okay. I also wanted to introduce Dr Ronke Akerele. Ronke is a, I have to say, a peer of mine in People Directorate, and she teaches me something new about this agenda every time that we talk about it. One of the things that I was fascinated to learn as a newcomer to the NHS, is that with your national perspective Ronke, you can spot the trends, can’t you — you can spot the relationship between those people who do this work well and their general performance health, and those people who don’t do this well and what happens. Tell me a bit more about your national insight.

06:05 Ronke: Yes, thank you Jacqueline and it’s an honour to be with yourself, Henrietta and Jane at this discussion in such a pivotal time whereby we are encouraging speaking up. I think for me personally, I’m very passionate about enabling the NHS workforce and the organisations to bring to reality and make sustainable transformation to the culture.

When we look at it from a national landscape, we know that in the failings of healthcare delivery, and then Jane mentioned the Francis report that there’s so many inquiries — over 150 actually in the last 50 years. Most of these inquiries have come up with similar findings about cultural issues, behaviours and values. And the common things — with the exception of weak and incompetent leadership — the main common things from these inquiries has been poor communication, has been disempowerment and marginalisation and victimisation of staff and patients. That is as a result of bad culture of speaking up, that is a result of bad culture of people being unable to listen up.

With our plans, with the People Plan, our goal is to ensure that staff have a voice, our goal is to ensure that we do not get into attitudes, behaviours and values whereby we suppress the voice of our workforce. We need staff to be confident to express their views. With our work with the National Guardian’s Office, across the organisations and through the regions, we want to make sure that regardless of who you are, whatever disadvantaged or marginalised group are within a big workforce of 1.3 million, they’re able to adopt a different way of speaking up, but also listening up. That’s really key to everyone’s goal from the national angle.

What can chief executives do to support Freedom to Speak Up?

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00:01 Jacqueline: I want us to think about our first time chief executives, or aspiring chief executives, approaching an organisation for the first time – ¬who maybe doesn’t have a Freedom to Speak Up (FTSU) scheme in place yet, or one that’s really kind of working. Where would you start? I’m going to go to Jane for this question. Jane, where did you start, what would be the two or three tips you would give a new chief executive in terms of either setting up a FTSU scheme or reviving one, or getting more out of one?

00:33 Jane: So I think the starting point would be to absolutely believe in FTSU on a personal level – that this is something which is so important to your organisation whatever it delivers. That you personally will take a very visible leadership role in promoting it and you won’t hide behind policies or delegate some of the more difficult stuff, but to really think about what the objective is with FTSU and if the answer is ‘it’s about openness and belongingness and safety and fab experience for patients but also a brilliant place work’ then you can’t really go very wrong, because actually it will flow from that.

But it’s also about devoting proper time to this, and this isn’t something you can do as an add-on to everything else in you know, ten minutes on a Tuesday afternoon, you need to devote proper time and space for the thinking, for the inclusion, for the discussion, for the visibility, and to get out there and talk the talk and walk the walk, and the actions need to demonstrate your absolute commitment for this throughout the organisation. In a way that breaks down hierarchies, in a way that engenders trust, in a way that staff feel that they can see results rapidly, that what you’re saying isn’t lip service, that this genuinely comes from here (touches heart) because it is crucial to your people in whatever role, or whatever part they have to play in the delivery of excellent care.

02:16 Jacqueline: Thank you, that was really neat summary. So, Henrietta, this is all about power, right? This is all about, you know, you think you get to the senior leadership role and actually when it comes to speaking up, it’s about, kind of, giving people more power, giving yourselves more space, walking the talk, as Jane’s said. What other observations would you have for a new chief executive, in terms of what they need to think about?

02:45 Henrietta: Well, my experience is that when I’ve gone to organisations with new chief executives, it’s fascinating to see how quickly they can have a positive impact on the workforce, and one of those things is about being really visible. Now, being visible doesn’t mean you have to physically be there because I know there are some chief execs at the moment, who are actually not able to get onto their site, but they’re still really visible to their workforce.

And talking to your staff, listening to your staff, understanding what their needs are – now that could be through conversations on the stairs, or it could be by looking really carefully at the staff survey results, talking to the chairs of your staff networks, just talking to everybody and listening and being really interested in what they have to say.

One example that I can give is of a Trust where they went out to their staff and said what are you looking for from your FTSU Guardian, do you want someone whose ever worked here before, never worked before, clinical, not clinical, full time, part time and based on what the staff said, that’s who they went out to go and recruit. And I think having an open recruitment process is key to this, because the Guardian has to have an impartial role, working as the interface between the workforce and the board. They have to have the confidence of the board, and the confidence of the workforce. So tapping someone on the shoulder is not a great way to start that conversation.

The other thing that I would say is working in partnership, Guardians can actually have a really proactive element to their role, so that they listen to complaints teams and incidents, the staff side, the chairs of staff networks, the junior doctor committee chair, all of these people who will have a really good insight into what’s happening in the organisation. And these people will have, they’ll be the fresh eyes, they’ll bring really great insights, but as a chief executive, there’s a limit to how much you’re going to be able to know. So by bringing all these people together, they’ll be able to tell you which parts of the organisation might be struggling, and where can they get additional support. So those are the two things I would say: listen, listen, listen, use that to make the improvements, but also bring people together to have really rich conversations.

05:06 Jacqueline: Thank you. Ronke, this sounds to me, if I was a chief executive going into an organisation, like one of the critical things you need to do to do a cultural health check. Can you say a bit more about the linked culture from your perspective?

05:24 Ronke: Yes. I mean, voice and power are so interlinked, and they form one of the various strands of culture, and there isn’t anyway whereby you would need to look and do an assessment of knowing where you are today, what’s your current situation, our staff survey is a good benchmark to view your staff from. From the staff survey result – I can see Jane nodding – maybe that’s where she started from, because when we have staff results, it gives you a barometer of where we are today, and then, I think, there are other things we need to do. There are so many best practice exemplar cases across the country. Jane has shared some of the things they have done in the organisations, they are pockets of good practices and then it’s just looking at where you are, what kind of services do you provide and then we are happy to buddy you up with those that have done this well. That have walked the walk, that have actually seen how they’ve been able to transform their culture and it doesn’t happen overnight. It takes time, but it actually can happen if there’s strong leadership that owns it, I know one of the things Henrietta has always wanted us to do better is how do we actually reinvest the time of FTSU Guardians in our organisation, because some of these people decided to take on the role, but the moment they take on the role they’re still so consumed in the everyday job and we need to make sure that their time is protected so that they can help to promote this more within their workforce and that’s one of the things we want to do differently as part of the implementation of our People Plan.

06:58 Jacqueline: I think this is an important point in terms of what we’re starting to see now in terms of the maturity of these schemes, the organisations that do this well get more engaged people, get healthier cultures, get better patient outcomes and we can clearly see that link now all the way through.

Good to great: reinforcing your commitment to Freedom to Speak Up and always striving to do better

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00:01 Jacqueline: Jane, one of the reasons you were invited here today, not to spare your blushes, is because you’ve proven that relationship between establishing a healthy Guardian culture all the way through to your patient outcomes. And I just wanted to just go now, in terms of into thinking, ‘I’m an experienced chief executive, so I’ve got my scheme up and running, I do the listening events routinely, I do the actions when I can, I’m doing some interesting things in terms of building the capability of the Guardians, I’m doing all of that stuff, how do I go from good to great? How do I go from that as a baseline and start to make in more integral to everything that we do, and particularly, how do I get to those patient outcomes?’

Jane, can you give us some insight on that?

00:56 Jane: Yes, thank you, that’s an excellent question, good to great – I’m not sure we’re at the great stage yet… I think it’s not getting complacent about your progress, and absolutely keeping that listening, that conversation going. It’s about really communicating effectively your personal commitment to this, and I know I said this for new chief execs, but good to great requires the ongoing commitment. And an example of that is, my staff are very bored of hearing me talk about the three pledges which I make personally to every member of staff on their first day of employment — because I personally take the time out to do the corporate induction — and I reinforce it in every single team brief and board meeting.

And these are my pledges – no one’s made them up for me. The three pledges are, number one: I actively encourage colleagues to speak up if they’re concerned about the care or treatment of a patient, a colleague or themselves. Secondly, they raise something through the multi-channels — and this is again, a thing to think about — the multi-channels of raising your speaking out issues. We will investigate fully, openly and transparently, and if you let us know who you are — recognising some colleagues wish to remain anonymous — we let you know the outcome of that investigation. And the third pledge is very important, that if you raise something and you feel you’ve had any form of detriment, and the definition of detriment is pretty broad, but if you feel you’ve had it, we’ll keep you safe.

And to start your employment in an organisation with that ringing in your ears and you hear it every three weeks at the team brief and you get bored of hearing it, but on the day you need it, it’s really important. And on top of that, we benchmark. We triangulate what’s going on across the organisation. The speak ups, the staff survey, the complaints, the issues, the risk reports, we’re getting a full understanding of rich information about what’s going on, we’re bench marking, we’re looking for good practice, reading Henrietta’s report slavishly, and picking up every time, half a dozen fresh things to add too. Freedom to Speak Up Guardians roll their eyes: ‘Oh, you’re giving me more to do’, but it’s about not standing still, it’s about constantly striving and getting into those really hard to reach groups, the people who are a bit concerned about speaking out. We’ve done work with the board, speaking truth to power and that was a really important piece where I think I’m lovely and approachable and when I say ‘Oh pop in for a cup of tea’, I think it’s a lovely treat for people — that’s maybe not quite the way it was perceived.

But, through going through those you’re holding that mirror up and doing the challenging that has been absolutely crucial in moving from something which was, you know, pretty good – but not good enough. And one of the big catalysts for us was looking at that indicator which says 99.9% of staff would recommend this as a place for treatment, but only 78% would recommend it as a place to work. This is a mismatch, it’s not good enough. So probing in different and fresh ways and constantly learning, but listening with open ears constantly.

04:25 Jacqueline: Thank you Jane. Henrietta, you have this kind of oversight of where it’s working well and where it’s not working well. What are your takeaways in places where they’ve really got this, in a virtuous circle? They are building, they’re inquiring, what are the leaders doing that take things from good to great?

04:52: Henrietta: The first thing I would say is that the organisations who are doing this really well, really want to do better, and come to us and say: ‘How can we do better?’, whereas others who are struggling may not do that, and I think that’s a really interesting…

05:10 Jacqueline: Is that modesty or is that a cultural curiosity?

05:15 Henrietta: I think it’s just a desire to do better and better and better. And I think it comes from confidence actually, and what I’ve found is that when we publish a report, there are some organisations, like Jane’s, who look at it and say, ‘Oh, we’re not doing that yet, we could do this’, but also will even raise the bar higher and will take the data — for example that we publish nationally — and start using that in really innovative ways.

So, we have developed a FTSU index, with four questions from the annual NHS staff survey. These are about whether people feel that their knowledgeable about how to raise a concern, whether they feel encouraged to do so, and supported to do so, and whether they believe they or others will be treated fairly if involved in an error, near-miss or incident. Now, it’s not perfect, but it’s a start and it’s a way for organisations to do that thing that Ronke was describing, which is, you know, how am I driving, where am I now, where would I like to be and how can we get there, and who is doing this really well and how can we learn from them.

And because we publish all of this, we publish the speaking up data, we publish the FTSU index, we publish our pulse surveys during COVID, there’s a lot of information that’s there for organisations. I think as Ronke was saying, if Guardians don’t have ring fenced time, how on earth are they going to be able to make those improvements, that iterative improvement, so that every month, every six months, they’re able to get together with their regional networks, share and learn from each other, get that buddying, get that support, and egg each other on a little bit to be fabulous. And that’s something I’ve really valued from FTSU Guardians, that they really want to learn and share with each other. There’s no barrier to improvement, there’s no ‘not invented here’, there’s no organisational fortress mentality, it’s very much a, ‘do you know anything about this, yes I’ll help you, you help me and all together we just get better and better’. But for the organisations that are struggling, maybe their Guardians don’t come to the regional networks, maybe they don’t read the bulletins or the reports that we publish, and so that they’re, actually, the gap between those who are getting better and better, and those who are lagging behind, is becoming increasingly large.

07:45 Jacqueline: Wow that’s interesting, it sounds like your, you know, as well as the leadership mindset that Jane has described, and that you’ve described in terms of having that relentless focus on improvement, it sounds like there’s something really important about building the capability and confidence of the Guardians themselves. I can see Ronke nodding. Ronke, what would you add to this good to great discussion?

08:09 Ronke: Yes, the good to great discussion, I know you posed the question to Jane about you being a CEO and you have the appetite and you want to do this; how do you do this. It’s not just about you as the CEO and it’s not just about the executive team. It’s about everyone having that drive and taking ownership of it. This is about collective leadership, regardless of what band you are. You might have the drive Jacqueline, your board members might have the drive, but it needs to trickle down, it needs to be owned by the ward manager, the service manager, the band 6 to be able to be a champion – it has to start like a movement.

So the Guardians are just one out of a four thousand population of a trust, so for me it’s about when we look at good to great, it’s about how do we start that movement within the ward, how can we debrief: ‘I did something wrong yesterday’. How can we bring people together and add a communicative space to open up and share it, maybe because I’m just too shy to tell Henrietta, who could be my ward manager — but I’m open to go to someone else and just debrief, as part of the health and wellbeing. Opening spaces up for people to talk and actually take it, so it’s not… as much as we actually want the leaders to own it, but in, when we look at the aspects of collective leadership it…leadership doesn’t just say at the higher echelons of the organisation, it’s everybody owning it, regardless of who you are. I think that’s where the sustainability will be from.

How can Freedom to Speak Up support our response to COVID-19 and winter pressures?

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00:01 Jacqueline: One more question — I’m afraid it’s a challenging one. It’s related to taking all of the stuff that you’ve talked about, and thinking about it now, leaning into winter. We all know that winter is going to be one of the most challenging, complex demanding times that we’ve ever experienced in our history, we’ve got service recovery underway, we’ve got the recovery from wave one of COVID, we’ve got potential wave two of COVID, and we’ve got all the usual flu and winter pressures. All of that is about to play out over the next three to six months. How do you maintain focus as an executive leader on this agenda during that challenging time? Just some final thoughts and tips from you please, for our audience Jane?

00:52 Jane: So, a very timely question Jacqueline, the pressure’s started for us. We’re in the middle of an outbreak and what it says to me is that speaking out has never been more important than at times of intense pressure, and we learnt from the first wave that staff were, became a little bit inward focusing – they were focusing purely on the patients and the issues in front of them to the extent we found some staff were getting really stressed. Stressed about perceptions of the availability of PPE, about their access to, you know, the basics – when I get home, I won’t be able to buy a loaf of bread because people have stripped the shelves. What we did was, we had a welfare team which was headed up by our Freedom to Speak Up (FTSU) Guardian with a network of champions who went round all the areas every day, including weekends, and out of hours, just to say: ‘How are things, how are you feeling, what can we do to help, is there anything we need to be aware of?’. They went into some places and it was absolutely fine, no issues, too busy to talk to you but come back tomorrow and they did. We collected quite a good document whereby we could pick up the themes, we could identify the issues and that meant we could take action.

As part of the response to all of this, we like every other organisation created the gold command, but every day in gold we reviewed the feedback from the previous day to see if there were actions we could take. My question was always ‘What can we do today to stop that happening again?’ and it was very powerful. Yes, it required resources, but what we found was that a lot of people whose day to day role wasn’t there because of the changes, or was different or because they personally — for example, pregnant staff — couldn’t do a lot of the front line, they could go to some departments and talk to staff. So we used our workforce flexibly to adapt to the changing situation, but we never for one minute considered pulling back on this, because listening through the pressure is even more important.

03:20 Jacqueline: That’s such a sobering thought isn’t it, about listening through the pressure, listening through the pressure. Ronke, I’m going to come to you, and Henrietta I’m going to give you the final word, so listening through the pressure… Ronke, is it observations, learning from wave one, or do we need to know that it is important for a wave two? Tips, insights, what would you share?

03:45 Ronke: Yes, indeed, and it’s interesting to hear that listening to the pressure is really key. From what we’ve heard from wave one of COVID-19 and trying to plan into wave two, it’s what should we do differently. How do we ensure that in the noise of what’s happening in the pandemic, we’re also there to listen to our staff and make changes, and be fluid, remove some form of bureaucracy? What we’ve learnt from wave one is that changes that needed to be made — because people were listening — changes then happened simultaneously, rather than the kind of bureaucracy and protocol that it could take about two months before things are approved. So what we’re hoping to do in wave two is to empower others to ensure that listening to the pressure is really key, and speaking truth to power. We know that there’s quite a lot of work that’s been done in that space and trying to challenge where power is not used over people, rather than where power is used with people. Also trying to promote whereby voice is voicing with others, rather than just voicing on others. It’s quite key that as we’re going into the winter pressures, we’re looking at what we thought COVID-19 would look like, we do not stop, we do not put our bricks down and just continue striding along.

05:11: Jacqueline: Thank you. You know, so what I’ve heard in this conversation so far is the FTSU Guardians they don’t just play a role in terms of calling out areas that require attention, they sound pretty essential for chief executive listening. They sound pretty essential for good cultural health, and what I’m hearing now, is that actually, they seem to be fundamental in terms of helping lead through crisis. Henrietta, I just wanted to give you the final closing thoughts on this, and in there thinking about what insight have you got for our leaders to take away on this, to help them through the difficult winter months.

05:53 Henrietta: Well thank you very much, and the first thing I would say is I think it’s natural to feel anxious, it’s a very difficult time, unprecedented times. Everyone from every single member of staff, right the way through to board members needs to be able to get the support to get them through these difficult times. The FTSU Guardians can be really helpful in that by creating that alternative channel and being there so that small problems can be fixed quickly, so people can get that level of support that they need. Now, I don’t underestimate how difficult this can be, and that Guardians themselves face a lot of pressure because they are the conduits of sometimes quite difficult truths as well, so it’s really vital that chief execs get the support they need. That’s from their commissioners, from their regulators, from their inspectors – but they’re then able to provide that support to their workforce and to have all of those channels for listening and then turning that into positive actions and giving that feedback. I think that as we spoke earlier, speaking up is probably never more important and can save lives, but it’s not just about Guardians doing this. It’s about those values and behaviours filtering out across the whole workforce, so that it actually becomes a business as usual activity in the NHS.

07:20: Jacqueline: Henrietta, Ronke, Jane, thank you so much for your wisdom today. I think one thing that I’m taking away is that this FTSU is not just for October, it’s an all-round year thing and it’s going to be absolutely vital. Listening through the pressure as Jane said, keep on moving on as Ronke said — but also critically Henrietta as you said, really thinking about making sure we take care of the Guardians themselves as we go through this difficult winter period and work together collaboratively to see each other through. Thank you, thanks everyone.

07:58 All: Thank you

Building on key issues from this panel discussion, you may also find Mersey Care NHS Trust’s free online training on just and learning cultures useful, which focuses on the creation of an environment where staff feel supported and empowered to learn when things do not go as expected, rather than feeling blamed.