Developing a network of Freedom to Speak Up Guardians to support workers to speak up safely 

15 September 2021

Tags: Speak Up, Supportive Environment

Read our latest guest blog, by Dr Henrietta Hughes OBE, National Guardian, NHS.

Freedom to Speak Up in the NHS arose from the tragedies at Mid Staffs where an atmosphere of fear and futility pervaded. As Sir Robert Francis QC identified in his inquiry, fear about the consequences of speaking up and lack of confidence that concerns would be addressed were deep seated issues in the NHS. 

As the National Guardian for the NHS, I was appointed following Sir Robert’s recommendations, to lead a network of Freedom to Speak Up Guardians in England so that people can speak up about anything which gets in the way of delivering great care. The National Guardian’s Office provides training, support and insights to the system, disseminating good practice and providing challenge to tackle barriers to speaking up.

At the start of 2016, this was unchartered territory – there was no equivalent in other sectors or other countries. We needed to fan this spark into a flame and turn a report into a reality. 

In those first days, our task was focused on building the national network of Freedom to Speak Up Guardians in Trusts. At the end of my first 100 days in post, I reported that 200 Trusts had recruited Freedom to Speak Up Guardians. Now we have over 700 guardians in more than 400 organisations. The network has spread beyond Trusts and into primary care, independent providers, hospices and national bodies.

While there are many existing routes for workers to speak up, through incident reporting mechanisms, via their line manager or educational supervisor, there may be occasions where none of these channels are suitable or trusted. Sometimes people may be fearful that they might be victimised for speaking up or they have tried to raise matters before and been blocked or ignored, or as trainees, they may be uncertain of who to speak to or even whether they can. 

Freedom to Speak Up Guardians provide an additional channel for healthcare workers, volunteers, students, trainees, contractors, partners and others and work proactively to support a positive speaking up culture. 

They thank workers for speaking up, listen, offer support, act to preserve confidentiality where requested and if possible and ensure action is taken and feedback is given. Any speaking up matter can be brought to a guardian – a safeguarding concern, a patient safety issue, concerns around bullying and harassment, but also suggestions for improvement where there is no obvious place to raise it. For example, ideas to save money, or improve patient experience, or make workers feel valued and empowered. Guardians will escalate to the appropriate person in the organisation, maintaining confidentiality or supporting the worker to speak up themselves.

Usually employed by their organisation, Freedom to Speak Up Guardians act independently and impartially to support all workers to speak up and remove barriers to speaking up. They are the interface between workers and leadership and need to have the independence to command the trust of both. Guardians support leaders to listen and act and report on themes to their Boards or equivalent and leaders. 

The hierarchical nature of NHS culture is a challenge. Freedom to Speak Up guardians have been recruited from different staff groups; nurses, chaplains, therapists, managers and doctors; and different grades and seniorities to offer different perspectives. Many organisations have networks of Freedom to Speak Up Champions or Ambassadors, drawn from a broader cross-section of the workforce.

The Universal Job Description outlines the Freedom to Speak Up Guardian role and sets out the values, expectations and responsibilities of Freedom to Speak Up Guardians.

All Freedom to Speak Up Guardians complete introductory training to give them a broad understanding of the principles of the role. They need to complete this before they can be included on the Freedom to Speak Up Guardian Directory. We are currently working on producing an e-learning product for new guardians so that we might meet the needs of the growing network as guardians become embedded into primary care organisations. 

Peer support is also vital. Freedom to Speak Up Guardians are encouraged to join their local or national networks which provide support, share learning and resources. The work of Freedom to Speak Up Guardians can impact emotional and psychological well-being. We ask that organisations provide their guardians with that support, but we also offer a confidential 24-hour well-being helpline available if they need it, which is external to the National Guardian’s Office. 

The skills required of Freedom to Speak Up Guardians are complex. We have developed an Education and Training guide which helps guardians self-assess against a competency framework with a view to achieving the highest levels across the board in what we consider to be a leadership journey.  But for speaking up to be effective, leaders need to listen up and follow up. Together with colleagues in Health Education England we have developed Speak Up training for all workers, Listen Up training for leaders and managers and will soon launch Follow Up training for senior leaders as well as embedding Freedom to Speak Up into leadership development programmes.

In the ever-evolving nature of the healthcare system, the National Guardian’s Office supports the Freedom to Speak Up Guardian network issuing guidance and supportive materials, including a regular bulletin and monthly webinars. We survey Guardians annually to understand how the role is being implemented and their perceptions of the speaking up culture in their organisations and the sector. 

I am humbled by the courage of workers who speak up, especially those who do so in unsupportive organisations. Their passion and commitment to their patients and colleagues, their bravery to raise issues in the face of these barriers inspires our work. Freedom to Speak Up Guardians share their speaking up data with us. Since the network began, over 50,000 cases have been raised with guardians; that’s 50,000 opportunities for learning and improvement for the benefit of colleagues and patients.

As I step down as National Guardian, after five years in the role, I can see a measurable difference although there is still a huge amount that needs to be done. Now, with hundreds of Freedom to Speak Up Guardians, supporting tens of thousands to speak up, the flame is burning brightly and lights the path to speaking up being business as usual in the NHS.


Dr Henrietta Hughes OBE
Dr Henrietta Hughes OBE

National Guardian, NHS

Dr Henrietta Hughes OBE FRCGP was appointed in July 2016 as the National Guardian for the NHS, a key recommendation from the Francis Inquiry into the events at Mid-Staffordshire NHS Foundation Trust.

She provides leadership and support to Freedom to Speak Up Guardians across England in NHS and Independent sector organisations, and other parts of the healthcare sector, with a view to making speaking up business as usual.

In addition to leading a network of Freedom to Speak Up Guardians, the National Guardian’s Office also undertakes and publishes case reviews when it appears that speaking up has not been handled according to best practice. Part of the remit of the office is to provide challenge and learning to the healthcare system as a whole.

Previously a Medical Director at NHS England, Dr Hughes continues her clinical role one day a week as a GP in central London. She was made a Fellow of the Royal College of General Practitioners in 2019 and honoured with an Officer of the Order of the British Empire (OBE) medal in the Queen’s New Year Honours List 2020.