Freedom To Speak Up Guardians are an important additional route for healthcare staff to raise concerns, but the role is fraught with risks that need to be addressed if guardians are to survive, thrive and have the impact intended.
There are currently over 1200 freedom to speak up guardians (guardians) in NHS primary and secondary care and independent healthcare sector organisations, hospices, national bodies and elsewhere. The National Guardian’s Office (NGO) and guardians were established in 2016 after the groundbreaking 2015 Freedom to Speak Up (FTSU) Review by Sir Robert Francis KC following the tragic events at Mid-Staffordshire NHS Foundation Trust.
Guardians work to a universal job description set by the NGO and operate as an additional speaking up route for staff, identifying barriers to speaking up to help improve their organisation’s culture. A localising negotiated approach to the job description means that the role is also highly localised and variable. The appointment of guardians is mandatory for healthcare providers delivering services under the NHS Standard contract. The majority are employed by the organisations they support (‘internal guardians’) with further variability in whether this is a standalone role (34% according to the NGO Guardian survey 2023) or as an add on to existing roles. ‘External guardians’ who provide guardian services in healthcare organisations but are employed by third-party organisations make up a small percentage of the guardian population and account for approximately 1 in 12 of the cases reported to the NGO.
The NGO leads, trains, and supports guardians, and is expected to provide challenge to healthcare providers and regulatory/oversight bodies in England on all matters related to speaking up. This includes calling out poor culture and practice through its Speak Up reviews. The NGO is co-funded by NHS England and the Care Quality Commission (CQC) and is legally part of the latter which has led to questions about the optics and extent of its independence.
I conducted research as part of an MSc which looked at the medium-term impact and sustainability of the guardian role and the wellbeing of guardians almost 9 years’ post implementation. The findings echoed an earlier ‘first of its kind’ study which exposed worrying inconsistencies in the implementation of the role in acute and mental health NHS trusts in the variation in ring-fenced time, resources available, and support provided. Wide differences reported in pay, seniority, professional background, and a problematic ‘workaround’ functioning where, for example, some guardians were ‘adapting’ NGO guidance, dismissing perceived ‘lesser concerns’ to preserve time, leading to concerns that the data collected and reported nationally by the NGO was unreliable. The study highlighted risks posed to guardians’ mental health. Data from the 2023 NGO guardian survey reports that over 50% of guardians have 1 day a week or less for the role, which inevitably impacts on them and the service they provide to workers. Only 65% of guardian respondents to the same survey felt that they were meeting the needs of workers, illustrating a 7% decline in confidence since 2021 (NGO Guardian survey 2023).
Findings based on interviews with internal and external guardians in a wider range of settings, including in primary care, echoed the above variability in recruitment, FTSU understanding, support for and implementation of the role, including in terms of escalation and resolution routes and the involvement of guardians in those processes.
Worryingly, they highlighted the personal and professional risks to internal guardians and the people they support, especially if working in organisations with ‘cover up’ cultures which caused friction and sometimes put guardians in conflict with the leadership of their organisations, resulting in serious detriment to guardians and those speaking up. A number of guardians talked about the role being ‘career suicide,’ of making enemies throughout their organisations, and of being bullied in retaliation for performing their jobs. More than half of guardians interviewed reported a deterioration in health and wellbeing, with reports of ‘burn out’ and hospitalisation amongst guardian colleagues. The extent of guardian turnover nationally and the reasons for this are currently unknown. This is a missed opportunity to triangulate information to ‘problem sense’ and help identify ‘at risk’ organisations, as well as to identify and implement better support for guardians as needed.
While all guardians reported positive aspects from performing the role, such as making a difference for staff and patients, job satisfaction, and personal learning and development, this was countered by a number of them having to shoulder responsibility for overall FTSU culture and being scapegoated when things went wrong. Several guardians were successfully leading cultural improvement initiatives in their organisations, underpinned by genuine curiosity from their Boards, while some were struggling to perform their reactive function (dealing with cases) let alone the proactive aspect (the preventative function) due to the constraints above.
A reported lack of local and national support, for example, in complex case advice, setting guardian standards or a code of conduct, addressing conflicts, ensuring consistency in pay, skills/qualifications and enhanced (legal) protection when things go wrong, led some guardians to feel frustrated and concerned about the failure to keep pace with their unprecedented and evolving role. Variability in guardian involvement in opportunities for learning and improvement from the cases they dealt with resulted in a lost opportunity to fully utilise their organisational knowledge. A lack of transparency in (appropriately) sharing investigation and resolution outcomes negatively impacted guardians’ motivation and perceived performance as well as damaging the trust of staff speaking up.
A majority of guardians felt that too much responsibility for peer support and training was placed on regional and national guardian networks. The networks are run on the goodwill of guardian Chairs with associated costs borne by their (usually NHS) employers, rather than the NGO, which also led to concerns about using scarce resources for guardians from outside the NHS. Not all guardians attend quarterly network meetings, but they remain a crucial source of support, especially for those who were unprepared for the challenges and isolation they faced in post. For that reason, it would be beneficial for people to have completed training before starting in post and for such training to include elements of good investigation practice, professional codes and standards, governance, and employment law/discrimination aspects. This would inform their understanding of the ‘mixed bag’ of issues likely to be encountered as a guardian and allow individuals to reflect on their appetite, suitability and training needs.
The findings emphasised risks associated with guardians filtering concerns and reports to leadership to minimise what might be received as ‘bad news’ through case numbers and/or case type or feeling pressure to do so. In some cases, guardians reported having their FTSU reports re-written and raised suspicions about guardians’ confidential databases being accessed without permission. Being pressured to reveal confidential information about cases and people speaking up was another source of conflict. Guardians sometimes have little power to implement NGO guardian guidance about these matters locally and some lack the infrastructure and technology to comply.
Some guardians expressed concern about colleague guardians overstepping role boundaries, for example, becoming involved in investigations, breaching confidentiality, and ‘taking sides’ against people speaking up especially where litigation had resulted from concerns raised. Guardians are sometimes involved as witnesses in employment tribunal proceedings, which could compromise perceptions of trust and independence, and risk criticism about their handling of cases. In some cases, guardians were worried about having to resort to litigation themselves based on the detriment they suffered in their organisations.
There is still no national data available about what direct difference the guardian role is making in practice in terms of, for example, harm averted, money saved, addressing negative behaviours, and increased wellbeing and retention of staff. The number of guardians being recruited and the number of cases they deal with needs to be treated with caution in view of the inconsistencies reported in the study above and must be recognised as activity data rather than impact data.
In many cases, local guardian appointments are tick box exercises intended to satisfy, for example, contractual and CQC requirements, especially in primary care settings, with flawed understanding about the breadth and requirements of the role and available resolution routes. Increasing numbers of guardians/cases are also unreliable as a measure of success of the NGO’s purpose to make speaking up business as usual, which should surely mean greater reliance on existing line management/reporting routes, rather than having to approach a guardian.
The current review of the guardian job description conducted by the NGO is a necessary but premature exercise in the absence of an informed impact evaluation, especially given that the role is not universally or definitively agreed. Canvassing views from all staff, whether they have used the guardian route or not, about the role’s trust, value and implementation in the healthcare system is an essential exercise. Without addressing the above problems, and without wide and diverse stakeholder engagement and consultation about the role itself, the current review of the job description risks perpetuating a narrow, protectionist and ‘comfort seeking’ approach, ignoring the dangers posed to guardians and staff alike.
The October 2024 letter from NHS England to Integrated Care Board CEOs and Chairs to ensure the adoption of the national Freedom to Speak Up policy (2022) and access to a guardian for primary care workers, risks driving implementation of a role that has not been thoroughly evaluated, perpetuation of knee jerk reactions to comply with expectations and CQC well led inspection requirements, and despite the obvious differences in implementation required in primary care settings. A co-designed FTSU solution, including discussions about funding, need to happen before there is assurance about delivery of the “People Promise: we each have a voice that counts” in the General Practice, Dental, Pharmacy and Optometry sectors, and hopefully the intended positive impact on staff engagement, wellbeing, recruitment, and retention.
The NGO’s 2021 Five-Year Strategic Framework acknowledged many of the problems above, and emphasised focus on the issues of “quality and consistency in how the guardian role is conducted and how workers and organisations are supported.” However, many guardians felt that insufficient progress on tackling the issues identified has been made.
Unsurprisingly, there were strong feelings about the internal versus external model regarding issues such trust, conflicts and the independence of guardians, their availability to staff, and in terms of reducing the personal risks described above. Further research is needed before drawing clear conclusions about the different models in the context of impact, wellbeing, and sustainability.
In view of the discussions around the quality and consistency of data collected and reported, an independent evaluation of the existing NGO system is required. Of value would be a central data reporting solution for guardians which avoids local data manipulation and extends to categories of information that guardians receive, and feel are important, but which are not currently collated or reported by the NGO.
Guardians do a difficult job in often challenging circumstances. They serve an important need in healthcare organisations but currently carry too great an individual burden as change agents for organisational culture and are at risk. Effective local and national leadership from the NGO and associated bodies are crucial to the guardian role’s future success. Understanding their responsibility to simultaneously reduce the personal and professional risks to guardians while increasing their efforts to improve support offered to and from guardians will optimise the value, impact, and sustainability of this crucial role.
Lorraine Turnell
December 2024