Quality and safety in the independent healthcare sector 2025
Building a culture of greater transparency and openness – listening to patients and staff
Freedom to Speak Up
The independent healthcare sector continues to play a leading role in the national Freedom to Speak Up (FTSU) agenda. In 2024/25, independent providers submitted 2,114 FTSU cases, a 24% increase on the previous year, demonstrating the sector’s growing maturity in fostering open and transparent cultures.
Independent providers now account for nearly half of all non-NHS FTSU cases, underlining the sector’s proactive engagement in championing staff voice and psychological safety. However, variation in reporting levels and a modest rise in detriment cases (4.6%) highlight the ongoing need for leadership visibility, consistent guardian support, and compassionate follow-through.
During 2025, the independent healthcare sector continued to make significant progress in embedding Freedom to Speak Up as a cornerstone of patient safety, workforce wellbeing and organisational culture.
Growing reach and infrastructure
- The number of Freedom to Speak Up guardians operating across the independent sector grew to over 600 in 2025. This represents a doubling of numbers over the past two and a half years since mid-2023. In addition to these guardians, there are many more FTSU ambassadors in the sector.
- This expansion means that the majority of IHPN member organisations now have at least one trained guardian or ambassador, providing a safe, independent route for staff to raise concerns.
- Many providers have established dedicated FTSU networks that link directly to board-level champions and patient safety leads, ensuring that concerns raised translate into tangible learning and improvement.
Embedding Speaking Up in culture
- Providers are increasingly integrating FTSU principles into their governance, training and leadership programmes, reflecting a shift from compliance to culture.
- Staff awareness of how to speak up has risen markedly – internal surveys from leading independent providers show over 85% of staff now know how to raise a concern and more than 80% feel confident that their concern will be listened to and acted upon.
- The FTSU agenda is becoming part of everyday safety conversations, supported by open staff forums, “you said, we did” feedback loops, and inclusion in clinical governance reviews.
Positive outcomes and impact
- Guardians in the independent sector reported increased early escalation of safety and wellbeing issues, enabling prompt intervention and reducing potential harm.
- Case themes raised mirror the wider system picture: staff wellbeing, culture, and behaviours remain key topics – but with an increasing proportion of proactive, improvement-focused concerns rather than reactive complaints.
Several independent providers have been recognised for sector-leading approaches, as illustrated in the following case study.
Case study: Speaking Up – HCA Healthcare UK
About HCA’s Speaking Up programme
The Speaking Up programme has existed since March 2018. It is led by the director of ethics and compliance, Tim Graveney, who is also the Freedom to Speak Up guardian (FTSUG). The responsible executive is the corporate chief nursing executive, Kathryn Hornby.
There are 52 Speaking Up champions across all hospitals and locations, including four doctors/RMOs.
In most years, there are 130-150 reports to the FTSUG. 84% of cases have an HR theme primarily; 16% are primarily clinical/quality.
Reports are sent to the Corporate Ethics Committee, chaired by the director of ethics and compliance. Members include the group CEO and the heads of legal, nursing, HR and quality.
At sites, Speaking Up is covered in facility ethics and compliance committees, which meet quarterly at each hospital. It is a key area in annual mandatory ethics and compliance training programme for all colleagues.
What happened:
Long-term cultural malaise of a particular clinical team was reported to the Freedom to Speak Up guardian by more than one (separate) reporter. The reporters wished to maintain their anonymity from all except the FTSUG and the HCA UK Quality Executive.
The report included the impact caused by the handling (reporting, investigation, silence) of a prominent clinical matter (a possible patient safety breach).
What we did in response:
We persuaded the two reporters to meet confidentially with the HCA UK Quality Executive. With their permission, the local CEO was contacted.
An independent review was requested including representatives from HR (for team culture) and governance (for the patient safety incident, including its original investigation). Ongoing and regular check-ins were maintained between the FTSUG and the reporters as the review happened.
The patient safety incident was resolved with the help of the patient (this was key).
Why is it important to speak up?
- Don’t leave it to someone else: people had left it to each other to raise widely shared concerns formally.
- Not one person wanted the status quo to continue: all were relieved to have an opportunity to change direction in this team, including leadership.
How have we used the experience to improve practice?
- There has been greater stability within the team since, with fewer resignations.
- The team is reported to be a happier place to work; a dramatic improvement in staff survey scores has been seen.
- Procedure change was made within the specific team relating to the patient safety matter.
- The FTSUG and local Speaking Up champions have been invited to talk to this team on a regular basis about the power of speaking up.
- The reporters’ identity remains confidential, including from the hospital CEO. They are now powerful ambassadors for speaking up and remain at HCA UK.
Learning outcomes:
- If you have a situation that is in no-one’s interest to maintain, the chances are we can work collaboratively to improve all aspects.
- We really can look after your confidentiality and even your anonymity and still deliver results.
- There was excellent collaboration between stakeholders: governance, local executive team, HR and the FTSUG.
In summary, the independent healthcare sector is demonstrating strong, visible leadership in Freedom to Speak Up. Through expansion of guardian networks, improved staff engagement and greater board-level accountability, the sector is showing that creating open learning cultures is fundamental to delivering safe, high-quality care for every patient.
Martha’s Rule
Martha’s Rule was introduced in England to strengthen patient safety by ensuring that patients, families and carers can request an urgent clinical review if they feel a patient’s condition is worsening or their concerns are not being addressed. In response, some independent sector providers are introducing services such as Call 4 Concern, giving patients and families a direct route to seek additional clinical assessment when they are worried about care or deterioration. These services provide reassurance, encourage open communication and help ensure concerns are acted upon promptly, ultimately supporting safer care, improving patient confidence, and strengthening partnership between patients, families and clinical teams.
Case study: Martha’s Rule – The London Clinic
Listening, responding, and caring – because every patient matters: our response to Martha’s Rule
In late 2024, we implemented a service aligned with Martha’s Rule, ensuring patients and families have a clear pathway to raise concerns about their care. This reflects our commitment to patient safety, empowerment, and responsive clinical support as a charitable organisation delivering exceptional care.
Why we took action
Martha’s Rule emphasises listening to patients and enabling escalation when care does not meet expectations. In line with our patient-centred care strategy, we designed a solution suited to our organisation.
Collaborative design
We worked with trusts delivering similar services to share learning. The Call 4 Concern service at Royal Berkshire Hospital provided a strong foundation, and their team supported adaptation to our context. Our approach drew on:
- Best practice guidelines and literature
- Collaboration with experienced trusts
- Patient-centred care principles.
Addressing challenges
Independent hospitals face challenges including:
- Smaller clinical teams and limited on-site consultants, complicating rapid escalation
- Providing 24/7 coverage without overstretching resources
- Diverse patient demographics requiring language and cultural sensitivity
- Bespoke governance and policy development without centralised NHS frameworks
- Reputation sensitivity in a competitive environment.
Our strengths
Our strengths enabled rapid implementation:
- Organisational agility enabling quicker decisions
- An established outreach team with escalation pathways
- Strong support for patient-facing materials
- Integration of hotel services, housekeeping and catering service recovery
- Collaboration with the international office to support overseas patients
- Highly engaged clinical leadership focused on patient experience.
Implementation and patient education
The service is delivered through our 24/7 outreach team, escalating concerns to ICU teams and consultants. Key steps included:
- Developing and approving policy with support from stakeholders and the Medical Advisory Committee
- Displaying patient information in all rooms
- Educating patients and families at pre-assessment and on wards
- Engaging staff and appointing nurse leaders as service champions.
Key Achievements
- Policy developed and launched within months
- Partnership with Royal Berkshire Hospital to adapt a proven model
- Patient education embedded at pre-assessment and reinforced on wards
- Materials displayed in all patient rooms
- International patient inclusion supported by the international office
- Nurse leaders appointed as service champions.
Impact
The initiative strengthens our response to patient concerns, providing reassurance during times of stress while reinforcing our commitment to safety, transparency and compassionate care.
Jess’s Rule
Jess’s Rule is a primary care initiative to encourage GP teams to rethink a diagnosis if a patient presents three times with the same symptoms or concerns, particularly if symptoms unexpectedly persist, escalate or remain unexplained.
In 2026, we will work with primary care providers to identify ways to embed the principles of ‘reflect, review and rethink’ into their practice in situations where a patient presents three times with the same or escalating symptoms.
Supporting sexual safety
We continue to take the issue of sexual safety extremely seriously, building on the foundations laid last year to strengthen the sector’s collective response. In 2025, we brought members together for a dedicated Sexual Safety learning event, providing a space for open discussion, shared learning and practical actions to ensure that every organisation within the independent sector upholds a zero-tolerance approach to bullying, harassment and sexual misconduct of any kind within the workplace.
A key development in 2025 was the growing momentum behind the NHS Sexual Safety in Healthcare Charter, which sets out clear expectations for organisations to actively prevent, respond to and learn from any unwanted, inappropriate or harmful sexual behaviours. We are proud that:
- 57 IHPN member organisations are now signatories, demonstrating a strong and growing commitment across the sector.
- 94% of IHPN Strategic Council members have also signed the charter, reflecting leadership-level commitment to cultural change.
- As an organisation, we have formally signed the charter, underscoring our organisational dedication to driving standards and setting expectations for members.
In addition, we continue to support providers through practical tools and opportunities for shared learning. Our Sexual Safety managers’ toolkit, launched in 2024, remains an available resource for members, outlining six key steps for well-led organisations to promote safe cultures, respond effectively to concerns and support staff with confidence and clarity.
Together, these efforts demonstrate that the independent healthcare sector is not only aligned with national expectations on sexual safety but is actively working to enhance standards, empower staff and embed a culture where sexual safety is understood, prioritised and championed at every level.
Patient safety partners
Patient safety partners (PSPs) have become a growing area of focus within safety governance across the independent healthcare sector. Emerging from NHS England’s Framework for Involving Patients in Patient Safety, PSPs offer valuable lived experience perspectives that enhance organisations’ commitment to patient-centred safety. Our sector-specific document: ‘Recruitment of PSP’s Best Practice Principles’ is supporting providers as they develop and adapt PSP roles to reflect diverse organisational structures and needs.
Case study: Patient safety partners – Nuffield Health
As with many organisations, the recruitment of a patient safety partner (PSP) presented some challenges for Nuffield Health.
We decided that having the patient’s voice represented in an even more meaningful way than through methods we already use was a priority, so recruitment began during the implementation phase of PSIRF. As a charity, we have charity members, many of whom have a long relationship with the organisation and have a role in ensuring our good governance, so it seemed a logical step to see if one of them may be willing to interview for the role. Initially, we felt it was important that our PSP understood the charity, as well as healthcare, and was able to hold us to account on behalf of the thousands of patients we treat.
We were fortunate enough to find a willing volunteer, Bill, and even more fortunate that he ‘aced’ the interview and came with a background in both a safety critical industry (airline) and pastoral care (latterly a vicar in the Anglican Church). On reflection over the two years he has been with us, his experience has been vital as he brings a level-headed and compassionate approach to understanding our patient safety incident profile: reviewing patient safety incident investigation reports to ensure they meet the needs of the patient or family involved and constructively challenging us on safety actions emerging from these. Two families commented that they were surprised our investigations were as transparent as we had promised and that the reports were written in a way they could understand, as they had been sceptical about this. Bill played a vital part in this, scrutinising the language and level of compassion thoroughly.
In 2025, Bill worked closely with our patient safety specialist (PSS) to refresh our approach to patient experience forums. They ensured there was a standardised approach, which involved setting charity-wide terms of reference so that everyone involved understood their role and the essential need for confidentiality. They also established a clearly defined agenda which included sharing patient safety data at site level as well as complaints and their responses (anonymised). Bill supported our PSS to provide useful hints and tips on how to successfully recruit participants. His enthusiasm in the Teams meetings with sites to introduce the concept during roll-out provided a new perspective on the value of listening to patients to gain meaningful quality improvement.
Bill provides the patient’s voice as a member of our quarterly Board Safety and Quality Meeting, which includes the Nuffield Health Executive and Board of Governors, demonstrating the charity’s commitment to the CQC’s new strategy of having ‘an unrelenting focus on safety, …[through] learning, listening and acting on people’s experiences’. It will also enable us to achieve the second of our five ambitions – ‘to deliver the best possible customer and patient experience’.
Our plan is to recruit two further PSPs to work with Bill and provide some site-based PSP coverage by providing each of our three regions with direct access to a PSP to support at a local level.
As a final thought, here is what Bill says about his vital role as a PSP: “Often the wonders of medical science, combined with the clinical care we provide to patients, can overawe their perception of the enhancements to their wellbeing from their treatment. I believe that the role of the PSP is to promote and celebrate the importance of the patient’s voice, in terms of their engagement and participation in the successful outcome we are seeking to achieve.”