Speaking up for safer care

The ability of staff in the healthcare sector to speak up when they have concerns, and to have those concerns taken seriously, is of paramount importance not only for staff wellbeing, but also for patient safety. The recently published Ockenden Report and the inquiry into Paterson clearly illustrate this point.

In the former, the inquiry into maternity services at the Shrewsbury and Telford NHS Trust (SaTH) found many examples where staff were at best ignored when they raised concerns about the care that was being provided, and at worst experienced bullying and harassment for trying to speak up. As the report details, this inability to raise concerns, along with an overall poor workplace culture, directly contributed to poor patient outcomes which tragically included the avoidable deaths or serious injury of babies and women. Unfortunately, this is not a historical problem; a number of staff who had spoken to Donna Ockenden’s team withdrew their comments before the publication of the report out of fear that they would be identified, even though their contributions to the report were going to be anonymised. That staff still cannot speak up about one of the NHS’ biggest care failures for fear of repercussions shows how urgent and necessary it is to implement change around ‘speaking up culture’ to improve safety for patients.

Similarly, the inquiry into disgraced breast surgeon Ian Paterson found that there were numerous instances where staff had tried to raise concerns about his practices and behaviour but were not listened to or no action was taken. This contributed to the length of time it took to get Paterson struck off and for criminal charges to be laid; as a result, hundreds more people suffered harm. While Paterson is fully responsible for his actions and the significant harm he inflicted, had staff who worked with Paterson and had concerns been empowered to speak up and been listened to when they did, he may well have been stopped years before he actually was.

In order to avoid repeating the terrible failures in care detailed in the Ockenden and Paterson inquiries, providers across the entire healthcare system need to pay attention to and implement the learning from these reports, including the importance of creating a speaking up culture. Both of these inquiries, as well as many other investigations into healthcare failings, have occurred because of significant efforts from patients and families to get their concerns addressed. In many cases there were also staff who had been expressing concerns, but no action was taken. This shows the importance of having systems and policies in place for how to respond when staff members raise issues.

In the National Guardian’s annual survey of Freedom to Speak Up Guardians 73% of respondents from NHS Trusts and 78% of respondents from the independent sector thought the speak-up culture had improved in the last twelve months in their organisations. Moreover, 70% of Guardians in the independent sector reported spending at least half of their time focussing on “proactive” aspects of their role, such as working within their organisation to tackle barriers to speaking up, While this is encouraging, there is still more work to do. Having a Freedom to Speak Up Guardian gives workers ‘access to this essential, additional route to speak up’, and is a necessary part of any healthcare organisation, whether in the NHS or independent sector. While there are currently almost 200 Guardians in the independent sector, IHPN are calling for all independent providers to appoint a Guardian if they haven’t already done so.

The National Guardian, Jayne Chidgey-Clark, is a keynote speaker at this year’s annual IHPN/CQC patient safety conference on 25 May where she will discuss the importance of fostering open cultures in healthcare, highlighting the critical link between speaking up culture and patient safety. The National Guardian’s office, together with Health Education England (HEE) has also recently launched the third module of their learning package designed for leaders at all levels to help them foster a speaking up culture in their organisation. The module covers topics such as: what is a healthy speaking up culture, measuring the effectiveness of a speaking up culture, the role of leaders in setting the tone, and supporting your Freedom to Speak Up Guardian. It is available to any organisation and can be found here: Freedom to Speak Up – elearning for healthcare (

Although reports like Ockenden and Paterson show that there are many factors that contribute to unsafe care, the absence of a culture where staff could freely speak up and be listened to has been a key failing that has led to significant harm. The importance of creating a speaking up culture, including having a Freedom to Speak Up Guardian at every healthcare organisation, cannot, therefore, be overstated. Not only will this improve staff-wellbeing, which supports staff retention, but patients will receive safer, better quality care.

Kelly Marsh, Policy and Regulatory Executive, IHPN