INTRODUCTION
The Francis Report following the Public Inquiry at Mid Staffordshire NHS Foundation Trust identified that workers had tried to speak up about patient safety concerns but had been ignored and even victimised as a result.1 In the subsequent Freedom to Speak Up Report, Sir Robert Francis made recommendations for the changes needed to improve the NHS, leading to an open and transparent culture for the benefit of patient care.2 Freedom to Speak Up builds on the work already undertaken in primary care in order to tackle and prevent patient safety incidents. Nearly a quarter of responders to the consultation were from primary care, demonstrating that there is still more to do.3 NHS England’s guidance requires all primary care providers to identify a Freedom to Speak Up Guardian either within or outside the organisation. This editorial describes the requirements for Freedom to Speak Up in primary care in England and how NHS organisations are developing a culture of safety and learning where all workers are able to speak up safely.
SPEAKING UP IN PRIMARY CARE
The landscape of primary care is complex, with numerous smaller providers and some larger, multisite providers. Speaking up in small teams can be challenging particularly if your manager is also your employer, or for GPs, raising concerns about a partner or colleague. Regulations in primary care include the National Performers List regulations4 and Revalidation regulations5 which are the statutory responsibility of NHS England and the General Medical Council respectively. The commissioning landscape is complex and shifting, with CCGs taking on co-commissioning of general practice with NHS England. This raises the question — who do you turn to if you want to speak up? The nature of the concern may also dictate which agencies are required to be informed and involved, such as the Local Authority Designated Officer for safeguarding concerns.
PROTECTING THE INDIVIDUAL
For a worker who wants to speak up, it can be a very lonely and stressful situation. They may have worries about relationships with other members of the practice team, their current and future employment and whether this conflicts with their professional obligations to speak up about a patient safety, probity, or conduct concern. Staff may live near their place of work and have close social or family relationships with members of the practice team. Individuals may be fearful of being labelled a troublemaker or not being a team member. This is particularly difficult when general practice and primary care are under enormous pressure to meet patient and public expectations with reduced resources. Locum staff and trainees can view organisations through fresh eyes and may identify improvements for patient safety and patient and staff experience. However, it can be more challenging for new staff to speak up, particularly in a hierarchy or if staff feel vulnerable about being offered future work or having their training signed off. Additionally, some workers may feel less confident about speaking up.
The negative experience of some high profile whistleblowers who have suffered detriment as a consequence of speaking up can also act as a deterrent to workers feeling confident to speak up in the future. The Employment Support Scheme currently being piloted by NHS England aims to prevent whistleblowers losing employment and to help those who have left employment but whose performance is sound, return to the NHS.
NATIONAL GUARDIAN’S OFFICE
The National Guardian’s Office was set up as a key recommendation of the Francis Report into speaking up. The overarching principle is that every organisation needs to foster a culture of safety and learning in which all workers feel safe to raise a concern. All trusts are required to nominate a Freedom to Speak Up Guardian as part of their standard NHS contract. In March 2017 all NHS trusts had either appointed a single or multiple individuals to the role, contracted the role to an external organisation, or had plans to appoint to the role.
The Freedom to Speak Up Guardians listen to workers about concerns they have about patient care and then oversee the actions taken by the organisation as a result. This may involve an investigation, and the outcomes are communicated back to the worker so that they are aware about how their concerns have been addressed. As well as their reactive role the Freedom to Speak Up Guardians are also expected to act as positive agents for change, identify best practice in supporting workers to speak up using the Francis principles to establish the culture of safety and learning. The Freedom to Speak Up Guardians present information about speaking up to the Boards of the organisation concerned ensuring that the organisation is actively listening to the views of workers and responding to their feedback for the benefit of patient care. Guardians also work closely with other bodies locally including staff representatives, patient safety teams, organisational development, staff wellbeing, local Healthwatch and patient representative groups.
The National Guardian provides national leadership in speaking up and to this end all organisations within and around the NHS will be asked how they are contributing to the speaking up agenda. Regulators have a part to play in ensuring that staff are not victimised as a result of speaking up. Additionally the practices of other industries across England have been sought to ensure the best knowledge has been applied. This includes sectors such as aviation, education, banking, financial regulation, and telecoms.
THE ROLE OF NHS ENGLAND
The Freedom to Speak Up Report made recommendations for NHS England, which included NHS England becoming a Prescribed Person for whistleblowers and adapting the principles of Freedom to Speak Up for the different contexts of primary care. Staff working at GP surgeries, opticians, community pharmacies, and dental practices can raise concerns about patient safety or inappropriate activity directly with NHS England.6 Guidance has been issued to clarify the expectations of primary care organisations.7
NHS England recognises that there are differences within and between the different elements of primary care and has provided several options for implementing Freedom to Speak Up recommendations by September 2017. However, there are certain basic elements that all primary care organisations need in place. They will need to have reviewed their policies for raising concerns and responding to concerns and to make sure that everyone who works in the organisation understands where they can go to raise concerns. As a minimum they will have to ensure the policies are in place and that communications are clear. NHS England also recognises that some primary care organisations or GP federations will want to appoint their own Freedom to Speak Up Guardians. These Guardians can promote speaking up and ensure that employers are aware of their responsibilities and working to improve the culture of reporting and listening.
NHS England is developing resources to support workers in primary care organisations to raise concerns. Training materials developed for NHS trusts by Health Education England on how you raise and respond to concerns are being adapted to meet the needs of primary care workers.8 The principles will be the same, however the case studies and the language used will reflect the reality of working in a small or medium sized organisation, rather than a large organisation led by a Board. Where Freedom to Speak Up Guardians are appointed in primary care, NHS England will work with them to provide helpful and primary care focused materials. There are other organisations you can approach for advice and support (Box 1).
Box 1. Support organisations
If you are looking for support, you can also contact the following organisations:
NHS Whistleblowers’ Helpline
(www.wbhelpline.org.uk)
Phone: 0800 072 4725
Email: Enquiries{at}wbhelpline.org.uk
Public Concern at Work
(www.pcaw.org.uk)
Phone: 0207 404 6609
Email: whistle{at}pcaw.org.uk
CONCLUSION
The NHS is a complex and interdependent set of organisations with a wide range of staff groups. These may have professional obligations from their regulators as well as working under different sets of contractual and regulatory frameworks.
Freedom to Speak Up Guardians for primary care and NHS England resources and training materials will help to ensure that all staff feel safe to speak up and that organisations listen and respond appropriately to staff feedback for the benefit of patient care.
Notes
Provenance
Commissioned; not externally peer reviewed.
- © British Journal of General Practice 2017
REFERENCES
- 1.↵
(2013) Final report, The Mid Staffordshire NHS Foundation Trust Public Inquiry — Chaired by Robert Francis QC.
- 2.↵
- 3.↵
- 4.↵
- 5.↵
(2012) The General Medical Council (Licence to Practise and Revalidation) Regulations Order of Council 2012, Statutory Instruments 2012 No. 2685. Health Care and Associated Professions Doctors.
- 6.↵
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- 8.↵
