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Published 4 June 2018
The establishment of a network of Freedom to Speak Up Guardians across the NHS was one of the key recommendations of Sir Robert Francis’ Freedom to Speak Up review. It was precipitated by the findings of his earlier investigation into the failings at Mid-Staffordshire hospitals.
According to the annual report of the National Guardian's Office, published in October last year, nearly 4,000 members of NHS staff have spoken to their Freedom to Speak Up Guardians, raising over 1,000 patient safety issues.
Corinne Slingo, Partner at DAC Beachcroft, says that whilst the Guardian is a nationally recognised role, each organisation is approaching the job, and the way it is delivered, slightly differently.
“Within larger NHS organisations in particular, we have seen some blurring of lines between this important role and the other routes to raise concerns, including within HR processes. This can prove challenging to navigate, but that is more about the Guardian being clear on the scope (and limits) of the role than a problem with the role itself, and should be easy to resolve.”
Slingo feels that the ‘ultimate test’ is whether the role shows a demonstrable shift in culture and delivers an associated impact on patient safety. “Realistically the Guardian role remains but one of a selection of patient safety initiatives and cultural game changers introduced post Francis, which collectively are improving patient safety culture across the sector,” she concludes.
“Am I a friend or trouble maker? I was picked because I was seen as a person of trust and integrity who may not be the bringer of the best news.” So says Dr Judith Graham, the Deputy Director of Organisational Development at Rotherham, Doncaster and South Humber NHS Foundation Trust, the trust’s Freedom to Speak Up Guardian.
She describes the complexities of interactions where a concern has been raised. “Some people get defensive, feeling they are being accused of being a failure as a manager, asking ‘why did my staff come to you not me?’ It’s important to offer support to those who are being complained about as well as those who make the complaint.
“Some parts of the NHS feel ashamed that there is a need for Guardians, that it’s not a good thing to admit, and engaging more means more conflict. But is that a bad thing if it is managed well?” Graham stresses she does not want to build a power base. “We always tell people there are many ways of raising concerns; managers, unions, the Care Quality Commission (CQC), and Guardians are one part of that suite.”
When deemed necessary, Graham works to ascertain any immediate patient safety concerns. “If there is a nursing issue the Director of Nursing would look into it under the guise of a mock CQC inspection, if we need to maintain confidentiality. If not, we work with the complainant and their manager in an open and transparent way to gain a resolution.”
Concerns fall into two categories: patient safety, and staff bullying. “People seem happier raising patient safety concerns with managers, and come to us with bullying. They can raise concerns anonymously or confidentially, or they can be raised completely openly.”
Graham continues: “It’s made clear to complainants that, as a result of an issue being raised, their own competence could be questioned depending on what the complaint is about – and that could have repercussions. All we want all of the time is for any concerns to be raised so we can act on them immediately and provide the best care possible for our patients and staff.”
Graham says that a background as a Mental Health Nurse helps when dealing with traumatic situations. The trust suggested her for the Guardian role and she was appointed after an interview process.
She hopes the system helps put staff at ease about raising concerns. “People need to feel confident to talk so I have recruited Guardian Advocates who come from all sorts of grades, disciplines, ages and genders. If the complainant doesn’t want to talk to me, they can speak to someone else that they do feel more comfortable with.”
Dealing with actual concerns makes up just 5 to 10% of Graham’s work. “The rest is being a visible leader, championing the ability of others to raise concerns and breeding a safety culture. I walk about the trust, I wear the Guardian lanyard, there are posters and banners about Guardians across the sites.”
Graham has had training around legal and HR issues and more is being developed by the National Guardian’s Office.
“Some people come to see me because they have a concern, others come because they don’t want to see their line manager as they may be ashamed that they are not coping or working well enough,” says Graham. “My role is to either support them through this or for one of my Freedom to Speak Up advocates to offer them the necessary support.”
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Anne Crofts, Alistair Robertson
Anne Crofts, Dr Alexandra von Westernhagen, Udara Ranasinghe