Speaking up policy

Policy summary

All NHS Organisations and others providing NHS healthcare services in primary and secondary care in England are required to adopt this national policy as a minimum standard to help normalise and standardise speaking up for the benefit of patients and workers. Its aim is to ensure all matters raised are captured and considered appropriately.

Furthermore, the Public Interest Disclose Act 1998, as amended, (the Act) provides protection to staff (Speaking Up) who want to report suspected wrongdoing or danger at work such as corporate fraud, health and safety matters and breaches of legislation.

This policy is intended to explain how staff can report concerns and how the Trust will respond to them.

Policy title

Speaking Up Policy

Reference and Version No

RM36 Version 2.2

Author and Job Title

• NHS England
• National Guardian Office
• Freedom to Speak Up Guardian
• Executive Lead: Chief Nurse, Director of Patient Safety and Quality

Validated By

Policy Review Group

Ratified By

Joint Forum

Date Issued

8 March 2023

Date for Review

8 March 2026

Related Documents

• HR10 Standards of business conduct policy
• HR02 Resolution policy
• C46 Adult safeguarding policy
• C50 Children’s safeguarding policy
• GMC guidance – raising and acting on concerns regarding patient safety
• NMC guidance – Raising and acting on concerns for nurses, midwives and and nursing associates

This Policy is Intended for

All Staff Groups

Equality and Health Inequalities Statement – NHS England

Promoting equality and addressing health inequalities are at the heart of NHS England’s values. Throughout the development of the policies and processes cited in this document, we have:

• Given due regard to the need to eliminate discrimination, harassment and victimisation, to advance equality of opportunity, and to foster good relations between people who share a relevant protected characteristic (as cited under the Equality Act 2010) and those who do not share it; and
• Given regard to the need to reduce inequalities between patients in access to, and outcomes from healthcare services and to ensure services are provided in an integrated way where this might reduce health inequalities.

North Tees and Hartlepool NHS Foundation Trust and North Tees and Hartlepool Solutions is committed to the fair treatment of all, regardless of age, colour, disability, ethnicity, gender, gender reassignment, nationality, race, religion or belief, responsibility for dependants, sexual orientation, trade union membership or non-membership, working patterns or any other personal characteristic. This policy will be implemented consistently regardless of any such factors and all will be treated with dignity and respect. To this end, an equality impact assessment has been completed on this policy.

1. Speak up – We will listen

1.1 At North Tees and Hartlepool NHS Foundation Trust and NTH Solutions, we welcome speaking up and we will listen. By speaking up at work you will be playing a vital role in helping us to keep improving our services for all patients and the working environment for our staff.

This policy is for all our workers including independent organisations that provide NHS services, NHSP staff, staff who work across Trusts, agency workers, temporary workers, students and volunteers.

1.2 The NHS People Promise commits to ensuring that “we each have a voice that counts, that we all feel safe and confident to speak up, and take the time to really listen to understand the hopes and fears that lie behind the words” Alongside the NHS People Promise, The National Guardian Office (www.nationalguardian.org.uk) states “Workers can speak up about anything that gets in the way of high-quality effective care, or that affects their working life”.

1.3 We therefore want to hear about any concerns you have, whichever part of the organisation you work in. We know some groups in our workforce feel they are seldom heard or are reluctant to speak up. You could be an agency worker, bank worker, locum or student. We also know that some workers with disabilities, or from a minority ethnic background or the LGBTQ+ community do not always feel able to speak up. We want to assure you that this policy is for all workers and we want to hear all our workers’ concerns.

1.4 There is also a “Speak Up” training module available on our ESR course catalogue or the national e-learning for Health Care. If you have line management responsibilities, we recommend you watching “Listen Up” and “Follow Up” is for all senior leaders to complete. These modules are designed to help you understand the part you can play in developing a healthy speak up-listen up-follow up culture.

1.5 You can find out more about what Freedom to Speak Up (FTSU) is in these videos.

2. What can I speak up about

2.1 This policy takes into account the recommendations of Sir Robert Francis, following his review into Speaking Up in the NHS in 2016 after the report of the Mid Staffordshire NHS Foundation Trust Public Inquiry which found a serious failure to sufficiently listen to staff (and patients). It is intended that this policy will help staff to normalise the raising of concerns for the benefit of all patient.

2.2 You can speak up about anything that gets in the way of patient care or affects your working life including something which doesn’t feel right to you. Examples of this include (but are not limited to):

• Patient safety concerns, quality of care, unsafe staffing.
• A particular way of working or a process that isn’t being followed.
• Professional malpractice.
• You feel you are being discriminated against.
• Working relationships e.g. the behaviours of others is affecting your wellbeing or that of your colleagues.
• A bullying culture (across a team rather than individual instances of bullying).
• A breach of confidentiality, trust policy or procedures.
• Suspicion of fraud.
• A criminal offence has been committed, or is likely to be committed.

2.3 Speaking up, therefore captures a range of issues, some of which may be appropriate for other existing processes. For example, individual complaints such as harassment or discrimination can be handled in accordance with the Trust’s Resolution Policy – Formally Grievance HR02 via the People Services Team.

As an organisation, we will listen and work with you to identify the most appropriate way of responding to the issue you raise.

3. We want you to feel safe to speak up

3.1 We acknowledge that speaking up is not always an easy thing to do. Your speaking up is a gift to us because it helps identify opportunities for improvement that we might not otherwise know about.

3.2 Speaking up is also an educational opportunity to encourage and promote active listening to concerns being raised. Listening up and following up are key parts of the process albeit it is acknowledged that information shared is sometimes difficult to hear or accept.

3.3 However, we will also not tolerate anyone being prevented or deterred from speaking up or being mistreated because they have spoken up. If you have experienced detriment after speaking up, we want to know about this.

3.4 If you are told not to log a patient safety concern / incident via Datix for example, feel unable to raise work related concerns inside or outside your service area and don’t feel able to go down your route of choice, this would be considered a deviation to the Speaking Up Policy. This can be raised too.

4. Who can speak up?

4.1 Anyone who works in NHS healthcare, including pharmacy, optometry and dentistry. This encompasses any healthcare professionals, non-clinical workers, receptionists, directors, non-executive directors, managers, contractors, public health, researchers, volunteers, students, trainees / apprentices, secondees, junior doctors, locum, bank and agency workers, and former workers.

4.2 Issues raised relating to allegations made against staff in relation to safeguarding adults and children will be addressed via the appropriate protocol – arrangements for managing allegations against staff (Safeguarding Adults and Children).

4.3 If staff are uncertain whether something is within the scope of this policy, they are encouraged to seek advice from the Freedom to Speak up Guardian (FTSUG), a Champion or the Employee Relations Team to help signpost them to the appropriate place. Please refer to FTSU Staff Guide to Speaking Up for further details.

5. Who can I speak up to?

Speaking up internally

5.1 Most speaking up happens through conversations with supervisors and line managers where challenges are raised and resolved quickly. We strive for a culture where that is normal, everyday practice and encourage you to explore this option – it may well be the easiest and simplest way of resolving matters.

However, you have other options in terms of who you can speak up to, depending on what feels most appropriate to you. These routes include:

• Senior manager or director with responsibility for the subject matter you are speaking up about.
• Our Patient Safety Team or Clinical Governance Team (where concerns relate to patient safety or wider quality): [email protected]
• Local counter fraud specialist (for concerns relating to theft, bribery, fraud or corruption): Steven Sherwood-Hodgson – [email protected] or the Acting Director of Finance: Kate Hudson-Halliday
• Our People Services Team on [email protected]
• Our HR Team at NTH Solutions on [email protected] or 01642 624935.
• Our Freedom to Speak Up Guardian (FTSUG): We acknowledge that some of our staff may not want to speak up via the established internal or external routes. Where this is the case, the Guardian can be contacted as an alternative route. The Guardian although locally employed by the Trust acts independently to help staff raise their concerns. The FTSUG can be contacted on: [email protected] or 07769 922667. People who speak up will be thanked, the issues signposted or responded to, and the person speaking up will be offered feedback on the actions taken. You can find out more about the guardian role here.
• Our senior lead responsible for Freedom to Speak Up: Hilary Lloyd, Chief Nurse Director of Patient Safety and Quality who provides senior support for our FTSUG and is responsible for reviewing the effectiveness of the FTSU arrangements.
• Our non-executive director responsible for Freedom to Speak Up: Fay Scullion. The NED role is specific to organisations with boards and provides more independent support for the guardian. It also provides assurance at Board level that appropriate FTSU arrangements are in place.

Please refer to Appendix A – What will happen if I speak up?

Speaking up externally

If you do not want to speak up to someone within the Trust, you can speak up externally to:

• Care Quality Commission (CQC) for quality and safety concerns about the services it regulates – you can find out more about how the CQC handles concerns here.

• NHS England for concerns about:

• GP surgeries
• Dental practices
• Optometrists
• Pharmacies
• How NHS trusts and foundation trusts are being run (this includes ambulance trusts and community and mental health trusts)
• NHS procurement and patient choice
• The national tariff

NHS England may decide to investigate your concern themselves, ask your employer or another appropriate organisation to investigate (usually with their oversight) and/or use the information you provide to inform their oversight of the relevant organisation. The precise action they take will depend on the nature of your concern and how it relates to their various roles.

Please note that neither the Care Quality Commission nor NHS England can get involved in individual employment matters, such as a concern from an individual about feeling bullied.

• NHS Counter Fraud Agency for concerns about, theft, bribery fraud and corruption, using their online reporting form or calling their freephone line 0800 028 4060.

If you would like to speak up about the conduct of a member of staff, you can also do this by contacting the relevant professional body such as the General Medical Council, Nursing and Midwifery Council, Health & Care Professions Council, General Dental Council, General Optical Council or General Pharmaceutical Council.

Appendix B contains information about making a ‘protected disclosure’.

6. How should I speak up?

6.1 You can speak up to any of the people or organisations listed above in person, via MS Teams, phone or in writing (including email). The most important aspect of your speaking up is the information you can provide, not your identity.

You have a choice about how you speak up:

Openly: you are happy that the person you speak up to knows your identity and that they can share this with anyone else involved in responding. Staff are encouraged to speak openly where possible. We want staff to feel empowered and to be involved in any resolution, suggestions and ongoing improvements.

Confidentially: you are happy to reveal your identity to the person you choose to speak up to on the condition that they will not share this without your consent. Some staff ask for a 100% guarantee that their identity will remain confidential. It is not always possible to guarantee this and there may be some circumstances in which your identity will need to be shared e.g. if part of a legal process or a fitness to practice hearing. Also, if you have already shared information with others or where facts of the case may enable others to identify you, maintaining confidentiality could be impossible. Confidentiality should be discussed when you raise your concern and what this may mean for you.

Anonymously: you do not want to reveal your identity to anyone. Please note, whilst raising concerns anonymously is accepted, it may be more difficult to thank you and to ask you for further information about the matter in order to ensure the concern is actioned appropriately. It also means that you might not be able to access any extra support you need or receive feedback on the outcome.

Whichever way you decide to report, please be ready to explain your concern with civility and respect and be prepared to include any relevant information available that you want to share.

Corresponding with the Trust’s Resolution Policy:

• Please describe the nature of your concerns, clearly setting out your reasons.
• Please describe any evidence you may have in relation to your concerns and attach / include any appropriate paperwork.
• Please describe how you would like your concerns to be resolved.

You may also want to include any suggestions for improvement.

7. Advice and support

You can find out about the local support available to you via SharePoint. Please also refer to Appendix D for further contact details. Your staff networks could also be a valuable source of support. Please contact Employee Relations for a list of staff networks available to staff via [email protected].

You can access a range of health and wellbeing support via NHS England:

Support available for our NHS people.

Looking after you: confidential coaching and support for the primary care workforce.

NHS England has a Speak Up Support Scheme that you can apply to for support. You can also contact the following organisations:

• Speak Up Direct provides free, independent, confidential advice on the speaking up process.
• The charity Protect provides confidential and legal advice on speaking up.
• The Trades Union Congress provides information on how to join a trade union.
• The Law Society may be able to point you to other sources of advice and support.
• The Advisory, Conciliation and Arbitration Service gives advice and assistance, including on early conciliation regarding employment disputes.

8. What will we do

The matter you are speaking up about may be best considered under a specific existing policy/process; for example, our Resolution Policy or Standards of Business Conduct Policy. If so, this will be discussed with you. If you speak up about something that does not fall into an HR or patient safety incident process, this policy ensures that the matter is still addressed.

What you can expect to happen after speaking up is shown in Appendix A.

Resolution and investigation

We also support our managers/supervisors to listen to the issue you raise and take action to resolve it wherever possible. In most cases, it’s important that this opportunity is fully explored, which may be with facilitated conversations and/or mediation.

Where a review or investigation is needed, this will be objective and conducted by someone who is suitably independent (this might be someone outside your organisation or from a different part of the organisation) and who is appropriately trained. The aim is to reach a conclusion within a reasonable timescale (which you will be notified of), and a report will be produced that identifies any issues to prevent problems recurring.

Any employment issues that have implications regarding capability or conduct identified during the investigation will be considered separately.

Communicating with you

We will treat you with respect and will thank you for speaking up. We will discuss the issues with you to ensure we understand exactly what you are worried about. If a decision is made to investigate, you should be told how long the investigation is expected to take and an agreement made with how to keep you up to date with its progress. Wherever possible, we will share the full investigation report with you. Please note, in respecting the confidentiality of others and recognising that some matters may be strictly confidential, it may be that we cannot even share the outcome with you but assurance will be given about action being taken.

How we learn from your speaking up

We want speaking up to improve the services we provide for patients and the environment our staff work in. Where it identifies improvements that can be made, we will ensure the necessary changes are made, and are working effectively. Lessons will be shared with teams across the organisation, or more widely, as appropriate.

Review

We will seek feedback from workers about their experience of speaking up. We will review the effectiveness of this policy and our local process annually, with the outcome published and changes made as appropriate.

Senior leaders’ oversight

Our most senior leaders will receive a report at least annually providing a thematic overview of speaking up by our staff to our Freedom to Speak Up Guardian. A monthly report is also presented to Executive Staff.

9. Responsibilities

9.1 The Chief Executive of the Trust and the Managing Director for NTH Solutions are ultimately responsible for this policy and fully endorse the “speak up, listen up, follow up” ethos as mandated by the National Guardian Office.

9.2 Directors, Associate Directors & Clinical Directors are required to ensure the policy and procedure is communicated to all staff and applied within their area of responsibility.

9.3 The Chief Nurse / Director of Patient Safety & Quality and the Freedom to Speak Up Guardian will:

• be responsible for ensuring the implementation of this policy;
• oversee the operation, monitoring and review of this policy;
• be responsible for ensuring consistency of approach across directorates;
• regularly review this policy in consultation the National Guardian Office and NHS England
• Provide monthly reports on number of cases (“themes”) to the Executive Management Team
• Provide reports on number of cases (“themes”) to the Board annually
  Liaise with the Trust’s Communications Team to prepare information which is relevant to promotion and progress in evolving the speak up culture including posters, staff messages or any changes in FTSUG personnel.

9.4 The Non-Executive Director assigned to Freedom to Speak Up provides independent support to the FTSUG and acts as assurance that appropriate FTSUG arrangements are in place.

9.5 The Deputy Chief People Officer is required to ensure all staff within People Services are fully cited on this policy and have completed Speak Up and Listen Up training modules.

Please also refer to Appendix C, Monitoring of the Policy.

9.6 Employees are required to understand and follow this policy. Individual employees have a responsibility to raise concerns if they have reasonable belief that malpractice or wrongdoing has occurred or is likely to occur, and the disclosure is made in the public interest. Employees should try to keep a record of their concern, including the details of the believed malpractice/wrongdoing, who they reported this to and any feedback they have received following the investigation.

Support and guidance can be provided by the person the employee is speaking up to.

Please refer to Appendix D, Other Useful Contacts.

Appendix A – What will happen when I speak up?

We will:

• Thank you for speaking up
• Help you identify the options for resolution
• Signpost you to health and wellbeing support
• Confirm what information you have provided consent to share
• Support you with any further next steps and keep in touch with you

Steps towards resolution:

• Engagement with relevant senior managers (where appropriate)
• Referral to HR process
• Referral to Patient Safety process
• Other types of appropriate investigation, facilitated meetings or mediation

Outcomes:

The outcomes will be shared with you wherever possible, along with learning and any improvement identified.

Escalation:

• If resolution has not been achieved, or you are not satisfied with the outcome, you can escalate the matter to the senior lead for FTSU or non-executive lead for FTSU
• Alternatively, if you think there are good reasons not to use internal routes, speak up to an external body, such as the CQC or NHS England.

Appendix B – Making a protected disclosure

Making a ‘protected disclosure’

A protected disclosure is defined in the Public Interest Disclosure Act 1998. This legislation allows certain categories of worker to lodge a claim for compensation with an employment tribunal if they suffer as a result of speaking up. The legislation is complex and to qualify for protection under it, very specific criteria must be met in relation to who is speaking up, about what and to whom. To help you consider whether you might meet these criteria, please seek independent advice from the Protect or a legal representative.

Appendix C – Monitoring of the policy

Any concerns raised with the Freedom to Speak Up Guardian will be securely recorded to include summary of case and any follow up actions taken. The Trust Board will be given high level information about all concerns raised by our staff in accordance with this policy, including information on what actions are being taken to address any problems. The Board supports staff in raising concerns and wants employees to feel free to speak up.

Appendix D – Other useful contacts

Occupational Health Team
Email: [email protected]
Telephone: 01642 383211
Monday to Friday

Staff Support Psychology Service
Email: [email protected]
Telephone: 01429 522049
Monday to Friday

Chaplaincy Team
Telephone: 01642 624714 or 01642 383138

National Guardian Office
Website: https://nationalguardian.org.uk