FTSU case story: Getting staff to speak up in a primary care organisation

Principle 7: Identify and tackle barriers to speaking up


The NHS England Freedom To Speak Up (FTSU) guide for leaders discusses eight principles fundamental to creating environments in which people feel safe to speak up with confidence.

The case story below gives an example of how these principles have been used to cultivate and demonstrate evidence-based improvements in NHS organisations.

NHS leaders (including executive and non-executive FTSU leads) and FTSU guardians can take inspiration from these case stories and use them to help develop their own plans for improvement to ensure that they develop healthy speak up cultures.

What was the aim/problem?

A primary care network (PCN) launched a nine-month FTSU pilot programme, staffed by two fully-trained FTSU guardians.

Despite extensive preparation – the managing partner explaining to PCN staff the concept of FTSU and its benefits, guardians attending online meetings/events to introduce themselves and outline the FTSU pilot – no PCN staff contacted the guardians during the first two months of the pilot.

What was the solution?

The guardians felt that investing time in attending GP practices and becoming more familiar with staff might give people more confidence to speak up.

With the agreement of the managing partner, the guardians visited the five GP practices in the third month of the pilot and spent two hours on site attending a staff meeting and holding a drop-in session.

Practice managers at four of the GP practices publicised the visit ahead of the day by putting up posters and sending an email to all staff.

During the visit, the guardians attended a routine staff meeting and spoke about their role, what could be spoken up about, and who they were as people. The guardians mentioned that they were not employees of the GP practice, but of the (then) clinical commissioning group.

After the staff meeting, the guardians held a drop-in session to answer any questions staff had. During the one-to-one conversations the guardians made sure to shut the door of the room they were in to provide privacy.

What were the results?

In the month following the face-to-face sessions, 10 staff spoke up from four of the GP practices. Working practices and employment matters were among some of the matters raised.

The guardians provided an interim report to the partners and a response paper was circulated to all staff via email.

The pilot was extended for a further three months and the guardians are currently in the process of ensuring that the staff who spoke up receive personal feedback.

What were the learning points?

The guardians identified five main reasons why staff spoke up to them:

  1. Support from the practice manager was visible.
  2. Knowing that the guardians were not employed by the GP practice.
  3. Meeting with people face-to-face enabled the guardians to convey authenticity and commitment to listening and acting on concerns. It also gave staff the opportunity to gain a more in-depth understanding of the speaking up process and to make judgements about how credible and trustworthy they found the guardians to be.
  4. Providing staff with a confidential, safe space to speak to the guardians helped them open up about their worries and ask questions without feeling uncomfortable or vulnerable.
  5. The importance of ensuring partners are aware that concerns raised must be considered, and that feedback must be given to staff raising concerns.

What are the next steps?

An independent evaluation of the pilot has been commissioned by the local Health Education England training hub involved in setting up the pilot.

The guardians will be meeting with the GP partners and managing partner to discuss possible future FTSU arrangements, taking into consideration work being done by the training hub to establish these arrangements for all primary care workers within the integrated care system.

Find out more

This case study relates Principle 7: Identify and tackle barriers to speaking up in the FTSU Guidance. In addition, the following resources may be of interest:

  • Edmonson AC (2018). The Fearless Organization: Creating psychological safety in the workplace for learning, innovation, and growth. Wiley
  • Kline N (2002). Time to Think. Cassell
  • Reitz M, Higgins J (2019). Speak Up: Say what needs to be said and hear what needs to be heard. FT Publishing International

For further information, please contact the FTSU Team at NHS England: england.ftsu-enquiries@nhs.net.