Executive Summary

Board members are asked to note and discuss progress made by the National Guardian’s Office and priorities for this financial year. 

Background

1. The National Guardian’s Office was set up in October 2016 as part of recommendations from the Francis Freedom to Speak Up Review (2015). Dr Hughes stepped down from her role as National Guardian in September 2021 and Dr Jayne Chidgey-Clark was appointed and commenced the role in December 2021. 

2. The office leads, trains and supports a network of Freedom to Speak Up Guardians in England and conducts speaking up reviews to identify learning and support improvement of the speaking up culture of the healthcare sector. The National Guardian’s Office also provides challenge and learning to the healthcare system as part of its remit.   

3. Progress continues to be made to improve the speak up culture across a range of organisations, systems, and processes across the health sector. Since the National Guardian Office last update to the Board on 25 July 2024, there are now 1,400 Freedom to Speak Up Guardians[1] supporting thousands of organisations across the healthcare sector, who have handled over 142,000 speak up cases to date[2] allowing workers to speak up who might otherwise not be heard.

[1] As of May 2025.

[2] As of March 2025

4. The National Guardian lays an annual report before Parliament each year, and reports to the Boards of its funding 06 March 2024. The Annual Report can be found here. The report shares intelligence and learning collated by the National Guardian’s Office.  

5. The report also features case studies from across England and different healthcare providers, sharing the experiences of people who have spoken up and the difference Freedom to Speak Up guardians are making.

6. The National Guardian will bring the 2024/2025 annual report to NHSE Board later in the year. This report provides highlights of progress and priorities for this year.

Funding

7. In 2023 a memorandum of understanding was agreed for 2023 – 2026 between CQC, Department of Health and Social Care and NHSE. For the next three years the National Guardian’s Office’s budget has been reduced by 5% to £1.58m.  A business plan has been developed and approved based on the reduced budget. 

Governance

8. The National Guardian’s Office’s Accountability and Liaison Board meets four times a year. In accordance with the CQC/DHSC Framework Agreement on an annual basis the Office reports to CQC’s Audit and Risk Committee, CQC’s Board and NHSE’s Board.

Update following publication of the 10 year plan and Patient Safety Landscape Review

9. At the time of submission, following the recent announcement in the 10 year plan the National Guardian’s Office’s functions will be aligned with the other staff voice functions in NHS England and the National Guardian’s Office will cease to exist. NHS England will take on the National Guardian’s national functions. NHS England will transfer, in due course, to the Department of Health and Social Care.

10. Our understanding is that the role of guardians will remain across the health service. It is the functions of National Guardian’s Office that will be changing.    

Highlights of progress since July 2024 report

11. Freedom to Speak Up Guardian network. 

11.1.    There are now more than 1,400 trained Freedom to Speak Up guardians in the National Guardian’s Office ’s network and included on the published directory. Since the National Guardian’s Office’s establishment, the variety of organisations represented has expanded from NHS organisations with Freedom to Speak Up guardians being appointed in:

• NHS trusts and foundation trusts
• integrated care boards
• primary care providers including GP practices, dentistry, optometry, and pharmacy services
• independent providers of healthcare including hospices, hospitals and diagnostic services
• arm’s length bodies, national organisations, and regulators

11.2. Organisations in other sectors, including education and financial services, have also sought to learn from and implement the Freedom to Speak Up Guardian model. We have also had conversations with international organisations seeking to implement the Freedom to Speak Up model.

11.3 We have continued to collect anonymised data about the speaking up cases raised with Freedom to Speak Up guardians. This information shows that:

• one in every three cases raised (32.3 per cent) involved an element of worker safety or wellbeing. An increase from one in every four cases (27.6 per cent) in 2022/23
• two in every five cases raised (38.5 per cent) involved an element of inappropriate behaviours and attitudes. The most reported theme in 2023/24
• one in five (19.8 per cent) of cases reported included an element of bullying or harassment. A 2-percentage point fall compared to 2022/23
• nearly one in five (18.7 per cent) of cases raised included an element of patient safety/quality, a marginal drop compared to 2022/23 (19.4 per cent)
• detriment for speaking up was indicated in 4 per cent of cases, the same as in 2022/23
• the percentage of cases that were raised anonymously was one in ten (9.5 per cent). This was similar to the percentage raised anonymously in 2022/23 (9.4 per cent)
• four-fifths (79.8 per cent) of those who gave feedback said they would speak up again

11.4. NHS Staff Survey – We continue to work with NHS England and other stakeholders to improve understanding of the speaking up landscape in healthcare, including through the NHS Staff Survey and the pilot National NHS Bank Survey. The results of the 2024 NHS Staff Survey showed:

• The Freedom to Speak Up sub-score in the 2024 NHS Staff Survey remains virtually unchanged at 6.45 compared to 6.46 in 2023. While this suggests stability, it also highlights a lack of progress and risks a slide backwards into disengagement and silence. However, some groups of workers and sectors have seen improvements.

Where improvements have happened:

• ambulance trusts have shown slight gains in confidence, following a sector-wide review and targeted interventions.
• Minority ethnic staff has seen a steady increase in confidence that their organisations will act, rising from 54.5% in 2023 to 55.2 per cent in 2024.
• Internationally recruited workers report higher trust in organisational action than UK recruits – a key finding as we prepare to publish our review of overseas-trained workers’ speaking-up experiences.

Where progress has stalled:

• across the system, confidence levels have not increased, and in some areas, they are declining.
• workers who are part of the Wider Healthcare Team shows a steady decline in trust that their organisation will act on concerns – falling from 59.9per cent in 2021 to just 53.5 per cent in 2024.
• longer-serving staff report lower confidence in speaking up than newer employees, raising concerns about disengagement over time
• white staff have seen a consistent decline in trust that their organisation will act on concerns

11.5. These trends reinforce a wider issue: while targeted efforts in some areas have led to improvement, the overall speaking-up culture remains stagnant. Without renewed attention, there is a risk of further decline.

The action gap: a barrier to progress

• while some staff feel able to raise concerns, many do not trust that those concerns will lead to change. This action gap remains a key challenge for the system
• 71.5 per cent of staff feel safe raising concerns about unsafe clinical practices (unchanged from 2023). Yet only 56.8 per cent believe their organisation will act on patient safety concerns
• 61.8 per cent feel safe raising concerns about anything in their organisation (slightly down from 62.3 per cent in 2023), but fewer than half (49.5 per cent) trust their organisation to act on concerns more generally

11.6.  These results show that a speak up culture without action risks creating disillusionment, distrust, and disengagement. This trust gap is critical. Workers may still be speaking up, but confidence in follow through is eroding. If concerns are consistently met with actual or perceived inaction, many workers will stop speaking up altogether.

11.7.  We are calling on leaders to move beyond encouraging workers to speak up by building confidence in their Freedom to Speak Up processes to demonstrate that speaking up leads to meaningful change

12. Speak Up Reviews

12.1 As part of our mission to make speaking up business as usual, the National Guardian’s Office carries out reviews where we have information indicating barriers to speaking up exist. Speak up reviews seek to identify learning, recognise innovation, support improvement and improve the experience of workers, patients, and the public.

Listening to Workers – A Speak Up Review of ambulance trusts in England.

12.2 Our inaugural thematic Speak Up Review into NHS ambulance trusts in England was published in February 2023. We proposed this review in response to consistent findings that, despite their inspection ratings, the speaking up culture in NHS ambulance trusts tended to be more challenged compared to other trust types.

12.3 The report made four recommendations, which if actioned would improve speaking up culture within the next three years: 

• review broader cultural matters in ambulance trusts
• make speaking up in ambulance trusts business as usual 
• effectively regulate, inspect and support the improvement of speaking up culture in ambulance trusts
• implement the Freedom to Speak Up Guardian role in accordance with national guidance to meet the needs of workers

12.4 In December 2024 we published an update on progress made against the report’s recommendations. We have agreed with NHS England that the residual actions will be become part of its improvement programme.

Overseas-Trained Workers

12.5 In March 2024, the National Guardian’s Office announced its second Speak Up Review, looking into the experience of overseas-trained workers. The aims of the review are to: 

• enhance the understanding of the Speak Up culture among overseas-trained workers in the NHS
• identify and address barriers that prevent these workers from speaking up
• recognise and disseminate examples of good practice in supporting an open and safe environment for speaking up
• develop actionable recommendations to improve policies and practices, fostering a more inclusive and supportive Speak Up culture

12.6 The report was published on 1 May 2025. HSJ led on its publication on 1 May and partners with whom we shared the review described our approach as ‘structured and systematic’ and commended the resources the National Guardian’s Office provides to implement its recommendations.

12.7 Following publication, the Speak Up Review team will set up a quarterly steering group to oversee the implementation of recommendations. This group will exist for 18 months to two years.

12.8 The next review is scheduled to begin in summer 2025. It follows the Health Services Safety Investigations Body recommendation that the National Guardian’s Office, working with relevant stakeholders, identifies the barriers that prevent temporary staff from speaking up and develop mechanisms to address those barriers. This Speak Up Review will build on our work to explore barriers for other staff groups and enable all workers to contribute to patient safety improvements without fear of reprisal.

13. Working with our Partners

Primary medical services and integrated care systems 

13.1 We continue to work closely with NHS England and CQC to develop and embed speak up routes, including how Freedom to Speak Up guardian roles can be implemented effectively in primary medical services and integrated care system settings. We have established a Primary Care Guardian Network and an ICB Guardian Network to support learning and development of the guardian role within these settings

Recommendations to Impact working group

13.2 The National Guardian’s Office is a member of the Perinatal Culture and Leadership Steering Group which is made up of healthcare leaders from across the ‘perinatal’ landscape. The Office has been in discussion with members regarding where Freedom to Speak up could be embedded across several member initiatives regarding worker voice, team cultures, ways of working, protocols, policies and procedures.

Thirlwall

13.3 In March 2025, National Guardian’s Office submitted evidence to the Thirlwall Inquiry.

Review into the patient safety landscape:

13.4 In September 2024, the Secretary of State commissioned a review into the patient safety landscape to be led by Dr Penny Dash. The National Guardian met with Dr Dash four times as part of the National Guardian’s Office’s engagement and with other patient safety leaders on a fortnightly basis. The National Guardian’s Office supplied five returns to the review.

14. Guardian support

Training

14.1 The Freedom to Speak Up Guardian role is complex, and their work is constantly evolving. The National Guardian’s Office have developed an annual Refresher module to support guardians’ learning and development needs on changes and updates to the Freedom to Speak Up landscape. For 2024/25, the Office launched Equity, Diversity, Inclusion and Belonging for its refresher module. It has been well received and has become part of every new guardian’s foundation training from 2024/25. 

14.2 For those guardians who were unable to complete their training on time the National Guardian’s Office wrote to them directly and, where necessary their leadership asking for them to complete by 31st January. In total 23 guardians were removed from the registry, 11 notified the Office that they had stepped down from the role and 12 were removed for non-compliance. No Trusts were in breach of the NHS Standard Contract.

Review of the e-learning for Health (e-lfh) Speak Up and Listen Up modules.

14.3 Launched to all workers in 2020 the Freedom to Speak up in healthcare training modules are for everyone wherever they work in healthcare and explained in a clear and consistent way what speaking up is and its importance in creating an environment in which people are supported to deliver their best. . The training is divided into three parts – Speak Up, Listen Up and Follow Up.

14.4 This year the National Guardian’s Office undertook a content review of the Speak Up and Listen Up modules to ensure the content, including links to supportive materials and terminology is relevant and in line with NHS values. We have identified updates and will work with NHS England to revise the modules over the next six months.

14.5 A review of the Follow Up training has been scheduled for Q4 2025/26.

Guardian Development

14.6 Detriment Guidance – This guidance has been designed to make speaking up business as usual by ensuring those who have spoken up are supported. It also covers how to remove the barriers of fear of detriment that may prevent speaking up. The guidance was developed in collaboration with the Freedom to Speak Up networks to support Freedom to Speak Up Guardians, their organisations, and their leadership.

14.7 Employment Tribunals Fact Sheet – The National Guardian’s Office has seen an increase in queries from Freedom to Speak Up guardians about how to respond when they are approached for information or to be a witness at an employment tribunal or similar proceedings. In response, we have produced a fact sheet to offer guidance to guardians. 

14.8 Universal Job Description/ Guardian Recruitment Framework – In 2024/25, the National Guardian’s Office undertook a review of the Universal Job Description for the Guardian role. The review was prompted following Speak Up Reviews recommendations regarding ringfenced time and proper resourcing of the Guardian role. Feedback from Freedom to Speak Up guardians suggests that the current job description is no longer fit for purpose and clarity over role expectations is needed.

14.9 Launched in May 2025, following extensive stakeholder engagement, the current ‘universal job description’ has been replaced by one document Freedom to Speak Up Guardian Recruitment Toolkit, which has three distinct parts, these are:

1. a framework document for organisations and leaders and
2. a freedom to speak guardian up role specification.
3. Four example job descriptions

14.10 The four guardian job descriptions are current ones from the health sector. These were used in recruitment, went through HR processes like job banding, helped attract candidates, and led to hiring guardians. Using current job descriptions shows how the role is banded and delivered in different organisations. This approach supports leaders and HR departments to understand the required role and band for a guardian. The National Guardian’s Office recommends guardians be on NHS AfC bands 7 to 8a, or the equivalent in non-NHS organisations, as reflected in these descriptions.

15. Communications and engagement

Annual Conference 

15.1 In March 2025 the conference took place in London on 13 March. The theme was Speaking Up – Changing Organisational Culture for which 210 guardians, champions and ambassadors attended the event in person, with 518 joining online for part of the day.

15.2 We were delighted to receive videos for the event from Baroness Merron, Sir Julian Hartley, and Prof Mary Dixon-Wood. The day featured two panel sessions: why good teams matter in healthcare, and how to build an open and honest reporting culture.

Annual Report

15.3 The National Guardian’s Annual Report 2023/24 was laid in March 2025. The laying of the Annual Report before Parliament was a commitment made by the Secretary of State in his response to the events at Gosport War Memorial Hospital, as a means of holding the government to account on supporting the fostering of an open culture in the healthcare sector in England.

15.4 The report shares intelligence and learning collated by the National Guardian’s Office, which indicates that more work is needed for speaking up to be described as business as usual in the healthcare sector in England.

Speak Up Month

15.5 The theme for our seventh Speak Up Month in 2024 focused on listening and the important part we can all play in listening to one another and fostering psychological safety. 

Supporting Freedom to Speak Up guardians.  

15.6 Case studies showcasing good practice, blogs from leaders and stakeholders and 100 Voices stories from workers who have spoken up have been published on our website. These are also shared in our monthly newsletter for stakeholders, which is received by nearly 3,000 people who have signed up via our website. 

15.7 We continue to support Freedom to Speak Up guardians with communications resources to help them in their role and our fortnightly bulletins share information across the Freedom to Speak Up Guardian network. We produce a programme of webinars throughout the year which complements our annual conference for Freedom to Speak Up guardians.

Engagements

15.8 Over the past year a number of engagements have been undertaken including – Patient Safety Leader visits to British Airways and EasyJet, Board Development Sessions, Champion events, Trust and ICB conferences and Communities of Practice.

15.9 Health sector specific engagements included:

• Health Services Safety Investigations Body Pathways to Impact Workshop
• Health Services Safety Investigations Body Recommendations to Impact Workshop
• National Quality Board
• Healthcare Regulators Forum

Media engagements 

• 24/07/2024 Sky News – Sexual safety in the ambulance service
• 27/07/2024 HSE – Patient safety: England’s national guardian says ‘broken’ NHS can be fixed by listening to staff
• 29/07/2024 Financial Times – Whistleblowing cases on the rise in UK’s employment tribunal system
• 05/08/2024 HSJ – Support managers ‘to do the right thing’ says whistleblowers’ champion | News | Health Service Journal (hsj.co.uk)
• 14/11/2024 Sky News – Interview regarding Sky’s report into sexual misconduct amongst paramedics

Podcasts

• 24/08/2024 – Matthew Winn – Culture and fear with Jayne Chidgey-Clark – Leadership & culture in healthcare | Podcast on Spotify
• 02/2025 Outstanding Society – Adult Social Care
• 02/2025 Patient Safety Learning

Next Steps

16. All of the key areas identified in this progress report continue to be priorities for 2025/26. Our work programme and business plan will focus on: 

Continuing support and development for Freedom to Speak Up guardians, including: 

• Developing a champions video to clarify their role and support recruitment
• Developing executive Freedom to Speak Up lead video and guidance.
• Publication of How to guidance – for example the use of data.
• Publishing a Guardian handbook.

 Speak Up Reviews. 

• Support the implementation of the Speak Up Review into overseas-trained workers and tracking of recommendations
• Launch the next Speak Up Review on Temporary Workers in Autumn 2025/26.

Work with NHS England and CQC to support the implementation of the Universal Freedom to Speak Up policy and guidance.

Proposals for implementation of the new guidance including:   

• Develop bespoke training for CQC inspectors to better understand the implementation of Freedom to Speak Up and the role of the Freedom to Speak Up guardians
• Revise the Freedom to Speak Up: A guide for leaders in the NHS and organisations delivering NHS service in collaboration with NHS England.

Strengthening National Guardian’s Office governance, including: 

• Implement the collection of protected characteristics as part of the anonymised data collected by guardians.

Publication reference: Public Board paper (BM/25/25)(Pu)