Integrated care boards, integrated care systems and Freedom to Speak Up

Freedom to Speak Up is one way of ensuring our NHS people have a voice that counts, which is central to our NHS People Promise. The following information clarifies the expectations of integrated care boards (ICBs) and integrated care systems (ICSs) in relation to Freedom to Speak Up.


In June 2022, NHS England and the National Guardian’s Office published an updated Freedom to Speak Up guide and improvement tool to support organisations with delivering a speaking-up culture for their workers. In addition, an updated national Freedom to Speak Up policy was published. These documents apply to primary care, secondary care and more widely in health and care systems.

What integrated care boards should do

As you agree on ICS-level outcomes for all organisations in your ICS, it’s important to think about how Freedom to Speak Up will support the delivery of those outcomes in terms of worker voice, worker experience and patient safety. ICBs have a great opportunity to ensure speaking up routes are available for all workers in NHS healthcare providers across the ICS. This must include access to a Freedom to Speak Up guardian(s) at organisation, place and/or system level. Appointing an executive and non-executive lead for Freedom to Speak Up within your ICB will provide leadership for that work. Specifically:

Freedom to Speak Up for ICB workers by 30 January 2024:

  • ICBs must ensure their own ICB staff have access to routes for speaking up including Freedom to Speak Up guardian(s), and associated arrangements. Some of you may have adopted legacy clinical commissioning group arrangements and, as NHS organisations, ICBs are expected to adopt the new national policy and use the guide and improvement tool to map the plan for the next three years.

Freedom to Speak Up for primary care workers over the next 18 months:

  • ICBs should think about primary care workers across the ICS having access to routes for speaking up, including access to a Freedom to Speak Up guardian(s) who is registered with and trained by the National Guardian’s Office. Please note:
    • There are relatively very few trained and registered Freedom to Speak Up guardians that support primary care workers. Even where guardians are in place, levels of speaking up (both reported and not reported to the National Guardian’s Office) remain extremely low.
    • Building on the report by the National Guardian’s Office in 2021, NHS England and the National Guardian’s Office are working with those guardians already in place to better understand the practical challenges of Freedom to Speak Up in primary care and create a menu of support for organisations and ICSs.
    • NHS England is working with a small number of ICBs who already have work underway to address this, so that the learning from their experience can be documented and shared.

Freedom to Speak Up across the ICS over the next 18 months:

  • ICBs should start to think about:
    • How they will gain assurance that all NHS organisations across the ICS have accessible speaking up arrangements, in line with the guidance and policy recently published, considering the different barriers that workers face when speaking up and actions to reduce those barriers.
      • NHS England has asked that all NHS trusts adopt the policy and apply the guide and improvement tool over the next 18 months and have provided assurance to their public boards by the end of January 2024.
    • How they might share good practice and learning across the ICS about speaking up culture improvements.
    • The systems they will put in place to capture and measure speaking up data.

What next?

Based on our ongoing work with primary care and ICBs referenced above, NHS England and the National Guardian’s Office plan to share further information by 31 March 2024 about the precise expectations of ICBs in regard to Freedom to Speak Up for primary care workers and across their system. 

Please note:

  • If ICBs are considering appointing a Freedom to Speak Up guardian now as a point of escalation for staff across the ICS, we suggest they get in touch with NHS England’s Freedom to Speak Up team for guidance and support.
  • Should an ICB decide to appoint a Freedom to Speak Up guardian to support staff that work in organisations across the ICS, we would advise you to think about whether this role should be separate from a Freedom to Speak Up guardian role that supports ICB staff.
  • Once an ICB has appointed a guardian through fair and open recruitment processes, please contact the National Guardian’s Office to access the appropriate training and support. ICBs will need to consider the resources (time and support) that the guardian will need to meet the needs of the workforce.
  • When you have appointed a guardian, please ensure they complete their training and are added to the directory on the National Guardian’s Office website.
  • Please get in touch with the National Guardian’s Office to share your learning and reflections nationally on implementing freedom to speak up.
  • Please email the National Guardian’s Office to sign up to their newsletter and keep up to date with latest developments.