By Dr Minh Alexander NHS whistleblower and former consultant psychiatrist 16 May 2017
This is an early, quick and dirty look at the emerging characteristics of so-called ‘Freedom To Speak Up Guardians’ – roles that are not evidence based but provide a sop to calls for real reform of whistleblowing governance.
There is no good, complete evidence yet. The National Guardian reassuringly told the press in January 2017 that 201 trusts had appointed a Speak Up Guardian. 1
The reality is that the Speak Up Guardian landscape is akin to the Wild West. Only it is less organised.
Jeremy Hunt has endlessly cited the Freedom To Speak Up Review to prop up implausible claims that he is building the safest, most transparent health service in the world. In truth, the government hasn’t bothered much with the Review’s centre piece – the creation of Speak Up Guardians. Most likely as it was never considered a serious venture to begin with, serving only a decorative function.
Francis’ proposal for Speak Up Guardians was short on detail.
Then the government made the situation worse by allowing trusts to do whatever they wanted: installing whatever arrangements they liked, or delaying until guidance was available:
“In addition, if Trusts feel confident to appoint their Guardian without this guidance, they should not wait for the guidance to be published.” 2
The guidance came late – in September 2016 3 – given the glacial rate at which the CQC approaches its duties.
Inevitably in the absence of evidence base and guidance, all sorts of weird and wonderful permutations sprang up, which will make meaningful evaluation a nightmare.
Some trusts appointed networks of Guardians and champions. Some held elections. Professional backgrounds and seniority vary considerably. Many trusts have published little detail on how their Guardians work or what capacity in terms of WTE has been installed. A pre-conference poll by the National Guardian suggested that the majority of Guardians are part time – 70% indicated that they had less than one day of protected time. 4
An unenthusiastic tone is reflected in a number of trust board papers:
“Freedom to Speak Up Guardian Raj Bhamm, Head of Workforce Strategy, has been appointed to this role for a 3 year period. This is a CQC requirement.”
One can understand why some trusts may be reluctant to expend time and money on this imposed project, when the NHS is under such immense strain.
A wander through the gallery of Speak Up Guardians throws up interesting individual examples, if the paper trail is to be believed:
- A Speak Up Guardian who was formerly the Head of Legal Services at Mid Staffs.5
- A Speak Up Guardian who is also listed as Head of Comms.6
- A Speak Up Guardian who came from John Lewis.7
- A Speak Up Guardian who used to be the Chief Executive of the Foundation Trust Network 8
- A Speak Up Guardian who used to a Director of Comms 9
I wrote to Robert Francis about general concerns and gave the example of the former Mid Staffs Head of Legal Services. His response acknowledged that implementation has been variable and resulted in a lack of uniformity. 10
NHS Employers started publishing an interactive map showing all the trusts that had reportedly appointed Guardians:
The most recent version of this map, dated 31 March 2017, accounted for only 209 trusts.
Of the trusts that did not feature on the NHS Employers map, eight have not clearly appointed a Speak Up Guardian yet, based on published papers:
|Buckinghamshire Healthcare NHS Trust|
|Hertfordshire Partnership NHS Foundation Trust|
|Kingston Hospital NHS Foundation Trust|
|Pennine Acute Hospitals NHS Trust|
|North West Anglia NHS Foundation Trust
(previously Peterborough and Stamford NHS Foundation Trust and Hinchingbrooke Healthcare NHS Trust, which merged on 1 April 2017)
|Princess Alexandra Hospital NHS Trust|
|Queen Victoria Hospital NHS Trust|
|Royal United Hospitals Bath NHS Foundation Trust|
I must question the reliability of the data reported to NHS Employers by some trusts. It looks in some instances that trusts may have just given NHS Employers names of contacts who were not actually Freedom to Speak Up Guardians, usually senior managers. In some of these cases, a check of trust records shows that Freedom To Speak Up Guardians had not even been appointed.
A related question arises about whether the National Guardian’s above figure of 201 trusts with Guardians included duff data, given by trusts who just wanted the centre off their backs. I suspect it did.
Corporate Speak Up Guardians
There are also worries about the corporate nature of some Guardian appointments.
A trawl of all the Speak Up Guardians flagged on the most recent version of NHS Employers’ Guardian map and trusts’ papers revealed that 66 trust directors and 30 associate directors had apparently been appointed as Speak Up Guardians in 88 trusts.
Two directors were each Guardians for two trusts, and three trusts had more than one director acting as Guardians.
This is the supporting data:
Cross checking with other sources such as board papers confirmed only some of these apparent appointees as Guardians – only 28 out of the 66 directors and only 16 out of 30 associate directors were clearly Speak Up Guardians.
Of course, some of the unconfirmed cases may be Guardians. And many of those directors who were not confirmed as Guardians are nevertheless those who are in control of the appointment and operation of Guardians.
However, conservatively there are so far at least 44 confirmed ‘corporate’ Speak Up Guardians, in 37 trusts:
This is a list of those 37 trusts:
The 44 corporate Speak Up Guardians broke down as follows:
|Type of Trust Director||Number|
|Medical director||4 (3 medical directors, 1 associate medical director)|
|Director of nursing||4 (2 directors of nursing, 2 associate directors of nursing)|
|Director of human resources||3 (1 director of HR, 2 associate directors of HR)|
|Directors of corporate affairs||3 (2 directors of corporate Affairs, 1 associate director of corporate affairs)|
|Directors of governance (and similar)||10 (2 directors of governance, 8 associate directors of governance)|
|Other types of directors||5 (4 directors, 1associate director)|
It is a concern that there are so many corporate appointments, as questions arise about values, perspective and patient-centredness.
As Mid Staffs showed, unchecked managerialism can be deadly to patients.
Few BME Speak Up Guardians
As well as an unhealthy dose of corporate salts, the Guardians also look rather white so far.
I have so far come across only 15 Guardians who are from visible ethnic minorities.
This is despite a higher proportion of BME individuals in the NHS workforce than in the general population.
At last count:
17% of the whole NHS workforce were non-white
38% of NHS doctors and dentists were non-white. 11
I took a closer look at the available data on Speak Up Guardians in trusts that serve 38 of the most ethnically diverse districts (based on the 2011 census 12).
These districts ranged from Newham (29% white) to Coventry (73.8% white). 13
Of course, the percentage of BME staff in NHS services in these districts is higher than the average across the whole NHS. For example, the proportion of BME staff in the London NHS workforce is 44%, according to NHS England. 14
I found that in the 48 trusts serving these districts, there were 12 non-white Speak Up Guardians and 49 white Speak Up Guardians. 15
Even accounting for incomplete data, this suggests that power appoints in its own image.
This is not very good news for just culture, or for BME whistleblowers, who the Freedom to Speak Up Review acknowledged were much more likely to be ignored and to suffer reprisal. 16
But then, it’s not as if anyone really cared enough to administrate the establishment of Speak Up Guardians in a coherent and efficient manner.
No one tends to the window dressing once it’s been hung out.
As one trust illustrates, the focus is now on serious stuff….. such as ensuring a supply of green lanyards:
|“Freedom to Speak Up (FTSU) – The ‘Freedom to Speak Up’ review, published in February 2015, highlighted how important it is for every part of the NHS to develop a culture in which all staff are positively encouraged to raise issues about safety, quality and effectiveness of patient care and supported when they do so. It was a requirement for all NHS Trusts to appoint Guardians to work with trust leadership teams to implement this agenda. The National Guardian for FTSU has now been appointed, Dr Henrietta Hughes. She held the first National Guardians conference in March 2017. NCH&C have increased the number of FTSU champions and held its third steering group meeting. Actions developing from the group include; a role description for the advocates; implementation of the national reporting dataset; inclusion on datix for staff to raise concerns directly to the Trust Guardians; FTSU green lanyards for champions; development of a FTSU logo for NCH&C; communication plan to cascade information; implementation of dedicated phone line for reporting concerns.”
Norfolk Community Health and Care NHS Trust Board paper 26 April 2017
UPDATE 8 June 2017
Curiously, three weeks after I wrote about these issues of poor quality data on Speak Guardians, their questionable diversity and the large number of corporate appointments, one of the main published data sources has disappeared. It is NHS Employers’ interactive Speak Up Guardian map, which gave details of Speak Up Guardians appointed so far by trusts. A ‘page not found’ message is obtained when the relevant link is clicked. I have asked NHS Employers why the map has been erased and whether there are plans to replace it.
1 Learning Not Blaming, Department of Health July 2015
2 More than 30 trusts do not have whistleblower guardian. Health Service Journal, 12 January 2017
3 CQC guidance on job description for Speak Up Guardians
5 Rebecca Southall, former Head of Legal Services at Mid Staffs, currently Director of Corporate Affairs at University Hospitals of Coventry and Warwickshire NHS Trust is listed as the Speak Up Guardian for UHCW and also for Coventry Warwickshire Partnership NHS Trust
6 Sarah Newby Head of Comms and Fundraising at Luton and Dunstable NHS Trust is also Speak Up Guardian according to NHS Employers’ data
7 Caroline Owens is listed as the Speak Up Guardian for the very troubled Brighton and Sussex University Hospitals NHS Trust. Her LinkedIn data and other sources indicate that her background is in corporate affairs at John Lewis.
8 Sue Slipman, an non executive director at Kings College Hospital NHS Foundation Trust, and who was previously CEO of the Foundation Trust Network, is listed by NHS Employers as King’s Speak Up Guardian
9 Venessa James is a non executive director for South West Ambulance Service NHS trust, is named as the Speak Up Guardian for the trust by NHS Employers. Her LinkedIn data indicates that she was previously the Director of Comms at NHS Devon PCT.
10 Correspondence with Robert Francis about Speak Up Guardian appointments
11 NHS Employers ethnicity stats for the NHS May 2017
12 2011 Census: table of ethnicity by district
13 List of the 38 most ethnically diverse districts based on 2011 census
14 WRES 2016 Data analysis report for trusts, NHS England April 2017 Page 101:
“In London the proportion of the NHS trust workforce from BME backgrounds is 44%.”
16 Freedom to Speak Up Review by Robert Francis 11 February 2015