Freedom to Speak Up (FTSU) guidance for practices

  • Regulation

What practices should consider when setting out arrangements for speaking up in line with national policy and requirements.

What is Freedom to Speak Up?

Speaking up protects patient safety and improves the lives of workers. When things go wrong, we need to make sure that lessons are learnt, and things are improved. If we think something might go wrong, it’s important that we all feel able to speak up so that potential harm is prevented. Even when things are good, but could be even better, we should feel able to say something and should expect that our suggestion is listened to and used as an opportunity for improvement. Freedom to Speak Up is about encouraging a positive culture where people feel they can speak up, their voices will be heard, and their suggestions are considered and acted upon.

Freedom to Speak Up guardians have long been in place in other areas of the health sector. Whilst it is not a contractual requirement at present, there is now an expectation that ICBs ensure there are arrangements for GP practice staff, and this has gained increasing momentum recently. In 2023, NHS England set out this expectation and for the adoption of the National Freedom to Speak up (FTSU) Policy for all NHS organisations by the end of 2024. This was reiterated in November 2024.

What are the requirements?

We are aware that this is an area the CQC will look at as part of their assessment process. Under the Well Led key question, the relevant quality statement reads “We foster a positive culture where people feel that they can speak up and that their voice will be heard”. In recent assessments, practices have been specifically asked what their individual arrangements are and how these arrangements are communicated to staff. It is an assessment of the culture of your practice – how you openly encourage staff to confidently and safely raise concerns, suggestions or queries they may have.

The relevant CQC myth buster is helpful, this can also be found at the end of this page alongside other information and resources.

A whistleblowing policy has long been part of a standard policy library for General Practice, but practices should ensure they have updated this or replaced it with reference to the FTSU policy. FTSU encompasses not only whistleblowing, but raising a concern, a complaint or a grievance or making a disclosure and could also include offering a pathway for staff to make a suggestion for improvement. Staff should be thanked for raising their concern or issue, and feel they are able to do so without fear of detriment. The term ‘whistleblowing’ can have negative connotations which may be a barrier to speaking up.  Some people associate ‘whistleblowing’ with a formal process, or a matter that is escalated outside an organisation.

Who should be a FTSU guardian?

Further information on selecting a guardian can be found on the National Guardian Office (NGO) website, as well as a universal job description for the role and training requirements. Guardians must undertake the specific Foundation level training provided and be registered with the NGO. Further requirements include a reflective conversation with a mentor within 6 months of becoming a registered guardian, a quarterly reporting obligation as well as annual refresher training. Practice Index provide a helpful guide of further considerations and requirements for the role.

Training for all staff

We recommend that practices ensure appropriate training is in place for all staff. Evidence of this training can be used for the above CQC quality statement, and it will form part of demonstrating the practice’s culture and that senior leaders encourage speaking up. You can access the eLearning For Health core module for all workers for free (“Speak Up”, as below) as well as the subsequent modules for managers and senior leaders.

A summary of the modules:

  • Speak Up: Core training is for all workers including volunteers, students and those in training, regardless of their contract terms and covers what speaking up is and why it matters. It will help learners understand how to speak up and what to expect when they do.
  • Listen Up: This training for all line and middle managers and is focussed more on listening up and the barriers that can get in the way of speaking up.
  • Follow Up: This training is aimed at all senior leaders including executive board members (and equivalents), Non-Executive Directors, and Governors to help them understand their role in setting the tone for a good speaking up culture and how speaking up can promote organisational learning and improvement.

Many other online training providers will offer a similar relevant module for all staff.

Models for Guardians in general practice

The NGO suggests there are two models for ensuring sufficient arrangements for speaking up:

  1. Freedom to Speak Up within an organisation – an individual organisation model – such as a GP practice or Dental surgery; or an ICB.
  2. Freedom to Speak Up within a network or defined structure – a partnership model – for example Primary Care Network or alliance between practices, e.g. a Federation; a local support model – e.g. practices supported by their local ICB or NHS Trust; or an Integrated Care System Model.

Whilst you can have a practice-based guardian, you should consider the barriers this may present in staff feeling comfortable in raising concerns. They may feel they cannot bring issues internally to a colleague or to senior leaders, Partners or Practice Managers for example. Recent guidance from NHSE (Primary care patient safety strategy, 2024 – link available in the Further Resources section below) makes clear that ICBs should seek assurances that primary care staff have access to appropriate speaking up arrangements, and that these should be ‘independent to the provider service’. Should you feel a practice-based guardian suits your practice structure, it would be advisable to also have an alternative pathway to speaking up should the staff member feel this is required. You could have a reciprocal arrangement with a neighbouring practice for example.

Having a guardian at PCN/Federation level is advisable, and you may wish to explore this option with your PCN/Federation board.

Once you have decided upon and elected your guardian, ensure the guardian is well known to your staff and that policies are updated with the relevant contact details. Displaying posters in staff areas or having easily accessible information on your intranet/shared drive will further increase staff awareness. You could consider a training event or internal meeting to ensure this is communicated, there are various resources on the NGO website, including short videos to provide additional context and this can also form part of your evidence for CQC. Make sure to include your FTSU arrangements as part of your induction processes for new staff.

Further support

Should you require any further support or information you can contact Amy Elliott in the GP Support Team at Londonwide LMCs via the GP Support email address [email protected]. Amy is a trained and registered FTSU Guardian for the LMC and has provided this role at PCN level previously.

You can also contact the NGO directly via [email protected].

Further information and resources