The Quiet Crisis: Challenges, changes and co-production to hear the voices of healthcare staff
In complex healthcare systems, staff voice is vital for ensuring healthcare professionals and service providers uphold safe, ethical and high-quality care. When staff are unable to voice concerns about patient safety or their own wellbeing, mistakes and misconduct are more likely to go unaddressed, allowing scandals to happen or last longer. Organisations such as the National Health Service (NHS) have been long aware of these risks and currently use “speaking up” policies to combat the silencing or neglect of staff concerns. After 9 years of speaking up policy many NHS staff still find themselves unheard or silenced. Now, the U.K. government’s Department of Health and Social Care (DHSC), which oversees the NHS, proposes new plans to remove these existing policies and introduce new staff voice policy under the NHS Fit for the Future strategy (NHS England, 2025). In this blog post Sukhwinder Essie Kaur unpacks the failings of Speaking Up and explores how co-production research may be a key player in designing new policies and mechanism that better support NHS staff to voice their concerns.
What is Speaking Up Policy?
Nine years ago, Sir Robert Francis KC’s “Freedom to Speak Up” (2015) review of the Mid-Staffordshire scandal recognised staff voice as instrumental for identifying staff and patient risks early and preventing harm from escalating within healthcare services (Culture change in the NHS, 2015; Mannion et al., 2018; Wilkinson et al., 2024). This ushered an era of Speaking Up policies for promoting, supporting and protecting staff who voice their concerns. Dedicated routes and mechanisms for staff to voice concerns were implemented and the creation of the National Guardian's Office mandated the appointment of Freedom to Speak Up Guardians in every NHS trust. Over the years, the policy has helped millions of people raise concerns, access vital advice and guardians have handled thousands of cases raised by staff, often involving issues of patient neglect, bullying and moral injury from overwork and burnout (National Guardian’s Office, 2022).
Where Did it Go Wrong?
While the policy has its merits, it has struggled to move beyond compliance and the control of middle managers, posing a lack of meaningful change for staff, the role of guardian’s contested and deeper cultural problems to persist (Martin et al., 2021). Let’s start with implementation. The policy is intended to act as a national baseline for NHS organisations but studies, such as those by Adams et al (2021), have illustrated inconsistent implementation and weak enforcement of the policy at the department and team levels led to variations in its uptake and acceptance of its use.
Then there is the lack of local social and cultural change. For NHS staff, choosing to speak up about matters and toxic culture, such as mental health, incivility, unsafe care or misconduct is still considered a risk. In 2023, the National Guardian’s Office reported that 35% of NHS staff who spoke up experienced negative consequences, like being ignored, blamed or victimised as a whistleblower (National Guardian’s Office, Freedom to Speak Up Report, 2023). That figure alone raises serious questions about the protective value of the policy mechanisms as there is over a 1 in 3 chance of being unheard, silenced or the recipient of negative consequences.
Other argue that the policy is only as effective as the managers who support it. This includes criticisms that the role of Guardians is too large and under-resourced to work effectively, while a lack of follow-up and vague definitions of “resolution” have left many staff discouraged and mistrusting of guardians to action change. A 2024 Health Services Safety Investigations Body (HSSIB) review of staff wellbeing found that NHS workers often do not trust that they will be protected because they do not feel psychologically safe and there is a fear of speaking up, often because past experiences have shown it does not lead to action or support (Health Services Safety Investigations Body Annual Report and Accounts 2023/24, 2024). For many, it appears that the policy is failing to be implemented and its purpose upheld to provide the meaningful support and cultural change staff need to voice their concerns and have them resolved.
How Does the “Fit for the Future” Strategy Intend to Help?
By removing guardians and providing NHS staff voice mechanisms that will allow them to raise their concerns directly to the DHSC, implies a shift toward achieving a less centralised and hierarchical policy (NHS England, 2025). As these plans have just been announced, it is currently unclear how this will work and whether they will be welcomed by staff. But what is clear is that any new policy for staff voice and speaking up needs provide the meaningful support staff need and guarantee issues will get addressed so staff are confident in it. But how can we (anyone with the vested interest in supporting the voice and wellbeing of healthcare staff) ensure this is achieved?
The Potential of Co-Production for Designing New Speak Up Policy
Co-production is a widely used approach in health policy design. Grounded in participatory design, co-production brings together staff, patients, carers and managers to collaborate on matters and shared interests (Bovaird and Loeffler, 2021). If the DHSC want staff will be confident in the new policy and voice mechanisms, then using co-production in policy research and design with NHS staff may help to uncover what meaningful support means to them, how their concerns should be addressed, what is needed for effective resolutions to be achieved and how these insights can inform policy and be translated as an evolving social practice in NHS organisations. This may enable the new design of speaking up policy to be more accurate process for raising concerns and meeting the needs and unmet needs of staff who want to raise concerns,
Some cases have shown working in partnership with the primary users of the policy may help to cultivate the kind of trust, empathy and reciprocity needed with NHS staff for policies and mechanisms to be successful through co-production. For example, co-production workshops within the NHS East Midlands Collaborative have already led to novel peer-led wellbeing councils and restorative spaces for reflection that were found to be more effective than anonymous hotlines or external reporting under existing Speaking Up policies (see: IMPACT Provider Collaborative). These emergent models suggest that when staff are involved in the co-design of voice mechanisms for raising concerns, they are more likely to trust and use them (Bovaird et al., 2019).
Conclusion: Loud Opportunities
As the DHSC begin their journey to improve how they can listen to the voices of healthcare staff, it presents an opportunity to address the known and hidden challenges of existing speaking up policies and voice mechanisms. Co-produced policy with NHS staff may be a key approach to identifying these challenges and ensuring policy and mechanism designs are in fact, fit for the future, by being fit for purpose and sustainable. A starting point may require an in-depth look at the everyday realities in which staff have used speaking up to voice their concerns or experienced silence to determine what works, for whom, how, in what contexts, and why (Davidoff et al., 2015; Jones et al., 2021; Martin et al., 2023).
Sukhwinder Essie Kaur is based at the University of Birmingham. She is a PhD student at the College of Social Sciences and a Researcher in the School of Management. She was awarded an Elizabeth Garrett Anderson Fellowship (NHS Leadership Academy) and is also a member of the Health Services Research Exchange (Universitas 21 - U21). Her research explores the role of organisational behaviour, healthcare services policy and management in staff mental health and wellbeing.
References
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