Freedom to Speak Up in Hospices: values in action

Categories: Care, Featured, and Policy.

Dr Henrietta Hughes OBE FRCGP, National Guardian for the NHS:

Compassion and justice – the values of the Hospice movement – are an integral element of creating a Freedom to Speak Up culture where everyone feels confident they will be listened to when they speak up, and action taken.

It is a reflection of how psychologically safe people feel, that they are able to speak up, feedback, and work together to innovate and perform effectively. So, there is a strong case for encouraging a Speak Up culture and helping it to flourish.

Hospices working towards a ‘one staff concept’ – wanting to be inclusive of workers, whether they are staff or volunteers, will want to make sure that everyone is reassured that their voice is important. Speaking up and listening up is a dialogue between workers and their organisations.


The role of Freedom to Speak Up Guardians

While there are many existing routes for workers to speak up, through incident reporting mechanisms, via their line manager or educational supervisor, there may be occasions where none of these channels are suitable or trusted. Sometimes people may be fearful that they might be victimised for speaking up or they have tried to raise matters before and been blocked or ignored, or as volunteers they may be uncertain of who to speak to or even whether they can.

Freedom to Speak Up Guardians provide an additional channel for workers, volunteers, students, trainees, contractors, partners and others and work proactively to support a positive speaking up culture.

There are now over 650 Freedom to Speak Up Guardians in England, 6% of whom
work in hospices.

The National Guardian’s Office supports this network of guardians through training and guidance and supports the wider health system by facilitating opportunities for sharing and learning, disseminating good practice and providing challenge to tackle barriers to speaking up.

Guardians act impartially and independently. They thank workers for speaking up, listen, offer support, act to preserve confidentiality where requested and if possible and ensure action is taken and feedback given. Guardians have anecdotally described to me the positive impact of speaking up and listening well in their
organisations, whether that be about patient care, or a reduction in staff sickness absence, fewer grievances, improved staff survey results and better engagement of senior leaders.

Risk Management for Trustees

Speaking up is about anything which gets in the way of good care. There are? over 50,000 cases which have been brought to Freedom to Speak Up Guardians over the past 4 and a half years including those with an element of patient safety and also cases with an element of bullying and harassment. This matters, because we know that incivility in the workplace has a negative impact on patient care.

Workers are the eyes and ears of an organisation and it makes good sense that they should be listened to, especially considering the quality of patient care and worker experience. For Hospice leaders, Freedom to Speak Up Guardians provide an opportunity to understand what matters to workers. By sharing the themes of the
cases which are coming to them, their insights can provide opportunities for improvement and an early warning system of where the stresses and strains are within the organisation, before problems become crises, which could impact upon patients, workers and the hospice’s reputation or finances.


Freedom to Speak Up is for everybody

Making sure that Freedom to Speak Up is available to all workers is vital, especially in hospices who rely so much on volunteers, who may not feel that the usual speaking up routes are available to them.

To help ensure that all workers – whether staff, volunteers, agency, clinical or non-clinical – understand how they can speak up, the National Guardian’s Office, in in association with Health Education England, has developed a free e-learning resource –  – available for everyone wherever they work in health. It explains 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 first module – Speak Up – is for everybody. The second module, Listen Up, for managers, builds upon the first and focuses on listening and understanding the barriers to speaking up. A final module, Follow Up, for senior leaders will be launched later in the year to support the development of Freedom to Speak Up as part of the strategic vision for organisations and systems.

Freedom to Speak Up in Hospices

The Freedom to Speak Up Guardians who work for Hospices have formed one of our national networks for buddying and support. Some of them describe their experiences of establishing their roles below:

“Our Hospice is always looking for way to demonstrate it is well led and is keen to achieve a CQC rating of outstanding. After reviewing the management of a case in relation to alleged detriment we wanted to find a better way of responding. Research led me to Freedom to Speak up,”

says Janet Simkins, Freedom to Speak Up Guardian at St Joseph’s Hospice.

“Since establishing this route, some feedback we have received include: ‘I would not have come forward without this being in place’; ‘This is a really safe way to come forward. I felt safe.’ Clearly staff who feel safe and listened to having their concerns taken seriously feel more confident in the Hospice and as a result deliver better care to patients”

“Like all hospices, we are Values led,” says Cora Wukovich, Freedom to Speak Up Guardian at St Barnabas House and Chestnut Tree House (Sussex). “We all have a role to play in creating an open and transparent organisation true to our values – Caring, Connected and Courageous.

“We want to ensure that our service users, colleagues and volunteers are enabled to engage and communicate through various channels. Freedom to Speak Up is one such channel. Through this, we aim to create a safe environment in which our staff and volunteers feel empowered and supported not only to raise concerns, but to put forward thoughts and ideas that will ultimately improve services and enhance patient care.”

Sophie Cowan, Freedom to Speak Up Guardian at Isabel Hospice, also highlights her organisation’s values: “As a hospice our values are crucial to us and our identity. At the core of everything are our 5 values – caring, together, respect, responsive and dynamic,” she says.
“Freedom to Speak Up fits perfectly with these values – we care about our people (200 staff and circa 700 volunteers), we are collaborative in our approach, we respect everyone’s contribution, we respond to peoples’ needs and we challenge existing practices and strive to continuously improve. “Freedom to Speak Up has offered staff and volunteers another route to raise matters. Together with outputs from surveys, HR input and exit interviews, it has allowed us to spot themes and to deal with the individual concern, but also to learn in broader terms.”


As values-led organisations, hospices have care at their very heart, and that extends to their care for workers. A supportive Speak Up, Listen Up, Follow Up? culture is one where all of us should be able speak up about anything. Where we can share ideas, seek support, offer feedback, challenge decisions or speak up without fear of repercussions. The Freedom to Speak Up means we can ask questions where we might be uncertain and share positive practices that can be cascaded elsewhere in the organisation.

Freedom to Speak Up Guardians are helping to lead changes in the systems, processes and policies in their organisations to ensure that when workers speak up they are heard and the right actions are taken. Their insights can not only protect staff and patients, but also the integrity and reputations of the organisations in which they work. Together we can make speaking up business as usual.

If you don’t have a guardian yet, you can find out more at one of our information
sessions, details are on our website

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