Title: Evaluation of the implementation of “Freedom to Speak Up Local Guardians” in NHS Acute Hospital Trusts and Mental Health Trusts in England
Funder: Health and Care Research Wales (Welsh Government)

Abstract: Freedom to Speak Up Guardians" (FTSUGs) have been appointed across all NHS Acute Trusts and Mental Health Trusts in England to support staff to raise concerns. Trusts have selected or appointed anywhere between 1 and 8 FTSUGs, either operating part- or full-time in specific FTSUG posts, or in addition to existing positions such as Director of Nursing, Director of Workforce or Hospital Chaplain. Such variation informs the following research aims and objectives. RESEARCH AIMS? a) To map varying approaches to implementing and configuring FTSUG roles in Acute Trusts and Mental Health Trusts.?b) To generate evidence of the extent to which FTSUG roles have been “normalized” in organisations. c) To gain insights into benefits and drawbacks of different FTSUG implementation models on staff’s ability to speak up and act upon concerns. RESEARCH OBJECTIVES? 1. IMPLEMENTATION & USE: Assess the scale and scope of the deployment and work of FTSUGs. 2. IMPLEMENTATION & GOVERNANCE: Assess how the work of FTSUGs is organised and operationalised alongside other relevant local and national roles with responsibilities for employee concerns. 3. EFFECTIVENESS: Evaluate the comparative effectiveness of different types of FTSUG roles in supporting “freedom to speak up”.? 4. BARRIERS & FACILITATORS: Identify barriers, facilitators and unintended consequences associated with the implementation of FTSUG roles. STUDY DESIGN & ANALYSIS A 27 month mixed methods study is proposed consisting of: Work Package (WP) 1 (Months 1-5): (a) Systematic evidence synthesis of international literature focusing on interventions to promote employee speaking up in healthcare and other sectors; (b) Identify staff in FTSUG roles to help inform phase 2 survey; (c) Gain research governance approvals. WP 2 (Months 6-11): Telephone survey of FTSUG post-holders to: (a) Map the implementation of the FTSUG role. (b) Explore how the role has been recruited to, implemented, the working practices of FTSUGs and their "fit" with relevant others within and outside their organisations. (c) Collect anonymous details of numbers and types of concerns raised via FTSUGs. WP 3 (Months 12-21): Case studies of 6 NHS Acute Trusts and Mental Health Trusts, identified from analysis of phase 2. Rich qualitative data will be collected to explore the interplay of context, meaning and individual/collective engagement related to implementing this new role. Thematic analysis of documents, interviews and observations will be combined to explore FTSUG roles in practice. WP 4 (Months 22-27): Analysis and writing final report, dissemination activities. OUTCOMES?a) Guidance for NHS organisations on different approaches to implementing FTSUG roles and their possible effects on raising and responding to concerns. b) Contribution to FTSUG training modules and broader NHS employee training on raising and responding to employee concerns.?c) Key findings disseminated to policymakers, patient and public involvement and regulatory bodies. Detailed final report and open-access papers in high impact journals. MAIN BENEFITS & POTENTIAL IMPACT? a) Timely evidence about the implementation of a critically important new role and its effects on “speaking up” which will inform policy makers, regulators and all NHS employees who have a role in raising and responding to concerns.? b) UK and international impact on decision making in the design and implementation of interventions designed to best support staff to raise/respond to concerns.

Lay abstract: The aim of this study is to better understand the introduction of a new role in NHS England designed to support staff who wish to raise concerns about the quality of patient care. These roles are called "Local Freedom to Speak Up Guardians” (referred to here as “FTSUGs”). We are interested in finding out how FTSUG roles are being introduced in Acute Trusts and Mental Health Trusts and whether FTSUGs are helping staff to “speak up” about their concerns. BACKGROUND TO THE RESEARCH: Employees who “speak-up” or “raise concerns” about problems with healthcare services are often referred to as “whistleblowers”. Although "speaking up" makes an important contribution to patient safety in the NHS, whistleblowers have not always been treated well. For example, the Francis Report in 2013 into serious patient care failures at Stafford Hospital identified that whistleblowers were often ignored and mistreated by colleagues. The related Freedom to Speak Up review by Francis in 2015 recommended that raising concerns should become a normal part of the job for anyone working in the NHS.?The introduction of the new FTSUG role is described as potentially making a huge contribution to improving the way "Speak Up" cases are handled. However, there are some important differences in how the FTSUG role is being introduced by organisations across England. More information is needed to fully understand differences in FTSUG roles and what these differences mean for staff raising concerns and how concerns, when raised, are acted upon. DESIGN OF THE STUDY: The research study is planned over 27 months in 3 discrete but related work packages:? Work Package (WP) 1: A review of literature that investigates different approaches used to encourage staff to speak up in healthcare and other sectors. This will help us develop our survey questions for WP 2. We will also speak to staff in FTSUG roles to help us develop survey questions and gain NHS research ethics/governance approvals at this time.? WP 2: Telephone interviews with FTSUGs in Acute Hospital and Mental Health Trusts will provide a better understanding of the FTSUG role and what they do within their organisations. We will also gather information about the number and types of concerns that FTSUGs have dealt with. Survey results will show similarities and differences in FTSUG roles and how these influence FTSUG's work and how, when and how often staff concerns are raised. WP 3: Survey results from WP 2 will help identify case study sites in 4 Acute Trusts and 2 Mental Health Trusts. In these case studies we will interview FTSUGs, those working with FTSUGs and employees who have raised concerns and others who have not. We will also analyse documents (e.g. FTSUG role descriptions, minutes of meetings) and observe the FTSUG working in practice e.g. observe training delivered and meetings attended by the FTSUG. At the end of WP 3 we will better understand whether and how different ways of rolling out the FTSUG role affects staff speaking up. A respected framework called Normalisation Process Theory (NPT) used by health researchers to collect and analyse data will assist the team to better understand this unique new role in practice. We will analyse the six case study sites separately, before analysing findings across all cases. A project report will then be produced in WP 4 , describing differences in the FTSUG role across England and whether these differences have affected staff speaking up. We will also develop training materials and a ‘speak up’ guide for managers, clinicians, patients and others.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: GENERIC HEALTH RELEVANCE