Freedom to Speak Up Index published

A new index monitoring ‘speaking up culture’ in the NHS has found 180 trusts (82%) have made it easier for staff to speak out since 2015, with London Ambulance improving it’s rating by 18%.

NHS England commissioned the National’s Guardian Office to develop the index based on four questions from the annual NHS Staff Survey including whether staff feel secure raising concerns if they see something unsafe.

Dr Henrietta Hughes, National Guardian for the NHS said:

“Broadly speaking the index reveals a very strong correlation between trusts that are rated highest by the CQC and those that have the highest rated speaking up cultures,”

“Trusts should see the index as an insight into the views of their workforce around the issue of speaking up.

“The aim of the report is to commend those trusts doing well and those that have shown significant improvement, while encouraging those that have room to improve to take the opportunity to address the issues that may be affecting their index scores.”

Freedom to Speak Up Guardians are now well established in trusts and over the last two years they have reported handling over 19,000 cases.

The National Guardian’s Office provides training and guidance and also carry out case reviews in trusts where workers report that best practice has not been followed. The recommendations that arise from these case reviews not only allow the organisation concerned to address issues impacting negatively on their speak up culture, but can be used by all trusts in England to embed learning and continue improvement of their own processes and practices.

In addition to a table highlighting where every trust in England stands, the Freedom to Speak Up Index Report also showcases the achievements of the trusts that have the best FTSU cultures in the form of case studies.

These illustrate how the top performing trusts are encouraging a Speak Up culture and provide learning for others to follow.

For commissioners and regulators, the FTSU Index provides a new indicator which can be viewed together with other information about safety, workforce and culture.

Freedom to Speak Up Index Report 2019*

*Because CQC rating have changed the table highlighting ratings has been removed from this report.



1. The National Guardian’s Office supports the National Guardian for the NHS, Dr Henrietta Hughes, in providing leadership, training and advice for Freedom to Speak Up Guardians based in all NHS trusts.

2. Dr Hughes’ role was a key recommendation from Sir Robert Francis’ Freedom to Speak Up Review in response to the Mid-Staffordshire scandal.

3. Freedom to Speak Up feeds into the Care Quality Commission well-led inspection framework, with guardians contributing directly to inspections.

The FTSU Index was calculated as the mean average of responses to four questions from the 2018 NHS Annual Staff Survey.

Where percentage point improvement is recorded, this is based on the overall changes recorded between 2015 and 2018.

Nationally the median FTSU score has improved since 2015. Some trusts have seen a rapid improvement in their FTSU index score and in others there has been a reduction in the score.

The survey questions used to make up the FTSU Index are:

  • % of staff responded “agreeing” or “strongly agreeing” that their organisation treats staff who are involved in an error, near miss or incident fairly (question 17a)
  • % of staff responded “agreeing” or “strongly agreeing” that their organisation encourages them to report errors, near misses or incidents (question 17b)
  • % of staff responded “agreeing” or “strongly agreeing” that if they were concerned about unsafe clinical practice, they would know how to report it (question 18a)

% of staff responded “agreeing” or “strongly agreeing” that they would feel secure raising concerns about unsafe clinical practice (question 18b)

The FTSU Index
The following represent the trusts with the highest FTSU index result for 2018, broken down by trust type:

Trust type Trust FTSU index value 2018
Community Cambridgeshire Community Services NHS Trust 87%
Combined mental health / learning disability and community trust Solent NHS Trust 86%
Acute Specialist Liverpool Heart and Chest Hospital NHS Foundation Trust 86%
Acute The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust 84%
Combined acute and community Gateshead Health NHS Foundation Trust 83%
Combined mental health / learning disability Surrey and Borders Partnership NHS Foundation Trust


Combined mental health / learning disability Northumberland, Tyne and Wear NHS Foundation Trust


Combined mental health / learning disability Tees, Esk and Wear Valleys NHS Foundation Trust


Combined mental health / learning disability Tavistock and Portman NHS Foundation Trust


Ambulance Isle of Wight NHS Trust (ambulance sector) 79%

The Freedom to Speak Up Index for each trust and the CQC ratings for Overall and Well Led are included in Annex 1 of the report. The information is taken from the CQC website and the annual NHS Staff Survey at the time of publication.

October 8, 2019