What was the review about?

It was an independent review into creating an open and honest reporting culture in the NHS. It looked at evidence from a range of perspectives across the NHS and other sectors in order to make recommendations for the future.

Why was it set up?

The Review was set up in response to concerns about the reporting culture in the NHS, and the way NHS organisations deal with concerns and with the staff who raise them.

Who worked on the review?

The Review was chaired by Sir Robert Francis QC. He appointed three advisors: Professor Katherine Fenton OBE, Dr Peter Homa CBE and Professor Sir Norman Williams. He was also assisted by advice from Helené Donnelly OBE. Sir Robert was supported by a secretariat, staffed by a small team of civil servants who worked completely independently of the Department of Health.

How was the review carried out?

Sir Robert’s approach was to listen to the views and experiences of individuals and stakeholders with an interest in this area to identify what needs to be improved. This was supported by independent qualitative and quantitative research. Key sources of evidence were:

  • a call for contributions and a thematic review of responses
  • meetings with a broad range of individuals and stakeholder groups
  • seminars to discuss emerging themes and possible solutions
  • qualitative research including a desk analysis of whistleblowing policies and depth interviews on how policies are implemented
  • quantitative research surveys of staff, employers and regulators
  • review of whistleblowing in other sectors and countries.

What did Sir Robert find?

Evidence from the review, and from other sources, confirms that:

  • some people are mistreated after raising a concern
  • in a small number of cases, people have faced shocking consequences as a result of speaking up
  • this creates a climate of fear which deters others
  • some are put off raising concerns because they don’t believe anything will happen.

Other industries where safety is an issue have worked hard to achieve culture change. They confirmed that it is possible, but that it is hard work and takes time and effort. There is a great deal happening in the NHS to promote open and honest culture, but more needs to be done to join it up and to ensure that staff in all organisations feel free to speak up.

How many people contributed?

  • 612 people and 43 organisations wrote to the review to share their views and experiences.
  • A confidential online survey was completed by 19,764 staff (15,120 NHS trust staff and 4,644 staff in primary care).
  • Over 300 people (including some contributors to the review) attended individual or group meetings and the seminars.

What is Sir Robert recommending?

Sir Robert sets out 20 Principles, with associated actions, which he recommends should be implemented by all NHS organisations which provide healthcare. Together these will guide the development of a consistent approach to raising concerns across the NHS, whilst leaving scope for flexibility for organisations to adapt them to their own circumstances.

He recommends that the Secretary of State for Health should review progress in the implementation of the Principles and actions and report annually to Parliament. The overarching principle is that every organisation needs to foster a culture of safety and learning in which all staff feel safe to raise a concern.

The Review identified some key themes which need to be addressed: culture change, better handling of concerns, support to ensure the system works well, measures to protect groups who are particularly vulnerable, such as student nurses and trainees and finally, and extending the legal protection.

What are the aims of Sir Robert’s proposals?

  • Taken together, Sir Robert’s recommendations aim to make the NHS a place:
  • where there is a culture in which staff feel encouraged and safe to speak up – one where it is the normal thing to do
  • in which all concerns are heard and investigated properly, with the right support on hand for staff, managers and others involved in the concerns raised
  • where those who have been brave enough to speak up are celebrated and organisations who get it right are recognised
  • that supports good NHS staff who have suffered as a result of speaking up, to get back into work or to develop new skills
  • where all staff, but in particular vulnerable groups, such as student nurses and medical trainees, are protected from intimidation.

I work in the NHS, do Sir Robert’s proposals mean for me?

Under Sir Robert’s proposals, you will be encouraged and supported to speak up as part of your normal working day. There will be means to share concerns informally, as well as formally, and you will be able to call on the support of a Freedom to Speak Up Guardian who can listen to you and advise what to do. There will be training on how to raise and handle concerns and regular opportunities to reflect on your work. When needed, other support will be available, such as mediation and counselling. Where things are going wrong, you will be able to contact the Independent National Officer who could review your case and intervene where appropriate.

I've blown the whistle and suffered as a result, how will Sir Robert's recommendations affect people like me?

Sir Robert was not asked to review past cases or make judgements, he was asked to make recommendations for the future. The intention is that in the future it will be easier to raise concerns without suffering as a result.

During the review Sir Robert heard how some good NHS staff experience difficulty continuing in their current employment or finding new work after they have raised concerns. He concluded that the NHS has a moral obligation to offer support staff whose performance is sound, and proposes a new scheme is established to help them back into work in the NHS. He also proposes a review of the law to prevent discrimination against applicants for jobs in the NHS on grounds of having raised a concern.

I am an NHS leader, what is Sir Robert recommending for us?

What is needed is a new mindset which focuses on developing a culture of safety and learning. This needs strong, visible leadership, to encourage leaders and managers at all levels to demonstrate that they value and welcome concerns, and act on them.

Specifically the report invites leaders to:

  • treat concerns as a safety issues, not HR issues
  • ensure all staff are trained in how to raised and how to handle concerns
  • focus on building capability in a range of areas, including investigation, mediation, performance management and leadership,
  • identify a range of people to whom staff can go if they have a concern
  • provide a source of independent advice and advice (a freedom to speak up guardian) who can ensure the safety issues is addressed and staff well-being is protected
  • encourage time for reflective practice
  • address bullying and oppressive behaviours at all levels in the organisation
  • Share their experiences and learning both within their organisation and externally.

What would be the role of the Independent National Officer (INO)?

The INO would be the national equivalent of the local Freedom to Speak Up Guardian. They will be able to intervene if they have reason to think that the safety issue isn’t being addressed properly, or there is reason to believe that someone is being mistreated, by contacting the trust or asking one of the regulators to use their powers. They will be able to consult the local Freedom to Speak Up Guardian to check what is happening. They will also be able to work with the network of local guardians to spread good practice and learning. Sir Robert envisages that, for the most part they will be able to work through informal action, encouraging NHS organisations to get things right rather than react after the event.

How will the local Freedom to Speak Up Guardian role work?

The Freedom to Speak Up Guardian would be someone who is independent and impartial; who can ensure that the focus is on the safety issue that has been raised, who can make sure that it is properly investigated and addressed if found to be true; and who can ensure that there are no repercussions for the person who drew attention to it. They would have ready access to the CEO, or the Chair, or they could take a concern to a regulator if necessary. Sir Robert suggests it would be valuable to create a network of Guardians, led by the Independent National Officer to share good practice and learning across the NHS.

What were the terms of reference for the review?

The aim of the Review was to provide advice and recommendations to ensure that staff working in, or providing services to, the NHS in England feel that is it safe to raise honestly held concerns of any sort in the interest of patient safety. The full terms of reference are available here.

I have a concern to raise, what should I do?

If you have a specific concern, there are a number of things you can do. For advice and guidance on raising concerns you should first read the guidance, ‘Raising Concerns at Work’ published by the Whistleblowing Helpline which provides free, independent and confidential advice to workers in the NHS and adult social care. The guidance is available on its website: http://www.wbhelpline.org.uk/
If you want to speak to someone for advice on how to raise concerns you can contact the Whistleblowing Helpline by Freephone number or by email: http://www.wbhelpline.org.uk/contact-us/.

Did the review cover social care too?

No – the scope of this review did not extend to social care. However, there are likely to be similar issues that extend across both sectors and we would invite leaders in social care to consider the recommendations of this review.

What was the scope of the review?

The scope of the Review extends to England only. It covers all organisations and individuals who provide NHS services. For example: Foundation Trusts, private providers of NHS services and mental health services.

Did the review cover Scotland, Wales and Northern Ireland?

No the scope of this Review extended to England only. However, it is likely that the report and recommendations will be of interest to colleagues outside of England.