From submission to Department of Health consultation on the implementation of the Freedom to Speak Up Review, by Minh Alexander former consultant psychiatrist, 4 June 2015
“Francis greatly emphasised the example of the Cultural Ambassador at Staffordshire and Stoke on Trent Partnership Trust (SSOTP) as supporting evidence for his proposal to introduce whisteblowing guardians nationally. He featured the SSOTP model in the Freedom to Speak Up report. At the launch of his report Francis told whistleblowers that the present incumbent had proven that such a post could work.
Few facts had been offered about the provenance or efficacy of the model, other than that a low staff uptake had prompted this arrangement, and that uptake subsequently increased “dramatically”. No other parameters were explored in Francis’ report. Details of staff contacts with the Ambassador have now been requested from the Trust and are awaited.
The Ambassador post was established two years ago in April 2013. The Trust has confirmed to me that no evaluation of this new role has yet been carried out. 
The Trust signals an intention for evaluative research to be carried out, but no decision has been made yet on how this will be done.
What then are the other sources of information that might shed light on the effectiveness of the model?
Local press reported that recent, significant external whistleblowing disclosures were made about the Trust. It is alleged that staff reported externally because of issues of organisational culture and because little was done to rectify safety issues despite managers being made aware of the problems. [2,3,4] If so, this raises a question of what is contributed by a Guardian-type role where there are particularly serious and knotty problems that an organisation might find threatening. For example, some of these external disclosures ultimately led to regulatory action on staffing levels, which may in turn present other challenges for a Trust seeking Foundation status.
Notwithstanding, it is recognised that external whistleblowing is often an indication of an internal blockage of some sort. The Trust’s response to press coverage of leaks was to emphasise to its staff that internal reporting was encouraged, but there was no clear acknowledgment of failure to engage with staff. 
Some external disclosures by SSOTP staff have been made to CQC. A full list of disclosures has been requested under FOI arrangements and is awaited. Meanwhile, remarks in a CQC inspection report of 19 March 2015 may reflect tensions inherently thrown up by an Ambassador role:
“Action the provider MUST or SHOULD take to improve
- Review the internal communication arrangements for the Ambassador for Change to ensure transparent lines of communication and staff feel reassured that the role is organisation wide, not part of the management process”
It would be understandable that any Ambassador role, irrespective of the person in post, may be viewed hesitantly if staff are wary of management commitment to transparency.
NHS Staff Surveys for SSOTP in the last 3 years, against national averages for comparator trusts, do not show major changes over the period in which an Ambassador post was established:
|Overall staff engagement||3.70(average 3.69)||3.69(average 3.71)||3.70(average 3.75)|
|% of staff witnessing errors, near misses and incidents in the last month||21%(average 26%)||23%(average 26%)||19%(average 23%)|
|Fairness and effectiveness of incident reporting procedure||3.55(average 3.54)||3.45(average 3.53)||3.50(average 3.58)|
|% of staff agreeing that they would feel secure raising concerns about unsafe clinical practice||_||_||70%(average 72%)|
|% of staff reporting errors, near misses and incidents witnessed in the last month||88%(average 93%)||92%(average 925)||91%(average 94%)|
|% of staff reporting good communication between senior management and staff||26%(average 28%)||23%(average 29%)||28%(average 33%)|
|%of staff experiencing harassment, bullying or abuse from other staff in last 12 months||19%(average 20%)||21%(average 20%)||23%(average 24%)|
|Staff recommendation of the Trust as a place to work or receive treatment||3.58(average 3.58)||3.57(average 3.59)||3.56(average 3.66)|
These figures give only a rough indication of some of the issues, and may be affected by factors other than the work of an Ambassador. Broadly though, they are not by any means proof that an Ambassador model clearly generates improvement around issues of raising concerns. Confidence in the fairness of incident procedures remained slightly below average. When a measure about staff’s sense of security in reporting concerns was added in 2014, this was slightly below average too.
Whistleblowers, who have seen all that the most corrupt employers can do to manipulate and pervert processes, do not have any expectations that closed organisations will be transformed by Trust-appointed whistleblowing Guardians. In such trusts, Guardians will at best be ignored, and ineffectual as a result of impassable systemic issues. More likely, the worst organisations will appoint in their own image. The role could be used to help conceal continuing whistleblower reprisal whilst falsely white washing organisational reputations. The analogy of prefects from Tom Brown’s school days comes to mind.
There is another indication that Francis’ whistleblowing Guardian experiment will fail. There is already evidence that some organisations are ignoring Francis’ recommendations that:
(i) Whistleblowng Guardians posts should be dedicated roles
(ii) The Whistleblowing Guardian role should not be on top of someone’s existing duties
(iii) Whistleblowing Guardians are ideally in a professional role, to gain the trust and confidence of colleagues.
Of concern, these are examples of whistleblowing Guardians that have been quickly appointed by NHS organisations whilst the DH consultation has been taking place:
“Formally appointing the Executive Director of Nursing, Quality and Governance as the Trust’s Freedom to Speak Up Guardian”
“…also appoint: Assistant Director, Corporate Governance as the ‘Freedom to Speak Up’ Guardian”
“The identification of one official Freedom to Speak Up Guardian, to concentrate on the assurance side, proposed to be the Director of Quality and Assurance”
“The Head of Governance, who is identified as our designated officer in the Raising Concerns Policy, to also take on the role of ‘Freedom to speak up
“…Director of Communications and Business Services… has also been appointed by the Audit and Governance committee as the “Freedom to Speak Up Guardian”
These appointments are clearly at odds with the Freedom to Speak Up review’s intentions. Arguably, they show corporate bias, little prioritisation of whistleblowing governance, and failure to appreciate (or care about) the nuances of staff advocacy. It is questionable that Trusts were told that they could move ahead with making arrangements before the Department of Health Speak Up consultation had taken place. However, their actions are part of the evidence that the Trust-appointed Guardian model lacks sufficient robustness and credibility.
A whistleblower contributor to the Francis review, who has worked in a established Guardian type role for some time, has very clearly advised that such a role can make a contribution but:
“… is in no way a panacea for remedy to prevent further scandals within the NHS.
And the whistleblower remains of the opinion that:
“In order to change the culture a proper whistleblowing inquiry is necessary”
This person remains conscious of the marked imbalance of power, disadvantage and stress that staff face when raising concerns. In common with the majority of whistleblowers, this person emphasises that until root causes are genuinely addressed, the overall dysfunction will continue.
Robert Francis stipulated that Trust-appointed Guardians must command the confidence of Chief Executives. Where the Chief Executive is corrupt, this is clearly nonsense, as the Guardian would have to act corruptly too, in order to command the Chief Executive’s confidence. This contortion of logic lies at the heart of Robert Francis’ fatally flawed proposal.
It is also important to note that the more robustly those in current Guardian-type posts advocate for patients, the more likely it is that they will experience retaliatory mistreatment. This has reportedly sometimes been very serious.
In summary, Trust-appointed whistleblowing Guardians are the lynchpin around which Francis’ proposals are built. Given the lack of evidence that such posts can be relied on as the key intervention to prevent whistleblower reprisal or to reduce fear, and evidence that organisations are already making inappropriate appointments, the Freedom to Speak Up review falls.”
 Correspondence with Stuart Poynor SSOTP Chief Executive, 1 June 2015
 Leaked NHS dossier: nurses log concerns over care. D Blackhurst, Staffordshire Sentinel, 2 April 2015
 Leaked NHS report reveals dying patients left alone and in pain, staff at breaking point, Staffordshire Sentinel, 2 April 2015
 NHS ordered to appoint more district nurses in North Staffordshire, Staffordshire Sentinel, 9 May 2015
 Health staff told ‘don’t speak to press’ after regional daily expose. David Sharman, Staffordshire Sentinel, 5 May 2015
Postscript 20 June 2015
Comments were sought from the Ambassador at SSTOP. These were received after the submission above was made to the Department of Health. I add them here for completeness. It is the Ambassador’s view that:
“The ambassador role works alongside a range of mechanisms within the Trust to support staff to raise concerns and anecdotal evidence indicates that less staff are taking sick leave or leaving the organisation because they have been listened too and supported.
The Trust is committed to openness and transparency, however changing culture across such a large organisation is a process which will undoubtedly take a significant period of time to successfully achieve and more does still need to be done.
We know there are pressures on the services and staff are working flat out to try to keep pace with growing demand and expectations and the Trust is working hard to ensure teams are able to deliver quality care.
It is encouraging staff have had the confidence to raise issues either with the CQC or with ourselves and the Trust recognised many of the themes raised by staff. Following recent press reports regarding incidents, I would have liked this person to have felt they could approach me direct but obviously felt they could not.
Staff continue to be encouraged to use existing internal mechanisms to ensure that support and appropriate action can be taken to resolve any issues as quickly as possible.
With regards to evaluation of my role, there are plans to establish when and how this will be done”.
The data from SSOTP about staff contacts with the Ambassador is awaited.