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September brings a new school term.

On my way to my morning run, I cross paths with the school run for my local primary school. Tiny four-year-olds in oversized jumpers bought to last through growth spurts; harassed caregivers wrestling with meltdowns and scooters; and groups of ten-year-olds – the new Year 6s – walking to school on their own for the first time. Although some of them may only be a few steps ahead of their parents and siblings, you can see they are thrilled to be making their first forays into independence before secondary school next year.

This is what the babies who died at the Countess of Chester Hospital while Lucy Letby was working there should be doing now.

In the inquiry report published last week, Lady Justice Thirlwall comes to the devastating conclusion that some of those babies could have been saved if action was taken earlier.

In the UK, the available data suggests there have been fewer than 200 serial killers: far fewer than true crime documentaries might lead us to imagine. And a nurse who kills must (we hope, we believe) be even more rare.

I understand why managers at the Countess of Chester struggled to think the unthinkable about a nurse: a caregiver working with the most vulnerable babies. No one wants to suspect someone they know. The inquiry outlines issues of loyalty, of hierarchies. A tribalism which prevented concerns being listened to with an open mind. Our biases can cause us to become blind when we don’t want to see something.

But even if they could not go to the darkest edges of human possibility, why was there still such a gap in curiosity? Why did the focus become who had said what, rather than on why the number of deaths was higher than usual?

The cost of inaction

Across recent public inquiries, the refrain has been the same – not just inquiries into healthcare, but also the Post Office, Grenfell Tower, Hillsborough, the Met Police among others. People were afraid to speak up, or, when they did, nothing happened. If they persisted, they risked disciplinary action, being treated as if they were the problem, rather than as people identifying the problem.

As the subjects of these inquiries show, when concerns are ignored, the human cost is devastating.

One chapter of the Thirlwall Report examines the implementation of previous recommendations. This inquiry, which has reportedly cost the taxpayer £20 million, cannot become another exercise whose lessons are acknowledged but not embedded.

Freedom to Speak Up guardians: a role at a crossroads

“I firmly recommend that FTSU Guardians remain in place; that their work – and the responses to it by the hospitals/other healthcare settings – is properly monitored and reported upon”

https://thirlwall.public-inquiry.uk/final-report-chapter/volume-iii/part-two/chapter-40/

Ten years ago, Freedom to Speak Up Guardians were one recommendation from a previous inquiry that was implemented. Since then, the NHS has continued to reinvent itself. Like Romeo at the start of Romeo and Juliet, it falls for initiative after initiative as though each one will be The One. Another Health Secretary, another campaign, another pronouncement that Something Must Be Done.

Freedom to Speak Up guardians have remained, despite the NHS’s repeated cycle of abolition and reinvention.

One witness to the inquiry described the NHS as “a disconnected series of planets”, an image that perfectly describes the very different climates across the organisations that make up “the NHS”. For this reason, implementation has been inconsistently applied, but where there is leadership support and insight, the role has matured.

Lady Justice Thirlwall calls for better monitoring and training. That matters because, following the abolition of the National Guardian’s Office three months ago, support has been reduced to induction training and support calls with NHS England, leaving guardians to find their own professional development.

I have previously identified this as an issue for guardians, and I am heartened that the report echoes my calls for greater support, continuing professional development, and recognition of the confidence and resilience required to work in such a complex, nuanced and evolving space.

We are at a critical point in the development of the Freedom to Speak Up Guardian role. Ten years after its inception, guardians must be recognised for the distinctive skills they bring to challenging these deeply ingrained cultural issues in healthcare, and supported to maintain them.

Why national support matters

No single initiative can ever be a panacea for the ancient human impulse to shoot the messenger. Belonging to a national network gave Freedom to Speak Up guardians a sense of connection to a wider social movement. The value of the role is not only in how guardians handle individual concerns, but in how they translate those concerns into wider learning for their organisations and for the NHS as a whole.

One guardian described to me the danger of guardians losing their role as culture challengers to becoming a ‘speak up service’: “We are becoming the rule, not the exception. We have become focused on providing a service rather the person to turn to when all else has failed.”

This guardian was concerned that, without a renewed focus on challenging the barriers to speaking up and learning, they may inadvertently be contributing to the sense of futility, becoming just another route for concerns to become complaints to be passed into a process, rather than a catalyst for leaders to act.

The NHS Staff Survey consistently shows that support for speaking up is inconsistent across providers – a postcode lottery. Listening to those who speak up is therefore a national issue, and it requires a national network of guardians. Supporting the shared learning of the guardian network would help it evolve into a mature professional community.

The duty to listen and to act

In the coming weeks there will no doubt be much discussion about the training and regulation of managers in the wake of the report. I don’t want this blog to add to those calls of Something Must Be Done. But instead to provide space to think, could this happen here?

Professor Mary Dixon-Woods in her evidence to the inquiry described the dense, tangled, and often clashing “priority thicket” of targets which NHS managers have to cut through on a daily basis, and I have also written of the ‘squeezed middle’.

When everything is a priority, taking a breath to recognise first principles – Patients First – can cut through the noise. Giving space to think the unthinkable.

Leaders who prioritise organisational reputation over openness misunderstand how reputation is protected.

No organisation’s reputation was ever improved by a cover-up. Infact, I can only think of situations where the act of cover-up caused worse reputation scandal than swift action would have done.

This is why people who speak up are not trouble makers, but the greatest champions of ethical workplaces.  They are your early warning indicator. By listening, and acting on what we hear, we can make sure that lessons are learned before it escalates into a £20 million inquiry, arrests, and years of court proceedings. And, most importantly, that avoidable deaths could be prevented.

And that parents can wave their ten year olds off, as they take that first independent walk to school.

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Professional development and reflective practice for guardians

The Health Secretary, Yvette Cooper, has indicated that it may be six months before the Government responds to Lady Justice Thirlwall’s recommendations. In the meantime, Guardians face continued uncertainty about the level of support available to them, while NHS England – itself due to be abolished in April – takes on training with reduced capacity and staff facing redundancy.

In the interim, guardians who want to maintain their learning and curiosity can still use the NGO’s Development Guide, which offers development ideas under each of the core competencies.

Please get in touch to register your interest.