Open cultures in the NHS - What leaders say

Introduction

 The 2015 “Freedom to Speak Up Review” made clear that cultural openness in the NHS is essential. When people cannot speak up, or when those who receive concerns do not listen or act, failures occur. Though many initiatives have followed, there is little or no evidence that they have made any impact: in 2024 only 61.82% of NHS staff survey respondents said they felt safe to raise concerns, a decline of nearly four percentage points from 2020 when the question was first asked. “Feeling safe” is itself a low bar, far removed from creating an environment where people feel encouraged and confident to speak up.

The NHS now enters another period of significant change, including dismantling the National Guardian’s Office (NGO) – one of the initiatives that arose from the Freedom to Speak Up Review. As Dr Penny Dash noted in her 2025 review, the NGO had become “too distant from the people it needs to support and influence.” It also duplicates functions that are best led elsewhere, particularly by those with responsibility for actually leading and supporting the NHS workforce as they work tirelessly, under pressure, to deliver high quality and safe care.

Change brings both risk and opportunity: positive developments may stall, while normalised but ineffective practices may continue unchallenged. This moment, however, creates space to revisit the fundamentals of openness—an essential step if the NHS is to meet its aspiration, set out in the 2025 ‘10-year plan’, to become “the most transparent healthcare system in the world.”

The network of Freedom to Speak Up Guardians has grown way beyond what was ever originally expected – there are currently over 1,500 Guardians - and has become a powerful voice. Yet cultural openness is shaped most directly by senior leaders who set the tone, expectations, and organisational norms in which all NHS workers operate. Their views are often under-represented or not even sought. This report provides a voice for them.