Listening to Workers: A Speak Up Review of ambulance trusts in England

Recommendation 1: Review broader cultural matters in ambulance trusts This recommendation calls for an independent cultural review, bringing together the work of NHS England, the Association of Ambulance Chief Executives (AACE), the Care Quality Commission and partner organisations with Ministerial oversight. • The cultural review should consider management and leadership behaviours and focus on worker wellbeing, as well as: o The effectiveness of governance/leadership structures, particularly considering the complex geographical footprint of ambulance trusts. o Models/expressions of leadership, including ‘command and control’. o Defensiveness and ‘just’ culture. o Arrangements for appointments, including fair and open recruitment and values-based recruitment. o Operational and workforce pressures. o Bullying and harassment including sexual harassment. o Discrimination, particularly on the grounds of ethnicity, gender and gender identity, sexual orientation and disability. • Bringing together other blue light services and the military to share learning and good practice to facilitate effective speaking up cultures in similar operating environments. • An action plan to be agreed following the cultural review, with specific actions for delivery and organisations assigned to make improvements. Responsible organisation(s): Department of Health and Social Care and NHS England

Recommendation 2: Make speaking up in ambulance trusts business as usual This recommendation requires all ambulance trusts to: • Mandate training on speaking up - in line with guidance from the National Guardian's Office - for all their workers, including volunteers, bank and agency staff, as well as senior leaders and board members. • Ambulance trust leadership (including managers, senior leaders and board members) to fully engage with Freedom to Speak Up, evidenced by board members undertaking development sessions, delivered by the National Guardian's Office, with a view to role model effective speaking up, including purposefully providing and seeking feedback in the carrying out of their leadership roles. • Embed speaking up into all aspects of the trusts' work by proactive engagement by leadership, managers and Freedom to Speak Up guardians across ambulance trusts through regular communications. Trust leadership teams should identify the professional groups/areas within the trust that need support in implementing Freedom to Speak up by diagnosing root causes and putting in place a support mechanisms for managers and workers to feel psychologically safe when speaking up and reduce detriment. • Ambulance Trust Boards to annually evaluate the effectiveness of speaking up arrangements; including effectiveness of facilitating all workers, including those from groups facing barriers to speaking up, being able to speak up about all types of issues and action being taken in response to speaking up. Trust boards will report on this evaluation publicly in their annual reports. The National Guardian's Office commits to the following: • Working with NHS England on the development of board development sessions. • Working with partners including NHS England and the Care Quality Commission, to publicise a how-to-guide on effective metrics to evaluate speaking up culture and arrangements. • Working with the Care Quality Commission, NHS England and others to promote the impact of effective speaking up culture and arrangements. • Working with partners, including NHS England, NHS Providers, NHS Employers, and the Association of Ambulance Chief Executives, to facilitate networking and the sharing of good practice, innovation, policy and research in the field of speaking up among non-executive directors, including those on the boards of ambulance trusts. Other responsible organisation(s): Ambulance trusts, Care Quality Commission, National Guardian's Office, NHS England, NHS Providers and NHS Employers.

Recommendation 3: Effectively regulate, inspect and support the improvement of speaking up culture in ambulance trusts This recommendation requires the Care Quality Commission and NHS England to: • Ensure workers' voices are effectively captured and reflected in regulators' decisions when reviewing their frameworks and treated with parity to those of patients’ voice. • Implement mandatory and regular training on speaking up - in line with guidance from the National Guardian's Office - for all workers (including senior leaders) involved in the regulation, inspection, and improvement support of ambulance trusts. • Make assessment of the speaking up culture and arrangements a cornerstone of their regulatory and oversight frameworks, recognising that the safety of patients and the public - as well as the sustainability of the health service - depends on workers' ability to speak up and for regulators to listen and follow up when they do. • The Care Quality Commission to continue to improve their inspection methodology around the rigorous assessment of speak up culture and psychological safety. • Communication and partnership working among national bodies to share information about speaking up culture and arrangements. The National Guardian's Office commits to the following: • Support training for NHS England and the Care Quality Commission workers on speaking up. • Leading the collaboration with partners including the Department of Health and Social Care, the Care Quality Commission and NHS England. • Working with NHS England and the Care Quality Commission to strengthen their approach to addressing detriment. Other responsible organisation(s): Department of Health and Social Care and the National Guardian's Office.

Recommendation 4: Implement the Freedom to Speak Up Guardian role in accordance with national guidance to meet the needs of workers This recommendation requires all ambulance trusts to: • Meaningfully invest in the Freedom to Speak Up Guardian role. In discussion with their Freedom to Speak Up Guardian(s), leaders should identify the time and resources needed to meet the needs of workers in their organisation. Leaders should be able to demonstrate the rationale for their decisions and board plans for implementing Freedom to Speak Up roles should be clear on resource implications and set realistic timescales. • The National Guardian’s Office suggests that as a minimum, the equivalent to three full-time workers is needed to carry out the reactive and proactive parts of the Freedom to Speak Up Guardian role in ambulance trusts. This is because of the characteristics of ambulance trusts, including their complex geographical footprint, and broader cultural and operational issues. The National Guardian’s Office and NHS England will support, review and challenge the rationale arrived at by ambulance trusts about how much time is allocated to the role. • The recruitment process used for the appointment of Freedom to Speak Up guardians must be fair, open and transparent and comply with current good practice in recruitment and equality, diversity, inclusion and belonging principles. This will help ensure that people appointed have the confidence of, and are representative of, the workers they support. • Create (if not already in place), maintain and regularly evaluate a network of Freedom to Speak Up Champions/Ambassadors to support raising awareness and promoting the value of speaking up, listening up and following up. Consideration to the organisation’s size, geographical footprint and the nature of their work should be given to ensure support for workers, especially those facing barriers to speaking up. • Provide emotional and psychological well-being support to Freedom to Speak Up Guardian(s). This support should reflect the challenges of the role and ensure the need for confidentiality. There should also be periodic check-ins with Freedom to Speak Up Guardian(s) about the effectiveness of this support. The National Guardian's Office commits to the following: • Support ambulance trusts and NHS England in determining the amount of time and resources needed. • Review the feedback we received about the support the National Guardian's Office provides Freedom to Speak Up guardians, including review of the universal job description for Freedom to Speak Up guardians. • Publicising guidance to assist in the calculation time and resources needed to carry out the role. Other responsible organisation(s): National Guardian's Office and NHS England.