Speaking up, patient safety and the international workforce

When we recruit internationally, are we spending enough time preparing people for the culture of speaking up that modern healthcare expects?

Most international recruitment programmes focus on the practical: registration, visas, relocation, accommodation, banking, schools. All of it matters. But there is one part of working safely in a modern health system that almost no programme prepares people for: the culture of speaking up.

This is not a recruitment question. It is a patient-safety, leadership and workforce-culture question. And given how dependent the NHS, New Zealand and Australia all are on internationally trained professionals, I think it deserves far more attention than it gets.

What the evidence suggests

The NHS has spent more than a decade investing in Freedom to Speak Up, precisely because the evidence kept showing that some groups of staff felt less safe raising concerns than others. There are now more than 1,000 Freedom to Speak Up Guardians across the NHS, and over 32,000 cases were raised through them in 2023/24 alone.

The international workforce angle is especially striking. The National Guardian’s Office has undertaken work looking specifically at overseas-trained workers and their experiences of speaking up, and the very fact that a dedicated review was needed tells you the issue is significant. Wider data reinforces it: NHS staff-survey reporting has repeatedly shown that Black and minority-ethnic staff are more likely to report bullying, harassment and discrimination than white colleagues, and lower confidence in speaking up remains a known barrier.

Why this matters for international recruitment

Here is the question I keep coming back to: is being willing to challenge, question and raise concerns part of successfully integrating into a healthcare system? I think it is, and yet many internationally trained professionals come from healthcare cultures that are considerably more hierarchical than the one they are joining.

The NHS, for all its flaws, has spent years trying to build a culture where junior staff can challenge senior staff, nurses can challenge doctors, allied health professionals can challenge consultants, and everyone is encouraged to raise patient-safety concerns. That is not universal. For someone trained in a system where challenging a senior colleague simply was not done, this is not a small adjustment: it is a fundamental shift in how they are expected to work.

Preparing people, not just placing them

If speaking up is fundamental to working safely, then preparing people for it should be a fundamental part of how we recruit and onboard. That means being explicit, early, about how concerns are raised, what escalation looks like, and that challenging a decision is expected rather than disloyal. It also means leaders meeting people halfway: recognising that a quiet new colleague may not lack confidence in their clinical judgement, but may simply be carrying the habits of a different culture.

A discussion, not a criticism

None of this is about ranking systems against each other. The NHS still has real challenges with how safe people feel to speak: the Freedom to Speak Up system exists because staff too often felt ignored or fearful. But the infrastructure it has built (Guardians, a National Guardian’s Office, protected-disclosure frameworks, staff-survey reporting, and a People Promise that explicitly includes "a voice that counts") is something worth examining as New Zealand, Australia and others think about their own cultures of challenge and safety.

Final thoughts

We rely on internationally trained professionals more than ever. We owe it to them, and to patients, to prepare them for the whole of the role: not just how to arrive, but how to speak. Because a workforce that feels able to raise concerns is not a nice-to-have. It is one of the clearest markers of a safe, healthy place to work.