This article looks at the NHS’s commitment to EDI and asks whether the ambitions it expresses can be fully realised given the experiences of many overseas trained staff working in the service – and if not, what needs to change.
The NHS recognises that having a strong commitment to EDI – Equality, Diversity and Inclusion – in the healthcare workforce makes all kinds of sense. It acknowledges firstly the enormous diversity across the UK’s healthcare staffing and patient populations and secondly, that proactive EDI policies can drive positive change and deliver excellent standards of care at all levels.
EDI supports open cultures that recognise and celebrate difference. It recognises that diverse teams make better decisions, produce better solutions, reduce staff turnover, reduce workplace conflict, and attract good people. Care is more efficient, safer and has better outcomes.[1]
The 2022 Messenger Report on NHS leadership, the 2023 NHS equality, diversity and inclusion (EDI) improvement plan and 2024 NHS Confederation Briefing clearly set out some of the issues EDI seeks to address – including disproportionate bullying of minority groups[2], the cost to the NHS of that bullying (estimated as a significant percentage of £2.281 billion total in 2019[3]), and widespread evidence of considerable inequity in experience and opportunity for those with protected characteristics.
The documents set out the advantages of a commitment to EDI and recommend a series of actions, including the embedding of inclusive leadership practice, a stricter enforcing of existing measures to improve equal opportunities and fairness, and an implementation of fair and inclusive recruitment processes and talent management strategies that target under-representation and lack of diversity.
Clearly, any EDI plan must include a commitment to internationally recruited staff. The NHS EDI improvement plan states this explicitly:
Since its inception in 1948, the NHS has benefitted from the expertise, compassion and commitment of internationally recruited healthcare professionals. A warm welcome and comprehensive induction and pastoral support package will make them feel valued from the start and help retain this staff group.
The plan includes a number of measures designed to achieve this, but there are important omissions.
Staff who are recruited from abroad are often less likely and less willing to raise concerns and admit mistakes, an issue worsened if they have experienced any form of workplace bullying. This issue has been documented anecdotally[1] and recognised by the National Guardian for the NHS who are currently conducting a national Speak Up Review with overseas trained staff[2]. It was further raised by diaspora nursing group leaders (Indian, Filipino, Nigerian) at the OET Forum I attended in London in October 2024. The reluctance to speak up is clearly a challenge to the successful implementation of EDI policies.
There are a number of factors at play here.
The fact that many international recruits have passed a formal English test such as OET or IELTS does not mean they have the language skills or the confidence to communicate freely on sensitive matters.
The exams they take are very ‘teachable’ and learning programmes focus very much on the test experience, developing the language, techniques and strategies required to achieve the scores required by the GMC, NMC, HCPC, etc. The levels required are high – with the notable exception of carers, where the visa requirement is an intermediate B1 level [1] – but the language learnt doesn’t necessarily cover the vocabulary and expressions needed at work, especially when navigating difficult conversations.
Working with language and communication skills trainers on courses that focus on the language needed to manage a variety of challenging conversations gives participants the tools and confidence to express themselves and better fulfil on the Freedom to Speak Up. Sessions should consist of input, practice, experimentation, problem solving and provide a space for international recruits to ask questions they might feel embarrassed asking colleagues.
Not only is it important for internationally recruited staff to understand British life and culture in and out of the workplace, it is also important for their managers and colleagues to understand their cultures in turn.
Cultural competence training therefore works both ways. It acts as a space for everyone to discover and understand a wide range of beliefs, perspectives and approaches to a multiplicity of areas – from care provision to decision making, to accessing health, to turn taking in conversation to engaging with diverse communities, family roles, even food.
Ensure managers are talking to international staff on a regular and predictable basis. There must be a safe space for concerns to be raised, questions to be asked and misunderstandings to be addressed. Successful implementation of EDI training can never be a question of parachuting in, delivering a discrete course, and then hoping for the best. It’s an ongoing conversation that needs ongoing nurturing.
Notes
SLC has supported overseas trained healthcare professionals since 2014 to improve their healthcare-specific English language and communication needs and it is our experience in this field which informs this article.
Through the many thousands of conversations we’ve had, we see the issues listed above and are keen to work with healthcare employers to support staff and build stronger, more inclusive workplaces that work for everyone.
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