By Dr Elsayad
Communication is the silent gatekeeper of National Health Service (NHS) advancement. Promotions and pay hinge not only on clinical but also cultural competence: on how confidently doctors articulate, how comfortable they appear with ambiguity, and how effectively they navigate hierarchy within unspoken contexts.
Assessment of this key skill is relentless across interviews, ward rounds, MDTs, incident reviews, and handovers. The stringent IELTS and OET thresholds that international medical graduates (IMGs) must meet before registering in the UK might prepare them linguistically, but cannot save them from regular evaluation based on tone, framing, assertiveness, self-advocacy, and collaboration. Upward evaluation remains systems specific.
Systemic unfairness
A clinically excellent doctor perceived as hesitant due to cultural differences may be held back from opportunity, as their highly experienced colleague is labelled ‘unready for promotion’ simply because they communicate cautiously in a structure that rewards confidence over quiet accuracy, for instance.
These so-called ‘failures’ are about more than language. Professionals are expected to perform in ways that are culturally familiar to the NHS despite receiving zero cultural guidance. This contradiction may not affect UK-trained doctors, who readily absorb systemic interaction norms through years of foundational placements, but puts overseas talent – which now forms 42% of the country’s licensed medical workforce according to the General Medical Council (GMC) – at unfair disadvantage.
Speaking the system’s language
Professional expectations are rarely explicit within NHS systems, though deviations are immediately noticed. Questioning senior colleagues is discouraged in many backgrounds. Here, however, silence can be interpreted as disengagement – though speaking up too much in the wrong contexts just as easily backfires. Good communication is dynamic. Situation determines who is trusted and heard, and, ultimately, who is invited into informal networks where opportunities emerge. Key steps Drs should consider is taking the time to reframe cautious language into clear clinical statements, be bold in clarifying anything ambiguous as opposed to assuming meaning and treating communication as a trainable, clinical skill.
In addition, it pays for overseas doctors to seek ‘NHS-fluent’ mentors who can help them in speaking the system’s particular language. Without structured guidance, they’ll continue tripping over complex communicative steps they’re expected to intuit – often at significant personal and professional cost.
When language shapes pay
While NHS pay scales are nationally defined, starting points are not. Trusts retain discretion in how overseas experience is interpreted, particularly for speciality and locally employed doctors. Internships are frequently discounted and two years are typically deducted from CVs to ‘mirror’ UK core training.
The result is an informal ‘experience tax’, where six years of post-qualification work may be paid for as four. Challenging this requires clear, confident articulation of equivalence. Doctors who can frame their experience persuasively, in culturally aligned ways, are more likely to secure higher salaries. Those who cannot often accept lower pay, unaware that negotiation was even possible. Communication is not just a soft skill; it’s economic.
Onboarding professionals mustn’t be afraid to seek guidance from those already familiar with the NHS. It’s important to remember that, with 68% of those joining the GMC register in 2023 holding non-UK qualifications, the system needs them more than they might think. Self-advocacy can only lead to positive outcomes.
Fluency is the real fast track
Once employed, overseas doctors must then learn to navigate formal progression pathways. Training routes have become increasingly competitive, with 7.17 applications now being filed for each specialty post, according to Health Education England. Despite making up a growing share of these applications, acceptance rates among IMGs remain markedly lower – some cohorts securing fewer than one in four available positions. GMC data suggests this training gap only continues to widen, locking overseas professionals out of progression opportunities, largely due to discrepancies in cultural communication.
Doctors in non-training roles and local employment likewise struggle. Progression depends heavily on appraisals, references, and informal reputation – each mediated by social fluency. Those in charge look at how feedback is sought, how concerns are raised, and how contributions are self-described, making contextualised cultural competence the real fast track to promotion. IMGs must learn – not just how to speak – but how the NHS listens.
Learning the rules before they cost
Of course, communication also underpins patient safety. Serious Incident investigations repeatedly identify communication differences as contributing factors of failure, with PMC patient safety studies linking approximately 37% of medical errors to poor clinician fluency. Overt missteps such as omissions are rarely responsible. Rather, differences in expected tone, timing, or interpretation of unspoken socio-cultural expectations are at fault.
Rarely trained in local idioms, euphemisms, or emotionally charged consultations, it’s unreasonable to expect overseas professionals to intuit that patients who feel ‘something’s not quite right’ or ‘a bit under the weather’ might be suffering significantly. Yet, the system blames them when nuance is lost.
With GMC data showing that almost one in five internationally trained doctors joining UK registers between 2022 and 2024 have already left, the NHS cannot allow such bias to continue. It must address its own blind spots, no longer treating cultural and systemic fluency as assumed.
Meanwhile, doctors joining the NHS from abroad must protect themselves by recognising that progression, pay, and professional safety ultimately depend on learning how the system operates. NHS-fluent mentorship is currently the only proven path forward.
