For many overseas-trained workers in the NHS, their right to live and work in the UK is tied directly to their employment. They hold work visas sponsored by their employers. This creates a dependence that affects far more than just job security. It changes their relationship with workplace safety and their willingness to raise concerns.
Misunderstandings
“Many of us are on work visas and we fear that speaking up might jeopardise our jobs or create misunderstandings,” one worker reported during the National Guardian’s Office’s research into the speak up review, Listening and learning: Amplifying the voices of overseas-trained workers published in May 2025. “There’s always a worry that raising concerns could be misinterpreted, making us appear as if we’re not adapting well.”
When your employer controls your visa status, speaking up carries risks that UK-trained colleagues simply don’t face. For some overseas-trained workers, the loss of a job is linked to losing their right to remain in the country entirely.
The psychological impact on a worker is profound. As one system representative explained: “For UK-trained trainees, speaking up is difficult because they worry about their career. For overseas-trained workers, that fear is compounded by concerns about their ability to stay in the country. Their employer controls their visa status, adding another layer of hesitation.”
Vicious cycle
The review heard that some overseas-trained workers found themselves facing professional referrals soon after arrival. One system representative described a troubling pattern: “Some managers raise referrals within two weeks of an overseas-trained worker arriving, simply because they haven’t ‘hit the ground running’. There’s little consideration for the fact that they’ve left their home country, arrived in a foreign place with a different language and are still adjusting.”
Instead of recognising the natural adaptation period these workers need, some organisations jump straight to formal concerns processes rather than providing support. The response, instead, is punitive and lacks cultural intelligence.
This creates a vicious cycle. The fear of referrals, combined with visa insecurity, generates enormous stress and makes workers even less likely to speak up about legitimate concerns.
Visa-related barriers
Addressing visa-related barriers to speaking up requires acknowledging that immigration policy and patient safety are not separate issues. They intersect in ways that affect both worker well-being and care quality.
Healthcare organisations need to recognise these additional vulnerabilities and actively work to mitigate them. This means creating extra safeguards, providing additional reassurance, and ensuring overseas-trained workers understand their rights and protections.
It means moving beyond simply saying “everyone can speak up” to actively demonstrating that overseas-trained workers will be supported when they do. It requires cultural intelligence from managers and colleagues, recognition of adaptation challenges, and commitment to fair treatment regardless of visa status.
Safe
Every healthcare leader, manager, and colleague have a role to play in creating environments where overseas-trained workers feel safe to speak up. This isn’t just about being nice or inclusive – it’s about patient safety and organisational learning.
When structural barrier, such as visa insecurity, silence certain voices it harms individual workers and the entire system’s capacity to learn, improve, and provide safe care.
The NHS has always been strengthened by its diversity. This speak up review shows the NHS must ensure all voices heard, all perspectives valued, and all workers empowered to speak up when something doesn’t seem right. Patients and workers deserve nothing less.