What is it actually like to work in the NHS as an IMG?
Most international medical graduates (IMGs) find that the medicine itself is familiar. The anatomy, physiology and core treatments are the same. What feels different is how the work is organised, how people talk to each other, and what patients expect. These differences are rarely written down, which is why the first few months can feel harder than expected even for experienced doctors.
There is also no single NHS. Health is devolved, so England, Scotland, Wales and Northern Ireland run their services differently. Hospitals are run by trusts in England, health boards in Scotland and Wales, and health and social care trusts in Northern Ireland. Guidance and job titles vary, so always check which nation a policy applies to.
The GP acts as the usual gateway to hospital care. Referrals come from general practice and your discharge letters go back to it. Much of hospital work involves coordinating with community teams, mental health services, social care and the GP, especially when a patient is going home.
How is the NHS team structure different from home?
Many IMGs trained in systems with a steep hierarchy, where junior doctors rarely question a senior and doctors direct the work of other professionals. The NHS still has clear lines of responsibility. Each inpatient has a named consultant who holds overall responsibility for their medical care. But the day-to-day culture is flatter, and decisions are often shared across a multidisciplinary team.
| Role | What they are responsible for | What this means for you |
|---|---|---|
| Named consultant | Overall medical responsibility for the patient | Escalate through your registrar or directly if needed; consultants expect to be called |
| Nurses | Nursing care, observations, early warning scores | Often the first to spot deterioration; take their concerns seriously |
| Physiotherapists and other AHPs | Their own assessment and treatment plan as autonomous practitioners | Ask for their opinion rather than prescribing their treatment in detail |
| Pharmacists | Medicines review and advice | Expect them to query prescriptions; this is a safety check, not a criticism |
| Ward clerks and coordinators | Admin, bed flow, local systems | Often the best source of practical help in your first weeks |
First names are commonly used across grades, including with consultants. This is normal and is not a sign of disrespect. If you are unsure, follow how people introduce themselves. With patients, introduce yourself by name and role.
Allied health professionals in the UK are autonomous. A physiotherapist decides whether chest physiotherapy is indicated after their own assessment. If you disagree with a colleague from another profession, discuss it as a colleague rather than as an instruction.
Why do NHS seniors expect you to escalate early?
In some systems, calling a senior at night can look like weakness. In the NHS it is usually seen as safe practice. Most registrars and consultants would rather be called about a patient who turns out to be fine than miss one who deteriorates. Not speaking up because a senior seems confident is a recognised cause of patient harm.
Structured communication tools make escalation easier. The best known is SBAR: Situation, Background, Assessment, Recommendation. Many hospitals also use the National Early Warning Score 2 (NEWS2) for adults, with escalation thresholds set in local policy. Learn your trust's policy in your first week.
- Situation: Say who you are, who the patient is and what the problem is, in one or two sentences.
- Background: Give only the history that matters to this problem, such as the reason for admission and relevant conditions.
- Assessment: State your findings, including observations and early warning score, and what you think is happening.
- Recommendation: Say exactly what you need, for example a review within 30 minutes, and confirm the plan back.
What do UK patients expect from doctors?
UK patients generally expect to be treated as partners. They want honest information, a clear explanation of options, and the chance to decide with you. This is reflected in the GMC's guidance on decision making and consent and in law. The 2015 Supreme Court judgment in Montgomery v Lanarkshire Health Board confirmed that patients must be told about material risks, judged from the patient's point of view rather than only the doctor's.
- Use plain words: say 'blood thinner' rather than 'anticoagulant' when explaining.
- Explore ideas, concerns and expectations: what the patient thinks is wrong, what worries them, and what they hope will happen.
- Check understanding by asking the patient to explain the plan in their own words, rather than asking 'Do you understand?'
- Adults with capacity make their own decisions. Families are involved with the patient's agreement or within the law, not by default.
- Use a professional interpreter when needed. Avoid relying on relatives, and especially children, except in an emergency.
Patients may question you, ask for a second opinion, or bring information from the internet. This is normal. Acknowledge what they have read, explain your view and the evidence, and agree a plan. You do not have to provide treatment that is not clinically indicated, but you should explain why and discuss alternatives.
Your CT shows a lumbar disc prolapse with foraminal narrowing. You need analgesia and physio. Any questions?
The scan shows one of the cushions between the bones in your back is bulging and pressing on a nerve, which explains the leg pain. This is common and usually settles over weeks to months. Before I go through the options, what were you most worried the scan might show?
What are the unwritten rules that catch IMGs out?
Many early difficulties have nothing to do with clinical knowledge. They come from expectations that UK colleagues take for granted and so never explain.
| Area | Common pitfall | What usually helps |
|---|---|---|
| Indirect language | 'You might want to recheck that potassium' is heard as optional advice | Treat polite suggestions from seniors as requests and confirm if unsure |
| Tone | A brisk, direct style can be heard as rude | Add please, thank you and would you mind, especially on the phone |
| Documentation | Short notes that record findings but not reasoning | Record what you found, what you decided, why, and what you told the patient |
| Handover | Leaving before tasks are clearly handed over | Arrive on time and leave only when outstanding jobs have a named owner |
| Feedback | Taking structured feedback as personal criticism | Ask for feedback regularly; it is routine and meant to help |
| Incident reporting | Fearing that reporting an error means blame | Report errors and near misses; the system is used for learning |
British colleagues often use understatement. 'Not bad' can mean quite good, and 'that's an interesting idea' may mean they disagree. Small talk about the weekend or the weather is a normal way of building working relationships, and joining in helps.
Practical systems matter too. Ask for electronic record and prescribing training before your first clinical shift, never use another person's log-in, find out who your safeguarding lead is, and learn the basics of the mental capacity law for the nation you work in.
Which professional standards apply to me?
Every doctor registered with the GMC must follow Good Medical Practice. The current version has been in force since 30 January 2024. It is organised into four domains: knowledge, skills and development; patients, partnership and communication; colleagues, culture and safety; and trust and professionalism. Reading it early is one of the most useful things you can do, because it describes the behaviours your appraiser, supervisor and patients will expect.
The standards are not just about avoiding harm. They also cover speaking up about concerns, treating colleagues fairly, being honest when things go wrong, and supporting a positive workplace culture. You are entitled to the same respect. NHS organisations have policies to protect staff from racism, harassment and abuse, and you can report it.
A worked example: the first month on the ward
Ahmed has eight years of experience abroad and starts on a busy medical ward. On his third night, a nurse tells him a patient's NEWS2 has risen to 6. He reviews the patient, starts treatment and decides not to call the registrar because at home that would have looked weak. In the morning the patient's daughter asks him about the diagnosis, and he answers in full without checking whether the patient agreed. At the ward round the consultant asks why the registrar was not informed.
Ahmed's clinical care was reasonable, but he misread two expectations. Escalation in line with local policy is expected, and early escalation protects him as well as the patient. And an adult with capacity decides who receives information about them.
I managed it myself because I have done this many times. The daughter was anxious, so I explained everything to reassure her.
I reviewed the patient, started treatment and called the registrar using SBAR because the score met the escalation threshold. I documented my reasoning. When the daughter asked questions, I checked with the patient first, then explained the plan with his agreement.
Ahmed then asks his educational supervisor for regular feedback and starts writing short reflections on what he is learning. Within a few weeks the team trusts his judgement and he feels more confident.
How can I settle in and look after myself?
Moving country and health system is demanding. Many doctors feel isolated or less confident than at home, especially in the first six months. This is common and usually improves as routines and relationships develop.
- Ask for a named supervisor or buddy and meet regularly in the first months.
- Attend your trust's induction and any international recruit programme, plus the GMC's Welcome to UK practice workshop.
- Find occupational health, staff wellbeing services and the employee assistance programme early, before you need them.
- Join your Royal College, the BMA or an international doctors' network for peer support.
- Register with a GP yourself. NHS Practitioner Health offers confidential support to doctors with mental health concerns.
- If you ever feel in crisis, you can call Samaritans on 116 123 at any time.
Where to go next
If you want a structured way to work through these differences, our course Adapting to UK Clinical Practice and NHS Culture covers team structures, communication, escalation and the unwritten rules, with a reflective account you can use for your portfolio or appraisal. If you are still planning your move, GMC Registration Routes for International Doctors explains the routes to registration, and Good Medical Practice: Professional Standards for Doctors explores the standards in more depth. Always check current details with the GMC and your employer.
Frequently asked questions
Is the NHS hierarchy different from other countries?
Usually yes. The NHS keeps clear lines of responsibility, with a named consultant for each inpatient, but the culture is flatter than in many systems. Colleagues often use first names across grades, decisions are shared across the multidisciplinary team, and any team member is expected to speak up about safety concerns. Seniors are expected to listen and generally prefer early escalation.
Is it normal to call consultants by their first name in the UK?
In many NHS teams, yes. Consultants often introduce themselves by first name and expect colleagues to use it. Practice varies between departments, so follow how people introduce themselves. With patients, introduce yourself clearly by your name and role. Using first names is not a sign of disrespect and does not change who is clinically responsible.
What do NHS employers expect from a new IMG doctor?
They expect safe clinical care, clear communication with patients and colleagues, early escalation in line with local policy, good documentation, and willingness to learn local systems. They also look for the behaviours in Good Medical Practice, such as honesty, respect and teamwork. Most do not expect you to know every local process on day one, but they do expect you to ask.
Is the GMC Welcome to UK practice workshop mandatory?
The GMC describes it as a free workshop for doctors who qualified outside the UK and are new to UK practice, available online or in person. The GMC's page does not describe it as mandatory, but it encourages employers to include it in IMG induction. Many employers recommend it strongly, so check with your medical education team.
How long does it take an IMG to settle into the NHS?
It varies. Many doctors say the first three to six months are the hardest, as they learn electronic systems, local policies and communication styles. With a good induction, a named supervisor, regular feedback and support outside work, most feel much more settled within their first year. Feeling less confident early on is common and is not a sign of failure.
Where can international doctors get wellbeing support in the UK?
Start with your trust's occupational health service, staff wellbeing team and employee assistance programme. Register with a GP. NHS Practitioner Health provides confidential mental health support for doctors. Professional bodies such as the BMA and Royal Colleges offer peer support. If you are in crisis, Samaritans can be reached on 116 123 at any time.
Related courses
Adapting to UK Clinical Practice and NHS Culture
This course prepares internationally trained doctors and allied health professionals for the everyday realities of working in the NHS. It covers team…
GMC Registration Routes for International Doctors
This course explains how an international medical graduate can gain full registration with a licence to practise from the General Medical Council. It…
Good Medical Practice: Professional Standards for Doctors
This course explains the GMC's Good Medical Practice (2024), the core standards every doctor registered in the UK must follow. It works through the…
Sources and further reading
- Good Medical Practice (2024). General Medical Council.
- Welcome to UK practice. General Medical Council.
- Decision making and consent. General Medical Council.
- National Early Warning Score (NEWS) 2. Royal College of Physicians.
- Montgomery v Lanarkshire Health Board [2015] UKSC 11. The Supreme Court of the United Kingdom.
- The NHS Constitution for England. Department of Health and Social Care.
Practitioner Insight is an independent education provider. It is not affiliated with or endorsed by the GMC, MPTS, NMC, HCPC, GPhC or any NHS organisation, and this information is not legal advice. If you have been referred to a regulator, speak to your defence organisation, trade union or legal representative.
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