Language barriers between a healthcare professional and a patient can impact on health outcomes, increase the frequency of missed appointments, the effectiveness of consultations and patient experience. Interpreters provide a service for patients, carers and clinicians to help them understand each other when they do not speak the same language.
“It’s so much more than the words,” says Dr David Lehane. “I’m white, middle-class, and British born with an Irish father; one reason I need an interpreter is to tell me about where I might be going wrong and what I don’t understand about someone’s culture. I need them to do some of the work for me, and help the patient. know where to go for blood tests and X-rays, and also to put things in a cultural context.”
Lehane is a GP and a lecturer at the University of Sheffield, where he is looking particularly at the use of interpreting and translation services by GPs. It’s also an issue that NHS England has taken up; in September 2018 it issued new guidance for commissioners on reviewing and commissioning interpreting and translation services, with the aim of identifying the gaps in existing provision.
And those gaps are indeed being revealed as the commissioners look at their areas. To take just one example, the review of primary care services in Lambeth, Southwark and Lewisham has shown that over half the people who might need them were not told about interpreting services when they registered; nearly half of those who asked for an interpreter were told this was not possible; and a number are told to bring a family member or friend to interpret for them, even though this goes against all guidance and good practice.
But is this really something that hard-pressed services should be worried about? And in the scale of things, is spending money on translation and interpreting services really a cost worth incurring?
Language facts and figures in the UK
According to the most recent census (2011), around 4.2 million people in England and Wales speak a ‘main language’ other than English or Welsh: this amounts to 8% or one in 13 people. Within this, there are 88 main languages; the most common is Polish followed by Punjabi, Urdu and other European languages. Obviously, this is also clustered in many areas; and indeed many of those people also speak fluent English, but in some London boroughs and in Leicester up to 9% of the population either does not speak English well or does not speak it at all.
The same census asked respondents to rate their own health and the results are interesting because although – as one might expect – the people who do not speak any English are likely to be older this is not the full picture.1 Across all age categories, those who termed themselves ‘non-proficient’ were less likely to report their health as ‘good’ than those with better English, with the people aged 50 and over doing particularly badly.2 So they are definitely going to need primary care services.
Needs and options of translation services
The service that these people require is often referred to as ‘translation’ – but in fact most of it is not translation but interpreting. Translation refers to the written material. Some of this is often available in some format or other – patient information leaflets, website copy, information about treatments and so on – although it may take some finding. In addition, there also a need to translate material that this is specific to this patient like their medical notes and any documents they bring with them about their health and/or any medication they have been taking.
The second service is interpreting, or oral communication: someone who explains the meaning of what the doctor is saying. Interpreting can be done in different ways: by bringing in an interpreter to do so face-to-face; through a phone service; or, more recently, by using a video link. This is where many practices find it tempting to rely solely on friends and family – the free option – but for a number of reasons this is not a good idea.
Anna Ware, director of Clear Voice, a social enterprise language provider which also a member of the Institute of Translation and Interpreting explains some of reasons why not. “Even just on a day-to-day basis, people may not be comfortable about discussing personal issues in front of others. So as a doctor you may not be told everything.”
It is even more serious if there are bigger issues of power, control or violence, she adds. “That’s definitely the case for victims of modern-day slavery – if someone goes in who is ‘interpreting for them’ you are definitely not going to get the full story.”
Google Translate is not a complete solution either. Machine translation is now becoming increasingly accurate but it still requires ‘post-editing’ – checking by humans to ensure that it is accurate. In a situation where accuracy absolutely essential, there is no real room for error and machine translation does not guarantee this.
Added human value
However, as both Lehane and Ware point out, it’s more than linguistic accuracy alone. A good interpreter is not the main person in the room – that is the patient; but in situations like this they also support both sides by helping them clarify exactly what is being talked about.
“My Urdu-speaking patients, for instance, often refer to ‘pain in the vein’,” says Lehane. “That’s not a term I’m used to. Health beliefs are very important, too.” Interpreters who know the patient’s culture can help clarify misunderstandings that the GP was not even aware of.
Beyond this, there is the whole issue of learning how a particular culture’s health services work. “A lot of people need interpreter support at registration stage,” Ware explains. “They don’t know how the GP system works in the UK – how to access a doctor, what they can expect and so on.”
Value for money
The interpreter’s role, it turns out, is highly skilled. They need to be able to understand medical terms, convey these appropriately and also help patients through an unfamiliar health system – while maintaining both confidentiality and impartiality. In some ways their role in a GP surgery is more demanding and complex than interpreting high-level negotiations.
“When you’re not using them you think you are doing OK,” Lehane concludes; but when they are part of the consultation, they make a difference that can literally save a patient’s life.