Focus

The UK’s National Health Service and language service provision

Rachel Hideg is an in-house English proofreader at life sciences translation experts Albion Languages. She holds an MA in French and Latin from Oxford University and an MA in literary translation from the University of East Anglia.

Rachel Hideg headshot

Rachel Hideg

Rachel Hideg headshot

Rachel Hideg

Rachel Hideg is an in-house English proofreader at life sciences translation experts Albion Languages. She holds an MA in French and Latin from Oxford University and an MA in literary translation from the University of East Anglia.

I

n the most recent United Kingdom census, over 8% of the UK population reported speaking a main language other than English. A total of 726,000 people, or 1.3% of the population, could speak English, but not well, and 0.3% of the population (138,000 people) reported not being able to speak English at all.

A great deal of research has been carried out in the provision of public healthcare and the impact of language barriers on this, and the costs and benefits of interpretation and translation services in this field. In a research paper published in the Journal of General Internal Medicine, Jacobs et al. discuss how “conversations between physician and patient are recognized as being of diagnostic import and therapeutic benefit.” However, patients with limited proficiency in English are unable to benefit from this interaction, and — by relying on ad hoc solutions such as other patients, family members, friends and nontrained, nonclinical employees — are at risk of consequences such as reduced trust in physicians, lower patient satisfaction, breach of patient confidentiality, misdiagnosis, inadequate or inaccurate treatment and reduced quality of care.

The 2014 National Health Service (NHS) England Project Initiation Document (PID) “Primary Care Medical Services: Interpretation and Translation Framework” acknowledges that “language barriers in the health care setting can lead to problems such as delay or denial of services, issues with medication management, and underutilisation of preventive services.” At the same time, the provision of language services, such as translation and interpretation, can improve the quality of healthcare, patient experience, adherence to recommended care and health outcomes.

However, the PID also points out that, despite the NHS’s legal responsibility to ensure interpretation and translation services (as stated in the 2016 NHS Act), the current funding of such services in primary care is “messy.” In certain cases, Clinical Commissioning Groups are responsible for the budget; in some cases, money is transferred to NHS England Area Team budgets, and in other cases money is allocated to local authority budgets via public health funding.

With all this in mind, let’s consider the NHS’s current approach to the provision and funding of interpreting and translation services, as well as external views on the costs and benefits of such services.

The NHS approach to language services

Between 2015 and 2017, the NHS undertook to define good-quality interpreting and translation for the health service. Focus groups were organized in 2015, involving people from 12 ethnic backgrounds and speaking 22 different languages, including Punjabi, Hakka, Polish, Bangla/Bengali, Gujarati, Somali, Pushto, Turkish and Arabic. These public consultations resulted in the drafting of Principles for Interpreting and Translation Services. In 2016 and 2017, the principles were updated, and a guidance document for commissioners was produced.

According to the guidance document, not being able to communicate well with health professionals can influence health outcomes, increase the frequency of missed appointments, and impede the effectiveness of consultations and patient experience. Eight principles were defined in the document:

Principle 1: Patients should be able to access primary care services in a way that ensures their language and communication requirements do not prevent them receiving the same quality of healthcare as others. Interpretation and translation should be provided free at the point of delivery, be of high quality, accessible and responsive to patients’ linguistic needs. Patients should not be asked to pay or to provide their own interpreter.

Principle 2: Staff working in primary care provider services should know how to book interpreters across all languages, and book them when they’re required.

Principle 3: Patients requiring an interpreter should not be disadvantaged in terms of the timeliness of their access.

Principle 4: Patients should expect a personalized approach to their language and communication requirements recognizing that one size does not fit all. This includes gender, cultural identity or other special circumstances. In terms of end-of-life care, the continuity of care should include access to the same interpreter, where possible.

Principle 5: High ethical standards, a duty of confidentiality and safeguarding responsibilities, are mandatory in primary care, and this duty extends to interpreters. Interpreters should be qualified for working in healthcare settings, have undergone appropriate checks and clearances and be trained annually in safeguarding children and adults. The interpreter is only there to facilitate communication and should not be asked to undertake additional duties during the appointment (such as those delivered by a caregiver or advocate). There should be no physical contact or support with intimate or clinical procedures, and such procedures should not be performed in view of the interpreter.

Principle 6: Patients and clinicians should be able to express their views about the quality of interpreting services they have received in their first or preferred language.

Principle 7: Documents that help professionals provide effective healthcare or support patients to manage their own health should be available in appropriate formats when needed. The translation of documents for the benefit of patients must be completed by competent and appropriately trained translators, and not by practice staff. Patients should be able to request a summary of their care record at no cost to themselves. Translation of documents can also include reading information for the patient in the language they require (“sight translation”). If patients have medical records in another language that relate to their health, these should be translated into English as soon as possible, where there is a clinical need. Automated online translation services such as Google Translate should not be used, as there is no assurance of the quality of the translations.

Principle 8: The interpreting service should be systematically monitored as part of commissioning and contract management procedures and users should be engaged to support quality assurance and continuous improvement and to ensure it remains high quality and relevant to local needs. The service should be subject to regular performance monitoring to guarantee that it meets patient needs. This includes checks to ensure that interpreters are suitably qualified and registered, review of vetting and barring, review of safeguarding training, checks that appointments are being kept, monitoring of costs, and the level of compliments, comments, concerns and complaints. Interpreting services must demonstrate that they can process personal data and sensitive personal data in a secure, confidential manner, including online, in conformity with the GDPR.

Although the guidance document expands on these eight principles in detail and is aimed at improving local translation and interpreting services, a survey of the websites of different NHS Trusts suggests that the principles are not yet being followed in practice. Principle 7 states that “Automated online translation services such as Google Translate should not be used, as there is no assurance of the quality of the translations.” However, many NHS Foundation Trust websites offer the Google Translate service all the same. In fact, with reference to the Google Translate option, the NHS Bedfordshire Director of public health has stated: “We welcome the addition of this free translation facility on NHS Choices. It allows members of the public from the many different communities in Bedfordshire and Luton, who may have been prevented from using the site previously due to language barriers, to benefit from the site’s useful information.”

Likewise, the Great Western Hospitals NHS Foundation Trust states at the top of its page on translation and interpreting that the text of its website can be translated using Google Translate, which can also be used to translate pdf documents downloaded from the website. However, it also refers to free of charge face-to-face and telephone interpreting services and document translation services.

Otherwise, there are various approaches to the provision of telephone and/or face-to-face services. The Sheffield NHS Trust site states: “If you do not speak English and need to have an interpreter for your appointment, please ask someone who speaks English to telephone the ward or department you are visiting. This telephone number should be on your appointment letter. Most interpreting is now done via the telephone on the ward or clinic. Only in exceptional circumstances will we offer a face-to-face interpreter.”

However, the NHS Northern Care Alliance has its own page with details of interpreting and translation services, which include face-to-face interpreting by permanent interpretation staff. Moorfields NHS Foundation Trust also offers telephone-based interpretation or face-to-face spoken language interpreting services. The King’s College Hospital NHS Foundation Trust is unique in actually having foreign-language content directly on its webpage.

Many of the NHS sites for general practitioners include a list of languages spoken by practice staff. However, one NHS surgery website states that its telephone interpreting service is available “where patients do not have a carer or family member who can interpret for them…” which seems to directly contradict Principle 5 concerning the professional qualifications of interpreters working in healthcare settings.

The 2020Health assessment

In 2012, the independent social enterprise think tank 2020Health produced the report “Lost in translation,” investigating NHS expenditure on translation services. Its website refers to the “shocking cost” of translation in the NHS, which it quotes as £64,000 a day, or £23.3 million in 2011 on services for speakers of 120 languages. Part of the problem is that the NHS Trusts translate their own materials independently, rather than providing access to a central pool of translated documents. However, the report raises some complex social questions concerning integration and the meaning of citizenship. On the one hand, it quotes statements such as that made by the director of the TaxPayers’ Alliance, who argues that “those who live in Britain should make an effort to learn to speak English so that they are not burdening services like the NHS.” On the other hand, it quotes a Bangladeshi human rights lawyer in the East End of London who says that the provision of translation and interpreting services is actually damaging to his community, as it reinforces the language barrier that separates his community from the rest of Britain and disincentivizes Bangladeshis from learning English. In some communities, such services may even contribute to upholding the practice of not allowing women to learn English for fear of them becoming “corrupted” by integration.

The report recommends translating materials into “easy-to-read” English rather than other languages and making them available across all NHS sites. Knowing a patient’s origin, it argues, is not always enough, as some patients may be illiterate in their own language.

It also recommends making more use of free web-based translation such as Google Translate.

While the Google Translate option will doubtless result in savings on translation services, it is important to bear in mind the potential savings that can be achieved by having good-quality language services in place in terms of the efficacy of treatment and the uptake of preventive care, which may lower the cost of care in the long term.

Although the “Accessibility” page on the NHS site states that the health information on the NHS website can be translated using an online translator, it adds this disclaimer: “Although online translators can accurately translate individual words and phrases, they may not always be able to interpret the meaning of larger or more complex pieces of information.”

Futureproofing the NHS’ language services strategy

As a national, free-to-access health system in a highly multicultural and multilingual society, the NHS clearly faces major challenges in engaging with its non-native English-speaking patients and their family members.

As can be seen from the above, the approach implemented in assisting those facing language barriers has been rather fragmented thus far, with considerable regional variations between health authorities in the quality and usefulness of language services provided. In order to address these challenges more effectively, it seems that a more concerted language services strategy is needed.

This should obviously be preceded by a thorough study of the nature and extent of actual needs in the many linguistic communities that make up the UK, with consideration also given to the likely impact of Brexit on altering the numbers of those in the different linguistic groups. Such data will be of great use in effective targeting to ensure optimal usage of a potentially limited budget.

In creating an appropriate strategy, a number of factors should be considered going forward. Firstly, the right balance needs to be achieved between the need for a certain degree of centralization and the empowerment of regional authorities. It’s vital that the benefits of centralized procurement, such as reduced translation costs and coordination of document translations, are secured — while at the same time leaving sufficient freedom for regional health authorities to flexibly handle their specific, local needs like interpreting.

Secondly, the language services provided need to be made a key element of the user-friendly health information delivery system rather than as an afterthought, with the aim of ensuring that nonnatives can also take care of their health without language barriers.

Thirdly, the language services strategy should ensure that nonnative patients can also enjoy the benefits of AI and cognitive technology with the patient becoming the focus of provision. Key elements of this include taking into account the language obstacles of nonnative users in population health optimization efforts and also facilitating doctors in reducing the administration time for such patients.

Finally, with the expected explosion in the use of preventive care technology in healthcare (such as wearable smart trackers or implantables), it’s vital that the data and benefits of such systems can easily be conveyed and made transparent to nonnative speakers too.

The challenges facing NHS decision-makers in this field are thus clearly multilayered and complex. This is especially the case in the context of an aging population, rising patient numbers and ever-increasing patient expectations. Given the organization’s proud history and the unfailing commitment of its staff, we trust that the NHS will be able to rise to the challenge.