Should the NHS curb spending on translation services?

Abstract

Millions of pounds are spent on NHS translation services each year. David Jones believes that current service provision is patchy and more investment is needed, whereas Kate Adams argues that doctors should encourage patients to learn English to avoid future public health problems

When the BBC reported the high cost of interpreting services, the conservative estimate was £55 million (€82m; $107m).¹ My initial response, as a general practitioner using interpreting services every day, was that this seemed a fairly small sum given the scale and diversity of non-English speakers who are entitled to use the NHS and other public services. I was also troubled by the way the subject was reported, with widespread expressions of concern about waste and the secretary of state for communities and local government asking for a review of language services across government. The message to the public was of a government setting out to find ways of reducing spending in this area. As the complex issues of identity and integration have become of central political concern in the United Kingdom, the government's attitude has shifted.

Full citizenship already requires a test of competence in English. Now we are hearing that non-English speakers have a responsibility to learn English in order to contribute to the process of integration and share in British identity and public life and even to hold on to unemployment benefit.² The darker side of this idea is that the state's responsibility to provide adequate language services for those who fail to become competent speakers of English is limited.

Complex factors determine whether a migrant to the UK will acquire sufficient English competence to communicate effectively with health professionals. In a 1996 study that explored English language skills in five different ethnic groups, people who were in employment or education performed much better than those at home or retired.³ Cause and effect are difficult to disentangle, and the cultural factors that confine women to the home may not be easy to shift. Longer formal education and younger age on arrival in the UK also seemed to be important factors associated with better English language competence. In this important study the length of time in the UK alone had little relation to English language attainment.

In my practice in Tottenham, a deprived inner city area of London with a diverse population of new migrants to the UK, like all GPs, I often care for three generations. It seems completely unrealistic to expect, for example, a 76 year old Somali woman, often with no previous formal education, to attend English classes and acquire English. Such patients, who may expect to live for 20 years, will always need an interpreter. Her daughter struggles a bit, and we often use an interpreter, usually via the telephone. Her granddaughter, aged 10, is of course effortlessly bilingual. We need to take a long view sometimes.

Faced with enormously powerful cultural, demographic, and technological influences, GPs and other health professionals must not underestimate the importance of such factors in determining whether a specific patient will acquire English competence. In Carr-Hill et al's 1996 study, nearly 90% of 1200 people from nine different minority linguistic communities watched television in English.³ Ten years later technology has moved on, and the homes of my patients have satellite TV invariably tuned to non-English channels.

Even the governments of liberal democracies may be incapable of influencing this area. The presence of many different language communities with many members unable to speak the main language of the host country is a global phenomenon and exists despite different national responses. The United States, for example, is often used as an example of a country that has encouraged a strong sense of national identity. It remains a country struggling to manage the language barrier.⁴

It is clearly a disadvantage not to speak the majority language of the country in which you live: people disadvantaged in this way are likely to find language is a barrier to accessing information and social and cultural contacts are likely to be limited to those who share the same language. It is not clear that this results in psychological damage. Migration to the United Kingdom may have been a difficult experience in many ways, and psychological problems associated with this process are well recognised.⁵ We have no evidence to support the suggestion that being a non-English speaker is an independent cause of mental illness because of “alienation from the wider mainstream culture” or for any other reason. It may just as well be the case that people who do not speak English are protected from many of the negative features of the wider English speaking culture in ways that have a positive effect on mental health.⁶

What role, if any, is it appropriate for doctors to have in encouraging patients to acquire English language skills? Doctors who offer, in the consultation, their view that a patient should learn English are offering a personal, and in many ways political, belief. Such a suggestion could be perceived as inappropriate and as a rejection.

But what is good medical practice in this context? The GMC's 2006 publication, Good Medical Practice, clearly states: “To communicate effectively you must: make sure, wherever practical, that arrangements are made to meet patients' language and communication needs.”⁷

All too often no such arrangements are in place. This is not because such arrangements are impractical but because provision for translation and interpreting in the NHS is patchy and often not adequate or not used. Interpreting services are not audited for quality or uptake, and health professionals do not have training or clinical governance guidelines for the use of interpreters.

In my practice I have on many occasions received letters from hospital consultants explaining that a full exploration of a particular patient's problem had not been possible because “no interpreter” was available.

A recent usage review of telephone and physically present interpreting in two primary care trusts in north London showed that although interpreting services in a range of languages are available, many GPs are choosing not to use them, while a small number of GPs are intensive users.⁸ We should not find this surprising. The use of interpreters, either physically present or available remotely via a telephone link, is time consuming and not supported or rewarded by the GP contract. In addition, the use of family members, practice receptionists, and children as informal interpreters as a substitute for professional interpreters is widespread.⁹

What is needed is more, not less, spending on language services. Current NHS interpreting services may well have negative health and social care consequences because they are so poor. A new study from the United States has shown that adverse clinical events are more likely to result in physical harm in patients with limited English proficiency.¹⁰ All doctors working in the NHS, certainly in the inner cities, understand quite clearly that care for non-English speakers regularly falls short of the GMC's expectation of good communication with patients.⁷ We must not let the politicians persuade us that it is the patients' fault.