Jonathan Haslam looks at the difficulties created for general practice by the increasing numbers of non-English speakers in the UK.

The structure of the UK population is changing, and this is placing increasing challenges on GP practices. In 1981, just over 6% of the UK population were born overseas. By 2001, this had risen to over 8%, and latest estimates from the Labour Force Survey indicate that in 2006 almost 10% of the UK population were born overseas.

In May 2004, eight Central and Eastern European countries joined the European Union, and by 2006 more than 400,000 people who were born in these countries were living in the UK.¹

There are wide variations around the country. In Tower Hamlets, according to statistics from 2001, more than 30% of the population were born outside the EU (the overall figure for London is more than 20%). By comparison, in rural Cornwall, less than 3% of the population were born outside the EU.

Practices are faced with a more diverse landscape, in terms of language and culture, than ever before. And, of course, it is not just the population of patients that is changing. The new countries of the EU are a vital source of trained medical professionals, who are willing and eager to work in the UK, often in out-of-hours situations, where, often operating without records and with no previous knowledge of the patient, good communication is even more important.

These changes to the population bring real challenges for healthcare professionals. One of the most important areas of healthcare is communication. In terms of medicolegal risk, it is arguably the most important. There are an increasing number of studies that show that a breakdown in communication can be the trigger of a complaint or claim, sometimes even if there has been no fault in the care the patient has received. These dangers are magnified where one participant in a consultation is (literally) talking a different language.

Of course, it is about more than language. There are many other cultural factors that come into play, such as the use of particular gestures, body language and wider issues such as the role of women and the family. Even when speaking English, patients may have a different understanding of what a “familiar” English phrase means. Consultations can be a mess of misunderstandings.

In general practice this is a potential, and growing, risk. MPS has received a number of calls on this issue. To date these have mainly been for advice or following a complaint, and there are no clear cases that have led to direct harm to the patient, and a subsequent claim.

Maternal deaths

In its latest report, the Confidential Enquiry into Maternal and Child Health reported on the deaths of the 19 women who were murdered between 2003 and 2005, and who were pregnant or had recently given birth. Of these, five could not speak English, and their husbands translated for them.

Each has at least two of the recognised risk factors for domestic abuse, but none were referred for further help or advice. Of the 295 women in the report who died from maternal causes, coincidental causes or some months after childbirth, 48 (16%) spoke little or no English. Few had access to translation services, and in most cases, family members, friends or the woman’s children were used as interpreters.

This situation is not ideal. Using children to translate, for example, may prevent mothers from getting vital, but embarrassing, information. And, as we have seen, other members of the family may have an interest in controlling the information that is passed to and from the patient.

Care should also be taken when using dual-role translators (individuals who have another job in the practice). While these can provide a convenient and effective service, it is important that their skills are up to the task. A study in the US found that more than 20% of dual-role translators were only fluent enough to translate at a basic level, rather than as a medical interpreter.

In a perfectly resourced world, a professional interpreter is the preferred answer. Studies have shown that the use of professional interpreters improves care for patients with limited English proficiency. Patients who rate their translator highly are more likely to rate their healthcare highly.

Rising costs

In the last few years, demands for professional translation services have grown dramatically in the UK. The BBC recently estimated the cost of translation services to the NHS at £50 million, although this seems likely to be an underestimate. One Manchester teaching hospital saw demand for its translation service rise by 70% between 1998 and 2003.

Yet around the UK, the provision of these services is still largely ad hoc. Interpreters, particularly those working in healthcare, are not subject to regulation. The National Register of Public Service Interpreters provides a professional quality-assured register but does not regulate.

Practical implications

So what are the main risks for practices? In their guide to valuing diversity, the GMC say that: “The Human Rights Act 1998 and other legislative changes such as the Disability Discrimination Act 1995 (as amended) provide a strong case for the provision of effective communications in hospitals, in the community and in GP practices. Wherever possible, communications should be provided in languages and formats appropriate to the patientgroup.” ³

Among the practical tips that the GMC provides are:

• Try to look at your patient and not at the interpreter when you are speaking, even if the patient cannot understand you. This can reduce certain anxieties or suspicions from your patient. It also allows you to monitor body language.
• Remember that the interpretation process takes time, and ensure that background noise is at a minimum.
• Some people who most need information in their own language may not be literate in any language.
• Be aware that non-medical staff – for example, receptionists – are usually the first people that service users and patients encounter. Communication problems with a busy receptionist can cause distress or discomfort for a range of patients/service users who have specific communication requirements.
• Patient information (leaflets, posters etc) and important signage and announcements should be in plain language and accessible to all the main groups served by the healthcare organisation. 
• Remember that some languages do not have a written form, so audio material may be preferable.

While good communication is important in any patient consultation, there are particular situations where patients are more at risk, such as:

• Consent. Particularly where consent to treatment is complicated, it is important to check the patient’s understanding of the risks and benefits.
• Older people and those lacking capacity. The difficulty of establishing the needs and wishes of those with limited capacity will prove more difficult when their English is poor. This may be exacerbated if it is difficult to separate the interests of the carer, acting as translator, from those of the patient.
• Child protection. Again, providing support for vulnerable children is made more difficult by communication problems.
• Dual residence. Patients living in two different countries may be seeing different health professionals. Matching treatment and prescribing options can be difficult.

It is important to establish what resources are available locally to manage language problems. Putting appropriate resources in place for the communities that you serve will help prepare you for any issues that may arise.

References

1. Office of National Statistics, Population Trends, Winter 2007,www.statistics.gov.uk
2. Saving Mothers’ Lives 2003–2005, Confidential Enquiry into Maternal and Child Health www.cemach.org.uk
3. Valuing Diversity Guide, General Medical Council, www.gmc-uk.org

Also check out Primary Care English by R. Ribes at www.spandoc.com.

Last updated: December 2008

Please note: Medical Protection does not maintain this article and therefore the advice given may be incorrect or out of date, and may not constitute a definitive or complete statement of the legal, regulatory and/or clinical environment. MPS accepts no responsibility for the accuracy or completeness of the advice given, in particular where the legal, regulatory and/or clinical environment has changed. Articles are not intended to constitute advice in any specific situation, and if you are a member you should contact Medical Protection for tailored advice. All implied warranties and conditions are excluded, to the maximum extent permitted by law.