Interpreting services are failing to meet the needs of black and ethnic minority communities, and risk dilluting the level of patient care. But despite the perceived cost, Maqs Khan explains why investment in interpreting services could safeguard a more efficient future for community care.
To convey what we mean, feel or experience is difficult in itself with variables such as class, gender, age, health profiles, but in social contexts where people do not have the same language, it may lead to embarrassment or frustration, and/or to consequences that can be life quality compromising if not life threatening. The notion of “disadvantage” commonly used to express this experience does not adequately capture its potential or its reality.
Interpreting services find it difficult to escape from political agendas associated with the integration of new communities in Britain and presented as services that maintain the “lack of integration”. In assimilationist and integrationist models they are temporary services but this charge presupposes that the same people continue to use them.
While it is true that BME communities themselves meet the majority of their interpreting needs through family members acting as interpreters, there are many that do not have this support infrastructure, and equally they may wish to speak to a doctor or a nurse alone and may not feel comfortable seeking support about their ailment in front of their child due to embarrassment or sibling or friend, due to privacy.
Issues of language competence are compounded by other access factors that inform the experience of many non English speaking patients when accessing health care services such as
- Failure to understand what services are available and how to use them;
- Lack of confidence in dealing with people in authority – this may manifest itself in over compliance, lack of challenge or nervousness;
- Lack of clarity as to what they should do first;
- A fear of being a nuisance;
- Lack of cultural competence of staff and the organisation on the whole, e.g. a patient with little English is visited by the district nurse. The patient is suffering from anxiety and is unable to explain this to the DN. This immediately has led to failure in seeking treatment from a patient perspective and providing appropriate treatment from the staff perspective.
For a community of people to disproportionally feel any of the above would suggest the presence of institutional racism as articulated by the McPherson Report, where discrimination is experienced through practice and process is part of the organisational culture and it can on occasions lead to patients being overly aggressive to compensate for the feelings generated by the above.
The need for health staff to engage with patients effectively in order to ensure that the treatment/educational plan are understood by the patient is essential for the successful implementation of treatment. This is particularly relevant for community staff members who rely on the patient to self manage their care plans with support.
It is imperative that staff gain the cooperation and support of the patient in the hope they comply to the treatment plan. In order to obtain this compliance, the patient needs to be confident in asking questions, clarifications to a point that s/he understands what is expected from them.
Hudelson’s notion that “Effective patient-provider communication is central to the delivery of high quality medical care” means that interpreting is not just about language and improved communication but also involves communication on “causes and consequences of staff patient difference in ideas about the illness, its causes, treatment and meanings”.
Interpreters therefore need to demonstrate competency on cultural practices, beliefs, concepts and even gestures providing bilingual and bicultural support to staff and contribute indirectly to the build up of a care plan. An interpreter can contribute to the cultural competence of the organisation by ensuring the following:
- Being able to identify points of difference – where different meanings are being derived by the health worker and the patient, it’s important that these are fed back and becomes part of the general cultural competence of an organisation;
- That the patient is not stereotyped as “typical of a community” and their individual needs are subsumed by this caricature, the reverse is also possible where an interpreter may seek to ingratiate him/herself by pandering to the perceived prejudices of colleagues;
- To act as a “dialogical conductor” that allows effective communication between staff and patient identifying and developing a vocabulary that can adequately name conditions e.g. anxiety and depression;
- To establish relationships that are open and respectful giving the patient the confidence to express themselves to the health care worker and to challenge or ask for clarity and vice versa.
In order to achieve cultural competence, language support is essential as, stated by the CIPD, it enhances “better communication with the diverse groups of potential concern” but as interpreting costs increase this is reported by the media as a political correctness luxury that reinforces inward looking communities with no interest to integrate. This perception is being given added weight and momentum as the NHS alongside other public services faces cuts. The media is reporting this service and its costs as excessive and a luxury the NHS cannot afford.
In 2006, the BBC reported that the NHS spent £55m in translation services. The Daily Mail, in October 2008, reported that the NHS lost £250,000 just in interpreting costs for the NHS Direct services. In Dec 2010, the BBC again reported that the NHS had spent £2.57m from June to December 2010 on interpreting services.
An increase from 2006, but in my opinion these costs are only touching the tip of the iceberg. The real costs of interpreting services could possibly be ten times that as each PCT has its own local system, some planned to the final detail for reporting purposes, others offering interpreting services on an ad-hoc manner.
After various reports by the BBC, Ruth Kelly asked for an interpreting cost review across government departments, but to date there is little organised response to interpreting services across the public sector. There appears to be little organised data available to identify the reality of interpreting services across the public sector, this is however understandable given the levels of public and political antipathy towards interpreting services – what is evident is that they emerge out of real need outside of public and political discourse and this need has been seen by the private sector as a lucrative business opportunity with companies offering international, national and regional interpreting services to all sectors.
The legal right to translation services is unclear. Equality in access to health services is a guiding principle for the right to health as a human rights obligation. However, interpreting service provision nationally, regionally and locally is patchy and more investment is needed. There does not appear to be a nationwide strategy in place on how the NHS collates information on spends, take up, and benefit. Furthermore there are no protocols, no guidelines and each provider does what it can, therefore making the service vulnerable to public antipathy. It exists because it is needed and demonstrates;
- Commitment to health needs of the minority groups;
- Business sense for providing language support for minority groups as it means less expense for NHS in the long run;
- Improved effectiveness of the cultural and language competence of staff delivering health care plans, treatments, education and training;
- Compliance with Care Quality commission standards, equality diversity system outcomes, FREDA principles.
Staff need to understand the relationship between a culturally competent workforce and a culturally competent service to achieve higher compliance rates with standards of care. This requires that existing or new training addresses cultural competence needs and skills. Many of the staff across the NHS perceive cultural competence and language to be two very separate components of their work contributing to inconsistency in terms of what cultural competence actually means across the NHS. This is something that needs to be addressed at Department of Health level by ensuring the term is “operationalised” and measured for its effectiveness. For this to happen, it needs to be made meaningful to staff with a clear definition.
I believe that the drivers for managing interpreting service within the health care setting cannot be the local providers in isolation. My proposal is as follows:
- Develop a centralised budget for interpreting services;
- Develop national contracts with Interpreting providers, this will lead to Cost Improvement Plan savings and impact on the Cash Releasing Efficiency Savings agenda by default. This in turn will embed quality within commissioner-provider discussions and create a culture of continuous quality improvement via the Commissioning for Quality and Innovation Framework;
- Develop national training on the use of interpreters leading to consistency across the NHS;
- National information interpreting/translation library on common issues.
- Develop a profile of the makeup of local communities and main languages;
- Standardise translated information which is relevant to local community, i.e. when consulting minority groups on EQIA’s, a shared regional consultation brief in common languages can save money, create consistency and ensure all groups in the area are engaged with.
Local (organisational) Level
- Identify the best method of language services, i.e. face to face, telephone;
- Monitor frequently encountered languages;
- Ensure there is language support 24/7;
- Inform patients of their right to receive language support;
- Record language support required on patient records.
As well as taking reasonable care to ensure a safe system of healthcare and using qualiﬁed and experienced staff, interpreting services too should be registered with the CQC as this can provide consistency across the NHS in terms of quality assurances, as well as provide an audit trail of how local health providers meet the standards of language.
Interpreting services may be expensive and an added burden on the NHS when it is experiencing the biggest shake-up ever, possibly in its history. There are many arguments about the need for immigrant, migrant communities to integrate.
However, the reality is interpreting services are not just about the interpreting for the migrants, immigrants, it is also about supporting those with visual, hearing impairments, mental health problems, dementia epidemic and more. It makes financial sense in particular for the NHS to offer interpreting services early on in the patient’s journey as it helps achieve a quicker diagnosis, an informed and understood treatment plan that is put in place at an earlier stage of the illness.
Overall for the NHS it means a better management of the diagnosis and treatment and speedier discharge and return to some normality for the patient.
Interpreting services do not necessarily exist due to media pressure, political will or a pro active strategic/policy imperative. They exist because they are a necessity for health professionals and patients and this is the reason for their ad hoc emergence and regional difference. T
he service is caught between strategic/political ambivalence and practical need. The impact of this ambivalence means that it is possible that the financial management and quality of assurance of these services is vulnerable to compromise and with it, so is patient care.
Note: cultural competence in the context of this article means “the ability of health care providers in health care organisations to understand and respond effectively to the cultural and language needs which are brought by the patient to the health care encounter
Find out more
- Easton, M., Translating Cuts into Savings, BBC.co.uk, 2010
- Easton, M., Cost in Translation, BBC.co.uk, 2006
- MOCK, K., Effective clinician-patient communication.PhysicianNews.com, 2001.
- NHS Constitution Handbook (PDF)
- Patient Safety