BMJ  2007;334:398 (24 February), doi:10.1136/bmj.39126.572431.47

Feature

Head to head

Should the NHS curb spending on translation services?

Hackney, London N1 5DR

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

On 12 December 2006, the BBC reported on the high price being paid for the provision of translation services. A conservative estimate for the National Health Service alone was £55 million (82m; $107m), with the true figure likely to be much more, and the cost of providing such services across all public services was said to be rising sharply.¹ The report received lots of public feedback, mainly expressing concern. Ruth Kelly, the secretary of state for communities and local government, asked for a review of language services across government departments.

The complex concept of citizenship, with its emphasis on encouraging integration, is high on the government's agenda and a vital part of this is language competence. People applying for UK citizenship are now required to pass an English test.

As a general practitioner in Hackney in inner London I see many patients whose English is either non-existent or so poor that they need translation support. In individual cases, both clinically and ethically, the justification for providing translation services is overwhelming: the provision of care would be substandard without it. But I am concerned that the provision of translation services is inadvertently compounding some of the underlying health and social problems that we are being asked to help with. A significant number of my non-English speaking patients present with either explicit psychological problems, such as anxiety or depression, or with physical problems that seem to me to have psychological origins and studies support this.² It strikes me in my discussion with many of these patients that an important contributory factor to much of this psychological suffering is a sense of being alienated from the wider mainstream culture.

In some of the larger immigrant communities people can shop, move around their communities, and access public services relatively easily without the need to speak any English. A population survey throughout the United Kingdom in 2006 showed that 5.3% (2.3 million people) speak another language at home.³ There are many people who have lived in the UK for more than 20 years who speak little English. Can we really say that this is in either their interests or the interests of the wider community? Less able to pursue self determining activities such as employment and often restricted to smaller communities that may be culturally and politically marginalised, these patients are vulnerable to depression and related psychological responses to alienation. Gender is an important factor here. In some communities, women will often remain at home while the men go out to work. The men are therefore more likely to learn sufficient English to enable them to function in the wider community. Such opportunities are denied to women who remain at home. Where there are relationship problems—a violent husband or partner, for example—the near total dependence that may result from being unable to seek help beyond their community can drive women into depression. What we are seeing is, at least in part, the medicalisation of problems that are actually social or cultural in origin, with some of the costs being borne by the health service.

Treating people from an enormous variety of cultures and backgrounds, people who have very different approaches to illness, who present symptoms in unfamiliar ways, and whose cultural beliefs are so varied, is an interesting and rewarding part of inner city medicine. But it is also time consuming and expensive—and in general, not recognised in doctors' pay systems. Translation services also present some practical problems. Some areas are better served than others and although, in theory, interpreting services by telephone are available around the clock, patients who do not speak English are vulnerable in hospital settings, particularly out of hours, when access to services is difficult. Patients not able to communicate effectively are at risk, and this is a patient safety issue. A US study published in February 2007 showed that hospital patients who have limited English proficiency are more likely to be harmed by adverse events than other patients.⁴

It is interesting to draw comparisons with British expatriate communities abroad. If you decided to live in a non-English speaking country, would you expect interpreting services to be readily available? This is now an issue in Spain, where there is a large, ageing British ex-patriot community and many speak little Spanish. Some Spanish doctors are now refusing to treat anyone who cannot speak Spanish unless an interpreter is present.⁵

In the UK, the legal right to translation services is unclear. Under international obligations, equality in access to available health services is a guiding principle for the right to health.⁶ Citizenship must balance rights against duties, and may include a right to a reasonable standard of health care that will, in certain circumstances, entail the use of a translator. But should there not also be a corresponding duty to learn the language of the adopted community which has granted the rights? However we decide to respond to this, health professionals need to encourage their patients to learn English, thereby helping them in the process of integration, otherwise we will be storing up public health problems for the future. Without employment people are more likely to face deprivation, and the links between ill health and deprivation are well known.² Translation services will always need to be available for elderly people whose English is poor, and for new arrivals, but at a time when the NHS is facing a huge financial crisis, is it in anyone's interests to see the costs of translation services increasing? High profile campaigns around the UK and from within communities are needed to encourage people to learn English. If doctors can prescribe gym classes for depression, is it really so far fetched to suggest that we should also be prescribing English classes?

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Competing interests: None declared.

References

1. Easton M. Cost in translation. BBC News 2006 Dec 12. http://news.bbc.co.uk/1/hi/uk/6172805.stmhttp://news.bbc.co.uk/1/hi/uk/6172805.stm
2. Health Protection Agency. Migrant health. Infectious diseases in non-UK born populations in England, Wales and Northern Ireland. A baseline report. November 2006. http://www.hpa.org.uk/publications/PublicationDisplay.asp?PublicationID=53
3. Office for National Statistics. Annual population survey. 2006. (Unpublished data from National Centre of Languages.)
4. Divi C, Koss RG, Schmaltz SP, Loeb JM. Language proficiency and adverse events in US hospitals: a pilot study. Int J Qual Health Care 2007 Feb 2. http://intqhc.oxfordjournals.org10.1093/intqhc/mzl069
5. Stevens J. Dark side of sunny Spain for Britain's elderly expatriates. Observer 2006 July 9. http://travel.guardian.co.uk/article/2006/jul/09/travelnews.spain
6. Toebes B. The right to health. In: Eide A, Krause C, Rosas A, eds. Economic, social and cultural rights. 2nd ed. The Hague: Kluwer Law International, 2001:178.

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