Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Spending on language support
- Mark RD Johnson (23 February 2007)
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Should NHS curb spending on translation service? No.
- Makarand K Oak (24 February 2007)
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...not while English classes are being cut
- Philip R Matthews, NE4 6BE (26 February 2007)
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What about the Deaf community?
- Emma Stapleton (26 February 2007)
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Can relatives help?
- Rohit Lodhi (26 February 2007)
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How about doctors learning their patient's languages
- Nazzar Tellisi (27 February 2007)
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NHS Translation Services: call for continued funding
- Anandagiri M Shankar, Sam Ramaiah (1 March 2007)
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Urgent need for local data to meet the translation need
- Paramjit Gill, Terry Quirke (1 March 2007)
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Let's keep translation straightforward
- Amber D Porter, Nelson Porter, and Sarah Porter (2 March 2007)
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Health illiteracy contributes to inequalities in health
- Qaim Zaidi (16 March 2007)
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Mark RD Johnson, Director, Mary Seacole Research Centre, Clinical Lead, NHS Specialist Library for Ethnicity & Health MSRC, De Montfort University, 266 London Road, Leicester LE2 1RQ
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Kate Adams and David Jones have brought an important subject into debate (BMJ 334 :398, 24 Feb 2007). I cannot deny that it is in everyone’s interest to promote the learning of English – it is after all a (the?) premier world language, which enables English-speakers to travel anywhere in the world without the bother of learning the local ‘lingo’. Nevertheless, I fear that Dr Adams is misguided, although one can sympathise with some of her points – and I am indebted to her for finding evidence that adverse effects are more common in those with limited English proficiency. Our UK insurance schemes seem unable to supply such chapter and verse although I remain convinced that it happens, albeit perhaps often unreported. Dr Adams believes that psychological suffering is caused by a sense of being alienated from mainstream society. Do Brits in Spain, whether retired pensioners or criminals evading justice suffer psychologically from their lack of Espanol? Inability to seek ‘outside’ help for (e.g.) domestic violence is not (solely) due to language isolation, but more importantly issues of shame, awareness/knowledge, and indeed feelings of community solidarity. There is also a paradoxical protective effect, as shown by studies of the uptake of immunisation (Bhopal & Samim 1988) and maybe also an immunity conferred against advertising of unhealthy foods and drink? Our own estimates of the costs of language support (Johnson et al 1999) are now well out of date ( and were flawed by the lack of anyone keeping records of use and cost) but would not support an estimate of £55 million at today’s prices. The failure – or at least ending, of the NHS ‘Framework Contract’ for interpreting support with Bowne Global suggests that it was if anything being under-used. Similarly, we have struggled to locate well-validated examples of translated patient information materials to add to the NHS Specialist Library for Ethnicity & Health (www.library.nhs.uk/ethnicity), although articles demonstrating need are not hard to find. I would welcome support for a radical review – such as I fear will not be provided by Ruth Kelly’s departmental inquiry, and find myself in agreement with Dr Jones, that it must not be seen as the patient’s fault if they cannot communicate. Finally, however, I will agree with Kate Adams that it would be nice to prescribe a course of language-learning. This could be very prophylactic for Brits about to travel, but in the case of migrants to UK, I fear will be impracticable unless the NHS can find the funds to rescue an ESOL (English for Speakers of Other Languages) service that is being heavily cut back by a Government dedicated to costcutting. Prof. Mark R D Johnson
Adams K, Jones D 2007 ‘Should the NHS curb spending on translation services?’ BMJ 334 :398-9 Bhopal, R., Samim, A. (1988) ‘Immunisation uptake of Glasgow Asian children: paradoxical benefit of communication barriers’ Community Medicine 10,3 :215-220. Johnson MRD, Clark MD, Owens D, Szczepura A (1999). The Unavoidable Costs of Ethnicity: A review of evidence on health costs. Centre for Health Services Studies, University of Warwick, Coventry, UK. June 1999. ISBN 0953 5430 05. (Note: I use the term Language Support, as this includes both (oral) interpretation and (written) translation, and maybe also the use of bilingual linkworkers and indeed bilingual professional clinical staff. Each has its use, cost and value). Competing interests: : The journal Diversity in Health & Social Care is about to publish, a guest editorial by Tasneem Irshad, Allison Worth and Aziz Sheikh, headed “Are translation and interpretation services a necessity or a luxury?”, in issue 4,2 (Spring 2007). (MRDJ is Editor of DHSC) |
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Makarand K Oak, Consultant Obstetrician and Gynaecologist Lanarkshire ML2 0DP
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Should NHS curb spending on translation service? No. BMJ 334:399 24 Feb 2007 Editor, This article supports my belief that something called ‘individual responsibility’ has disappeared from English language. Its use is either criminalized or shortly will be with minimum sentence of execution by hanging-well metaphorical. Take the very example of the 76 year old Somali woman in the article, who may live for another 20 years or so and the disservice the NHS or the government, I mean the taxpayer will be doing to her by not offering translation service. We do not expect her to become an orator or understand the nuances of the language but I ask if it is beyond human capability to learn to say and describe health problem in three months or so. I am not a theologian but I do not believe that any religion criminalises learning. Surely, if we have to throw taxpayer’s money then the prudent use would be towards making efforts in working with community leaders and increasing awareness and achieving culture shift, which would not only benefit individuals but also the community at large. Rights and responsibility is a two-way traffic and not simply one section has rights and the other responsibility. Effective communication has the potential to make a positive contribution to ones health just as not smoking and alcohol use in moderation. If I continue to abuse my health by excessive drinking and smoking then even the entire GDP of the whole world will not save my life. NHS is a caring organisation so are people in it but caring is a two way process and I would say lets us take a pragmatic view rather than a ideological view. Mr Makarand Oak Consultant Obstetrician and Gynaecologist Motherwell ML1 2UF 01698230324 Mobile 07771738692 Competing interests: I am Indian by birth and have been in the UK since 1974. |
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Philip R Matthews, Staff Grade Psychiatrist Newcastle General Hospital, NE4 6BE
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The BBC News report on the high cost of translation in December of last year (surely they also meant interpreting) for public services seemed to assume that the amount being spent was more than adequate (which is debatable), that immigrant patients are reluctant to learn English, and that providing translation services dissuades people from learning English. Cutting services, it was implied, would be “tough love” to help non-English speakers help themselves. In my experience of working as a GP and as a psychiatrist with asylum seekers, they are usually very keen to learn English and the rate at which they, especially children, pick it up is often amazing. English classes are also an invaluable form of occupational therapy for those feeling depressed, traumatised and isolated. When someone doesn’t learn English, there is usually a reason. Anecdotally, one main reason appears to be gender: e.g. a woman who is expected, or is forced by circumstances, to stay at home to look after the children. The second reason is often a mental health problem: I have frequently heard patients tell me “I go to English lessons, but can’t learn anything because I can’t stop thinking about my torture/the family I left behind/my fear of being returned” Furthermore, even for someone who has learned reasonable English, an interpreter is necessary to discuss subjects such as hallucinations and thought insertion. Is it good “tough love” (never mind good ethical practice) to deny an interpreter under such circumstances? Government policy is increasing the cost of interpreting. Interpreters historically often came from asylum seeker communities themselves, but when the Home Office stopped them working, this source dried up. I have often had to use the far more expensive telephone interpreting service because there has been no face-to-face interpreter. And now the Government is planning to cut English teaching entitlement to asylum seekers over 19, limiting their opportunities to learn English and forcing public services to rely on interpreters even more. Competing interests: Dr Matthews has producing printed and web-based translated materials for use with asylum seekers |
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Emma Stapleton, Clinical Research Fellow University of Edinburgh Department of Otolaryngology, Lauriston Place, EH3 9EN
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In their article, Kate Adams and David Jones both make interesting and valid points regarding the cost, availability and appropriateness of translation services in the NHS. I note in particular David Jones' comment 'I have received letters from hospital consultants explaining that a full exploration of a patient's problem had not been possible because no interpreter was available.' In acute specialties, it simply isn't feasible to use an interpreter. Patients' relatives and friends, or helpful multilingual colleagues are often indispensible on such occasions. Both authors discussed the issue of British citizenship, but did not consider the British Deaf community. British Sign Language has been a recognised British language since 2003; it is the fourth commonest language in the UK, and is the primary language used by around 250,000 Deaf British citizens, many of whom cannot understand spoken or written English. The waiting time for a BSL interpreter is around six weeks. It is impossible to acquire one in an acute situation. As an SHO in ENT, I found it embarrassing that there was not a single member of staff able to communicate with our Deaf patients. Deaf people are British citizens, but their lack of English is an enormous barrier to communication, which is far from ideal in the acute clinical setting. Communication with our patients doesn't only allow us to acquire clinical information and to offer advice and treatment options; it is essential for fostering trust within the privilege of a doctor-patient relationship. I signed up for BSL night classes which I funded myself, and after two years my BSL is not excellent but I can communicate with Deaf patients regarding their clinical conditions on a safe, basic level. In my last six-month post I used BSL on only four occasions, but on each of these occasions the patients' operations or clinic appointments would have otherwise been postponed. Perhaps - instead of 'prescribing English classes' for our patients as suggested by Kate Adams - the NHS should keep a record of multilingual staff who are willing to help out in clinical situations. Perhaps - instead of concerning itself with the cost of external services - the NHS should consider such basic clinical priorities as communication. If the NHS used its pre-existing staff for interpreting purposes (it might even consider funding training courses for interested staff, or offering incentives for suitably qualified staff) this would decrease the cost of interpreters; decrease the waiting time for interpreters, and improve communication with non-English speaking patients. Competing interests: None declared |
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Rohit Lodhi, S.H.O Child Psychiatry and Neuropsychiatry Park Hospital
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Kate Adams has a valid point in suggesting that immigrants who do not speak English should be encouraged to learn the language. In today’s N.H.S anything that saves money without causing any problems with patient care has to be a good idea. ‘Is it in anyone's interests to see the costs of translation services increasing?’ was a question in the article. I think the answer is obvious, it is in the interest of the ‘language barrier facing immigrant’ who is there in your G.P surgery asking for help. I am a psychiatry resident and my currency of dealing with patients is nothing but language. I have developed a sense of respect for good professional translators. The translator is of immense benefit in knowing the symptoms of such patients, without which I would have no idea of what the person is thinking. It is important for me to breakthrough the cultural and linguistic barriers to understand the mental state. It also helps if the translator knows the cultural background of what is being said instead of just providing literal translations. Like for example, to describe sadness, a Chinese person may use a term that is often translated as "congested." A doctor who does not understand the subtleties of the expression might offer treatment for allergies or the flu, rather than depression. Looking back, I can remember times when relatives volunteer to provide translations of what is being said. In theory they should be the best translators considering that they know the cultural background, common terms used for psychological symptoms and have been with the patient for whatever period of time! Most of them are all too eager to try and help out. The information they provide can be invaluable. But in practice it can be more complicated. Mental illness in the family takes a toll on relatives too. To expect them to be unbiased in their translations might be too much. Relatives may distort history in order to avoid the stigma of having a mentally ill person in the family or to avoid them being blamed for the symptoms. The underlying dynamics of the family always impacts thinking, understanding and the way problems get looked at. To conclude if I have a good professional translator in such situations I will accept that anytime, even if it costs money because my duty to the patient is to provide the best care. English speaking relatives maybe helpful but it can be difficult to rely on them all the time. Competing interests: None declared |
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Nazzar Tellisi, HSS Fellow NY 10021
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I guess the response to my question is why should we. I think UK doctors should be familiar with foreign languages or at least include multilingual doctors and those from ethnic minorites in their practices to solve this problem. Competing interests: None declared |
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Anandagiri M Shankar, Specialist Reigstrar Department of Public Health, Walsall Teaching PCT, Jubilee House, Bloxwich Lane, Walsall WS2 7JL, Sam Ramaiah
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The view expressed by David Jones (1) is indeed true and we whole heartedly support the idea of continuing funding for NHS Translation Services. Often, these services form the only means of getting across health information to Non-English speaking patients. This is particularly true in deprived populations having a significant proportion of Non- English speaking people. In Walsall, which is one of the most deprived districts in England there is a large proportion of Black and ethnic minorities, who are Non- English speaking. They are currently 3rd or 4th generation migrants from South Asian countries and culturally the women folk tend to be indoors and have practically no basic English Language skills. An Asian Health and Life style survey conducted in Walsall, in 1995 on a group of 1500 Adult South Asians revealed that 15% of them showed ‘no use’ of English language (2). The same cohort was followed up and a repeat survey conducted in 2000 revealed that the same percentage had gone up to 16% (2). More than five times as many women as men had no skills in English (3). Walsall has also witnessed changes to demographics with the proportion of South Asians in the total quarter million population gone up from 7.5% in 1991 to 10.5% in 2001 (4). We strongly believe that stopping funding of the NHS Translations Services will seriously affect these disadvantaged groups and may even adversely affect the gains thus far achieved. On the other hand, additional funding is of paramount importance to disseminate new medical knowledge to these communities to empower them to adopt healthier lifestyle practices, which in the long run could actually benefit the NHS and the wider community in terms of financial gains. References: (1) Adams K and Jones D. Should the NHS curb spending on translation services? BMJ 2007; 334: 398-9 (24 February) (2) Pooransingh S, Kumar J and Ramaiah S. Walsall’s Asian Health and Lifestyle Survey 2000. Department of Public Health Medicine. Pg 2; September 2001. (3) Department of Public Health, Walsall Health Authority. The Health and Lifestyle of Walsall’s Asian Community- the Results of the 1995 Lifestyle Survey- a Summary of the Main Findings. Pg 3. 1996 (4)Department of Public Health. Minority Communities Matter. The 2005 Annual Report of the Director of Public Health. Pg 11. 2005 Competing interests: None declared |
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Paramjit Gill, Clinical Senior Lecturer University of Birmingham, B15 2 TT, Terry Quirke
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Dear Editor
We welcome the debate on need for translation within the NHS and as Adams and Jones highlight this is a complex issue.
Communication is at the heart of patient-doctor encounters. The moral, business and the legal case for interpreting are established. [1] However there is no data on the number of non-English speakers who require an interpreter at local and national level. We calculated a national estimate by using the Health Survey for England [2], where participants are asked how well they spoke English, with responses of, very well, fairly well, slightly or not at all. By applying the combined numbers of the latter 2 categories to the 2001 Census, estimate of numbers unable to conduct a consultation in English was calculated. Age groups were combined due to small numbers.
Table 1 shows that there are 559,199 individuals from these 4 main minority ethnic communities who have been here over 30 years. The results reflect the complex migration patterns for each group [3] and assuming that consultation rate is 6/year then there are 3,355,194 consultations/year that require an interpreter. Infact the majority of this ‘translation need’ has, and continues; to be met by the many overseas trained general practitioners who are due to retire imminently. [4] With no one coming forward to fill their shoes in deprived, over-stretched areas, there is an urgent need to plan for this need. But first we need accurate local data on ‘the number of patients speaking a different language to their primary health professional’ (www.nhsempoyers.org/primary/primary-891.cfm).
Competing interests: None declared |
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Amber D Porter, GP Heckington Surgery NG31 9QP, Nelson Porter, and Sarah Porter
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Our main concerns in the translations that we have seen from English to Urdu are that the expressions used are often quite complicated and rather refined with unusual vocabulary. Many of the people who the translation is aimed at would have difficulty understanding it. Looking at the photograph in this article the waiting room translation could have been in more simple, everday Urdu. Even the word 'Waiting Room' written phonetically with Urdu script would be easier to follow. The word for room is 'kamra', rather than 'gah' in easy-to-understand Urdu translation. Competing interests: None declared |
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Qaim Zaidi, Ethnic Strategy Co-ordinator British Heart Foundation, W1H 6DH
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Dr Adams’ idea that we should encourage people to integrate by limiting their access to healthcare, in effect holding their health hostage as a guarantee, runs against the founding principles of the NHS and the tenants of good public health. In order to address health inequalities, it is often necessary to allocate resources unequally by targeting those most in need. Thus translation services for NHS patients whose first language is not English can help ensure that they have equal access to NHS services. Translation services provide better outcomes for patients and allow them to better mange their conditions. In the sort term, it is simply about providing the best possible care. In the long term this is about helping people to become productive and integrated members of society. We need to spend more money on translation and interpreting services, not less, so that the NHS can be proud of a service that meets the needs of all British citizens. The British Heart Foundation is committed to reducing inequalities in health. We have so far focussed on South Asian communities, but are working on providing culturally specific and relevant information in various languages to newly arrived communities as well. Qaim Zaidi
Competing interests: None declared |
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