Breaking down language barriersBMJ 1998; 316 doi: http://dx.doi.org/10.1136/bmj.316.7143.1476 (Published 16 May 1998) Cite this as: BMJ 1998;316:1476
The NHS needs to provide accessible interpreting services for all
- David Jones, Lecturer,
- Paramjit Gill, Senior lecturer
- Department of Primary Care and Population Sciences, Royal Free and University College Medical Schools, Whittington Hospital, London N19 5NF
- Department of General Practice, Medical School, Birmingham B15 2TT
The movement of human populations over vast distances in the search for a better or safer life is not new,1 but the 20th century has been distinguished by migration on a unprecedented scale: 90 million people may now live outside their country of birth, over 13 million of them refugees.2 Their countless individual journeys have transformed the demographic characteristics of large Western cities, which are now home to many different minority ethnic communities.
The NHS was established before the period of greatest immigration into the United Kingdom, and doctors could once have expected to share the same culture and language as their patients. This expectation has changed— minority ethnic groups comprise 6% of the UK population3—but it is far from clear that the NHS as a whole has changed rapidly enough, especially in the inner cities, to meet the challenge posed by patients whose English may not be good enough to communicate adequately with health professionals.
Health authorities lack knowledge about the languages spoken in their districts and of the extent of the need for interpreter services, which are generally not available outside traditional working hours.4 Inadequate resources devoted to communication and information services underlie a much impaired service for patients from minority ethnic groups.5 Doctors and other healthcare workers struggle to provide adequate care but are thwarted by an institutional orientation towards a standard service no longer appropriate for a heterogeneous population.
Most initial healthcare contacts take place in general practice. General practitioners in inner cities can often obtain a professional interpreter for “important” consultations, but what of consultations that are not planned in advance? Only practices with a majority of patients from a single language community can expect to have an interpreter available throughout surgery hours. The much more typical inner city practice, with small numbers of non-English speaking patients from several language communities, is likely to have very limited access to professional interpreting.
Healthcare professionals then must choose between several imperfect alternatives. Phelan and Parkman have drawn attention to the disadvantage of using friends and relatives for interpreting medical consultations and, in particular, the importance of not using children.6 Children lack the emotional and cognitive maturity to assume the responsibility of interpreting conversations between parents and professionals. In many families details of bodily function and dysfunction are private and an unsuitable subject for discussion with children. Despite official acceptance that children are not appropriate interpreters for their parents, young children are often used as interpreters. The lack of intepreting services for non-English speaking patients presenting acutely is a source of real danger for the patient and adds significantly to the stress experienced by the clinician and the informal interpreter. If we are really committed to a multicultural society and equal access then we must close this gap.
Provision of physically present interpreters for all possible languages, 24 hours a day, in all health settings is unrealistic. But great improvements can be made with some additional resources. Pointon has highlighted the advantages of telephone, or remote, interpreting.7 Appropriate equipment and training are essential: ideally a hands off conference telephone should sit between doctor and patient to allow the consultation to be consecutively interpreted. Telephone interpreting carries the obvious disadvantage of not allowing the interpreter to see a patient's non-verbal communication and is demanding for both doctor and patient. However, patient confidence in the confidentiality of the consultation may be higher when the interpreter is not present, especially if physically present interpreters would otherwise be recruited from the patient's local community.
In the United Kingdom commercial telephone translation services are available but are expensive and employ interpreters who may not have experience in medical interpreting; some districts run local telephone interpreting services, but provision is patchy. Little is known about the effects of different translation provision on the quality or costs of health care, but evidence from the United States, where interest in telephone translation is growing,8 suggests that it can allow high quality consultations and is valued by patients.9 Clearly more research is needed into the effects of remote interpreting, and we need to explore how various combinations of remote and physically present interpreter services might best meet needs at an affordable cost. One day, a rapid access, all day, comprehensive telephone interpreting service in the NHS might help to make equality of access to health care more of a reality for some ethnic minority groups.