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Jakub Sacharczuk, an interpreter and Board member of the Institute of Translation and Interpreting, looks at interpreting within the NHS including best practice and technology developments
Imagine a scenario. Arriving at the GP practice but unable to speak English, you bring along a friend to help you. The doctor tells you that you have ‘angina’ and your friend, not knowing the right terminology, uses the same word. If you are unlucky enough to be a Polish-speaking patient, you were just told that you have tonsillitis instead of a heart problem. ‘Angina’ in English and Polish is what is known as a false friend – they sound the same but mean very different things. This is just one example of how poor-quality interpreting within a healthcare environment could have negative consequences.
The NHS is committed to providing equality of access to high-quality healthcare services, including to those for whom English is not their main language or whose hearing impairment could create communication barriers. This principle is enshrined in legislation and a number of documents including the NHS Constitution 2012, the Health and Social Care Act 2012 and the Accessible Information Standard 2016.
However, providing this equality of access is complicated for a variety of reasons including the proportion of the population whose main language is not English and the diversity of languages spoken. According to the most recent census (2011), around 4.2 million people in England and Wales speak a main language other than English or Welsh; this amounts to eight per cent of the population. In London, more than 300 languages are spoken, and, for many people, English is not the primary language spoken at home.
We commonly hear the arguments that people living in the UK should just learn English, and that the NHS is spending too much on interpreting services.
It is important to note that it can take a long time to achieve fluency in a language, and that medical language is one of the last areas acquired in language learning. In addition, for most people language ability can drop in stressful situations.
Such commentary also fails to consider the cost of not providing professional interpreters.
It is not only levels of satisfaction in care that suffer. Academic studies (Flores, 2005 and Karliner et al, 2007) have found that the lack of quality interpreting services can lead to patients’ poor understanding of their diagnosis and planned treatment, and also a higher number of communication errors in total and significant errors (for example, relating to dosage, allergies, past history) which could lead to medical errors. In turn, this can result in sub-optimal care for the patient, higher expenditure due to inefficient diagnosis and treatment, and costly litigation.
All these factors highlight the merits of providing a quality interpreting service, but what are the specific challenges in providing such a service?
The individual interpreter
In addition to being fluent in both English and the patient’s language, the interpreter also needs to have excellent cultural understanding. For example, patients with limited proficiency in English may have health beliefs that stem from their culture or background that are different to the health practitioner’s. The interpreter should remain impartial, but they need to be aware of and able to clarify cultural issues that may result in misunderstandings.
The requirement for: excellent language skills; the ability to recognise and deal with cultural nuances; and the need for total impartiality all mean that it is desirable not to use family or friends as interpreters. The recently published Guidance for commissioners: Interpreting and Translation Services in Primary Care (September 2018) states: “Patients should always be offered a registered interpreter. Reliance on family, friends or unqualified interpreters is strongly discouraged and would not be considered good practice.”
While not always possible, it can be valuable to use the same person to interpret if several contacts are required to enable a relationship of trust and understanding to develop between the client and interpreter.
As regards achieving satisfactory and consistent competency levels in interpreters working for the NHS, economic constraints create an ongoing tension right across the public sector. On the one hand, there is a desire to only use individuals who fulfil a variety of recognised criteria – as enshrined in NHS guidance and the registration requirements of the National Register of Public Service Interpreters.
On the other hand, continued downward pressure on costs within the NHS can lead to low rates of pay and unfavourable working conditions, which is not an incentive for individuals who have spent some years achieving relevant qualifications and membership requirements of industry bodies. The Institute of Translation and Interpreting (ITI) has anecdotal evidence from a number of members who say they have stopped doing such assignments for this reason. The worry is that this effect could lead to an influx of less qualified and experienced practitioners, resulting in a lowering of standards overall.
Meeting the demand for interpreters
Ensuring the availability of interpreters in a wide variety of languages requires an appropriate system to be in place. Typically, NHS trusts will have a bank of freelance interpreters; this may be managed in-house or run by an external agency.
In certain cases, for example when very limited, routine information is needed or where someone is in Accident and Emergency and there is no time to bring in an interpreter, the hospital will commonly use an on-demand telephone interpreting service.
When it is not possible to source a suitably qualified interpreter from the bank, for example for less common languages or dialects, an agency will typically be contacted to fill the gap.
It is important that diversified systems of supply are in place; relying on one source can lead to problems and mean that healthcare professionals find themselves getting bogged down in trying to find a suitable interpreter.
The qualified and experienced interpreter can be trusted to arrange seating in a way that works for all the participants and aids effective communication. Above all, the doctor (or anyone else speaking) should talk directly to the patient, not to the person who is facilitating their communication.
An interpreted consultation will of necessity be longer than an equivalent meeting with an English-speaking patient. The previously referenced guidance for commissioners in primary care states that the time taken will be ‘typically double that of a regular appointment’.
In some cases, it may be desirable to have a pre-session briefing with the interpreter, such as for mental health issues or where there may be discussions about a sensitive or culturally ‘taboo’ issue.
The dynamic of the three-way communication involving an interpreter is very different to that of a conversation between only the healthcare professional and patient. Training medical students and health professionals in how to consult through interpreters using role-play has been shown to significantly improve skills and confidence (Bansal et al 2014).
Following a patient consultation, debriefing between interpreter and clinician is also valuable so that the clinician can gain additional relevant information on the linguistics or cultural references that might have affected the communication. This could be particularly useful for follow-up appointments to understand if any parts of the interaction with the patient can be improved.
Remote interpreting, by telephone or some other digital means, is becoming increasingly common and offers a number of advantages in terms of cutting back on travel and therefore time and costs, and enabling communication in situations where it would not otherwise be possible. However, it is important to sound a note of caution; this type of interpreting should only be used to complement the interpretation service in cases when a face-to-face interpreter is not an option rather than as an alternative.
Much communication is non-verbal, meaning by default that telephone interpreting has more potential to create misunderstanding. There is also the possibility of communication difficulties arising from the technology and the risk of patients feeling alienated. It should be avoided for complicated procedures, serious diagnoses and mental health encounters. And it is of no use at all to the hearing impaired for whom eye contact, clear expression and non-verbal gestures are essential.
Remote technology that offers video has wider potential as it more closely resembles an actual face-to-face meeting.
ITI puts forward a number of recommendations about the use of remote interpreting in its recently published (2019) position statement on this subject, including the importance of maintaining identical requirements for interpreters in terms of qualifications, experience and briefing, whether they are working on site or remotely.
Technology developments will continue to offer new opportunities for innovation and efficiencies, but will require capital investment to reduce the present limitations and for now cannot diminish the continued importance of face-to-face interpreting within the NHS.