Speaking in tongues: how do translation services work in the NHS?

The NHS spends millions on translators and interpreters every year. Radhika Holmström asks why these services are needed in hospitals, and what do they offer?

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 one in 13 people. Within this, there are 88 main languages; the most common is Polish (1% of the total population), followed by Punjabi, Urdu and other European languages. Obviously, this is also clustered in many urban areas, and of this group, while some people speak fluent English, in Leicester up to 9% of the population either does not speak English well, or does not speak it at all.

The issue of whether people should take up English language classes aside (though it is worth noting that provision has been severely cut in recent years), these people have health needs. In fact, the same census asked respondents to rate their own health and the results are interesting because although – as one might expect – the people who do not speak any English are likely to be older this is not the full picture. Across all age categories, those who termed themselves ‘non-proficient’ were less likely to report their health as ‘good’ than those with better English, with the people aged 50 and over doing particularly badly. With this in mind, it is easier to understand why hospitals are making such a (comparative) outlay on language provision for patients who cannot understand what doctors are telling them.  

Across all age categories, those who termed themselves ‘non-proficient’ were less likely to report their health as ‘good’ than those with better English, with the people aged 50 and over doing particularly badly.

Radhika Holmström, journalist

Provisions and practicalities

Two kinds of service are provided. The first is written, translated material. Information such as patient information leaflets, website copy, information about treatments and so on is often available already in translation. However Kavita Parmar, the commercial director at Word360 (the largest provider of NHS interpreting care in the West Midlands) feels there is still not enough information in minority languages. ‘I think there is a need for a framework or toolkit for trusts.’ In addition, there is also a need to translate material that this is specific to this patient like their medical notes and any documents they bring with them about their health and/or any medication they have been taking.

The second service is interpreting, or oral communication and by the stage where they are attending hospital, most patients who need an interpreter have been identified. ‘Not everyone is aware of interpreting services, but even if someone comes with a family member to interpret for them, that is not sufficient,’ says Dr Teodora Manea Hauskeller, who is doing PhD in medical sociology at the University of Exeter. ‘Even if the family has the best of motives, there is a tendency for family members to filter information and even keep information from the patient; and there are also issues around privacy. And for paperwork and legal matters, an interpreter is compulsory.’

‘Typically, the outpatients clinic will note the fact a person can’t speak English and will book an interpreter,’ says Subodh Dave, a consultant at Derbyshire Healthcare NHS Foundation Trust and associate professor at the university of Nottingham, explains how interpreters operate in his trust.

‘A hospital environment instructs all staff, clinical and also administrative, to take a decision on whether or not an interpreter is needed,‘ adds Yaron Matras, Professor of Linguistics at the University of Manchester, who has looked at provision locally. He does qualify this by explaining that the hospital he and his colleagues looked at is known for being absolutely world-class in terms of the interpreting services it offers. ‘We’re not aware of any of any environment that is so far-reaching.’ However, the cases where lack of provision has led to deaths or permanent damage do appear, thankfully, to be rare; the ones on record appear mainly to do with women who are in labour or have just given birth, such as the widely-reported case of a newborn baby who was left severely brain-damaged because nobody explained to his Tamil-speaking mother how to feed him.

That also means the first responsibility is with the practitioner, not the interpreter, to make sure the patient understands what they have been told.

Radhika Holmström, journalist

The human voice

Interpreting can be done in different ways: by bringing in an interpreter to do so face-to-face, through a phone service, or by using a video link.

‘Telephone interpreting is an instant service: you can get hold of an interpreter within a couple of minutes. In fact we get a lot of consultants who phone us directly,’ says Parmar. In addition, she points out, a slightly more remote service can be useful in its own right. ‘The anonymity can be very helpful, because you are able to talk more freely – for instance around domestic violence, when you may want to talk without someone knowing who you are. That’s especially important if you come from a small community and a face-to-face interpreter is likely to come from that community themselves.’

On the other hand, there are situations where it’s not ideal. ‘You don’t want telephone interpreting for an end-of-life conversation. Really it is for the clinician to determine what would be the most appropriate service, and they don’t always think about that – it often left to the medical secretary. In certain situations, of course, it’s not always easy to pre-empt what type of service is required but it’s obvious that for instance you don’t want a male interpreter at a gynaecology appointment.’

If an interpreter is physically present, the most important thing to remember is that they are the means of communicating with the patient. They should sit with the consultant, in the patient’s line of sight (the ‘interpreter triangle’) and above all the doctor (or anyone else speaking) speaks directly to the patient, not to the person who is facilitating their communication. ‘The basic code of conduct is that the interpreter is impartial,’ says Parmar. That also means the first responsibility is with the practitioner, not the interpreter, to make sure the patient understands what they have been told. ‘You don’t need too many steps: it can be done by asking someone to repeat back to you their understanding of what has been said. It can seem more hassle, but think about how much clinic time will be wasted if the information isn’t clearly conveyed.’

Radhika Holmström is a journalist with a long-standing specialty in health, mental health, disability issues and social care.

This is an excerpt from her full article, which features in August's Commentary magazine.