Treating non-English speakers

GPs are at the forefront of the cultural melting pot, treating an increasing number of non-English speakers. Sara Williams explores how to overcome the difficulties this presents

The structure and make-up of the UK population is changing, and this brings challenges to the NHS, and can place a strain on GP practices. In 2001, 8% of the UK population were born overseas, and by 2006 this had risen to almost 10%. Practices are at the forefront of this cultural melting pot; serving an increasingly diverse patient population requires practices to keep on their toes to tackle the range of languages and cultures that contribute to the fabric of the country.

These population changes bring real challenges for sessional GPs; if you cannot communicate effectively with a patient, how can they consent to and receive treatment?

Communication is a core skill in delivering safe healthcare and medicolegally it is arguably the most important area of risk. Every day, MPS deals with cases where a complaint or claim was triggered by a breakdown in communication, even when the care given was sound. These dangers are magnified where those involved in a consultation have different language skills.

This is particularly challenging for locum GPs as they have to tackle the new environment of every practice they work in as well as communicating with new patients. The first step for locum GPs is to realise that this is a particularly sensitive area and to tread carefully.

Being human

Of course, it is about more than the spoken word. Human interaction is a mixture of different gestures, actions and words. Body language varies from person to person and from culture to culture. Cultural factors may, for instance, strongly influence the expected roles of different members of the family unit. Even when speaking English, patients may have a different understanding of what a “familiar or colloquial phrase” in English means. Consultations can be complicated by many misunderstandings.

For GPs this is a growing challenge. MPS has received a number of calls from clinicians about these issues. To date the calls have mainly been for advice or following a complaint, and there are no clear cases that have led to direct harm to the patient, and a subsequent claim. In a perfectly resourced world, a professional interpreter would be the ideal solution. Studies have shown that the use of professional interpreters improves care for patients with limited English proficiency. Patients who rate their translator highly are more likely to rate their healthcare highly.

Yet around the UK, the provision of and access to these services is inconsistent. And there are a multitude of different languages to translate, so it is difficult to cater for them all. The National Register of Public Service interpreters provides a quality-assured register of healthcare interpreters, but it does not regulate them.¹ So if an interpreter is not a practical solution option, what are the options available to GPs?

Problem areas

Being aware of the risky areas where there is the potential for problems to arise is a good starting point for GPs, such as: 

• Consent – particularly where the information about proposed treatment is complicated, it is important to check the patient’s understanding of the risks and benefits. 
• Dual residence – patients living in two different countries may be seeing different health professionals. Matching treatments and prescribing options can be difficult. 
• Child protection – again, identifying and providing support for vulnerable children is made more difficult by communication problems. 
• Older people and those lacking capacity – the difficulty of establishing the needs and wishes of those with limited capacity will prove more difficult when there are language and cultural differences. This may be exacerbated if it is difficult to separate the interests of the carer, acting as translator, from those of the patient.

Finding out what resources are available locally to manage language differences will help prepare you for issues which might arise. However, you may find out that they are limited (your PCT may only fund telephone translation, for example), or inadequate for your patient population. If this does or could compromise patient care, then follow GMC advice and draw the matter to the attention of your employer or practice manager.

GMC practical pointers

• Talk to your practice manager – find out what patient information, ie, leaflets, posters, etc, is available. Check that important signage and announcements are in plain language and are accessible to all the main groups served by the healthcare organisation. 
• Be aware of the communication chain – non-medical staff, eg, receptionists, are the first people that patients encounter. Communication problems with a busy receptionist can cause distress or discomfort for a range of patients/service users. So non-English patients may be on edge when they walk in to the consultation room. 
• Maintain eye contact – particularly when working with an interpreter, even if the patient cannot understand you. This can reduce certain anxieties or suspicions from your patient and allows you to monitor body language. 
• Remember that the interpretation process takes time – suggest that your chambers, agency or personal conditions state that a double-appointment is necessary to allow adequate time to consult effectively. 
• Ensure that background noise is at a minimum – this should be the case even if an interpreter is not present. 
• Be cautious – some people who most need information in their own language may not be literate in any language. 
• Be patient – being sensitive to the needs of non-English speakers by being patient and working with them can safeguard you against complaints.

The GMC says...

In their guide on valuing diversity, the GMC says that: “The Human Rights Act 1998 and other legislative changes such as the Disability Discrimination Act 1995 (as amended) provide a strong case for the provision of effective communications in hospitals, in the community and in GP practices. Wherever possible, communications should be provided in languages and formats appropriate to the patient group.”²

Useful resources

• NLH Specialist Library for Ethnicity and Health – Aims to select the best available evidence about management of a healthcare service and specific needs in healthcare for minority ethnic groups.
• Sounds Healthy – Provides health information in audio and text formats in several languages.  
• Emergency Multilingual Phrasebook – The Department of Health website’s publication section includes various languages, (including Amharic, Bosnian Bosanski, Farsi, Kurdish, Slovak and Welsh in downloadable PDF files).  
• Electronic Quality Information for Patients (EQUIP) – The website has links to a wide range of resources in other languages, including medical factsheets, organisations and translators.

References

1. National Register of Public Service Interpreters – www.nrpsi.co.uk

2. GMC, Diversity and equal opportunities – Effective Communication (resource guide) – www.gmc-uk.org.