Karliner LS, Jacobs EA, Chen AH, Mutha S. Do professional interpreters improve clinical care for patients with limited English proficiency? A systematic review of the literature. Health Serv Res. 2007; 42:727-754
Translation services are central to effective communication with patients unable to speak English, or with hearing impairment. This article gives an overview of the cost of translation services in key secondary care locations and provides guidance on how best to optimize their use clinically. Freedom of information requests were made to 20 dental hospitals in the United Kingdom to ascertain the number and cost of interpreter and sign-language appointments. We highlight the importance of using these necessary but costly services effectively.
CPD/Clinical Relevance: Guidance is given on how to best use translator services in a dental setting, better ensuring valid consent and promoting patient autonomy.
Article
The inability to communicate effectively is a known barrier to using healthcare services.1 In the 2011 census, 726,000 individuals (1.3% of the population) in England and Wales stated that they ‘could not speak English well’, and a further 138,000 (0.3% of the population) reported being ‘unable to speak English at all’.2 This is likely to be an underestimate of the true figures within the UK, because individuals may be missed from the national census.3 Problems accessing healthcare as a result of communication difficulties have been shown to negatively impact the health of such patients.4
This paper aims to provide guidance on the effective use of translation services. The use of these services across dental hospitals in the UK is also described.
The Office for National Statistics estimated overseas net migration to the UK at 226,000 in the year to March 2019; this is almost twice the size of the population of Cambridge.5,6 Greater diversity in the UK population has meant that a larger number of individuals require translation services to effectively access healthcare.7 In the UK, 2.3 million people speak a language other than English at home.8
In the UK, the first language of non-English speaking individuals varies significantly. Those from a Bangladeshi background were the most likely to self-report ‘not speaking English well or at all’. Of all the individuals reporting an inability to speak English well, 60% were females mainly from Pakistani and Bangladeshi backgrounds.²
Patients may not be aware of the availability of translation services and as dental professionals we are responsible for identifying patients who may benefit from them, and facilitating their use. There are a number of instances where not having adequate translation support could hinder patient care, and potentially render it unsafe. These include taking a comprehensive medical history and obtaining valid consent.9
Freedom of information request
A freedom of information (FOI) request was sent to all 20 UK dental hospitals. A response rate of 95% was achieved (n=19). Three dental hospitals were unable to provide the information requested.
Table 1 gives the average number and range of interpreter and sign language appointments over a 24-month period in 16 UK dental schools.
Mean number (SD)
Range
Interpreter appointments
1691 (1565)
4–4536
Sign-language appointments
177 (359)
4–1267
To allow comparison, data were extrapolated where it was unavailable. This was done on the assumption that the monthly number of appointments and costs were similar.
The mean number of patient ‘did not attend’ (DNA) events over this 24-month period was 129 (for the 12 dental hospitals that provided these data). This ranged from 0 to 404. For the hospitals that provided the relevant data (n=13), the average combined cost of interpreter and sign-language services over this 24-month period was £56,847, ranging from £1163 to £191,647.
We enquired into whether dental hospitals sent correspondence letters in a patient's first language. Of the hospitals that provided this information (n=15), eight did not send correspondence letters in the patient's first language. Six were able to send letters in the patients' first language, upon either patient or clinical request. One hospital automatically catered for the patient's first language, if this was recorded in their computerized patient management system. Information was not provided on which languages were catered for.
This information was collected to demonstrate the variability in practice across the UK. These figures also highlight the substantial cost in providing these essential services, and so their efficient and effective use must be prioritized.
Recommendations from national bodies
The General Dental Council (GDC) state that communication difficulties should be addressed by ‘using an interpreter for patients whose first language is not English’.10
The British Dental Association (BDA) recommend that ‘reasonable’ adjustments should be made for patients with disabilities such as hearing impairment.11
NHS England stipulates that interpretation services should be high quality, free at the point of delivery and cater for the patient's linguistic needs.1 During registration at a primary care service, patients requiring translator support should be made aware of the various modes of interpreting services available to them. This includes face-to-face, telephone and video remote interpreting/video relay services. NHS England also advises that longer appointment slots should be booked when an interpreter is required, typically double the length of a regular appointment. Language preferences should be recorded in the patient notes and shared with other service providers, eg on referral to specialist services.1
The Care Quality Commission (CQC) states that providers must ensure interpreters have an enhanced disclosure from the Disclosure and Barring Service, and hold the correct qualifications and appropriate insurance.12
Table 2 summarizes advice for effective working with language interpreters.
▪ Respond to both verbal and non-verbal cues
▪ ‘Chunk and check’ the patient's understanding as you would in any other circumstances
▪ Speak in simple terms and do not overload the translator with excessive information to translate, avoid jargon
▪ Speak clearly and slowly, pause frequently
▪ Before and after consultation the interpreter should be debriefed
▪ Keep control of the consultation
▪ Respect the patient and be mindful of body positioning – face the patient, not the interpreter
▪ Maintain eye contact with the patient
▪ Direct questions towards the patient
▪ Appear attentive when the patient responds. If the patient does not appear to understand, consider visual aids)
Working with British Sign Language (BSL) interpreters13-14
The principles of working with a sign interpreter are similar to language interpreters; however, there are some variations in approach:
For many individuals using BSL, written English may be inaccessible, thus written notes may not be beneficial
Sign language interpreters should sit beside and slightly behind the interviewer to allow full visualization of the dentist and interpreter's hand movements
This chair arrangement should be organized before the appointment
In addition to the use of a BSL interpreter, the following guidance should be used where hearing impairment is not absolute:14
Listen attentively and speak at a slow pace while enunciating words clearly
Where infection control allows, remove your mask so the patient can see your lips
Consider communication aids (induction loop for patients with hearing aids and provision of written information)
Minimize background noise, such as clearing away instruments, because this can be intrusive
Written information describing the stages of treatment a patient will experience may pre-empt the need for difficult verbal explanations
Discussion
Communicating effectively with patients requiring language or BSL interpreter services may present certain challenges. However, these services may not always be available, and the clinical situation may necessitate the clinician using alternative methods. One such scenario may arise when a non-English speaking patient presents for an emergency appointment or new patient assessment without a translator available. In this situation, one should remember to ‘first do no harm’. Clinical red flags, such as sepsis or airway compromise may necessitate immediate referral to secondary care and whatever means available, including online electronic translators, should be employed to impress upon the patient the severity of the situation and the need to attend hospital.
In less pressing situations, such as irreversible pulpitis, it may be feasible to arrange an appointment for later the same day, when there is the time available to use a telephone interpreter, or the patient is able to attend with an English-speaking friend or relative. This scenario requires compromise from both the patient and clinician as treatment will not necessarily be immediate, but when it is instigated one can be better assured of the validity of consent and the patient's understanding. Often clinicians are forced to use family members or friends, which should be done with caution, as there is no guarantee that the information is translated fully and accurately. In 2007, a systematic review of the literature found that using professional interpreters yields improved clinical care in comparison to the use of ad hoc interpreters such as family members.15 In addition, close relatives may find it difficult to relay information in an objective and factual manner.12
This is an additional difficulty in cases of possible safeguarding where one cannot rely upon the veracity of translations. It may also be dangerous and impossible for the patient to disclose reports of abuse in the family member's presence. Hence, it is considered best practice to use professional interpreting services rather than friends, family members or untrained members of the public.16 Here the clinician should appreciate the potentially time-sensitive nature of the scenario and professional interpreting services, most likely via telephone, should be urgently sought. As ever, delicacy and tact should be used to separate the necessary individuals such that a true account of events can be elicited.
Patients may be resistant to having a translator present. This does not oblige the clinician to proceed with treatment as this clearly is not in the patient's best interests. It is down to the dental professional's judgement to determine whether understanding is adequate.
In the case of a dentist who speaks the patient's language and a dental nurse who does not (or vice versa), one may question where the dental clinician would stand medicolegally if a complaint was made against them. It would be pragmatic to have both members of the dental team speaking the same language, permitting a dental nurse to act as a witness, an individual of utmost importance in complaints handling or fitness-to-practice cases. There is no current guidance on this topic, but in the authors' opinion, it would be prudent to arrange translation services for an appointment if all members of the treating healthcare team are not able to communicate with the patient. It is important that all parties involved in the patient's journey through the practice are able to communicate with the patient; this includes the receptionist and dental nurse, as well as the dentist.
With regards to the translation of written materials, practices should be mindful of varying ethnicities and respond to the local demographic they are treating. Practices should consider producing information leaflets in several languages if this is required to meet the needs of their patients.12
Conclusion
The appropriate use of translation services is of vital importance for patients.
In order to efficiency, planning and preparation prior to the use of translator services is essential. Lack or improper use of these services impedes timely treatment for patients and causes NHS organizations to incur avoidable costs. During these appointments, dental professionals must carefully consider their approach and technique to maximize the utility of translation services.
