Interpretation and Translation services

The NHS has a statutory obligation under the Equality Act 2010 to provide access to interpreting services. Providing high quality interpretation and translation services is an important part of ensuring that patients receive the right care, with informed consent, and have improved health outcomes.

NHS Nottingham and Nottinghamshire Clinical Commissioning Group and Integrated Care System engaged patients, patient representatives and GP Practice staff who have accessed, or are likely to access, interpretation and translation services, because the citizens first spoken language is not English, to understand their views and experiences.

The engagement ran from the 13 April 2022 until 16 May 2022. A variety of approaches were used to offer opportunities for citizens and healthcare professionals to engage,

including individual interviews, online focus groups, an online survey with translated versions shared with community groups. A total of 18 healthcare professionals and 32 patients participated in the survey. The focus group discussions were attended by a further 5 participants. Please see Appendix 3 for a full list of stakeholders.

Feedback collated from the engagement will inform the specification of a new service commencing in December 2022.

Findings included:

• Professional interpreters enable the healthcare professional to gather a full and clear patient history and an opportunity to ask detailed questions.
• Interpretation and translation services were viewed as very important by patients especially in incidences where otherwise individuals would have to rely on friends or relatives to translate and they would not want them to know about their medical problems.
• The new service needs to offer an efficient and accessible service that is simple for both the patient and GP practice.
• There is a preference for face-to-face interpreting, with telephone interpreting second and video assisted interpreting being the least favoured by healthcare professionals. Patients also favour face-to-face interpreting, however, would consider video assisted interpreting as a reasonable second option, followed by telephone interpreting.
• There were issues found with telephone interpreting, stating that it was not as satisfactory in providing healthcare as face-to-face interpreting. Problems such as the phone line dropping, or being a bad line, lack of body language, managing a three-way conversation with one person on the telephone can interrupt the flow of conversation and make communication difficult.
• Introducing a criteria would not be helpful as it is not always possible to predict what a patient will present with as patients’ needs do change and can be hidden. There was a perception that by introducing a criteria the CCG is looking to cut costs and save money rather than bringing a benefit to patients using the service or practices facilitating access to the service.
• With GP Practices mainly operating reception services by phone, ordering medication, requesting fit notes, and booking appointments are all difficult for patients who do not speak English.

Further findings and recommendations based on findings, are detailed within the report.

A warm thank you to all who supported, promoted, and took part in the engagement opportunities.

Within Nottingham and Nottinghamshire CCG there is an historic inequity to interpretation and translation services accessed via GP practices between Nottingham City and Nottinghamshire County which we are trying to address as part of the latest review. 

In Spring 2021 the CCG conducted a review of interpretation and translation services which looked at the current commissioned services and the needs of the population. It also looked at how potential changes to services would impact on patients. Feedback was gathered through two engagement events as well as an Equality & Quality Impact Assessment (EQIA).

About the service:

Nottingham City GP practices – since 2017 access to Interpretation and Translation services has been via Nottingham CityCare Partnership. This service was commissioned by the former Nottingham City Clinical Commissioning Group based on the needs of their patient population and includes:

• Face to face interpreters
• Telephone/remote interpretation
• Medical document translation available at a cost to the practice / patient

Nottinghamshire County GP practices – service available via Language Line Solutions Ltd commissioned by NHS England and includes:

• Telephone interpreters
• Medical document translation

This period of engagement was scheduled to more deeply understand what patients, patient groups and health professionals deem to be their priorities and their views on application of criteria when accessing interpretation and translation services.

• Provide patients with accurate information that clearly explains the options under consideration.
• Provide patients and healthcare professionals with an opportunity to provide comment on the options under consideration either through attendance at a virtual event or through completion of an online survey or both.
• Seek expert advice from CCG communications team in relation to communicating with individuals whose first language is not English and use the learning from promoting the flu and Covid vaccine to promote these engagement opportunities.
• Make the outputs of the engagement available to Primary Care Commissioning Team colleagues, to incorporate into the options appraisal for consideration by the decision making committee. 

Communicate the decision about future provision to patients and stakeholders.

Engagement commenced on 13 April with focus groups on 12 May and 16 May, evening and daytime sessions were available, with an offer of telephone interviews available to those unable to attend the focus groups.

The engagement opportunities were widely promoted to a range of our diverse community groups and organisations across Nottingham City and Nottinghamshire. (Please see Appendix 3 for a full list of stakeholders). They were further promoted in local publications to include:

• East Midlands Academic Health Sciences Network ‘Public Face’ bulletin (Issue 286, 26 April 2022), which covers patient and public involvement (PPI) related activity across the East Midlands with links to find out more.
• Primary Care Network and GP bulletins and newsletters which update health professionals on local activity and news.
• Community groups, and meetings that bring together health and care professionals
• CCG online platforms such as social media and website (Current and previous engagement & consultations – NHS Nottingham and Nottinghamshire CCG (nottsccg.nhs.uk))

Online engagement opportunities were offered via a survey and focus group sessions. Hard copies of translated surveys in 26 different languages were circulated via advocacy and community groups with responses returned to the engagement team. The online surveys and focus groups were also promoted internally to primary care colleagues via GP bulletins and internal communication systems.

As a result of the broad range of promotional activity, specific expressions of interest to be involved in helping to shape this work were received from English language classes, link workers, Healthwatch Nottingham and Nottinghamshire and local community organisations across Nottingham City and Nottinghamshire.

Nottingham and Nottinghamshire Refugee Forum contributed to the survey design and questions. Heya Nottingham, a group offering a safe space for Arab women to improve mental health and well-being, shared surveys translated into Arabic to group members. Mojautu Foundation, a Charitable Incorporated Organisation working to empower and support Black, Asian and minority ethnic communities in Nottingham, also circulated the surveys to group members translated into Portuguese. Emmanuel House, a city centre charity supporting vulnerable adults to tackle isolation, vulnerability and homelessness, contributed by representing the views and feedback on behalf of Eastern European citizens. This was in addition to the representatives and citizens who came across the engagement activities opportunistically and participated in their own time.  

All engagement materials were available in different languages and formats on request by contacting the engagement team via nnccg.team.engagement@nhs.net. Engagement activities ended on Monday 16 May 2022.

Survey findings

There were in total 60 responses.  However, one respondent did not give permission for their views to be recorded so this respondent’s views have been excluded from the subsequent analysis.

Although 59 respondents gave their permission for their views to be recorded, the analysis in this report is based on 50 completed responses due to 9 respondents not answering any survey questions. Furthermore, the results of the analysis are presented into two groups – the first being ‘health professionals’ (18 responses) and the second being ‘patients/advocacy groups/representatives/other’ (32 responses).

Of the 50 responses, 84% were from Nottingham City,12% from Mid Nottinghamshire and 4% from South Nottinghamshire.

Demographic Profile of Respondents:

• The demographic profile of these two groups is markedly different. Health professionals responding were predominantly white, heterosexual females that speak English with respondents spread throughout the working age-bands. 

• In contrast, the largest proportion of respondents in the patients/advocacy groups/representatives/other group were Arab and Portuguese, who predominantly speak these languages. Arabic is the number one requested language countywide, 3^rd highest in City with Portuguese the 11^th countywide and 13^th across the city. These respondents were also predominantly heterosexual female and, although over a third were aged 35-45, there was a wider age range than for health professional respondents.

• 36% of all respondents did not answer or preferred not to say whether they had a health condition or disability that impacts on their life, while a further 54% reported they had no known disability.

Options offered for consultations with clinicians at a GP Surgery:

Patients, advocacy groups, patient representatives/other feedback

• There was no obvious preference for a particular type of interpretation service for appointments as between 69 and 84 per cent of these respondents, stated they thought each of the alternatives offered for both routine and same day/urgent consultations with clinicians at GP surgeries were ‘very important’ or ‘important’.

Healthcare professional feedback

• For same day/urgent appointments, health professionals did not think ‘video linked interpretation’ offers are as important as a ‘telephone interpretation service’ or ‘face to face, telephone or video interpretation that will provide the earliest appointment’.

• Health professionals stated they were less likely to use interpretation and translation services using a video linked interpreter and much prefer telephone and face to face interpretation services.  

• For routine consultations, health professionals did not think ‘face-to-face appointments with a healthcare professional through a video linked interpreter’ or ‘video linked consultations with a patient, healthcare professional and interpreter’ are as important as ‘face-to-face interpretation’; ‘telephone interpretation’; and ‘either face-to-face, telephone or video interpretation that will provide the earliest appointment’. 

Response to proposals:

As shown in the graphs below, there is a notable disparity in the responses provided by the two groups over the two proposals put forward, with the patients/advocacy group/representatives/other overwhelmingly supporting the proposals while health professionals do not.

One proposal is to make face to face interpreting available only for those who do not speak English as a first language AND have one of the following communication needs or vulnerabilities: Dementia, learning difficulty/disability mental health condition, lip reads, has reduced hearing or the patient has requested a reasonable adjustment in line with the Accessible Information Standard.  

Do you think this should be done?

One proposal is to introduce a criteria offering face to face interpretation only to those patients who require interpretation services where English is not their first language attending an appointment where they will either:

Receive complex / bad news or make significant decisions on their care

Or where an intimate examination is taking place

Do you think this should be done?

Factors when Commissioning Services:

Patients, advocacy groups, patient representatives and other feedback

• Patients/advocacy groups/representatives/other attached slightly more importance to the ‘cost to the NHS’; ‘promotion of the availability of translation services’; ‘flexibility of appointments’; ‘range of methods offered’; ‘speed of response’; ‘value for money’; and ‘written translation of medical documents to support care by general practice’. 

• The two most very important issues for the patient group are ‘speed of service’ and ‘reliability of the service’.

Healthcare professionals’ feedback

• Health professionals attached slightly more importance to ‘range of languages offered’ and ‘reliability of service’. 

• The two most very important issues for health professionals are ‘reliability of service’ and ‘range of languages offered’

• Both groups attached fairly equal importance to ‘interpreter to have experience of interpreting in a healthcare setting’; ‘good patient experience’; and ‘good practice experience re; ease of booking and practicalities’. 

Respondents were asked how likely they were to use a range of interpreting services. These included, accessing an interpreter by phone, face to face interpretation, video linked interpretation, or whichever method would provide the earliest appointment.

 As shown in the following five graphs healthcare professionals are less likely to use interpretation and translation services using a video linked interpreter and much prefer telephone and face to face interpretation services.

Survey findings – additional comments

Additional comments – Health professionals

• There were concerns that without an interpreting service there would be an inequality in health services. And important diagnosis such as cancers may be missed.
• It is not always possible to predict what a patient will present with. If it becomes clear a face-to-face appointment is then needed the original appointment will have been wasted.
• Introducing a criteria for offering face-to-face appointments will increase the difficulty a patient has in navigating services when they do not speak English.

Additional Comments – Patients, advocacy groups, patient representatives/other

• It is important to offer interpretation and translation services to reduce the anxiety and stress caused by patients trying to make themselves understood and feeling anxious that they will not be treated.
• There were a few comments made from individuals around BSL interpretation. This service and piece of work didn’t cover British Sign Language, as it is commissioned by the local authority. However, as a patient group that requires an interpreter to access primary care services, a British Sign Language supported meeting for members of the Deaf community was held 30 May 2022 led by Alex Ball, Director of Communications and Engagement. A representative from the local authority commissioning team attended the meeting and the views gathered will feed into and support the procurement exercise due to be undertaken by the local authority next year.
• There was a suggestion to integrate the interpretation and translation services within Nottingham to enable a better and more effective use of local interpreters.
• It was felt that it was important to plan the service around the patients and their individual needs.

Focus group findings

Two focus groups ran offering daytime and evening sessions. Attendee’s present were from Healthwatch, a community group representative, Nottingham City GP practice managers and a local community trust.

Top two priorities for providing Interpretation and Translation services

• A service that is accessible in a timely manner with minimal administration tasks.
• It is always the GP practices preference to use a professional interpreter as opposed to patients’ family members.
• Easy and accessible booking system for practice staff.
• Reception staff need to offer the service out to patients, ensure the service is promoted and it becomes part of business as usual for practice staff to offer the service. 
• People currently don’t know that the service is available and certainly wouldn’t know how to access it.
• The service needs to be timely in terms of getting hold of an interpreter.
• It is important to have materials available in different languages, a private fertility clinic did not have leaflets available in Arabic. Translated materials promoting healthcare services are particularly important.

Experiences of the current Interpretation and Translation service

• The anonymity of Language Line can help patients feel more confident that the information about their health will not be shared within the community as the interpreter is not local.
• Patients may not be aware that Language Line (telephone interpreting) is available as an alternative which would likely provide an earlier appointment.
• Currently the online booking system can get overwhelmed and often face to face interpreters are not available. It can also sometimes take 15 minutes to get through to an interpreter on the phone.

Video consultation

• Some GP practices have not yet started to include video consultations for English speaking patients and therefore are not able to offer video consultations for interpretation services.
• There are concerns about the lack of capacity and time to offer video consultations and potential safeguarding issues for patients.
• Video linked interpretation would be preferable to telephone interpreter but acknowledged that it could potentially cause delays.  Face-to-face is always the preferred option.
• It was felt that video consultations would be an added complication for GP practice staff to manage.
• With the right resources and infrastructure video interpreting could work but it would need to be equitable across the City and County with funding available to replace IT kit if needed.
• Patients not having access to the necessary technology, if they were not present at the GP practice for the appointment, could be a potential barrier for some consultations.  Privacy issue needs to be considered and ensure that the patient had access to somewhere suitable.

Introducing a criteria

• It was felt that introducing a criteria would be very difficult to implement and would be detrimental to the service. There was a perception that by introducing a criteria the CCG is looking to cut costs and save money rather than bringing a benefit to patients using the service or practices facilitating access to the service.
• It would be difficult to determine whether a patient meets the criteria prior to an appointment. 
• It was felt that it was not the role of the practice to determine if patients meet the criteria.
• There were concerns about the increased workload for reception staff should a criteria be introduced.
• There was a suggestion that if a criteria was introduced it could be to split into patients with acute conditions and patients living with complex, long term conditions.
• Introducing a criteria would exclude lots of people who have their own additional needs that would not necessarily be included in the criteria. Introducing a criteria would leave it open to the GP practice to determine if the patient was eligible for a face-to-face interpreter.

Providing translated text messages – for appointment confirmations and calling patients for screening

• Would need to be a good degree of confidence that the message is well translated.

Focus group findings – additional comments

• Positive feedback has been received from patients about askmyGP; it has been efficient and very well received by patients.  Access to mobile phones has not been a barrier. The ownness is on the patient to use Google translate.
• Nottingham and Nottinghamshire Refugee Forum provide interpreting courses. Nottingham and Nottinghamshire CCG could link in with them to use local interpreters. It is important to liaise more frequently with local community groups – this is an opportunity to empower the community and provide volunteering opportunities.
• The Ambulance service use a book for circumstances where an interpreter is not available, patients can point to their language and there are a few simple questions that have been translated. It was suggested that a similar document could assist practice staff and reception with booking appointments for example. https://www.sja.org.uk/first-aid-supplies/manuals-and-guides/first-aid-manual-and-guide/multi-lingual-emergency-aid-phrase-book/

• It has been increasingly difficult for patients who do not speak English to book an appointment at a GP Practice since social distancing measures were introduced during the Covid 19 pandemic. During this time patients were required to contact the surgery via phone or online. For those patients with language barriers it has become impossible for patients to independently contact the GP Practice. Prior to these changes in process patients could walk into reception with a translated note communicating their request. With the move to phone calls only to contact the practice patients are unable to do this.
• Having to call the practice at 8am to book an appointment is also a barrier for those patients who do not speak English. Support workers are unable to assist in booking appointments as community resources often do not open until 9:30am by which time all appointments at the GP practice have been filled.
• Face to face interpreting is much better for efficient communication. There are problems with telephone interpretation such as a bad line or the interpreter getting cut off.
• In some instances, face-to-face interpreters have had to leave before the end of the appointment, possibly rushing to their next appointment and the patient has not had enough time to ask all of their questions.
• Some patients have shared that the quality of the translations has been unsatisfactory.
• It sometimes takes a week to get an appointment with a healthcare professional and an interpreter.
• Some patients have not found the process easy to request an interpreter assisted appointment.
• Patients who do not speak English are aware the Interpretation and Translation service is available, however are unable to request or query why a translator has not been offered.
• The current appointment booking process excludes people who do not have a telephone or access to the internet.
• Telephone interpreter appointments are not satisfactory if the GP needs to examine the patient.
• There needs to be more flexibility for individuals to walk into the GP Practice and book an appointment if the patient does not speak English and do not have a phone or access to the internet. Patients need to be able to access the service independently.
• In some instances, patients have been asked by the GP Practice if a friend or family member can translate at the appointment.
• With GP Practices mainly operating reception services by phone, ordering medication, requesting fit notes, and booking appointments are all difficult for patients who do not speak English.

GP Practice

• For GP practice staff to identify the patient’s preference on the method of interpretation, for example face to face, telephone, video linked. GP practice staff may need a translated pictorial document to assist in communicating with the patient to understand their preferences.
• To support patients who require an interpreter specifically with ordering medication, requesting fit notes, and booking appointments.
• To provide an option where patients who do not speak English and do not have a phone or use the internet, can access the GP Practice to book an appointment.
• To ensure the Interpretation and Translation service is strongly promoted to patients.
• It would be helpful for the GP practices to make the interpreter aware of the type of consultation they are attending, where possible, so that messages can be delivered and worded sensitively by the interpreter.

The provider of Interpretation and Translation Services

• To offer an Interpretation and Translation service that is accessible in a timely manner with minimal administration tasks for GP Practice staff.
• The service needs to be representative of the languages that are spoken in Nottingham City and Nottinghamshire. The provider needs to be able to provide the languages that are required in each area offering translations to a high standard including dialects.
• The provider of the interpretation and translation service needs to ensure they have a range of male and female interpreters available. 
• For all patients who do not speak English as a first language to be eligible for all methods of interpretation and translation regardless of additional communication need or reason for appointment. To offer face to face, telephone and video linked interpreter appointments to all patients where their first spoken language is not English.
• To explore the options for offering auto translated text messaging reminders for booked appointments or reminders for screening. This may help to reduce missed appointments.
• To ensure that the interpreters can be present for the entire length of the appointment, to enable the patient to ask or answer all questions.

Additional recommendations

• For the CCG to develop relationships with the Deaf Community across Nottingham City and Nottinghamshire to engage and involve this community in continuing our conversations around pieces of engagement.
• To offer support to GP Practices to implement video consultations. The CCG IT Team has confirmed each practice received a headset and webcam and both clinical systems in use throughout Nottingham City and Nottinghamshire are able to support video consultations. As of 1 October 2021, it is a requirement of the GP contract for GP practices to offer and promote, to registered patients, video consultation.
• In any future engagement to further simplify the survey questions and ensure it is ‘sense checked’ by the interpreting service prior to circulation.

The insights and understanding gained from engagement will inform the decision making Committee and in turn the specification of a new service commencing December 2022.

A ‘You Said, We Did’ style report will be published to reflect how citizens’ voices have shaped the development of the new service

For a full list of the appendices, including:

Appendix 1 – Stakeholder briefing                                                    

Appendix 2 – Survey analysis                                                                                                          

Appendix 3- List of stakeholders                                                                                                                

Appendix 4 – Focus group presentation                                                                                                                                

Appendix 5- English version of the survey                                                                                                           

Appendix 6- Translated versions of the survey and list of languages

Please email nnicb-nn.engagement@nhs.net.