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Lost in translation

23 October 2015

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General practices are treating an increasing number of patients from overseas. While it can be challenging for the team to tackle both the language and cultural barriers that arise, it is being done with success and sensitivity across the UK

Immigration is a heated topic in the media – and its impact on the NHS often evokes strong views. But, without making a fuss, many practices are dealing with the everyday issues of providing care to people who were born outside the UK.
For many of them it is about understanding the different needs of these patients and making sure the practice can meet them. “We have been proactive,” says Alison Somers, the practice manager at the Southlea Group Practice in Aldershot. More than 8% of its 14,000 patients are of Nepalese origin. The practice now employs a receptionist who speaks Nepalese – and can help translate for patients who struggle with English. However, many older Nepalese are illiterate.
“There’s no point in giving leaflets if they can’t read. The young people can’t read Nepalese because they went to school here,” she says. So face-to-face communication – often facilitated by the receptionist – has been important along with DVDs about healthy living that can be watched in groups.

Translation techniques
In Lincolnshire, where many eastern Europeans came to work after their home countries joined the EU in 2003, practices have also recruited staff who can help with the different languages patients speak.
David Harding, practice manager of Parkside Medical Centre, Boston, Lincolnshire, says that 18% of the practice’s patients now come from outside the UK. The practice has made a number of adjustments to cope with the different needs of its new patients. It initially employed a Polish-speaking receptionist who could also act as a translator for Polish patients who could not speak English – although Harding points out that four out of of five of the new arrivals speak good English and don’t need this help. As Lithuanians and Latvians began to arrive, a receptionist who could speak Latvian and Russian was also employed. Another practice in the town has a Romanian doctor, who has helped translate letters brought in by a Romanian patient.
These arrangements have been cheaper than using telephone translation services, Harding says. Many practices around the country will face similar issues, especially if they have patients who speak unfamiliar or relatively rare languages. Sometimes they use members of a patient’s family to translate for them – although this can be inappropriate with sensitive subjects. In some cases they will have to arrange for either a face-to-face translator or use a telephone service. Lisa Doyle, head of advocacy at the refugee council, says: “There is quite a high proportion of women refugees who have suffered sexual violence. You are not going to want your 12-year-old daughter translate for you in that situation.”
A survey by Healthwatch Liverpool last year highlighted that interpreters and interpreting services were of variable quality and availability. Practices also usually need warning to arrange interpretation services – especially with less common languages – and have to cover the cost.
Even in Boston, the practice will occasionally struggle to help someone who doesn’t speak English: one patient was sent to A&E when he indicated he had a problem with his chest. Without a common language, the practice was concerned he might be suggesting a cardiac problem (in fact he had a chest infection and needed antibiotics). A local deaf group had to be recruited to help with a deaf Polish lady (sign language is not the same in English and Polish – but the group has a member who could sign in Polish).      
Harding is also keen to get eastern European patients on the practice’s patient group, this has proved difficult as the group meets in the afternoon when most of them are at work.

Understanding the NHS
Another key area for practices is raising understanding of how the NHS works and how best to access it, along with understanding new communities’ expectations of healthcare. Many will come from entirely different systems. In some eastern European countries, for example, people will be used to more frequent hospital visits for conditions that would be dealt with in general practice in the UK.  
Practices in Boston have worked with the local A&E and the county council to produce an information booklet, translated into a number of languages. Posters have also been put up in local shops. “The practices in Boston are all very proactive and help each other,” says Harding. “We are all in the same boat. Yes, our population has gone up and we have increased staffing. As a practice, we are fortunate to have a new building.”
In Aldershot, Hampshire practices have tried to understand the social structure and needs of the local Nepalese community – where acceptance by the elders was important, but there can also be concerns among younger members about confidentiality. Some Nepalese spend several months a year in their homeland – which can create problems for practices as patinets may seek medical care in both countries.
But are the health needs of migrant communities – or asylum seekers and refugees – really that different to other groups? On the whole, no but there can be subtle differences. Many recent migrant groups are predominately young and healthy and make relatively few demands on the health service. Some may come from countries with a higher prevalence of hepatitis B and tuberculosis (TB) than the UK and offering screening may be appropriate.
However, there can be differences. Women within the Nepalese community were having more terminations than expected, says Somers. This turned out to be partly because of a lack of awareness of the morning after pill.
There is also a relatively high rate of diabetes among Nepalese living in the UK: lack of understanding on both sides can be a problem, as healthcare staff may not be knowledgeable enough about Nepalese diets to recommend healthy changes.

Asylum seekers
Mental health problems can still be stigmatised in some communities, making it less likely people will seek help in the early stages. Screening services, such as breast and cervical screening, may be unfamiliar and chaperones (or female doctors and nurses) may be needed.   
The Faculty of Public Health has said that some asylum seekers and refugees may have health needs related to their experience. Their mental health may have been affected by torture or seeing societal breakdown in their home country, and physical health problems may have worsened due to difficulties in accessing healthcare, living in refugee camps, and the consequences of injury and torture. Pregnant asylum seekers are at far greater risk of complications during childbirth.
Practices will need to refer some of these into secondary or even tertiary services – but mental health charity Mind says there are a lack of services for people who have intermediate mental health needs or who have experienced torture. The Medical Foundation for Victims of Torture can be a useful starting point.
Asylum seekers who have had their request to remain in the UK refused are in a particularly difficult situation as they may not be able to access secondary services without paying. Doyle says there can also be issues around continuity of care for asylum seekers who can be moved at short notice. Here, GPs can help by pointing out when moving someone who is accessing specialist services such as maternity or mental health would be detrimental to them, she suggests.

An unknown future

Some communities who have little experience of refugees are likely to encounter them over the next few years as Britain accepts 20,000 vulnerable Syrians. However, the planned nature of this may allow public services such as health to prepare to offer better care.  
But amidst all the rhetoric about immigration many healthcare workers are aware that many migrants are working in the NHS, helping to alleviate staff shortages. Hospital and community trusts have recruited extensively from Europe and further afield, to help mitigate shortages of nurses. And without the 4,000 doctors who qualified elsewhere in the European economic area and 11,000 who qualified in other countries on the GP register, many practices would struggle to fill their rotas.

Alison Moore, freelance journalist and writer specialising in healthcare.