Authors: Ellen McCourt / Editor: Liz Herrieven / Codes: / Published: 16/06/2020
As a native English speaker (although a Geordie so Ill leave you to pass judgement on my proficiency) I have always had the luxury of being understood. It wasnt until I spent some time working in France and in the DRCongo that I really developed an understanding of communicating in a second (or third) language, or not being able to communicate with someone at all; the bewilderment, the vulnerability, the frustration. A-level French did not equip me to consent for a chest drain or explain the management of a head injury (although I can recommend some excellent courses in medical French if youre interested). In the same way speaking only a small amount of English may leave a patient at an extreme disadvantage when accessing healthcare in the UK.
4.1 million people in the UK do not consider English to be their first language: 1.5% (880,000) could not speak English well, and a small percentage (0.3%, 161,000) of the overall population could not speak English at all. In addition there are visitors to the UK with varying degrees of English proficiency. Even speaking a little English doesnt not mean that someones language skills are sufficient to give a history, understand a management plan or consent to medical procedures or treatments.
In an unscientific poll of my Twitter followers, I asked how UK doctors usually communicate with those with limited English proficiency. From the (I hope) tongue in cheek arm flailing method, to telephone translators and online services, answers generally expressed a frustration amongst professionals that there was no single good option.
Many of our Clinicians are multilingual – and if you feel comfortable consulting in a different language, thats fine. But make sure you document the consultation was in a different language, and what language that was – so that people reviewing the patient after you dont think their cognition has suddenly and drastically altered.
In the NHS the responsibility to ensure effective communication between doctor and patient lies with the healthcare professional and failing to provide communication support, particularly in the case of sign language interpreters, could be considered a breach of the Equality Act (2010).
In a fast-paced ED, using helpful family members or online translation tools can feel like the most convenient and functional option. Do these tools really provide patients with everything they need to be understood and make informed decisions about their or their child’s care, especially as they are only about 57% accurate?
Having said that, translation technology has improved dramatically since 2020. Accuracy varies enormously depending on:
- language pair
- medical terminology
- sentence complexity
- context
Current evidence suggests that modern machine translation systems are considerably more accurate than they were when the article was written, but accuracy is still insufficient to replace professional medical interpreters for clinical decision-making, consent, safeguarding discussions, or discharge advice.
What options do we have in the ED?
Much of the advice regarding translation and interpretation services for the NHS is focused on primary care and elective services. Interpreters are an essential part of healthcare and the quality of care delivered improves with their use. However, when we are faced with an acutely unwell patient at 4am in rural Yorkshire, the chances of finding a “best practice” face-to-face translator, whilst technically possible, are optimistic at best.
Telephone translation services
Telephone translation services (such as LanguageLineSolutions or DALS) are frequently the choice. Multiple languages are available 24 hours a day, with professional staff trained in confidentiality and safeguarding as well as a minimum standard of linguistics.
The reality is not always quite so golden. After finding the mobile phone and moving the conversation to a private room confidential history booming over the speaker is easily heard past cubicle curtains there is both a financial and time cost associated with the use of these services to be considered. Consultations are often at least twice as long as normal. Tone and intent is lost from a purely audio conversation and there remains a risk that the meaning of a statement or question is lost in translation.
Family or friends
Family or friends will often attend ED with the patient and volunteer to translate. A interpreter who definitely speaks the patients language and is immediately available and willing *FIST BUMP* Not exactly
There are clear advantages in the use of relatives in translation, however extreme caution should be used and the pitfalls may outweigh the benefits. Relatives should really only be used if there are no other alternatives, or if the situation is extremely urgent. It goes without saying that children are never suitable interpreters.
Its worth remembering that a competent patient has the right to choose an unqualified interpreter. Clinicians should clearly document this decision and advise the patient that they can take no responsibility for errors in translation however even if the patient makes this choice, the responsibility for ensuring effective communication still remains with the health care professional.
Online translation tools
have emerged in recent years as frequently chosen options to translate in health settings. Tools can include the online and easily used Google Translate or apps such as
sayhi a tool that translates speech into both written and audio on a mobile phone or tablet (disclaimer many tools are available, and no one pays me anything to mention things).
These tools are quick and easy to access, there is no mystery person at the end of a phone and patients retain a degree of control over their communication. The risk of filtered or diluted information that might occur through a family member or possibly a interpreter is removed. However, the use of unvalidated tools risks inaccurate or imprecise translation and can disempower the patient or put the doctor at risk if an adverse event occurs.
Most medical defence organisations now take a more nuanced position about translation. They generally continue to discourage reliance on machine translation for critical clinical communication, but many acknowledge that translation apps may have a role as supplementary tools when professional interpretation is unavailable. They caution doctors against the use of tools such as Google Translate as they could increase risks to patient safety and leave doctors vulnerable to criticism, regulatory action or litigation if there is an adverse outcome. They also advise that in the event of an investigation the courts could conclude that the doctor using the online tool was negligent.
A more pragmatic approach advised by the defence unions is that online tools may still be useful in situations where the alternative is to use nothing and when this would bring harm to patients; they advocate that doctors should speak up when services are not good enough.
Written information
for the patient to take away is also beneficial to those with limited English proficiency. While some trusts/health boards may have leaflets immediately available in multiple languages (or the most common local languages) services can be used to translate written English leaflets into multiple languages, and even read them out to patients in their native language. On a daily basis in the ED we provide patients with verbal advice, particularly regarding red flags with which to return to the ED it can be all too easy to miss this stage in those with limited English proficiency.
AI in Translation
Artificial intelligence has the potential to transform medical encounter interpreting services by supporting interpreters with real-time terminology assistance, automated note-taking, speech recognition, and translation suggestions. Rather than replacing qualified medical interpreters, AI can help reduce administrative burden, improve consistency, and provide rapid access to specialized medical vocabulary during complex consultations. AI-powered tools may also assist with scheduling, quality assurance, and the analysis of anonymized encounter data to identify communication trends and service gaps. As healthcare organizations continue to expand language access services, the most effective approach is likely to be a human-in-the-loop model, where AI enhances efficiency and accuracy while trained interpreters maintain cultural competence, contextual understanding, and patient trust.
References
- Office for National Statistics (ONS). Language, England and Wales: Census 2021. ONS; 2022.
- Flores G. The impact of medical interpreter services on the quality of health care: a systematic review. Med Care Res Rev. 2005 Jun;62(3):255-99.
- Moberly T. Doctors are cautioned against using Google Translate in consultations. BMJ. 2018 Oct 29;363:k4546.
- Moberly T. Doctors choose Google Translate to communicate with patients because of easy access. BMJ 2018; 362 :k3974.
- Nazem N. Lost in translation: overcoming language barriers. FYi. 2019
- NHS England. Guidance for commissioners: interpreting and translation services in primary care. NHS England; 2018.
- NHS Lothian. Interpretation and Translation Policy. NHS Lothian; 2023.
- BSL Health Access