Limited English Proficiency in the ED


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Authors: Ellen McCourt / Editor: Liz Herrieven / Codes: / Published: 16/06/2020

As a native English speaker (although a Geordie so I’ll leave you to pass judgement on my proficiency) I have always had the luxury of being understood. It wasn’t 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 you’re 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.

4.2 million people in the UK do not consider English to be their first language: 726,000 report limited English and 138,000 speak no English at all. In addition there are visitors to the UK with varying degrees of English proficiency. Even speaking a little English doesn’t not mean that someone’s 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.

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?

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 (such as LanguageLineSolutions) 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 will often attend ED with the patient and volunteer to translate. A translator 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 translators.

It’s 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 translator 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.

The defence unions unanimously advise that doctors and healthcare professionals do not rely on computer translation. 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 such as browsealoud 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.

So, really, theres no easy answer, is there? Different options may suit different situations. What remains constant though, is that whatever you choose, the responsibility still lies with you, as the clinician, to ensure that both you and your patient have understood the information exchanged, so make that choice wisely.


  1. Flores G. The impact of medical interpreter services on the quality of health care: a systematic review. Med Res Rev 2005; 62: 255-99
    Language Line Solutions. Tips for working with an interpreter. Accessed 1.5.19
  2. Moberly T (1). Doctors are cautioned against using google translate in consultations. BMJ. 2018; 363: k4546
    Moberly T (2). Doctors choose google translate to communicate with patients because of easy access. BMJ. 2018; 362: k3974
  3. Nazem N 2019. Lost in translation.
  4. NHS England. Principles for high quality interpreting and translation services in primary care. Accessed 1.5.19
  5. NHS Lothian. Interpreting and translation in NHS Lothian. Policy for meeting the needs of people with limited English proficiency. Accessed 1.5.19
  6. Office for National Statistics: Language in England and Wales 2011. Accessed 2.5.19

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