commissioning framework for language support · language monitoring in all services, including...

Commissioning Framework forLanguage Support2011

East of England

Commissioning Framework forLanguage Support2011

By Susan Stallabrass

Increasing globalisation and the importance of migration requires aresponse to overcome language barriers to care. These guidelines aim tosupport commissioners in the provision of language support to achieveequity and excellence in health and social care services.

ContentsEXECUTIVE SUMMARY .....................................3

INTRODUCTION..................................................6

SECTION 1:

Why this matters – acknowledging the casefor change...........................................................8

SECTION 2:

Assessing your local needs and priorities ....19

SECTION 3:

Identifying suitable service solutions ............27

SECTION 4:

Defining and specifying services basedon best practice................................................45

SECTION 5:

Working with and developing providers ........51

- Challenges and issues .....................................10

- Legislation and key policy drivers.....................13

- Meeting the QIPP agenda and the financialcase for change................................................16

- Sources of information and data available .......19

- Using the data ..................................................24

- Models of language support .............................27

- A service provision model of language support ..28

- A social inclusion model of language support ..37

- Public Service Interpreting and Translation......45

- A social inclusion model of language support ..48

- Specialist clinical issues ...................................49

- Working with third sector providers ..................51

- Procurement and contractual approaches .......51

- Mapping existing services and funding ............55

SECTION 6:

Monitoring performance..................................57

SECTION 7:

Recommendations ...........................................63

GLOSSARY

APPENDIX 1:

Regional and national resources....................65

APPENDIX 2:

Local BME and community agencies.............69

APPENDIX 3:

Equality Impact Assessment...........................75

REFERENCES

ACKNOWLEDGEMENTS

- Key performance indicators..............................57

- Service inclusion model evaluation ..................60

- Reporting performance.....................................61

Commissioning Framework for Language Support

1

List of tables, figuresand case studiesCase study 1 -

Figure 1 -

Case Study 2 -

Case study 3 -

Table 1-

Case study 4 -

Table 2 -

Case study 5 -

Case study 6 -

Case study 7 -

Figure 2 -

Case study 8 -

Case study 9 -

Case study 10 -

Case study 11 -

Figure 3 -

Clinical issues without languages support ...........7

Number of visas issued 2009...............................8

Passive and active English capability (HSE)........9

Written communication (SRSF)..........................10

Issues caused by inadequate language support ..11

Patient understanding of illness (SRSF) ............15

Meeting the QIPP agenda..................................16

Meeting the QIPP agenda (INTRAN) .................18

Data collection (SCC).........................................23

Community engagement (NHSP).......................26

Language support continuum.............................27

The role of the interpreter (HSE)........................28

Training staff to work with interpreters (ISCRE) .32

Interpreter training (HERTS) ..............................34

Regional service provision model (INTRAN)......36

Models of language support ...............................38

Table 3 -

Case study 12 -

Table 4 -

Case study 13 -

Table 5 -

Case study 14 -

Table 6 -

Case study 15 -

Table 7 -

Case study 16 -

Advantages and limitations of language supportstrategies............................................................43

A socially inclusive model of language support(SCRT) ...............................................................44

Key measures of a good service........................48

Local multi-agency partnership (TIP) .................52

Reasonable adjustments for language support..54

Occupational health and safety (ISCRE) ...........56

SLA / tender specification headings ...................57

Partnership working (INTRAN)...........................59

Feedback form (TIP) ..........................................60

Monitoring (NHSP) .............................................62

2


Executive summary1. Why this matters – acknowledging

the case for change

Commissioners should:

• Make communication and language supportcentral to the way care is provided

• Develop a clear conceptual framework thatdescribes the differing contexts of languagesupport and recognises the complexities ofcommunicating across language andcultures and allows the professional toachieve effective communication

Migration is an important and permanent featureof population change across the world. Withincreasingly multicultural societies there is agrowing recognition of the need for culturallycompetent care and migrant inclusive healthsystems. Failure to provide language supportresults in poorer health outcomes for patients,compromised delivery of care for practitionersand inefficient services with increased costs. Thispresents certain forcommissioners to consider.

Legislation and key policy drivers demand equalaccess to services and to positive healthoutcomes for migrants and Black and MinorityEthnic (BME) communities. The values espousedin Equity and Excellence: Liberating the NHS(DH, 2010) are those of fairness and of patientcentred services. Language mediation is not onlyan essential right in a patient centred service butalso meets a basic human need and isfundamental to the patient practitionerrelationship.

An innovative language support strategy willimprove the quality and productivity of servicesand will contribute hugely to the preventionagenda. Provision of interpreting is oftenperceived as costly and is sometimes limited ornot routinely offered to save costs. Whilst acomprehensive cost benefit analysis does notappear to be developed or readily availablecommissioners must consider the hidden costs ofpoor language support to patients, practitionersand services.

challenges and issues

Legislation and key policy drivers

Meeting the QIPP agenda and the financialcase for change

2. Assessing your local needs andpriorities


• Collect a range of data not only to identifycommunity languages but more specificallyto describe language support needs

• Collect, collate and interpret data andinformation in partnership with localcommunities and third sector agencies

• Ensure detailed and quality ethnic andlanguage monitoring in all services,including interpreting and translationservices

The commonest cited barrier to any developmentof a coherent approach to communication supportis the lack of clear data regarding ethnicity andlanguage needs for the population. Whilst there isno one agreed source of data for informing acommunications support strategy, this cannot beallowed to deter from provision of languagesupport options.

There is a wide range of national and local dataalready available from differing sources whichprovides a useful and sufficient basis for servicedevelopment. Sources include census data,national surveys, national and local administrativedata and third sector and provider activity data.This should all contribute to the Joint StrategicNeeds Assessment which will be fundamental toidentifying level and types of language supportneeds.

Numerical records of ethnicity and languages isinsufficient of itself and needs to be takentogether and enhanced with the rich and nuancedinformation available in local BME voluntarysector and community organisations.

Sources of information and data available

Using the data


3

3. Identifying suitable service solutions


• Start from the point of view of those whocommunicate in forms other than spoken orwritten English and consider multiplecommunication approaches that will giveservice users choice and take into accounttheir concerns, experiences, aspirationsand lifestyle

• Develop commissioning partnerships withcommunity organisations, voluntary sectoragencies and interpreting services whichare crucial to community needs assessmentand decision making regarding languagesupport provision

• Create a language support strategy whichincludes a locally based interpreting andtranslation service with and for localcommunities and ensures every servicecommissioned includes reasonableadjustments and a wide range of options forlanguage support provision

Service providers’ dependence upon patientsbringing their own ‘interpreter’ results in theunethical use of family and friends. Often it ischildren who are utilised in this role with severeconsequences for the child. This approach tolanguage support cannot be allowed to continue.

A coherent strategy of language support shouldnot only utilise

in partnership with the goodPublic Service Interpreting and Translation(PSI&T) agencies available; but should provide arange of different ways to meet diverse needswhich provide more cost effective solutions andensure a approach to languagesupport. Reasonable adjustments must always bemade and these include for example dual handsetphones on reception and conference phones inevery consulting/clinical room, plainEnglish/pictorial service information, flexibleappointment systems and facilities for drop inservice provision etc. Consideration must begiven with every service commissioned tobilingual staff, community volunteers, bilingual linkand support workers, working with advocacyagencies and joint working across BME agencies.

Models of language support

a service provision model oflanguage support

social inclusion

4. Defining and specifying servicesbased on best practice


• Apply the conceptual framework forunderstanding language needs and thelanguage support strategy to every servicedeveloped.

• Consider the full range of options that areavailable for delivering language support.

• Decide what outcomes each individualservice should deliver and consider howlanguage support options available willsupport those outcomes for BMEcommunities.

A comprehensive strategy across all serviceprovision will enable a broad range of options forlanguage support to be available to all serviceareas. The ability of such a strategy to deliver arange of options is dependent upon thedevelopment of a social inclusion model oflanguage support.

Understanding the roles and methods of workingof the interpreter or translator is essential toestablishing basic principles and identifying keymeasures of a good interpreting and translationservice. Service specifications should incorporatepathways to employment for interpreters andinclude training not only for existing interpretersbut also for new interpreters and new languagesas migration trends change.

The options broadly available within the strategycan be specifically defined within each servicecommissioned and integrated into the servicespecification, especially within specialist areassuch as mental health, health promotion, andscreening services.

Public Service Interpreting and Translation(PSI&T)

A social inclusion model

4


5. Working with and developingproviders


• Work in partnership with the educationsectors required to develop language skillin local communities, provide training andprofessional development for interpretersand support health staff training anddevelopment

• Familiarise all NHS staff with languagesupport options available, sources of

Working with third sector providers

mapexisting services and funding

Procurement and contractual approaches

The central and most important resource to theprovision of language support is local BMEvoluntary and community sector organisations.They possess a keen understanding of languageand cultural issues and are in a position to identifyboth needs and solutions: with local communitiespossessing the language and cultural resourcesto develop those solutions. The overall aim of anylanguage support strategy should be to create apartnership approach which seeks to coordinatethe support provided by a wide range of partneragencies. The localisation agenda and theconcept of the ‘Big Society’ underpin such astrategy. Commissioners therefore need to

in partnershipwith a range of community agencies in order toidentify what should be commissioned and how toaccess alternative providers.

There are elements that need to be addressedbeyond the commissioning of individual serviceswhere language support needs should beconsidered. Workforce development could includefor example staff training in cooperation withinterpreters, cultural competency and in locallyrequired languages; training in local communitiesfor higher level English skills, and the provision ofpathways to volunteering and employment in awide range of roles (including reception/adminstaff, health trainers and clinical staff); and thetraining of interpreters to the level of Diploma inPublic Service Interpreting (DPSI) and inspecialist clinical areas such as mental health andpalliative care. Community participation in thedesign of care pathways and identification of thelanguage support solution most appropriate toeach stage of the care pathway.

translated information accessible, the workof other organisations locally and nationallythat can help support service users,legislation, guidelines and policies

• Ensure all services users are aware of theoptions available to them and empowerthem to participate in the development andprovision of support options and identifyingdeveloping needs and new ideas

• Work with service providers in health,housing, social care and in thethird/voluntary sector to co-ordinate theirwork together for individual patients and forcommunities, share the provision of link,support and advocacy workers andcollaborate on the provision of interpretingand translation services


• Actively seek feedback from individuals,communities and staff who are all users oflanguage support

• Create guidelines and policies with clearstandards with means for their monitoringand evaluation

• Ensure the employment, training,assessment and deployment of interpretersand translators meets minimum bestpractice standards to ensure safety, efficacyand quality of interpreting.

• Apply robust monitoring systems essentialto facilitating cost effective provision oflanguage support

• Build in evaluation of commissioning,planning, service development and deliveryfrom the start

6. Monitoring performance

Monitoring performance of Public ServiceInterpreting and Translation services can beclearly defined through

However, aof language support involves monitoring healthoutcomes across the board and identifying ifthose patients with limited English proficiencyhave equity of access to positive healthoutcomes. Language support monitoring is thustied intimately to the monitoring of all elements ofa service. Service user and community feedbackis essential.

key performanceindicators. social inclusion model


5

Introduction

“To communicate effectively you must:make sure, wherever practical, thatarrangements are made to meetpatients' language and communicationneeds.”(GMC, 2006)

The aim of these guidelines is to supportcommissioners in the development of coherentand robust evidence based language support andinterpreting/translation strategies and policies,which can be used to deliver culturally competentservice provision.

Migration is an increasingly important feature ofpopulation change across the world, so peopleare crossing national borders to live in countrieswhere they may not be fluent in the nationallanguage. In order to embrace diversity, and meetthe health needs of people with differentexplanatory health beliefs and culturalconstructions (Tribe and Tunariu, 2009) there is agrowing recognition of the need for culturallycompetent care (Bennett and Keating, 2009) anda migrant inclusive health system. The right tolanguage mediation not only meets a basichuman need, but is fundamental to the patientpractitioner relationship (Umer et al., 2009) and isan essential element of equal access.

Approaches to communication needs havetended to focus upon access to interpreters andwhilst it is true that health and social careservices are making increasing use of interpretersand translated information, broader approachesto language support are required with theutilisation of a variety of models of provision. The

overall aim of any strategy should be to create amore joined up approach with overarchingfinancial, strategic or developmental planningtaking due consideration of language supportservices. It is also important to realise thatlanguage support services do not operate in avacuum and their development must take placewithin the context of strategies for equalities andequity of service.

(DH,2010) firmly sets the grounding for

(p6) and

(p8). The values espoused centre on fairness foreveryone in society, with patient centredapproaches where services are designed aroundpatients (p8),and patient involvement that enables

betterunderstanding of health issues and a resultantimproved cost effectiveness (p13). Languagesupport will be key to achieving the changesproposed and ensuring improved patientexperience and safety. Without language supportpatients with limited English proficiency cannotcontribute to Patient-Reported OutcomeMeasures (PROMs) and real time surveys; willnot have access to

(p13), will beunable to have meaningful access to their carerecords and their collective voices will not be

(p19).

Equity and Excellence: Liberating the NHS‘Putting

patients and the public first’ ‘Focusing onimprovement in quality and healthcare outcomes’

‘needs, lifestyles and aspirations’improved

outcomes, increased satisfaction,

‘comprehensive, trustworthyand easy to understand information’

‘strengthened’

6


Case Study 1 - Clinical issues with inadequate language support

Difficulties accessing interpreters means that professionals often have to compromise with informalinterpreters with the following results:

Consent not properly obtained:

Sensitivity with using family or people from the local community:

There are examples where community members have not registered with a GP and have neveraccessed primary care services because of lack of knowledge about the way things work in the UK:

Patients do not know what to expect:

E.g. Portuguese people sitting all morning in a surgery waiting in vain for their appointment as theyhave not arranged one.

Community members do not understand how the NHS works and visit the A&E department whenthey have a minor ailment:

A&E staff

Community members have less access to prevention programmes than other groups, henceincreasing risks of incurring serious illnesses or even death:

E.g.:

Patients may overuse diagnostic, specialist services or beds:

E.g.

E.g.

Patients may be misdiagnosed:

E.g.

Patients may not be able to understand the nature and consequences of medical procedures:

E.g.:

All quotes Gidney (2010) Unpublished document

“…her 10 year old son interpreted for me. However, it occurred to me that her son might notunderstand all the concepts I was explaining and therefore the woman could be signing somethingthat she didn’t actually understand.”

“Mr X was referred to me as having severe psychotic episodes, he did not speak English and his wifeinterpreted. However, I was aware that there were relationship problems and it was inappropriate forhis wife to act as an interpreter but I couldn’t get hold of any other interpreter.”

“She was 65, lived in a small Norfolk village for 35 years and had never registered with a GP,because she did not understand the “system”. If she had seen a GP, she would never have ended atthe A&E and nearly died there.”

“This Portuguese lady turned up at the A&E because her son had not had a poo that day.”

A Bengali man used an informal interpreter. He was diabetic and ate something very sweetwhich resulted in him falling into a coma. His son had not interpreted “otherwise you could die” to hisfather because in their culture children do not tell their elders what they can and cannot do.

“I saw this patient again and again for the same issue.”

“We were not able to discharge him, because we did not know where to get an interpreter.”

“I realised that in the past I used to establish my diagnosis based on the few words patients weregiving me. With the interpreter, my patients are more relaxed, and are able to give me a fuller picture.On a few occasions with the interpreter, I realised that my diagnosis changed radically as a result ofthat story.”

“She was trying to have a baby. Because of the lack of an interpreter staff had not explained toher the consequences of having a hysterectomy”.


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With globalization people are increasingly movingacross national borders to live and work(www.statistics.gov.uk). Thus if equity of access tohealth and social care across those borders is to besupported there is an increasing need for languagesupport (Tribe and Lane, 2009). There is a dangerin believing that interpreting needs are a temporaryproblem that will somehow diminish. Beliefs thatimmigration figures are falling for whateverreasons; that new migrants are required to learnEnglish and provision of interpreting and translatedinformation somehow hinders this; or that currentprovision of telephone interpreting is sufficient tomeet need, are false and lead to short-termism inthinking and ad hoc forms of provision.

Such short-termism does not reflect the reality ofthe situation experienced by service users andproviders on the ground. Migration, rather thanbirths and deaths, is now the principle componentof population change (ICOCO, 2007). At least threemillion people living in the United Kingdom wereborn in countries where English is not the nationallanguage (National Centre for Languages, 2006).Long term migration, defined as stays over 12months, has increased from 320,000 in 1997 to574,000 in 2006 (ICOCO, 2007 p3). The HomeOffice Statistics for 2009 (Home Office, 2010) showthe number of visas issued to people entering theUnited Kingdom had increased by 2% to 1,996,500and there were 24,250 asylum applications whichinvolved some 29,845 people.

There are a range of languages in commonusage in the UK. British Sign Language wasofficially recognised as a minority language in the

Language diversity

SECTION 1:

Why This MattersAcknowledging TheCase For Change1. “…providing interpreting services…isa financially viable method forenhancing delivery of health care topatients with limited English proficiency”(Jacobs et al., 2006)

United Kingdom in March 2003 and is believed tobe the preferred language of 50,000 of the totalregistered 8,945,000 deaf and hard of hearingpeople in the UK and the ratio of fully-qualifiedinterpreters to sign language users is 1 to 275.(Perez and Wilson,2006). Also there are 23,000deaf blind people in the UK. Communitylanguages include those of established BMEcommunities and the 2001 census identifies theseas Urdu, Bengali, Punjabi, Chinese (Cantonese),Polish and Italian. It is important to recognisehowever, that communities are not homogenousand that there are differences in dialect and incultural expressions within such communities.

National statistics give an important pictureregarding the range and numbers of migrants inthe UK. Commissioners will however need toknow the profile of their own communities andcan use national data to identify the types of datathat might be important: for example: studentsnumbers would indicate the need for data fromHigher Educational Institutions and theidentification of local language schools.

(1) Tier 4 of the Points Based System(2) Visitors, working holiday makers, Tier 5(3) Tiers 1 and 2, Highly Skilled Migrant

Programme, Work Permit Holders(4) Spouse / civil partner actual and proposed(5) Indefinite Leave, Certificate of Entitlement

Home Office (2010)

Number of visas issued (excludingdependants) 2009

8


Temporary Visas(2) 1,333,815

69%

Students (1)273,610

14%

British Citizen203,865

10%

Asylum apps24,250 1%Settlement

(5) 11,005 1%

Family (4)38,385 2%

Employment55,300 3%

Learning EnglishNew migrants experience specific difficulties indeveloping English language proficiency andusing English to communicate effectively. Firstaccessing courses as requirements for somecategories of students, for example new spouses,to meet nationality and residence status asdefined by the Home Office, means that theyhave to wait until they receive settled status foracceptance as a home student before becomingeligible for funding (Home Office, 2003). Also,waiting lists for courses can be long: over 100people in Ipswich according to one third sectorprovider (CSV Media, 2010), “There are notenough ESOL classes being delivered toaccommodate the growing number of people whorequire ESOL they are timetabled during theworking day, which is not convenient for thosemigrants working irregular shift patterns duringthe day” (ISCRE, 2007 p29). Additionally, themajority of classes being provided in Suffolk arefor learners working at Entry level 3 or below,meaning that each entry 3 learner would needabout 200 guided learning hours to reach theequivalent of GCSE English (SCC ACL, 2010).

Some people experience difficulties in learninglanguages especially if they are not literate intheir own language. Many ESOL courses provideonly basic English and do not develop languageskills to sufficient degree to be able tocommunicate in complex situations or wherespecialist language is used (Home Office, 2003)especially to the level required to communicate tocommunicate in a clinical context. Also, age,crisis, fear, pain and illness all impedecommunication in a second language whenpeople will revert to their first language.

“I have been here two years and onlybeen able to go to an English class atThe Forum once or twice. Where can mychildren go when I go to class? Who willtake me? I live outside the town andthere are no classes there. I can speak inEnglish to buy food but not to explain myproblem to the doctor…”Female Turkish service user (Stallabrass, 2005)

Case Study 2 - Passive and active English capability

MM (over 50), a Polish patient suffering from chronic pain in the right hip area radiating down to hisright leg and left hip area. MM is a historian by profession and has worked as a bus driver for a fewyears in the UK. He was dismissed from work due to his health condition and made an appointmentwith a GP to seek help with his condition and learn what other work he would be able to do. He alsostressed that he was not willing to claim disability benefit. The patient did understand the Englishlanguage, the problem started when he tried to communicate and express his problems. That iswhere the interpreter’s assistance is indispensable to facilitate the easiness of conversation anderadicate any distortions, misinterpretations and annoyance resulting from lack of propercommunication.

What I found is that the passive understanding of English is not as much of a problem as the activeproduction including specialised vocabulary, unfamiliar to the Polish patient. The interpreter added toboth patient and GP’s feeling of comfort ability and introduced some light humour. Prior to theassignment the patient had spoken to the receptionist and asked for a Polish doctor who was,unfortunately, unavailable on that day. As a result, the patient became anxious and wished to cancelhis appointment with an English speaking physician. Only when he learnt that there was aninterpreter available, did he calm down and agree to see the doctor on that day.

Contact: Dr. Forsythe-Yorke & Kasia Urbaniak, HSE Norwich [email protected]


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1.1 Challenges and issues

Case Study 3 – Written communication

The patient is in her 30s and has been with her husband for more than 10 years and has 3 children.She has lived here for 5 years and has 5 years leave to remain - refugee status. Patient speakssome English but cannot really read or write in her own language or English. She comes from aconservative Muslim background. I was surprised when in an advice session she pulled out anenvelope from her GP. This contained a prescription with a scrawled handwritten message on theback. Basically stated a swab had tested positive for Chlamydia and she needed to take theprescription once she finished the course of medicine she was on. I honestly thought that there was amistake but was told by the receptionist that it was correct.

The interpreter and myself then had to try and explain to the patient about the illness using theinternet. Obvious implications about her partner etc. Patient stated that she had shown the messageto her son who is 10 but he didn't know what it meant. Patient was VERY upset and to try andremedy the situation I arranged an appointment with the GP and an interpreter provided by us. Inaddition to all the obvious I wondered if the GP would have bothered to talk to patient about herhusband being treated.

Contact: Liz Wood, Suffolk Refugee Support Forum [email protected]

There are a variety of issues caused by the lack ofprovision of interpreting: poorer health outcomesand vulnerability of patients, poor communicationand associated risks for practitioners, inefficientservice provision and increased costs for serviceproviders, difficulties disseminating healthinformation, widening health inequalities forcommissioners and increasing marginalisation forcommunities. The following table identifies some ofthe specific issues and gives sources to explore thedetails more fully.

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Table 1

Issues caused by inadequate language support

Patients

Practitioners

• Use of family, particularly children places stresses upon family dynamics and unacceptable stresseson children under 18

• Unable to make appointments with services (Alexander et al., 2004)

• Unable to access positive health outcomes which leads to lower health status (Dubard and Gizlice2008; Bischoff 2010)

• Miss out on opportunities to access preventive, diagnostic and therapeutic services delivered throughprimary care, including vaccination screening services (HPA, 2010)

• Those most in need are less able to access services (Alexander et al., 2004)

• Receive inappropriate medication or do not understand medication requirements (Andrulis et al.,2002)

• Loss of English language proficiency with age (Alexander et al., 2004), crisis or mental health need

• Prefer to use family and friends because they are more culturally aware and sensitive (BMA, 2004)

• Lack of confidence that interpreters provided by services are reliable (Alexander et al., 2004)

• Psychological support received is limited (Gerrish et al., 2004) or less effective (Farooq and Fear,2003)

• Feel dissatisfied with services and care received (Weech-Maldonado et al., 2003)

• More serious adverse outcomes from medical errors (Divi et al., 2007)

• Poorer understanding of their medical diagnosis and treatment (Flores et al., 2005).

• Women and children subject to abuse and trafficking are not identified or enabled to speak forthemselves (Stallabrass, 2009)

• Misunderstandings in 20% of GP consultations (Roberts et al., 2005)

• Late presentation of more ill patients (Johnson, 2007)

• Difficulty in obtaining accurate patient histories, joint patient-provider decision-making on treatment,and supporting self care (Wisnivesky et al., 2009)

• Poor adherence to medication regimens

• Use of family and friends as interpreters compromises confidentiality and reliability

• Error in diagnosis may result in the provision of inappropriate treatment and care (ISCRE, 2007)

• Multiple presentations of the same issue take up time and resources (ISCRE, 2007)

• Increasingdissatisfaction inserviceprovided(Hampers,2002)

• Lack of training and support to overcome language barriers (Gerrish et al., 2004)

• Lack of understanding of the access, development and use of translated information

• Poor skills in identifying appropriate interpreting and in working with interpreters (Johnson, 2007)


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Table 1

Issues caused by inadequate language support

Providers

Public Health

Commissioners

Communities

• Poor standards of care (ISCRE, 2007)

• Missed appointments (Brach et al., 2005)

• Inappropriate use of services by patients creating higher consultation and treatment costs (Hamperset al., 2002; Smedly, 2003)

• Higher rates of communication errors leading to increased likelihood of clinical errors (Flores et al.,2005)

• Governance and legal risks of misdiagnosis and unsafe treatment (Bischoff and Denhaerynck, 2010)

• Legal risks of failing to provide interpreting

• High costs of providing unsupported ad hoc interpreting and translation

• Language difficulties lead to negative judgments and stereotyping and patients are seen as difficult(Roberts et al., 2005)

• Language issues seen as the greatest barrier to health care (BMA, 2004)

• Less health promotion advice given on contact with a health professional (Ngo-Metzger et al., 2007)

• Minimal access to relevant information for health protection [e.g. malaria, TB, smoking, obesity]

• Difficulties in disseminating essential information [e.g. swine flu]

• Increasing health inequalities (Messias et al., 2009)

• Less use of preventive care (Ku and Flores, 2005),

• Reduced attendance at routine check-ups (Pearson et al., 2008)

• Less effective health promotion campaigns

• Poor health outcomes (Anderson et al., 2003)

• Inadequate data collection to identify ethnicity and language needs

• Lack of commissioning without robust ethnicity data

• Unequal access to services (Bischoff and Denhaerynck, 2010)

• Non compliance with legal and policy directives

• Increased costs of uncontrolled ad hoc interpreting use

• Lack of skills, capacity and training for staff to work cross culturally and with interpreters

• Limited interpreting and language capacity for some languages and in new migrant communities

• Without ethnicity breakdown there is no way of understanding needs, trends for disease or illness tothen be able to inform commissioning of services

• Confusion over language/interpreting issues were consistently identified as barriers to access, formigrants as well as for organisations commissioning and providing services. (HPA2010)

• Increasing marginalisation (ISCRE, 2007)

• Greater dependence upon voluntary sector services (ISCRE, 2007)

• Greater requirement of support from small and marginalised communities

• Reliance upon a small number of interpreters can reduce trust or create fear regarding confidentiality

• Some interpreters can act as gatekeepers to services minimising or complicating access

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1.2 Legislation and key policy drivers

Legislation

The Equality Act 2010

The Disability Discrimination Act 1995 and2005

Race Relations (Amendment) Act 2000:Race Relations Act

(1976)

The Equality Act became law in October 2010. Itreplaces previous legislation (such as the RaceRelations Act 1976 and the DisabilityDiscrimination Act 1995) and ensures consistencyin what you need to do to make your workplace afair environment and to comply with the law. Therequirement to be pro-active in preventingdiscrimination is emphasised.

The Equality Act covers the same groups thatwere protected by existing equality legislation –age, disability, gender reassignment, race,religion or belief, sex, sexual orientation, marriageand civil partnership and pregnancy and maternity– but extends some protections to groups notpreviously covered, and also strengthensparticular aspects of equality law.

All service providers are obliged to providecommunication support to people whosepreferred language is British Sign Language.

Amends and strengthens thethrough which it was made unlawful to

discriminate on racial grounds either directly orindirectly. Failure to provide language serviceswhere there is a known language need could beconstrued as indirect discrimination. TheAmendment Act places a further enforceable dutyon all public authorities, including healthauthorities, trusts and primary care trusts, topromote equal opportunities and good racerelations and to address racial discrimination bytheir employees (Section 71). Failing to provide

“I sign in Farsi and no-one here can dothat. In London I started to learn BSLbut there are no classes for me here. Ihave to communicate through writingthings down in Farsi for an interpreterto translate for the doctor”Iranian service user (Stallabrass, 2005)

interpreting facilities in relation to serviceprovision, when it is known that there is alanguage barrier, could be construed as unlawfulracial discrimination.

Failure to provide language support breachessome of the articles of the

explicitly inrelation to access to an interpreter when arrestedby police or appearing in court, and implicitly, forexample the refusal of treatment, of registrationwith a service, or lack of information because ofinadequate language support facilities can beinterpreted as a breach of Article 25

(Potts,2008).

Places an explicit responsibility uponcommissioning agencies and purchasers ofhealth and social services to carry out a needsassessment and to consult with the localpopulation in order to determine local needs.Gaps and unmet needs in service provisionshould lead to specific service development.

Children have the right to learn and use thelanguage and customs of their families (Article30); All organisations concerned with childrenshould work towards what is best for each child(Article 3); Children have the right to say whatthey think should happen when adults are makingdecisions that affect them, and to have theiropinions taken into account (Article 12). In orderto meet these requirements language support isessential if the child has limited Englishproficiency.

Explicitly recommends the use of interpreters inthe explanatory memoranda and codes ofpractice.

Human Rights Act 1998

1950 EuropeanConvention on Human Rights

NHS and Community Care Act 1990

United Nations Convention of the Rights ofthe Child 1989

Mental Health Act 1983

The right tothe highest attainable standard of health


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Key policy drivers

Equity and Excellence: Liberating the NHS2010

Inclusion Health: improving primary care forsocially excluded people 2010

The Marmot Review 2010

Towards the Best Together. A Clinical Visionfor our NHS, now and for the next decade.NHS East of England 2009

The focus on patient experience, serviceeffectiveness and patient safety, and theunderpinning values of equity and fairness requirecommissioners to consider how they will engagewith services users and make service userinvolvement meaningful. The document makesexplicit reference to providing assistance to thosewho have difficulty accessing information (p15),being responsive to services users’ needslifestyles and aspirations (p8), and supportingpeople who have a lack of capacity to makechoices (p19). Language support will be key toachieving these aims.

The four strategic aims utilised in addressing thecomplex health needs of some of the mostmarginalised groups includes: people shapingservices, promoting healthy lives, continuouslyimproving quality, and locally led change.Language support is identified as a basicrequirement to address access barriers andimprove outcome measures.

examined persisting inequalities in health with asocial determinants approach. The reportidentifies a social gradient in health where thelower a person’s social position, the worse his orher health. Action focusing on social inequalitiesand across all the social determinants of healthwas identified as a key policy objective. Thereport advocates cross sector partnerships andeffective local delivery systems focused on healthequity in all policies; participatory decision-makingat local level and empowering individuals andlocal communities.

Towards the best, together is the vision for theNHS in the East of England, setting out howhealth and healthcare services should beimproved, now and over the next decade. A

Fair Society, Healthy Lives: A Strategic Review ofHealth Inequalities in England Post-2010

theme highlighted in the document is the lack ofinformation and understanding to enable choice:whether it is knowing which service is mostappropriate; choice of hospital; registering with aGP; or access to an NHS dentist. Whilst thisapplies to all groups of the population, it isparticularly relevant to those with learningdisabilities and mental health problems and thosewith limited proficiency in English. The documentstates:

Guidance and recommendations were made tocommissioners for the design and delivery ofcommunication support services followingresearch into the use of communication supportat a number of NHS sites. Whilst theserecommendations are offered as guidance andare not mandatory, when considered in relation tothe legislative framework it is clear that acoherent language support strategy is a minimumrequirement.

Lord Laming’s original report into the death ofVictoria Climbié (Laming, 2003) ushered in majorreforms to children’s services through the EveryChild Matters agenda, culminating in the ChildrenAct 2004. Language support provision is essentialin increasing the focus on supporting families andcarers and on the protection of the safety andwelfare of children.

“The failure of the NHS to provide choiceto patients is unacceptable and it can stand in theway of effective and timely treatment” (p6).

Guidance on Developing LocalCommunication Support Services andStrategies 2004

Children Act 2004 and Every Child Matters2003

Mrs K has often attended hospital toact as an interpreter for her friend whowas admitted to hospital as anemergency yet: 'they don't speakEnglish, but I'm trying to help them. MyEnglish is no good. I'm using dictionaryall the time, especially for doctors –they use words we don't use in normallife'Polish woman – age 28 (SCC ACL, 2010)

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Inside Outside: Improving Mental HealthServices for Black and Minority EthnicCommunities in England 2003

Inquiry into the Death of David ‘Rocky’Bennett 2003

Communication support strategies are clearlyfundamental to the achievement of the three keyobjectives for reforming mental health servicesidentified in this report, including the developmentof cultural capability in mental health services.

(Norfolk, Suffolk and Cambridgeshire StrategicHealth Authority, 2003). One of the key findings ofthe Inquiry into the death of this

African–Caribbean man was that institutionalracism does exist in the NHS in general and inmental health services specifically. Failure to putin place the structures and processes required toprovide appropriate language support can beconsidered to be institutional racism if it meansthat an organisation cannot provide adequateservices to all its actual and potential patients(Bennett and Keating, 2009).

Particularly cited the language barrier as a factorin what appeared to be a differential quality ofcare for patients from minority ethnic groups.

Acheson Report 1998

Case Study 4 – Patient understanding of illness

The patient is from Iraq and is 27 years old. He came here in 2002 fleeing the war. He has Perthesdisease which is a bone problem affecting the hip joints. If children have it in this country it is normallydiagnosed pretty quickly whilst they are young. Treatment is given so that it only becomes a problem inmuch later life. This did not happen to the patient as he was with his family in the back of a lorry going overthe mountains of Northern Iraq fleeing Saddam Hussain. He believed that his illness stemmed from thistime because of the journey.

As he gets older the pain has got a lot worse and the patient is now unable to work. The hospital isreluctant to give him a hip replacement because of his age. He claimed ESA but was turned down after amedical at ATOS - the company who do the medical checks for people who say they are too ill to work.The form was then filled in by SRSF but in all fairness if the patient does not know what his illness is thenhow can a person filling in the form on his behalf be able to give the correct information. The patient thengot more and more depressed as SRSF had to appeal the outcome. The GP at this stage did write a letterto the Benefits Agency at Bury St Edmunds but it was not sent to the right department. The GP did give acopy to the patient who by chance showed it to me. I was then prepared for the tribunal hearing whichtook place in June some 18 months after the original form was filled in. The GP on the panel took one lookat my and the GP's letters and awarded ESA.

With an interpreter I had to explain to the patient what Perthes disease was using pictures off the internet.If the patient had understood or even known what his illness entailed then time and money would havebeen saved for everyone.Aclear letter written by the GP some 20 months earlier would have made all thedifference. There is a big difference between saying “my hips are painful” and stating “I have Perthesdisease”.

Contact: Liz Wood, Suffolk Refugee Support Forum (SRSF) [email protected]


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1.3 Meeting the QIPP agenda and thefinancial case for change

By taking action to ensure communication supportfor a wide range of different members of thecommunity commissioners can contributesignificantly to the Quality, Innovation, Productivityand Prevention agenda for their area.

Table 2

Meeting the QIPP agenda

Quality

Innovation

Prevention

Productivity

• Provision of adequate and appropriate language support services on first and subsequent contactimproves the quality of interaction for both the patient and the practitioner. This improves concordancewith treatment protocols, increases understanding around service provision and referral processesand helps to ensure that appointments made are attended.

• Tackling health inequality through improved language support for those migrants who are amongsome of the most vulnerable people with the poorest access to primary care, can improve healthoutcomes and ensure ‘inclusive practice’ for all (Department of Health 2010).

• A range of communication support strategies within a comprehensive commissioning frameworkreduces the dependence upon simply finding interpreting provision and increases the flexibility andaccessibility of services: for example bilingual staff including reception and admin staff; link workers;services joining together to provide surgeries in a specific language and in-house interpreters.

• Innovation and development of local services to provide jobs for local people can reduce the costs ofbringing in trained interpreters from outside the area, enhance a community’s economic status andeducational opportunities, and improve social cohesion.

• Improved availability of translated information enables better understanding of lifestyle issues (e.g.smoking and obesity) and knowledge of the availability and purpose of services. Language supportstrategies such can increase the use of preventative services and early intervention.

• Dissemination of urgent public information can be assisted where language support strategies andcommunity are already established [e.g. pandemic flu situation and migrant workers].

• The distress and disruption caused to family, and particularly children, will be prevented thus reducingthe need for additional services and support in education and children’s services and enhancingmechanisms to ensure child protection and welfare [e.g. child carers, children missing from school].

• The risk to patient safety, even to the point of loss of life, can be lessened.

• Appropriate, sufficient and flexible communication support will prevent inappropriate use of services asa result of failure to identify needs, flawed diagnosis, missed appointments or over-use of crisis orintensive services as a result of late presentation of needs. Resources for individual agencies would beused more effectively and improve the cost benefit ratio.

• The risk of legal costs resulting from poor communication support (e.g. negligence) would be reduced.

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The financial case for change

There are few studies which adequately describethe costs incurred for failing to provide languagesupport (Bischoff and Denhaerynck 2010), and itwas not possible to identify any current cost-benefit analysis for the purpose of theseguidelines. Assumptions informing the debateinclude evidence that poor care results in greatercosts in the long term, and that costs incurred byproviding interpreting are not beneficial or costeffective or result in increased health careconsumption thus increasing overall costs.

The use of interpreters has been shown to improvequality of care (Morales et al., 2006; Karliner et al.,2007) and reduce health inequalities (Karliner et al.,2006; Jacobs et al., 2004; Flores, 2005). Access toprofessional interpreters improves outcomes withbetter chronic disease management, reducedinpatient episodes and a consequent reduction inhealth care costs (Graham et al., 2008; Chan et al.,2008; Fernandez et al., 2010). Jacobs et al., (2004)argue that patients using interpreter services incurhigher costs with greater utilization of health care(prescriptions, screening, appointments) but thatthis is offset by a lower number of ineffectivereferrals, improved illness prevention and reducedhospital admissions. They conclude that providinginterpreting services

(p869).

More longitudinal research and detailed costbenefit analysis is required in this area to furtherexplore these arguments. However, experience oflocal service providers has identified areas of costsaving when using interpreting services. And theuse of bilingual staff and workers would suggest

“is a financially viable methodfor enhancing delivery of health care to patientswith limited English proficiency”

further cost savings, though again there is noempirical evidence to support this.

- One off ad hoc interpreting, ‘as andwhen’ most needed, costs the health serviceprovider more per unit than the cost of the sameassignment completed as part of a comprehensiveservice provision through a service levelagreement. (Stallabrass, 2005)

- The deployment of interpreters locallyreduces travel costs and time, which can form themajor part of the costs to the heath service provider ofusing face to face interpreting (Gidney,2010)

- Efficient use of interpreting servicesby trained health staff able to discern the mostappropriate type of interpreting from a range ofoptions costs less to the health service providerthan untrained use of services (Bischoff andDenhaerynck, 2010).

- Patients with limited Englishproficiency, without interpretation, incur highercharges and longer stays in hospital than otherpatients, increasing the cost of patient care forNHS Trusts (Jacobs et al., 2004).

- Patients with limited Englishproficiency, without interpreting access, have ahigher incidence of adverse events requiringemergency care, increasing the cost of patient careto NHS Trusts (Divi et al., 2007).

- "Did Not Attend" costs currently costthe NHS over £400 million per annum. Languagesupport reduces these costs (Bischoff andDenhaerynck, 2010).

Cost saving

Cost saving

Cost saving

Cost saving

Cost saving

Cost saving

“When I ask for an interpreter at thehospital I am told that I can't have onebecause it is too expensive. But I don'tunderstand what the doctor is saying tome so I can't see how that is saving costsbecause I have come here and ask youto contact the doctor to see what he saidand make another appointment. Whydon't they just listen when I say I need aninterpreter.”Polish service user (Stallabrass, 2005)


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Case Study 5 - QIPP Agenda and the INTRAN Partnership

INTRAN (the Partnership) creates solutions needed by public service providers and members of thepopulation with limited English proficiency or who are deaf. The Partnership has grown to 37 partnersacross the Eastern Region and in 2009/10 recorded nearly 32,000 bookings for interpreters (52% ofwhich are for the NHS alone).

Barriers to understanding between clinical and support staff and patients are minimisedthrough the use of qualified interpreters, which leads to safe and high quality care. Services areaccessible 24/7. The Partnership has a robust quality assurance strategy, monitoring service deliveryand satisfaction closely against contractual expectations.

Joint funding of a central development team, with specialist knowledge, and the creationof a cross-sector network of champions, have enabled each individual partner to benefit from majoreconomies of scale and of learning. The Partnership has developed a wide range of innovativeenablers for its partners to help them promote “reasonable adjustments” to its staff and users. ThePartnership continually researches new developments to benefit its partners

A cost effective service is delivered by tendering for a service which secures a pool oflocal interpreters and minimises travel costs. Paying the interpreters a fair rate that is affordable bythe public sector means that qualified interpreters work for INTRAN partners for less than if they werefreelancing. The Partnership works with its partners to help break down barriers through the activeimplementation of communication and education strategies, focusing on “how to do things moreeffectively”. By utilising the Partnership’s statistical analyses and local intelligence, NHS Norfolkidentified the potential for considerable savings and quality improvements in healthcare for Thetfordresidents with limited English proficiency and developed regular clinics with an interpreter.

The role of the INTRAN champion in provider organisations is crucial in ensuring thatpeople understand how NHS services work and are able to access PSI&T services when necessary.Empowering staff to use the Partnership’s services at the first point of contact prevents repeat visitsor conditions worsening so that patients need more intensive services.

Quality:

Innovation:

Productivity:

Prevention:

Contact: Valerie Gidney, INTRAN Partnership [email protected]

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19

SECTION 2:

Assessing Local andPriorities

2. Your Needs

2.1 Sources of information dataavailable

Census data

Commissioners need to be proactive inthe identification of communicationneeds rather than simply reactive towho walks through the door.

There is general recognition that migrationstatistics are inadequate at national andparticularly at local level. The commonest citedbarrier to any development of a coherentapproach to communication support is the lack ofclear data regarding ethnicity and languageneeds for the population. There is no one agreedmethod or source of data for informing acommunications support strategy.

However, poor quality ethnicity data should not beallowed to prevent its use in addressing healthinequalities and disparities (Aspinall andJacobson 2007). There is a wide range of dataavailable and although each source has itslimitations, taken together and enhanced withother local data it does provide a useful picture onwhich to base service development.

The Census is a 10 yearly national censusproviding a comprehensive snapshot of ethnicityand migration information. However, it does notcollect information on languages and as it is onlytaken once every ten years (last in 2001) it issimply a snapshot in time and does not reflectnew migration or changing patterns of migration.Nor does it reflect the needs of those withinsecure immigration status who are unable orunwilling to contribute. The groupings in relationto ethnicity do not necessarily identify accurateethnicity data. In the census (and many other

National Census

surveys), respondents sometimes have difficultyin identifying the appropriate ethnic group fromthe limited list of categories on offer.

This annual census of all children in grantmaintained schools in the UK includes address,age, ethnicity (not nationality) and mother tongue.This does not capture the children arriving andleaving within the year or pupils as they leave thesystem but does give an indication of thenumbers of languages in an area.

This survey is important to the collection ofnational data with over a quarter of a millionpeople interviewed every year and involves avoluntary face to face interview of passengersarriving and leaving the UK.

However, there are limitations to the use of thisdata particularly at local level. Not all ports ofentry are covered and the data is aggregated toproduce national migration estimates. It alsomakes adjustments to take account of the factthat the survey is not conducted at night. Thesample size is very small compared to allpassenger movements (0.2%) and only around1% of those sampled are migrants thus it isdifficult to draw conclusions particularly for thelocal level (ICOCO 2007) with the result that thereis a tendency to extrapolate figures to giveestimates of too many in-migrants into London,and centres of higher concentrations of migrantsand too few into some of the other regions. Afurther issue is that the IPS measures people’sintentions, which may or may not accord with finalactions, migrants plans are often uncertain andwhen asked to give a destination respondentstend to give the name of the nearest big city andnot their actual destination if known.

The Labour Force Survey is a quarterly samplesurvey of 60,000 households living at privateaddresses in Great Britain which providesinformation on the UK labour market that can thenbe used to develop, manage, evaluate and reporton labour market policies. Information onrespondents' personal circumstances and their

Pupil Level Annual School Census (PLASC)

International Passenger Survey (IPS)

Labour Force Survey (LFS)

Surveys

labour market status is collected during a periodof one week or four weeks (depending on thetopic). It does include questions on nationality,ethnicity, current and last address, and date ofarrival in the UK. Its main drawback is thesample size and the sampling methodologymeans that data cannot be extrapolated to berepresentative of any given area.

The Office for National Statistics (ONS) hasdeveloped annual local area datasets called theAnnual Population Survey (APS) householddatasets. They allow production of family andhousehold labour market statistics at local leveland for small sub-groups of the populationacross the UK, between the ten-yearlycensuses. The APS combines the Labour ForceSurvey (LFS) and the English, Welsh andScottish Labour Force Survey boosts. APShousehold datasets cover the calendar period ofJanuary to December for individual years from2004. There are approximately 170,000households and 360,000 persons per dataset.

Thus it is able toprovide more robust local area labour marketestimates than from the main LFS. Whilst one ofthe key strengths of the APS is that socio-economic data can be analysed in a wide rangeof ways at sub-regional level, analysis canbecome restricted by small sample size andreliability issues, which can have a considerableimpact at local area level, and is one of the mainlimitations of the APS estimates (ONS, 2010).

Administrative data is available as Local AreaMigration Indicators on the Office for NationalStatistics website - www.statistics.gov.uk andallows comparisons to be undertaken within localauthority areas.

These statistics from the Department of Workand Pensions show the number of foreignnationals applying for National Insurance

The Annual Population Survey (APS)

National Insurance Number (NINo)registration data

Additionally, the WRS scheme will ceasecompletely from May 2011.

Administrative data

Numbers, broken down by their country of originand by local authority of UK residence. It cites thenationality of adults from abroad who have beengranted a National Insurance number to allowthem to work in Britain. Because a job offer isrequired in order to apply for a NINo, migrantswho do not choose to register for work, andchildren are not included. Also the local authoritycoding in this dataset is likely to indicate the areaof first settlement in the UK rather than the pointof entry to the country. Another majordisadvantage is that there is no availablecorresponding measure of outflow, and thus it isnot known if the registered person has moved outof the area.

The WRS was introduced to regulate access tothe labour market of the nationals of the A8accession countries that joined the EU in 2004.The data provides numbers of A8 nationals whohave applied to register to work in the UK (but notself employed). Those who leave employment arenot required to de-register from the WRS, sosome applicants since May 2004 are likely tohave already left the UK. The data is based uponfirst registration so does not account for movesand changes in occupation. Whilst the schememay be mandatory, the need to sign up within thefirst 30 days of starting work and the £90 fee doespresent a barrier to those in low skilled low paidoccupations, so some don’t register making thedata flawed.

A person registering with a GP whose previousaddress is outside the UK is flagged ('Flag 4’) andthis information can be used to identify newmigration into an area. A separate flag can be

Worker Registration Scheme (WRS)

General Practice ‘Flag 4’ registrations

“I went to the doctor to register but theywouldn't use the form I had filled inwith your support worker. They gaveme more forms, some of them lookedthe same as the ones you gave me. Ididn't understand what I needed to doso I left without registering”International Student (Stallabrass, 2005)

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used to identify migrants returning from overseasand re-registering with the NHS. Flag 4 countsare useful to identify persons who arrive to stayfor periods of 3 months to under one year,however many people do not register if here for ashort time and may delay registering with a GPuntil they have a medical need. Also the flag islost when a patient moves within the UK.Currently GPs are incentivised to collect theethnicity of patients newly registering with themunder the Quality and Outcomes Framework.

HESA maintains a register of all students in theUK, recording the total number of internationalstudents and all students’ arrival and departures.However, until recently this was based uponinstitution address and not domicile. Studentsform an important part of migration in the UK

A form is sent annually to every household,requesting information regarding householdcomposition in order to identify and register thosewho are eligible to vote. Flags can now beallocated to the names of those entitled to vote, intheory enabling data to be kept on non voters.However, this register is not specifically designed totrack migration and data is incomplete, particularlywhere temporary residents and others who do notbelieve they are able to vote do not respond.

The UK Border Agency publishes figures to alocal level regarding asylum supportaccommodation and subsistence payments, InitialAccommodation statistics and ‘Section 4’applicants (refused asylum seekers applying forsupport until removal can be arranged, or whilstfresh claims are pending).

Third sector translation and interpreting agencies(telephone and face to face) are oftenapproached for statistics regarding languagesused and number of episodes of interpreting.Whilst this is certainly useful information it doesnot help to identify languages that are notrequested and is dependent upon services beingsupportive and pro-active in their use ofinterpreting facilities. Commissioners need to look

Higher Education Statistics Agency (HESA)

Electoral Register (ER)

Asylum Statistics

Third Sector and Provider Activity Data

beyond the statistics to the rich data languagesupport agencies and other BME Voluntary andCommunity Sector agencies hold. There are awhole range of agencies working withcommunities from small community organisations,to outreach services, Race Equality Councils,Racial Harassment initiatives etc. They maychoose to collect ethnicity data and whilst codingof ethnicity may vary they are working at the frontline with communities and are a rich source ofinformation regarding service needs and gaps,barriers to positive health outcomes, experiencesof patients, and issues and concerns withincommunities.

Service providers in public sector agencies willalso have nuanced information regarding BMEcommunities. The monitoring of victims of HateCrime records ethnicity, nationality and languageas well as the sorts of issues and circumstancesfaced by BME communities. Police forces havegrowing data concerning BME community issuesand are mapping communities throughcommunity-led policing. Partnerships amongstpublic sector agencies are an important source ofinformation.

This data records births to mothers who wereborn outside the UK, and as such is retrospectivein nature, thus current migration will be reflectedin future birth statistics.

Acute hospitals are directed by DH to collect theethnicity of in-patients so every time a patient isadmitted to inpatient services, their ethnicity isrecorded. However, ethnicity coding is not alwaysconsistent, and a patient’s recorded ethnicity maychange from one admission to the next.

The Annual GP Patient Survey is commissionedby the Department of Health and run by the NHSInformation Centre. These large sample surveysare a rich source of data and include analyses byethnicity. GPs are also required to collectinformation regarding the ethnicity and languageof all their patients under the Direct EnhancedService. In this instance subset categories

Live Births by Country of Origin

Hospital Episode Statistics (HES)

General Practice Data

Other NHS Ethnicity Data


21

detailed in Department of Health ethnic datacollection guidance can be used to support localunderstanding.

The dataset contains record level data about thecare of adults and older people using secondarymental health services. The dataset records dailyclinical and legal interventions for every patientand includes ethnicity data (Care QualityCommission, 2010). The lack of national reportingand feedback to Trusts has probably had animpact on the overall quality of the data collected.There are still concerns with the coverage,completeness and quality of the data.

Data on topics such as healthcare associatedinfections, Infectious Diseases (HPA, 2009)

NHS data on drug and substance misuse

Mental Health Minimum Dataset (MHMDS)

Health Protection Agency (HPA)

National Treatment Agency (NTA)

Healthcare Commission reports

Public Health Observatories (PHOs)

University of Nottingham, School ofCommunity Health Services

These reports provide robust evidence regardinghow BME people access and experience theNHS. Each year, the Commission undertakes aseries of patient-focused surveys collecting dataon the age, gender and ethnicity of patients andlooking at different aspects of health.

PHOs operate in each Government Office regionand collect and analyse a range of health–relateddata, including ethnicity and other equality data.Each PHO specialises in particular themes, withLondon PHO leading on BME health and data.The London PHO, in partnership with the NHSInformation Centre and the Association of PHOs(APHO) has developed a national collation of awide range of measures that can be used at alocal level to track progress against local prioritiesfor action on health inequalities, some related toethnicity.

Provides a Q Research database derived fromthe anonymised health records of over ninemillion patients in the 550 or so GP practicesusing the EMIS clinical computer system; subjectto the quality of ethnicity data from GP practices.

(For a detailed review of data sources see HPA(2010)http://www.migranthealthse.co.uk/sites/default/files/report/Migrant%20Health%20Report.pdf)

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Case Study 6 – Data collection

Suffolk County Council (EELGA 2010)

Contact : Allison Coleman, Social Inclusion & Diversity Suffolk County [email protected]

NINo registrations, Worker Registration Scheme data and school census data were used to identifythe top 10 nationalities in Suffolk on which to base the sample for the survey. Public Perspectivesthen undertook 400 quantitative face-to-face interviews with migrants who had been in the county forless than 3 years, plus a further 12 in-depth qualitative interviews across the 7 districts in Suffolk.

The main report summarises the findings from all aspects of the research. Each question in thequantitative survey has been analysed against a set of key demographic and conceptual variables.Commentary is then provided where significant or meaningful findings and differences are identified.

A small majority of respondents (52%) said that it was easy to access local services. One factorwhich may affect the ease of accessing local services is the ability to speak English well, with 8%of those who say they can speak English well finding it difficult to access services compared to23% of those who say they cannot speak English well.

The main barriers to accessing services are language and not knowing what services areavailable. Where barriers to accessing local services exist, the most common is language (cited by26%).

Suffolk needs to plan and deliver services for migrants with children. 25% of migrants havechildren. Services such as children’s centres, health services and schools need to be future-proofed for their potential impact. A significant proportion of the children (66%) are currently under5.

Challenge the accessibility of services – the main factor which eases access to local services is theability to speak English well. Suffolk needs to test if it is providing information about services inappropriate languages. There is a need to encourage service providers to consult migrants whenplanning service delivery.

Suffolk needs to manage the relationship between health services and the migrant population – thereis an awareness of and understanding of the health service, but there are instances of misuse, whichplaces a burden on the health service. Need to examine what measures can be put in place to managetheir expectations about where and when to access appropriate health services.

There is scope to improve ESOL provision – only 45% accessing ESOL are satisfied. In addition,poor English language levels are one of the most significant barriers to accessing services. Suffolkis developing the programmes it offers to improve access to and the quality of its ESOL provisionas this may positively impact on access to services.

•

•

•

•

•

•


23

24


2.2 Using the data

There have been huge improvements in publichealth data collection for specific geographicalareas and there are general sources ofinformation that taken together can provide ageneral picture. Existing data can providesufficient information on which to base acommunication support strategy but effective useand interpretation of such data requires specificactions which should be incorporated into anycommunication support strategy.

Insufficient ethnicity data is taken from withinservices and this issue should be addressedwithin a comprehensive communication supportstrategy, with standards, protocols and methodsfor coding ethnicity effectively. There is clear(Department of Health (2005)

guidance to the NHS on the categories and codesto use when monitoring the ethnicity, religion, andlanguage proficiency of patients. However, thereremains some discussion of the usefulness of thisin relation to language as ethnicity/country of birthis not a proxy for language and there are manydialects within countries/ethnic groups. Also, asnoted in the DRE framework:

(3.105).

It has to be recognised that ethnicity data,including population size and the languagespoken does not give information regardinglanguage proficiency. Assessment of the fluencyof spoken and written English cannot beeffectively determined from ethnicity data in a waymeaningful to determining the needs of thepopulation. A larger established population mighthave large numbers of people with limited writtenor spoken English but might also have a numberof people who could become sufficiently trainedas interpreters, bilingual support workers or asstaff members. The smaller and less establishedthe population, the less capacity within thecommunity and the greater the dependence uponservices to provide formal interpreting.

Collecting data

Language proficiency

A practical guide toethnic monitoring in the NHS and social care)

“Even whereservices are based on high quality needsassessment, the assessment should be re-examined regularly to discover whether changesin the local population require a change in serviceprovisions. This is an issue that particularlyaffects BME communities”

“Most clients cannot read theappointment letter and are not awareof their appointments. Some clientshave consented to have their contactnumbers given to our interpreters inorder to be reminded of theirappointments. We offer this free extraservice in order to reduce the rate ofnon attendance at their appointments.Receiving a telephone call from theirinterpreters helps immensely andclients feel safe to attend theirappointment knowing someone will bethere for them”(Mason, 2010)

Data can be collected regarding not only firstlanguage but also proficiency in English. Thereare a number of ways to do this: self assessmentof language proficiency (Karliner et al., 2008);preferred language spoken (Roat, 2005); andlanguage spoken at home (Glimpse, 2009).However, it must be remembered that levels offluency also change with need: using English asyour second language may be acceptable whenyou need only to communicate about somethingsimple but with mental health issues (Farooq andFear, 2003), crisis or severe illness (Ayanian etal., 2005) and increasing age (Alexander et al.,2004) fluency can be lost.

The data collected about languages also providesimportant information about issues of arrivals inthe area, perhaps relating to specific healthneeds, and identifying specific areas of exclusion.A coherent language support strategy can makeproper and informed use of such information toguide planning.

Partnership working is essential to not onlyidentify ethnic groups but to link this with patternsof need and offset some of the various limitationsinherent in particular data sources (Department ofHealth, 2010). The Joint Strategic NeedsAssessment needs to ensure ethnicity, languageand communication issues are incorporated.Local Strategic Partnership involvement isessential in identifying new and emerging issues.

Partnership working

Local Government research and intelligenceservices are critical to the collation andinterpretation of the varieties of data available.

Partnership working with the various BME groups,voluntary and third sector services, employersand other service providers is essential. However,short-term migrants, who arrive here to seek workand are highly mobile, are unlikely to be countedas part of the resident population and appear inany formal statistics. Services on the ground,however, will have contact with this group andunderstand the needs and impacts and have linksinto communities.

It has to be remembered that the giving of ethnicdata is voluntary and ethnic monitoring stillarouses suspicion for some people who see it asa means of further discriminating against them.The reasons for ethnic monitoring should, beclear and analyses and decision making shouldbe transparent. Minority ethnic communities andstaff need to be involved in gathering andanalysing the data and developing anunderstanding of its relevance to the issues athand and in making decisions. Useful guidancemay be found in the ODPM's 2004 publication

Information regarding language support needs fordifferent services can easily be gathered fromservice users, who often have clear ideas of whatwill help and suggestions for service improvement(see ISCRE, 2007).

"Ethnicity monitoring involvement - guidance forpartnerships on monitoring involvement"

Service user comments

“There is a big Kurdish communityhere now so why can't the GPs providea Kurdish clinic with an interpreterthere for those who need help with thelanguage and a health support workerto help with the forms. Better still mydaughter could work as the receptionistas her English is very good and shecould help people make appointments”Kurdish service user (Stallabrass, 2005)


25

Surveys and audits

Community Engagement

A proper survey of the linguistic communitiesliving in the area served, and their levels offluency could be conducted to assess languagesused, levels of proficiency in English and writtenproficiency in their first language, gender and agevariations, the size of minority languagecommunities, and barriers or ease of access toservices. A concurrent audit of service providerswill also determine the capacity for languagesupport through bilingual staff, the level of accessto services by people with limited proficiency inEnglish and BME communities and experiencesof practitioners. Comparisons can then be madeto identify whether the current usage of languagesupport accurately reflects the needs of the localpopulation and whether more creativeapproaches to staffing and service provision arerequired to move away from dependence upontranslation and interpreting as the only languagesupport strategy.

Local people are often employed as contractedinterpreters or in bilingual link worker posts, thuslanguage support could advance opportunities forcommunity engagement for example to set up asteering group of interested individuals to monitorthe provision of language support, presentingfurther occasions for joint working and mutuallybeneficial communication. Important informationmay be held by interpreters, bilingualprofessionals and third sector partner agencies,who are rarely asked to inform colleagues aboutcultural world views, ideas on health and illness,etc. Whilst recognising that it is always a dangerto treat one individual as somehow being a“cultural expert”; given the homogeneity ofcultures within any given national or societalgroup, this would appear to be a rather wastedpotential resource that might be better used tohelp to shape services.

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Case Study 7 – Community Engagement

NHS Peterborough ran a ‘TB or not TB’ awareness project targeting the Pakistani community. Wetapped into existing groups and contacts such as children’s’ centres within the community, women’sgroups, Imams via Mosques, English Classes and Senior Citizen groups. We consulted thecommunity to find out their knowledge base about TB and what they would like to know andunderstand.

We used local demographic data, knowledge and experience of our staff having worked in thetargeted geographic area and existing networks to enable easy engagement of the communities.

The data supplied from the Health Protection Agency showed high prevalence of TB in the Pakistanicommunity but also some cases in East European communities. Therefore we decided fromknowledge we had to target the Pakistani community using bilingual staff from our team to deliverlevel 1 training in Punjabi to women and senior citizens in particular which was well received. Weused pictorial and easy translated information for the TB Alert which worked well. Initialquestionnaires were also short and easy as were evaluation forms. Initial master copies of thesewere translated into Urdu. In addition a couple of sessions were run in Punjabi using the languageskills of our staff.

Engagement and true consultation with the communities is an essential first stepCommunities often give us the solutions to problems if we only care to talk and listen to them

••

Contact: Geeta Pankhania, NHS Peterborough [email protected]


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SECTION 3:

Identifying SuitableService Solutions

3.

3.1 Models of language support

The overall aim of any strategyshould be to create a more joined upapproach which seeks to coordinatethe support provided by a wide range ofpartner providers and communitynetworks and enable the identificationof gaps in and solutions for languagesupport provision.

Being able to speak to patients in their ownlanguage is a fundamental pre-requisite toprofessional, clinical practice. The preference forpatient and practitioner would be to alwaysprovide a patient with limited English proficiencywith a practitioner who speaks that patient’s ownlanguage (McPake and Johnstone, 2002). Thereis now a growing wealth of research to evidencethe benefits of language concordance betweenpatients and providers (i.e. both speak thepatient's primary language well) (Ulmer et al.,2009).

Research finds that where providers and patientsare language discordant, some of thedisadvantages can be mitigated by having trainedinterpreters. However not all the disadvantagescan be ameliorated in this way and the presenceof an interpreter may actually interfere with theconsultation and communication (Ngo-Metzger etal., 2007). Whilst it cannot be possible orpracticable to always provide a practitioner whospeaks the patient’s preferred language, this is thegoal to which we should aspire.

A coherent strategy with regard to languagesupport should therefore address the provision oflanguage support in many ways, including:bilingual staff in a wide range of roles includingclinicians where possible; cultural diversitytraining; bilingual advocacy, link and supportworkers; community volunteers; support for ESOL

and interpreter training, and face-to-face, signlanguage and telephone interpreting; andtranslated information (inc. Braille). The overallaim of any strategy should be to create a morejoined up approach which seeks to coordinate thesupport provided by a wide range of partnerproviders and community networks and enablethe identification of gaps in and solutions forlanguage support provision.

In the last decade guidance and policy hasmoved away from a foraddressing language support issues to a morecomprehensive . However,this shift in approach is still not reflected in theway communication needs are met in practice (formore detailed discussion see McPake andJohnstone, 2002; Perez and Wilson, 2006).McPake and Johnstone (2002 p56) propose acontextual framework to assist in the importantprocess of decision making around languagesupport options. At one end of their continuum are

contexts where the consequences ofpoor communication could be serious or lifethreatening. In the middle of the continuum arecontexts where people are seeking advice andinformation to enable them to make decisions. Atthe other end of the continuum are routinesituations. They propose that the provision oflanguage support needs to take into account thecontext and the implications of failing to provideadequate support.

‘service provision model’

‘social inclusion model’

‘high stake’

Fig. 2

'High stakes' - complex care, medicalemergencies, child protection issues, treatment

Decision making' - health needs, lifestyle issues

‘'Routine contexts' – making appointments, fillingin forms, information about services

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3.2 A service provision model oflanguage support

The focuses onaddressing language barriers experienced bythose with limited English proficiency in publicsector services by supplementing existing servicestructures with additional provision of interpretingand translation. Thus a service user requiringlanguage support is viewed as having additionalneeds and often seen as a problem, or at leasttheir lack of English as their problem. Responseshave traditionally been reactive: illustrated bydemands that the patient ‘bring their own’ atworst; limited access to ad hoc telephone or faceto face interpreting as a norm, and at best, co-ordinated efforts to improve access and qualityand reduce costs in interpreting provision withinter-agency partnership. Whilst provision ofinterpreting certainly ameliorates some of thedisadvantages of limited communication betweenservice and service user it can also create furtherproblems, particularly in relation to quality,consistency and cost. Failure to address theseproblems has often hindered the development oflanguage support services.

However, sessional interpreters employedthrough outside agencies will always be neededas an option for smaller or more newly arrivedgroups, and in cases where the practitioners andbicultural workers employed are insufficient tomeet the needs of users. Understanding the roleof the interpreter is fundamental in making

service provision model

decisions regarding models of language supportto be commissioned and in ensuring staff workeffectively within the different options provided toensure quality and cost effectiveness. There are anumber of types of service provision identified inthis approach and the key to their utility is tocombine the available options, as providingonly one option [e.g. telephone interpreting]cannot meet all needs, be useful in all situationsand be cost effective.

Professionally trained interpreters:have a fluent command of English and theirinterpreting language(s),are competent in the specialist techniques ofinterpreting and translation,are neutral and independent,will only interpret what is said, and everythingthat is said, and will only interrupt forclarification or repetition,maintain confidentiality and are professionallyaccountable (National Register of PublicService Interpreters),have a specialist knowledge of the structure,procedures and terminology of the professionalareas in which they work (e.g. health, law),have had professional training (Diploma inPublic Service Interpreting),have an objective understanding of theculture(s) with which they work,are equal participants in the exchange,are paid for their professional role.

all

The role of the professional interpreter

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•

•

•

•

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Case Study 8 - Role of the interpreter

RR (over 55), a Polish patient suffering from musculo-skeletal problems, work-related attendedHealthcare-Nottingham for the purpose of medical evaluation. The patient was feeling poorly andexperienced acute pain in shoulder girdle. The pain radiated toward his chest, hips, arms and bothlegs. He used a walking stick to support his limbs. The patient was assisted by his teenage daughter,who was there to act as an interpreter, though not in a professional capacity as her language skillswere limited. It is important to underline that the assistance of a professional interpreter is crucial inorder to avoid miscommunication in a specialised environment (here: medical). The only problemencountered by an interpreter was the manner in which the patient spoke, snippets of information,factual and time-line confusion, disruptions, frequent digressions and sentence overlapping. Theinterpreter’s role was to pick up the relevant information and translate it so that it made sense to theEnglish interlocutor, ask for clarification and then translate the whole content to avoid chopping thesentences and their overlapping. If the interpreter was absent, the communication would be majorlyrestricted or even non-existent.

Contact: Kasia Urbaniak, Health and Safety Executive Norwich [email protected]


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Some interpreters employed by communityinterpreting services may have a lesserqualification than the DPSI. When engagingan interpreter it is important to understand thelevel of qualification: simple assignments areappropriate for bilingual interpreters with basictraining, whilst longer, more complex andspecialised assignments will require a higherlevel of training.

Service providers sometimes require aninterpreter to provide cultural information,explanations of systems and procedures, andadvice; whilst service users might expect theinterpreter to be acting as advocate on behalf ofan ethnic minority individual or community.However, codes of practice and ethics view thisas inappropriate for an interpreter, and this ismore the role of an advocate or befriender (seeCreation of Link Worker, Advocacy and SupportRoles).

This is when the interpreter is physically presentin the room (also known asliaison/dialogue/community or public serviceinterpreting). This usually requires “bilateral”interpreting, where the interpreter is working “inboth directions” between two languages. Thistype of interpreting may be either consecutive orsimultaneous, or involve a mixture of the two.

The advantages of this model of interpreting isthat it tends to be preferred by both service usersand health professionals, it allows other aspectsof communication to be identified and respondedto, it is easier to manage longer consultations orsensitive or distressing information, and it ispossible to maintain continuity by booking thesame interpreter for all consultations.Disadvantages include distance travelled andtravelling expenses raising the costs, interpretersfor some languages may not be locally available,it might not be possible to access an appropriateinterpreter in an emergency situation or at night,and community interpreters might be known bythe patient who may then fear breach ofconfidentiality.

Face-to-face interpreting includes British SignLanguage (BSL) and also Lip-speaking, which isused by hard of hearing or deaf people who lip-read and use spoken English as their

Face-to-face interpreting

communication choice. A professional lip-speakerrepeats silently what a speaker says, but withclear speech movements, appropriate gesturesand facial expressions and finger-spelling (Perezand Wilson, 2006).

This describes a style of interpreting workingthrough two interpreters, where it is not possibleto locate a single interpreter with competence inboth languages required. This could help facilitatea service for people with special language needs(Perez and Wilson, 2006) for example:

English < > Farsi (speaking interpreter) /Farsi(hearing and signing)< > Iranian SignLanguageEnglish < > Turkish/Turkish < > Kurmanji (alocal Kurdish language in Turkey).

Telephone interpreting is a system where a healthprofessional can access an interpreter at any timeof day or night through locally agreed processesand often a national or international provider. Theadvantages are the ease of access to aninterpreter, the availability of unusual languages,the reduction in costs by not having to pay travelcosts, and the ability to use the interpreter forshort assignments. The disadvantages are oftencited as being the cumbersome nature of thecommunication, concerns regarding inability tovet the competence and level of training of theinterpreter, and the fact that interpreters can besourced from other countries and may nottherefore be aware of UK processes andsystems.

Video-interpreting is used more widely in the USand other countries, and has the potential tosupersede telephone interpreting, particularly forBSL and other sign languages. Video interpretingwould also improve interpreting provision forspoken languages in situations whereunderstanding non verbal cues in communicationwould be beneficial. A video-conferencing systemcan be used to provide both audio and videoaccess to an interpreter; and improving videotechnology available on mobile phones might bea useful means to provide greater flexibility(Perez and Wilson 2006).

Relay interpreting

Telephone interpreting

IT based systems

•

•

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“Electronic Note-taking” or Speech-to-Text (STT)(e.g. live television subtitling) allows a verbatimwritten version of an oral conversation to beproduced on a computer screen and is useful toenable people who are hard of hearing or deafpeople who use English, to follow what is beingsaid. Machine shorthand systems (Palantype orStenograph) such as those used in a court of law,can be used by a trained person. Speech-to-Braille is a similar system to “speech to text” foruse by Deafblind people.

Other IT based systems to consider include webresources such as the MyUKinfo website(http://www.myukinfo.com/en/home), touchscreens in GP practices and in other serviceswhich can provide translated information and beupdated and developed centrally. On line BritishSign Language (BSL) interpreting via a webcamlink is available to GP practices and hospitalsthrough(http://www.signtranslate.com/interpreting.php).The website also offers a library of 500 commonmedical questions with yes/no answers in 12different languages.

Videoconferencing technology is well establishedin the legal sector and offers a potential solutionfor provision of qualified interpreting, especiallyfor minority languages ‘Remote interpreting (RI)would enable access to an interpreter at a distantlocation, even overseas, over a video link. Thiswould extend access to languages not availablelocally beyond that of telephone interpreting byproviding for the non-verbal aspects ofcommunication in a consultation. However,evidence regarding the viability of this form ofinterpreting provision, the training needs andtechnical requirements and supporting policies isawaited (AVIDICUS, 2009).

Translation refers to the written word.Consideration of translation tends to be neglectedas it is more hidden: the presence of a patientrequiring immediate care is more palpable (Perezand Wilson, 2006). The Department of Health(2004) document

raises this need directlywith some guidance around such issues asliteracy in own language, community basednavigators, access to health records, informationaccreditation, letters to patients etc. However,

‘Signtranslate’

‘Better information, betterchoices, better health’

Translation

further work is required in looking at theinformation provided and how it can be mademore accessible to people with limited proficiencyin English.

In general the best way of commissioningtranslation work is to find a qualified professional(for example from the Institute of translation andinterpreting www.iti.org.uk, or the "Find-a Linguist"pages of the Chartered Institute of Linguistswww.iol.org.uk where many "unusual" languagesare represented).

This is where untrained family, friends andcommunity members with a wide range ofbilingual skills provide language support in ad hoccircumstances. Whilst the disadvantages aremany and best practice statements hold the viewthat this should never be relied upon, this strategywas found to be used by 70% of service providersin one survey (Turton et al., 2003) and 92% ofScottish Health Authorities (SALSI, 2000) in asurvey of services to the deaf.

The disadvantages include: insufficient languageskills such that errors are common; lack ofconfidentiality; lack of openness in revealingimportant information or censoring of theinformation provided, damage to the balance ofrelationships within the family, particularly withchildren (Downing and Roat, 2002); impact ofschool absences for children (McPake andJohnstone, 2002: 35); the risk of non identificationof issues such as child abuse (McPake andJohnstone, 2002), domestic violence andtrafficking, stress on the informal interpreter(CRE, 1992); and devaluation of formalinterpreting services (McPake and Johnstone,2002).

Providers often see this as the easiest and mostcost effective means of ensuring languagesupport (Turton et al., 2003). Service users

Informal interpreting

“They said come back with someonewho can translate. The only person inmy family who can speak English is myson. How can I talk about thesewomen's things in front of him?”Female Kurdish service user (Stallabrass, 2005)


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themselves, whilst recognising that there areproblems and limitations often express apreference for using friends and family becausethey trust them and feel more understood, both incultural and personal terms; moreover they maytrust them more than a formal interpreter whothey see as not on their side (Alexander et al.,2004).

In providing this option as a means for languagesupport for service users, the provider mustensure that staff are fully trained and policiesclear in discerning when this is appropriate (e.g.making appointments, routine situations, socialsettings, immediate urgency) and when not (whena woman is always spoken for by anaccompanying male, clinical/psychiatric/socialcare issues, etc.). A range of other options haveto be accessible, advertised and explained, andunderstood by service users and also byproviders. The Joseph Rowntree Foundation(Alexander et al., 2004) advocates that basicinterpreting training be provided to family andcommunity members who often find themselvesin this role; to improve quality, reduce errors andmitigate stress.

Staff with language skills and cultural knowledgemay already be employed in various roles withinan organisation. Some NHS organisations,particularly hospitals have already identified staffwithin their organisation that can be called uponto interpret. This has advantages in that the staffmember is already employed, is more easilyavailable and this strategy would appear efficientand cost effective (Downing and Roat, 2002).

However, there are many drawbacks to thisarrangement. Bilingual staff might haveinsufficient language skills in both languages toprovide interpreting for clinical situations, andinsufficient interpreting skills or ability to cope withthe situations presented (Downing and Roat,2002). This form of interpreting provisionundermines professional interpreting and maycause confusion in terms of roles of the bilingualstaff. Additionally there is no continuity with thepatient, confidentiality is not necessarilyunderstood, the work of the staff member and theservice they provide is disrupted and the personinvolved in the interpreting can become quitestressed. High turnover rates have been noted

Registers of Bilingual Staff

where staff are used in this way (Downey andRoat, 2002), which incurs hidden costs to theorganisation.

This strategy does have a potential fordevelopment. Screening of staff to identify levelsof language proficiency, training in interpretingand allied issues such as confidentiality and childprotection, support for debriefing and making upthe time lost in the principle role and thecommitment of line managers is essential to thequality of the service. Pay differentials for staffrequired to interpret, having days where theywork solely as an interpreter and accreditedtraining make this role worthwhile in terms ofprofessional development and recognition.

Services are often not provided in a way that easilyfacilitates working effectively with interpreters.Appointment timings need to allow greater time forcommunication through an interpreter. Singlelanguage surgeries have been used effectively inareas where there are higher numbers of speakersof one particular language. Multi-agency surgeriescan provide a solution for reducing interpretingcosts for those patients who have a number ofstatutory and voluntary sector agencies workingwith them. A caseload of patients can be allocatedto one interpreter across agencies or repeatappointments made with the same interpreter inorder to develop trust between service providers,patients and the interpreter. All these opportunitiesrequire a co-ordinated interagency approach tointerpreting provision.

When providing a service consideration needs tobe made about the practical aspects of workingwith interpreters: consulting and treatment roomswith sufficient space to work effectively with aninterpreter; dual handset telephones; access toSkype and videoconferencing; telephones indental treatment rooms; reception areas thatallow access to the phone or computer screen forpatients at the reception desk, etc.

Patients also need to be made aware that theyhave a right to language support and the range ofoptions available needs to be clear. Issues of trustare important, particularly with local communityinterpreters and thus a patient must also be clearthat they can refuse a particular interpreter if theyhave any concerns.

Redesign of services to facilitate interpreting

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Training of staffAdequate training of staff is absolutelyfundamental to the success of any languagesupport strategy: especially in terms of quality,efficiency and cost effectiveness. Attitudes tointerpreting may also need to be addressed withthe belief that language support is the problem ofthe patient being revised to an understanding thatlanguage support is the need of the healthprofessional and a role for the service. A range ofoptions for language support is required and thusthe ability to discern which option is mostappropriate, with clear guidelines, procedures andmonitoring to ensure appropriate decisions.Working with the interpreter (face-to-face or

telephone) requires skills in managing theconsultation, briefing and debriefing theinterpreter, developing a three way relationship ina consultation and being sensitive to the issuesand nuances of this skilled interaction.

A comprehensive language support service willaddress issues of vetting of interpreters, levels ofqualification, how costs are to be managed,confidentiality and managing complaints, so thatfrontline staff can have trust in the quality andreliability of the provision. Services need to alsoconsider their use of language and jargon andhow they can more effectively communicate inplain English.

Case Study 9 - Training staff to work with interpreters

Ipswich & Suffolk Council for Racial Equality (ISCRE)

Contact: Annie Chow Translation and Interpreting Project (ISCRE) [email protected]

Based on feedback from interpreters and members of the community Translation and InterpretingProject (TIP is a project of the Ipswich and Suffolk Council for Racial Equality) decided to run aWorking with Interpreters course. We identified that in some cases individual staff members werefearful of working through an interpreter and this was a barrier. We also know that there is a lack ofunderstanding of just how much the barrier of language impacts on people accessing services. Weknow too that often, despite policy and need, interpreters are not always provided.

We advertised the course free for local regular customers via our e mail and web site. The responsewas overwhelming with more than 40 people expressing an interest.

We have developed our course based on local examples in order that delegates could get a realexperience. We invited trainee interpreters about to be assessed to support the course in order thatthey could practice in a local context. It was decided that no more than 15 could be on the course inorder that each delegate could get the opportunity to practice. We had a range of service providersincluding Housing, Health, Education and Hate Crime. 4 languages from 4 different nationalities wererepresented, which allowed the agencies not only to engage in respect of language but also buildlinks and relationships with local community members. One of the members of the communitycooked food from their country for lunch. The session was fully interactive and students were putfirmly into the shoes of someone who does not speak or read English.

The local media expressed an interest, and the Community reporter sat in on the session. This led toa piece in the local press, which told a positive, and therefore different, media story about the barrierof language and accessing services.

Feedback is extremely positive from the course and we have since delivered a bespoke one for theProbation service. All agencies who came said it reinforced their understanding of the importance oftrained professionals. All enjoyed the direct engagement with local people and learnt more aboutcultural backgrounds. They also learnt a bit more about ISCRE and feel more confident to ask foradvice as the session took place at ISCRE offices. The interpreters who came learnt more about thedifferent types of agencies who attended, and the services they provide, thus building their capacityfor living and working in the UK. Well trained staff, providing interpreters at the point of need is aboutproviding efficient services. Getting services right first time is the most efficient way of delivery.


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Training for interpretersInterpreters and translators should be required tohave a minimum level of professionalcompetence to ensure quality of serviceprovision. So that the linguist with no prior trainingcan be supported to provide basic bilinguallanguage support which will eventually lead ontoto a DPSI qualification. Professional interpreterscan demonstrate core interpreting skills, anunderstanding of the role of an interpreter, anability to work within standard procedures for aservice and can effectively manage commondilemmas within a code of ethics. In addition, theyneed specific training before being able to work incertain settings such as in mental health,palliative care etc. A comprehensive languagesupport strategy needs to ensure that those withspecialist training are used consistently in thoseareas.

Interpreters require support from services, healthprofessionals and staff to enable them to developtheir expertise and competency in working in ahealth and social care context. On registrationwith an agency a new interpreter might shadowother interpreters in certain areas of serviceprovision, or work as part of a team with a mentoror be supervised for a period. Interpreters alsorequire supervision and support to enable them tocope with some of the issues they face andprevent burnout: especially in mental healthwhere some areas have introduced copingtechniques and anxiety management to preventsecondary trauma (British Psychological Society,2007). Interpreters are often required to work indomestic settings when accompanying a healthvisitor or community nurse for example. Servicesneed to provide support and training for serviceproviders and interpreters in order to maintainsafety and apply lone working policies; butconsideration is also required regarding theinterpreter’s role and position in the communityand confidentiality issues.

Across all languages, including Deafblind support,there are difficulties in providing training,mentoring and supervision for new interpreters(Perez and Wilson, 2006). A lack of interpretersgenerally and a lack of skilled staff preventsadequate training and assessment. Often thosewith the required skills to provide such supportwould be needed instead to interpret rather thanspend time with a trainee. BSL interpreting was

underpinned by a more rigorous framework,incorporating an assessment system, continuousprofessional development and monitoring. Thiswas largely supported by the professional body(Association of Sign Language Interpreters).

Interpreters cannot necessarily work astranslators as this requires an entirely different setof skills. Translators also need to have access tothe Internet, both to help with research and tocommunicate with an agency and need to be ableto use word-processing equipment to produce afinal professionally-formatted document. Closecollaboration with the communications and ITdepartment of the agency commissioning thetranslation are essential for quality control,coherence and testing. All translated informationneeds to be checked by a reader group to ensurethere are no errors.

Case Study 10 – Interpreter Training

Herts Interpreting and Translation Service (HITS)

Contact: Mark Mitchell, Community Action Dacorum, [email protected]

is based within Community Action Dacorum andbenefits from being within an organisation which delivers a wide range of activities to supportidentified needs within the community. This includes having synergy with other initiatives within thecharity, such as the Strategic engagement agenda, training of ESOL and work with the MigrationImpact Fund.

HITS was founded in 2001 as a Dacorum Interpreting and Translation Project. Its initial purpose wasto recruit and train suitably skilled individuals solely within the Borough of Dacorum. Through fundingfrom Hertfordshire Community Foundation and the Lloyds TSB Charitable Foundation we were ableto support our initial training course starting in December 2001 for the Diploma in Public Service inInterpreting (DPSI) qualification.

This initial course included 16 local residents. Since 2001 we have now been responsible for trainingmore than 1,000 individuals from more than a dozen counties. We have also provided trainingcourses for local authorities in Swansea and Cumbria. Our intention is always to recruit people fromthe local area if possible but as a registered national training centre we are happy to acceptapplications from anywhere in the United Kingdom.Since the very outset of our service, our absolute commitment has been to the DPSI qualification.During the past nine years we have entered approximately 300 candidates into the nationalexaminations in the local government, health and law options. During this period we haveestablished ourselves as arguably one of the leading academic services for professional interpretertraining in the UK. In both 2007 and 2010 HITS has been awarded the Nuffield Trophy by theChartered Institute of Linguists as the best DPSI centre of the year. In addition 4 of our candidateswere awarded national cups as the leading candidate of the year in their respective options (includingboth the health and local government options in 2010).Our future plans include:

To maintain excellence as a registered exam centre for the DPSI, including expanding the optionswe offer to include LawTo ensure a high quality of service which meets the needs of the public sector, in terms of duty andquality of access for residentsto develop the local communities in which we operateto provide students with meaningful preferred qualifications, increased levels of confidence andemployment opportunitiesTo maintain our strong presence in the geographic areas in which we operate and to expandfurther afield

•

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Support for interpreting and translationagenciesTraining for interpreters is thus an important issueand commissioners have an opportunity tosupport local interpreting agencies withdeveloping the capacity to meet the interpretingneeds for local statutory and voluntary sectorservices. Research conducted by Perez andWilson (2006) in Scotland found that whilst theDPSI or a university postgraduate qualificationmay be available in certain core languages therewere very few training opportunities forinterpreters in more unusual languages. Moregenerally, there was a lack of training materialsand reference resources for interpreters workingin any language in the public sector.Commissioners might wish to assist languagesupport service providers with training for someminority languages in their area. However, thelack of trainers with the required language skills,the lack of advanced ESOL courses and thedifficulty in providing assessment in theinterpreter’s chosen interpreting language makesuch assistance complex.


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General principles of commissioning outlined byIDeA National Programme for Third SectorCommissioning apply to working with interpretingand translation agencies, who experience manyof the same difficulties regarding funding,capacity building and long term planning even ifthey are paid for the service they provide. Onlytelephone interpreting agencies seem to havesufficient volume of work to provide training,monitoring and supervision for their staff (Perezand Wilson, 2006). Responsible commissioningneeds to take account of the viability of suppliersas part of a long-term relationship. The moremutually beneficial approach to Third SectorCommissioning is described as ‘engaged funding’which involves a close collaboration andpartnership between commissioners andagencies with a long term strategic view (Unwin,2004 & 2006).

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Case Study 11– Regional Service Provision Model

NHS Norfolk and INTRAN Partnership (the Partnership)

Background/Development of INTRAN for NHS Norfolk

Development of interpreter sessions in two GP practices in Norfolk through INTRAN

Contact: Jennifer Downie, NHS Norfolk

Good Practice example, taken from Equality and Human Rights CommissionNHS Norfolk takes a partnership approach to the provision of interpretation and translation servicesfor the County and has been a key player in developing the Interpretation and Translation service inNorfolk with a partnership between the Trust, the County Council and 30 other agencies across theregion. This approach provides economies of scale, an ability to respond quickly to specific needs aswell as a speedy barometer of key emerging community issues. The Partnership trains community-based interpreters which provides local employment. This includes regular interpreting sessions attwo GP surgeries. The Partnership has been recognised as an example of social cohesion goodpractice by the Department for Communities and Local Government and it has received two nationalawards for procurement.

Since 2000 NHS Norfolk (initially the Health Authority) has been a major stakeholder in thePartnership and as such has been able to commission interpretation and translation services forpeople with limited proficiency in English or who are Deaf or hard of hearing. Being an INTRANpartner enables us to commission interpretation and translation providers who meet our requirementsfor professional, impartial, confidential and quality standards. The Partnership provides a seamless,high quality service for our patients. It has developed clear standards regarding quality and bypooling resources we are able to drive down costs and commission services that are appropriate toour local population. NHS Norfolk has embedded the Partnership within its equality strands and it isused as evidence that we are meeting our Public Duties regarding accessibility of services andinformation for our patients. In the year 2009/10 NHS Norfolk recorded 7,300 Partnership bookings,which is the highest number since its inception.

The Partnership interpreter sessions have been held at two GP surgeries in Thetford (School Laneand Grove Surgery) since 2004. These started as a three-month project to address the health needsof the Portuguese speaking population. At the time there had been a huge influx of migrant workersinto the area and there were problems around patients accessing and understanding the local healthservices and also a lack of understanding from health professionals as to how to make adjustmentsfor people who could not speak or understand English.

Through the Partnership we were able to book an interpreter for 2 days a week in one surgery andone in the other. The interpreter covers new registrations, immunisations, midwifery, etc. Thesesessions were advertised widely in Portuguese, and five years on the needs are still there andinterpreting services are as important to both the practices and the patients. Whilst initially this hasled to an increase in cost to NHS Norfolk, in terms of meeting our duties around access to ourservices and providing a cost effective service to a very high standard, it has been invaluable.

[email protected]


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3.3 A social inclusion model oflanguage support

A focuses upon the rightfor all to participate fully in social and cultural lifewhatever their linguistic and communicationability, and adopts alternative approaches thatinvolve changes in the ways services arestructured and provided and impacts every areaof public life. This requires a shift in thinking froma narrow language perspective to a broaderapproach to facilitate communication; and a shiftin emphasis from the problems to the aspirationsof those who do not use conventional English tocommunicate (McPake and Johnstone, 2002). Italso requires a shift in the power relationshipsbetween provider and service user: it is no longerthe prerogative of the provider to permit (or not)access to interpreting but the choice of theservice user to utilise a range of communicationsupport opportunities on offer as preferred.

There are a number of models of languagesupport that can be employed (see figure 3), eachwith its strengths and issues (see table 3). Thequestion is not whether to choose any one modelover and above another, but what needs to be putin place to ensure delivery of service outcomesfor each and every service and ensure positivehealth outcomes to meet the needs of BMEpatients using those services. The commissioning

social inclusion model

process needs to work in partnership withcommunity participation processes. Policy andstrategy development should be responsive tocommunity needs as described in the JointStrategic Needs Assessment.

There are elements that require considerationbeyond the commissioning of individual servicesin order to have a comprehensive languagesupport strategy (see figure 3) for example:

Outreach to communities to identify needs, tofacilitate community participation in servicedesign and care pathway development, toidentify the most appropriate language supportsolution and to monitor services;Pathways to employment for BME communitiesthat will include training in local communities forhigher level English skills, and to providepathways to volunteering and employment in awide range of roles (including reception/adminstaff, health trainers and clinical staff) and thetraining of interpreters to the level of Diploma inPublic Service Interpreting (DPSI) and inspecialist clinical areas such as mental healthand palliative care;Workforce development could include e.g. stafftraining in working with interpreters, culturalcompetency and basic competency in speakinglocal languages;Standards and codes of practice for services,staff, interpreters and agencies providinglanguage support.

•

•

•

•

Bilin

gu

al

sta

ffL

ink

an

ds

up

po

rtw

ork

ers

Ad

vo

ca

cy

wo

rke

rs/a

ge

nc

ies

Re

as

on

ab

lea

dju

stm

en

ts

Pu

blic

Se

rvic

eIn

terp

retin

g&

Tra

ns

latio

n

Co

mm

un

ityv

olu

nte

ers

Ele

me

nts

/ Selectio

n/ Train

ing

/ Assessm

ent

/ Pro

fession

al develo

pm

ent

/ Co

des

of

practice

/ Co

ntracts

/ Mo

nito

ring

Em

plo

ymen

tp

athw

ays/L

ang

uag

eco

urses

/Service

evaluatio

n/C

arep

athw

ays/S

erviced

esign

/Ou

treach

Sk

illsd

ev

elo

pm

en

tS

up

po

rtIn

form

atio

nIn

terp

retin

g

JOIN

TS

TR

AT

EG

ICN

EE

DS

AS

SE

SS

ME

NT

CO

MM

UN

ITY

NE

ED

SC

OM

MU

NIT

YP

AR

TIC

IPA

TO

RY

PR

OC

ES

S

PARTNERSHIP

RESPONSENEEDS

PO

LIC

YP

RO

CE

SS

MO

DE

LS

OF

LA

NG

UA

GE

SU

PP

OR

TC

OM

MIS

SIO

NIN

GP

RO

CE

SS

Fig

.3

38



39

Recruitment of Bilingual Practitioners andStaffIf patients prefer to communicate with apractitioner directly in their own language and ifthis makes for a better quality of interaction,then the provision of bilingual staff shouldprovide the most appropriate response (30% ofNurses in the NHS are recent migrantsPersonnel Today, 2006). Yet this can appear alogistically unsustainable task to implement; inareas where there are few bilingual health carepractitioners, even for long term communities;where there is a lack of (recognisable)professional qualification and bilingualproficiency in new and emerging communities,and in areas/services where a number ofdiffering languages and dialects are required.

Prioritising of certain areas of work may behelpful in focusing limited resources. In somecircumstances it is of particular value to recruitbilingual staff rather than work throughinterpreters; particularly in mental health,counselling and in sensitive work (e.g. withchildren, family mediators and with domesticabuse), as familiarity with the work situation andan understanding of the complexity of particularissues goes beyond a simple transfer ofinformation from one language into another(McPake and Johnstone, 2002). In cases wherethere are many users of a service in a localitywith higher numbers of a particular linguistic andcultural group, and few practitioners withappropriate language skills, it would bepragmatic to recruit practitioners specifically toaddress this need.

The Race Relations Act (1976) does permit therecruitment of staff on the basis of racial or

language skills if the case for doing so is clear.Whilst it might not be easy to recruit someonewith specialist or clinical qualifications (e.g. apsychotherapist) particularly from newcommunities, it is certainly possible to recruit non-clinical staff such as administration and receptionstaff, who can use their bilingual skills in thecourse of their job. This might be through directemployment or in partnership with a voluntarysector organisation working with a specificlanguage group or cultural community, wherecertain service functions (e.g. bookingappointments) can be undertaken by the partneragency.

In some geographical areas it is possible forpatients to select a General Practice based uponthe languages spoken by GPs in that practice.This has been noted traditionally with Asianpatients in places such as Bradford orBirmingham (University of Warwick, 2006).Service information provided by the practice oftengives the languages spoken by staff, and patientsfrequently get to hear about the presence ofbilingual GPs through community networks. TheNHS choices website specifies in some caseswhat additional languages are spoken in aparticular practice.

Access to a GP service by a higher proportion ofone language group can have negative impactsupon a practice where only one particular staffmember speaks that language; and whilst it is notpossible to provide GPs for all languages it ispossible to facilitate the development and use ofthis as a language support strategy. Removingthe geographical criteria for registration with GPsand/or provision of GP clinics by practicesworking in partnership to provide routine serviceswill allow for improved access across a largergeographical locality. Support would be requiredfor practices with Quality and OutcomesFramework exemptions and payment onachievement of additional targets aroundlanguage; and bilingual staff could be recruited forreception duties. Improved access to support andtraining for BME doctors could be provided atDeanery level, an action required to addresssafety issues.

40


Creation of Link Worker and Support RolesIssues of consistency and trust are found to be ofthe utmost importance when patients are asked toevaluate their experience of language support(Alexander et al., 2004). Service providers andpractitioners often find that repeatedappointments for additional follow up or supportare required to explain or reinforce certaininformation or in supporting therapeuticinterventions, complicated with the additionalexpense of an interpreter. Bilingual link/supportworkers can be employed to provide thisadditional contact thus supporting practitionersand services whilst enabling patients to expresstheir needs to service providers. They can act asmediators between professionals and patients,negotiate understandings of cultural issues andprovide language support. The development ofthe link/support worker role is particularly relevantin geographical areas where there are a largenumber of users requiring language support froma particular community.

Link/support workers will need to be recruitedfrom the local community and may not, especiallyin the case of newly emerging communities, havehad prior work experience in the UK. TheirEnglish skills may be limited and difficultiesencountered in recording patient notes orcommunicating medical terminology or healthconcepts (e.g. management of anxiety) (Downingand Roat, 2002). They may have experiencesclose to those whom they are supporting whichmight result in additional stress if they overidentify with the patients (e.g. refugees), or theymay hold prejudices or ideas which might conflictwith other members of their own community:communities are not homogenous or might evennot constitute what we might understand to be a‘community’. These issues will require additionalclose supervision and support, training andprofessional development opportunities (linkedwith further education establishments) andformalised accreditation and pathways intoemployment.

It is important to consider how their work linkswith the services provided by other organisationsand there may be opportunities to work inpartnership with a variety of voluntary or statutorysector agencies such that a worker could bejointly employed and carry a caseload of patientsaccessing multiple services.

Community Volunteers

Development of career pathways and routesinto employment

Recruiting bilingual volunteers from thecommunity, with adequate and appropriatesupport and role clarity can facilitate serviceprovision. Bilingual volunteers can help makereception and waiting areas more welcoming,they can provide basic immediate interpreting atreception, support patients with directions toservices they have been referred to, enhanceactivities such as providing health promotiondisplays and assist the service with a variety ofadministrative and support tasks. Many havespecialist areas of expertise or experience thatthey can offer and in turn hone and develop theirskills. Providing volunteer roles enables thedevelopment of pathways into employment andenhances links with communities. Bilingualvolunteers can have a particular role in workingwith communities: for example as health trainers,peer educators, health ambassadors and toidentify service improvements, support newdevelopments and evaluate provision.

As the largest employer in Europe, the NHS has aresponsibility to take a lead on equality anddiversity, not only meeting the legal requirementsto build a diverse workforce, but where possibleexceeding them. Linking into national initiatives tocreate routes into employment for BMEcommunity health care professionals is anessential aspect of local workforce planning.Strategies to develop career pathways forbilingual staff into a wide range of areas in theNHS need to be considered at local level andshould include support for English languageacquisition for newly engaged staff to enhancerecord keeping and other communication skills.

Much could be achieved by providing routes intowork for the 1,199 refugee doctors already in thecountry (BMA, 2008), through clinical placementsin practice, tutorials for IAPTS language andGMC PLAB examinations, and developing thePhysician’s Assistant role. It costs £25,000 tosupport a refugee doctor into work in comparisonwith £200,000 to train a new doctor (NHSEmployers, 2009).There are numbers of refugeedentists, psychiatrists, nurses, midwives andallied health professionals, many of whom end upin menial employment instead of using their skills.The Refugee Healthcare Professional


41

Programme (ROSE, 2010) has experience,information, advice and support for refugees andfor employers.

Communication is more than just a simpletransfer of words from one language into another.Staff will require skills in working in a culturallycompetent manner in order to be able to respondto the diversity of languages, beliefs, behavioursand situations for all BME groups. Improving thecommunication skills of service providers to helpthem adapt their style of language use to differentcontexts will be an important aspect of culturalcompetency training for staff. Particular attentionis required to the development of skills in workingwith interpreters: not only how to work with aninterpreter but also what sort of differentinterpreting options are available and mostappropriate to different situations and needs.

Bilingual skills within a workforce could also beachieved through language training in line with theKnowledge Skills Framework for all NHS staff(McPake and Johnstone, 2002). Whilst it takes timeto develop fluency and some staff may be fearful orreluctant to learn languages, it is possible tosupport the learning of a specific language for suchroles as reception duties. This would enable thesestaff to fulfill their roles more effectively.

Such training can be provided in partnership withinterpreters, bilingual staff, advocacy workers andvolunteers as well as local communityorganisations and other local and nationalproviders. Where those individuals providing

Training of Providers

“Someone who worked in a hospital asa hostess…witnessed some nursesasking a patient what he wanted to eat.Due to the fact that he could not speakEnglish and explain what he wanted toeat, they said give him 'cheeses andbiscuits or whatever'. As a result, fromthen on, the patient always said that hewanted cheese and biscuits… as thatwas the only word in English he hadlearnt…”(ISCRE, 2007 p10)

language support are enabled to take an activerole in service development and feed intoplanning mechanisms, they can also provideimportant information and help shape services inmore appropriate ways.

Commissioners need to understandcommunication needs in their local area.Pathways can then be designed to ensureproviders are able to offer appropriate support atthe time any intervention is required. Provision oftranslated information and of informationregarding options for language support isimportant for the service provider to enable themto deliver a service. Identification of the languageneeds of those who do not overcome the barriersto access a service requires engagement withcommunities. However, consideration of‘consultation fatigue’ and the focus on the need toempower communities requires differentapproaches. Bilingual staff and volunteers willcome from the communities accessing theservices and such communities often havequalified people with skills and knowledge thatcan be nurtured, developed and utilised by healthand social care services (McPake and Johnstone,2002). Neighbourhood renewal, Local StrategicPartnerships and social inclusion partnerships areall tools for more effective communityengagement (McPake and Johnstone, 2002 p25).

All services need to consider ways that they workwith Black and Minority Ethnic groups and withthose who have limited proficiency in Englishrather than expect that there will be a specialistoutreach service just for that group. The so called‘hard to reach’ groups need to be provided forwithin mainstream services. New methods ofservice delivery should be considered: times ofservice provision to coincide with availability ofpatients, more local venues for aspects of theservice, open door systems rather thanappointments, jointly provided one stop serviceswith other agencies etc. Incorporating Englishlanguage learning into real situations and as partof service provision helps to develop competencyand confidence of those with limited Englishproficiency (e.g. support workers modelling andthen encouraging small transactions in Englishlike booking an appointment), ESOL trainingprovision on site and in a variety of contexts (e.g.children’s centres).

Changes in the way services are provided

42


AdvocacyProvision of advocacy is the most sociallyinclusive means of language support involving adistinct change of emphasis. The personproviding language support acts as an advocateor patient centred interpreter, shifting roles fromone of communicating to the patient therequirements of staff, to communicating to thestaff the patient’s questions and needs. Theadvocate or patient-centred interpreter representsthe interests of the patient, working with them onan ongoing basis, getting to know their needs andhelping them to negotiate services and obtaintheir entitlements. Many service users seelanguage support not in terms of a professionalinterpreter with excellent linguistic ability but assomeone who can (Alexander etal., 2004, p.21), who is understanding andempathic, and who will be proactive on theirbehalf. Professional interpreters are oftenperceived to be under orders from the serviceproviders and many service users expressdissatisfaction with them until they have seenthem on a number of occasions and been able todevelop trust.

Advocacy workers have been shown to improveaccess to services, enhance control of patientsover their own decision making and health relatedbehaviours and improve a sense of well beingand health status (Warwick University 2006).Their ability to offer an ongoing relationship withthe potential for a very supportive bond todevelop is particularly useful with very isolatedpatients and those with mental health difficulties,and can help address wider issues than areaddressed by one particular service area (e.g.networking and skills development).

“argue a case”

“I am so grateful to…. (advocacyworker). I have been trying to get themto understand that I am depressedbecause I keep having miscarriagesand I don't understand why, but theyjust gave me tablets. Now I have thecounselling I need and have had teststo find out why.”Female Kurdish service user (Stallabrass, 2005)

Service providers often express fear and concernover working with advocates, anticipating a levelof criticism and hostility, which in practice is rarelythe case. Health advocacy often helps to bridgethe differing cultural understandings betweenpractitioners and their patients and services andthe community, particularly around health beliefsand behaviours (Warwick University, 2002).

However, it requires that advocates are trainedand supported in an ongoing way, so that theycan manage the demands of their role andmaintain boundaries. Working practices alsorequire a shift in emphasis: briefing advocates toenable them to work effectively with the particularservice provider, advocates meeting with thepatient prior to the meeting the service provider inorder to agree how to approach the serviceprovider and clarify what the patient wishes toachieve; and in situations like psychologicaltherapy, where the relationship between patientand therapist is central, the advocate can besupported to understand the importance ofworking as part of a three way therapeuticrelationship, building trust and allowing forexploration of difficult and challenging areas.


43

Table

3

Advanta

ges

and

limitations

of l

anguage

support

str

ate

gie

s

Lan

gu

ag

esu

pp

ort

Ad

van

tag

es

Lim

itati

on

s

Bilin

gu

als

taff

(clin

ical

•sta

ff, r

ecep

tio

nis

ts)

Reg

iste

rso

fb

ilin

gu

al

sta

ffto

actas

inte

rpre

ters

Lin

kan

dsu

pp

ort

wo

rkers

Ad

vo

cacy

wo

rkers

an

dag

en

cie

s

Co

mm

un

ity

vo

lun

teers

Reaso

nab

lead

justm

en

ts

Face-t

o-f

ace

inte

rpre

tin

g

Tele

ph

on

ein

terp

reti

ng

•P

refe

rred

by

patients

and

pra

ctitioners

Pra

ctitioners

not a

vaila

ble

inm

ore

unusual

•E

ssential i

nspecia

list s

erv

ices

languages

•E

ase

and

speed

ofc

om

munic

ation

•S

om

em

ay

have

limited

Englis

hpro

ficie

ncy

•C

ultura

lcom

pete

ncy

•Lim

ited

availa

bili

tyof s

pecia

listp

ractitioners

•E

mplo

ym

ento

pport

unitie

sfo

rm

arg

inalis

ed

com

munitie

s•C

annotc

overth

ew

hole

range

of l

anguages

inall

serv

ices

•E

asily

availa

ble

within

the

org

anis

ation

•C

om

pro

mis

es

sta

ffm

em

bers

’prim

ary

role

•P

rofe

ssio

nald

evelo

pm

ento

pport

unitie

s•P

oorcontinuity

of c

are

•T

rain

ing

required

tosupport

confidentialit

yand

qualit

y

•S

upport

patients

’ skill

sdevelo

pm

ent

•D

ifficultie

sfo

rin

div

iduals

managin

g•M

edia

tors

betw

een

com

munitie

sand

serv

ices

boundaries

with

and

expecta

tions

of

•Join

tw

ork

ing

acro

ss

agencie

scom

munitie

s•C

ontinuity

ofcare

acro

ss

secto

rs

•P

atient-

centr

ed

inte

rpre

ting

pro

moting

patients

’•P

rovid

ersta

ffcan

be

suspic

ious

ofa

dvocacy

pre

fere

nces

and

contr

olo

verdecis

ion

makin

gw

ork

ers

initia

lly•P

refe

rred

by

patients

•Im

pro

ve

access

toserv

ices

•B

asic

imm

edia

tein

terp

reting

•T

rain

ing

and

support

for

confidentialit

yand

•P

ath

ways

toem

plo

ym

ent

for

managin

gboundaries

and

com

munity

•C

om

munity

and

cultura

lknow

ledge

expecta

tions

•O

utr

each

(e.g

.health

train

ers

)

•E

ssentialt

om

eet l

egis

lative

requirem

ents

•F

acili

tate

sth

edevelo

pm

ent o

faw

ide

range

of l

anguage

support

options

•P

refe

rred

overte

lephone

inte

rpre

ting

•S

om

ela

nguages

not l

ocally

availa

ble

•F

acili

tate

ssig

nin

g/r

ela

yin

terp

reting

•T

ravelc

osts

can

be

pro

hib

itiv

e•P

rofe

ssio

nal,

confidential,

support

sunders

tandin

g•Locally

availa

ble

•A

vaila

ble

24

hours

perday

•M

isses

non-v

erb

al c

om

munic

ation

cues

•A

vaila

ble

inan

em

erg

ency

•N

otc

ost-

effective

forconta

cts

over20

min

ute

s•C

an

pro

vid

efo

runusual l

anguages

•C

oste

ffective

forshort

sim

ple

inte

rpre

ting(e

.g.

on

reception)

•N

otsuitable

for

com

ple

x,sensitiv

eis

sues

or

child

ren

44


Case study 12 – A socially inclusive model of language support

Suffolk Community Refugee Team General Practice

Contact: Susan Stallabrass [email protected]

was a nurse-led using various languagesupport methods to provide General Medical and Personal Medical Services for asylum seekers,refugees and migrant workers.

Bilingual staff

Reasonableadjustments

• French speaking receptionist

Refugee doctors fromAlbania, Turkey, Romania,Afghanistan, Sri Lanka

Clinical staff spoke someFrench and Arabic

Mental health worker bilingualin Urdu and English

On-site interpreter for Arabic,Kurdish Sorani

Advocacy worker trained inBSL by the service

Telephones & IT

Simple English

Room design

Choices of language support

Times

Open doors – drop-in

One stop

•

•

•

•

•

•

•

•

•

•

•

•

Link and support workers

Public Service Interpreting& Translation

From the Iraqi Kurdishcommunity:

Skills development withgroups and communities

Support work with individuals

Health training with groups

Mediation with communities

Cultural awareness for theservice

Language support

•

•

•

•

•

•

• Joint bookings with socialcare and other services

• Service Level Agreement withTIP to reduce admin costs

• Language Line

• Designated interpreters forcounselling, children andyoung people

Advocacy workers/agencies

Community volunteers

•

•

•

•

•

•

•

• Basic interpreting andwelcome in reception

• Community networks

• Readers groups

• Support group

• Service feedback group

Refugee Council

Suffolk Refugee SupportForum

Referrals and advocacy

Mediators

Feedback for/complaints ofthe service

Links with groups andcommunities

Information or data


45

SECTION 4:

Defining and SpecifyingServicesBased on Best Practice

4.

4.1 Public Service Interpreting andTranslation

Fundamental pre-requisites tosuccessful language support strategiesinclude a joint focus, commitment toprovision of language support andgood partnership working

Whichever language support optionscommissioners wish to adopt, certain underlyingfeatures and principles of best practice arefundamental to success. Many current primarycare and third sector providers are likely to havesignificant existing experience and expertise andexamples of good practice, which can be utilisedto shape and define services as they develop.

• Ad-hoc systems are inefficient and are notpatient-centred. This leads to fragmentedservices and/or to service duplication.

Good practice models help NHS agenciesmake reasonable adjustments to their services.They will be pro-active at identifying andcontinually looking at the way they deliverservices to help make improvements forpatients who cannot communicate fluently inEnglish.

Good practice models will be patient-focusedand will integrate “access”, “patient safety” and“risk management” in their strategies.

NHS agencies will develop internal systemsand procedures to help staff make an efficient,safe and cost-effective use of services. Staffwill be given support to achieve these goals.

Underlying features and principles

•

•

•

•

•

•

••

•

•

•

•

••

•

•

•

Equal Access to Service and Informationmeans that NHS agencies will:

Call interpreters and translators whennecessaryEnsure that those interpreters and translatorsare competent (DPSI qualified with medicalinterpreting training, ethics training, andaccess to mental health, drugs and alcohol,child protection additional training) and CRB-checkedProvide an effective service across culturesInterpreters will be accessible over thetelephone (immediate access) or on a face-to-face basis (by appointment). Interpretersmay be able to interpret consecutively,simultaneously and sight translate.

NHS agencies may consider operating inpartnership with other agencies, includingagencies operating in other public sectors, togain economies of scale and of learning as wellas addressing gaps in provision, such as locally.

NHS agencies will be committed in contributingto the development of locally-based interpretersand be supportive of providers of interpretingtraining.

The delivery of best model practice requires amember of staff to act as the central point ofcontact between the organisation andcommissioned suppliers. Communicating withmanagers and staff and with communities iscrucial to the success of the strategy.

Make language support a corporate issue.Communicate with staff to make sure that:

Budgets are securedStaff know about your provision of services,and know how to use services effectively.Controls are in place to monitor goodpractice and effectiveness.Monitoring and management information areused as intelligence to identify trends,achievements, gaps, and needs forcontinuing development.If staff decide not to provide interpreters, iscentral evidence kept of the reasons why itwas decided, in some particular instances,not to provide an interpreter, as in therecommendations of the Laming Report 2003.

46


Children require special consideration:

(Laming, 2003)

Common practical issues fall into four areas: thelogistics of organising interpreting, the accuracyand professionalism of interpreters, the dynamicsof working with interpreters and the use oftranslation services.

Interpreters might arrive late to sessions, cancelat short notice or not appear at all, without anysort of explanation. Whilst this does not occuroften it can be very disruptive to service delivery.Sometimes the reverse happens when a face toface interpreter is booked and the patient doesnot turn up, incurring additional costs. It is oftendifficult to arrange an interpreter at short notice atthe particular time and date available for theworker, or in a crisis situation. There also may beproblems when trying to arrange to use the sameinterpreter for ongoing work with a service user.When GPs do not inform hospitals in their referralletters that the patient needs an interpreter in Xlanguage, referral letters may be ignored by thepatient causing unintended Did Not Attends.

Booking of interpreters requires consideration ofcost effectiveness. Practitioners prefer face toface interpreting and may be reluctant to workwith a telephone interpreter even when sufficientand more cost effective. Face to face interpretersmay be booked for a whole day in day procedureunits, when only required face to face pre-operatively to gain consent and can be contactedby phone post-operatively to confirm and recapon what was said previously. Face to faceinterpreters are not given priority whenappointments are running late. One consequenceof this is that the agency incurs higher costs withinterpreters waiting for the appointment tocommence. Policies need to be implemented andcontrols put in place to ensure that agenciesmake a cost-effective use of public resources.

•“when communicating with a child isnecessary for purposes of safeguarding andpromoting that child’s welfare, and the firstlanguage of that child is not English, aninterpreter must be used. In cases where theuse of an interpreter is dispensed with, thereasons for doing so must be recorded in thechild’s notes/case file.”

Common practical issues

Logistical problems:

“This lady was pregnant and I told hershe was HIV positive, her 17 year olddaughter was interpreting. At the endof the consultation as my patientcontinued to smile at me, I decided torebook her with an interpreter. Throughthe interpreter I received theconfirmation that her daughter had notinformed her mother of her condition,and that the mother had not taken theanti-virals”(Gidney, 2010)

Patients benefit from a cross-sector partnershipapproach to translation and interpreting provisionas they will receive the same provision from eachagency. This results in the continuation of highquality, successful care throughout theirexperience. Lack of active management impliesthat some NHS agencies book face to faceinterpreters in the same place speaking the samelanguage several times a day. A coordinatedapproach would contribute to facilitating repeatbookings or internal organisation, so that thesame interpreter is used throughout the day,hence incurring no travel charges.

Without a structured, well organised system ofinterpreting and translation there will be confusionregarding which agency should pay for whichinvoices.

Communities are often unaware of the fact theycan access services in their language. As a result,people postpone their contacts with the NHS, withpredictable consequences attached.Patients postpone consultations and/oroperations as a result of not having interpretersprovided. Patients, who do not know otherwise,often bring a friend or family member, or volunteerto interpret. This often leads to omissions,additions and misinterpretations.

Professional interpreters are trained to provideaccurate and reliable interpreting within a clearcode of ethics, which is supportive of patient andpractitioner. They are skilled in managing some ofthe difficulties in consultations for example clinical

Accuracy of Interpreting:


47

terminology, embarrassment, anger and badlanguage.

It is vital for the agency providing the interpreter toascertain the nature of the appointment in order thatthe interpreter with the right level of competency isprovided. It is important that interpreters are welltrained and confident to explain to the provider thatthey require more time to explain particular issues forexample because the word may not exist in theirmother language or because of the level ofunderstanding of the patient.

There is a different dynamic between practitionerand service user when an interpreter is in theroom: this takes some adjustment, particularly inthe mental health setting or with complex issuesand staff require training to be able to manage theconsultation effectively. As a result somepractitioners might express concerns about theaccuracy of interpretation, or both practitionersand services users might be concerned about thestandard, capability, confidentiality andprofessionalism of the interpreter. These issuescan be overcome with training of bothpractitioners and interpreters and good translatedinformation for patients explaining howinterpreters are engaged by service providers.Good supervision processes, partnership workingand support for interpreting agencies areimportant if interpreters are to gain skills inworking in particular settings such as mentalhealth or palliative care.

Dynamics of Working with Interpreter:

Translation:A clear policy regarding translation is necessary,especially as the costs involved can be high.Sometimes it is not necessary to translate a wholedocument as only part is required for a particularpurpose. On other occasions all that might berequired is to read through a short document suchas a letter with an interpreter. Translated healthinformation is often available on the World WideWeb or from other agencies; and readers’ panels toassess this information can be useful in ensuringthe accuracy and appropriateness of the materialsto the local situation. Translation should becompleted by translators who have specialisttraining, skills and computer resources for writtentranslation, and documents such as translatedleaflets and letters..

Cambridge (2010) advises that the processshould include pre-editing in collaboration withboth the translator and designated communitymembers so that the original English textrepresents the level of language, lack of jargon,and general tone that will produce an effectiveOther Language document and the colour,graphics, style and production are appropriatealso. The draft translation can then be tested withthe community concerned and if necessary thetranslator asked to make small edits prior toprinting. The price and a reasonable deadline forall this will have been agreed with the translatorbeforehand, and the parties put in touch with oneanother

48


4.2 A social inclusion model oflanguage support

High Quality Care for All. Inclusion Health:improving primary care for socially excludedpeople (DH, 2010) details a number of bestpractice issues when commissioning for andworking with third sector agencies and BME orother communities. Many of these guidelinesapply to the provision of language support:

Achieving economies of scale can bechallenging, when some language groups havevery few people within them in a given area,and sometimes bilingual staff etc just cannot befound. Community interpreting services mayalso have difficulty in accessing specificlanguages in a given area with the result thatinterpreters may have to travel long distances.Partnership working across agencies isessential as an individual may be receivingservices from other agencies, and jointmeetings could be set up to make effective useof an interpreter. Telephone or audio-visual ITtechnology would also be of use and staffshould be trained to identify and work withthese choices effectively.

• Critical mass

•

Insufficient language capability is a key barrierto accessing services; however, many suchservices users may also experience a numberof other compounding barriers.

Commissioning partners, third sector agenciesand community champions need to providestrong and clear leadership and commitment.

Ensuring care pathways and language supportare integrated and seamless so that supportworker or interpreter provision in one area ofthe care pathway (e.g. primary care/midwifery)is continued into another care pathway or areaof provision (e.g. secondary care/deliverysuite). The most successful integrated modelswill emphasise joint delivery and co-location ofservices to promote integration. There issometimes confusion amongst staff regardingthe rules around patient confidentiality whenworking across services. The sharing ofinformation within agreed protocols is perfectlypossible and it should not act as a barrier.

Common barriers to accessing services andreceiving optimal care

• Local leadership

Integrated approaches and continuity ofcare

•

Table 4

Suppliers focus• Provide a speedy response for 24 hour, 7

days a week, 365 days a yearInclude deaf and hard of hearing servicesAccess locally-based qualified interpretersSupport interpretersEnsure suitable standardsProvide meaningful management informationAccurately monitor and manage information;including invoicesImplement solid Quality Assurance controlsProvide good quality Complaints feedbackInnovateAvoid cheap options that would imply thatinterpreters are paid the minimum wage; apostgraduate professional interpreter shouldwork for remuneration commensurate withtheir training

••••••

••••

Internal focus•••

•

••••

••

•

Integrate interpreting and translation servicesDeliver active contract managementMake patients central to your languagesupport strategy.Empower your staff through the active deliveryof “awareness-raising” programmesImplement a robust Quality Assurance policyMonitor usage, performance and efficiencyPlan realistic budgetsCreate one central point of contact to link yoursuppliers, senior management, staff andpatientsEvaluate services regularlyEnsure communication is central to theprocess of integrating interpreting andtranslation services Consider a variety ofopinions: few interpreting and translationagencies can claim to be full experts in allaspects

Key measures of an effective interpreting and translation service


49

•

•

•

•

•

•

Engaging individual service users andcommunities

Children and Families

Physical environment

Partnership working

Supported workforce/networked services

Personalisation

Good engagement with service users requiringlanguage support is not only a long termundertaking but requires language supportstrategies and resources and good planning inorder to build trust and achieve effectiveengagement to enable involvement in thedesign and development of services.

It is important to recognise that children’slanguage needs are often different from thoseof their parents. Interpreters, bilingual staff andadvocacy workers will be required to work invery different ways and will require additionalsupport and training.

Basic considerations such as clear, simplesignage (e.g. simple language, use of images,large text etc.), access to telephone interpretingon the front desk, volunteers and advocates inthe reception area can make a big difference toreducing the confusion and anxiety felt bypeople with language support needs, which cansometimes lead to them leaving before theirappointment.

Fundamental pre-requisites to successfullanguage support strategies include a jointfocus and commitment to provision of languagesupport and good partnership working(between commissioning organisations,between provider organisations, betweencommissioners and potential providers andbetween commissioners, communities andproviders).

Staff involved with provision of languagesupport whether external to an organisation(e.g. interpreter) or employed in the thirdsector; require support networks, supervisionand training.

A language support strategy will comprisemany different elements (e.g. telephone andface-to-face interpreting, advocates, bilingualstaff etc.) operating across agency and serviceboundaries. It is important that services are

commissioned and developed in a way whichpromotes the ability of the service providers tounderstand the different options for languagesupport available and respond to individualneeds. This will require clear protocols, andtraining and proficiency in integration and co-operation.

Therapeutic interventions to support people withmental ill health, respond to mental health crisesand promote mental well-being rely entirely oncommunication in its fullest sense. Languagebarriers will severely impede the provision of suchcare and will compound other barriersexperienced (cultural understandings, stigmaetc.). Good language support is essential withinterpreters, bilingual staff, advocates etc.) beingfully supported and appropriately trained in thisspecialist area of work. Telephone interpreting isneither appropriate nor cost effective. Theestablishing of an effective therapeuticrelationship cannot progress without trust in theinterpreter or advocate by the service user orhealth professional.

(DH, 2009) promotes strategies for improvingpopulation mental health and ensuring thedelivery of effective, evidence-based treatmentsand care in primary care and secondary mentalhealth services. Its approach addresses theneeds of people who are socially excluded whoare at greater risk of mental ill-health, andsupports the basic requirement for languagesupport for those excluded on the grounds oflanguage capability. Equality of access andoutcomes for BME groups is identified as aspecific action (p25) as is early intervention (p23).Appropriate language support is key to achievingthese actions.

Mental health

New Horizons: a shared vision for mental health

4.3 Specialist clinical issues

50


Health promotion and screening

Speech and Language Therapy

To combat the under utilisation of screeningservices and the failure of some health promotionmessages requires not only the provision of clearand appropriate translated information andinterpreting at appointments, but also the activeinvolvement of BME voluntary and communityorganisations with bilingual health trainers,support workers and advocates.

Speech and Language Therapists are skilled ataltering their style of communication according tothe children’s and parents’/carers’ needs.However, working through an interpreter tosupport patients (children or adults with forexample brain injury) and their carers will requireadditional support to ensure continuity ofinterpreter and training for the interpreter inworking within this specialism.

“This lady went to her mammogramappointment with her daughter actingas an interpreter. Her daughter was aBritish born Chinese and was able tointerpret some information but not all.She ended up not having amammogram check and had a hugeargument with her daughter when herdaughter explained the metal platewould be chopping her breasts off”(Chow, 2010)

Paediatrics / Children’s ServicesChildren must be given the opportunity tothemselves communicate in their own languageand practitioners not rely only upon parent /careers interpreting for the child or providinginformation on behalf of the child. Child protectionissues are paramount and experiencedinterpreters will be essential to any childprotection work. Children must also be protectedfrom the consequences of acting as theinterpreter for family members.


51

SECTION 5:

Working with andDeveloping Providers

5.

5.1 Working with third sector providers

Commissioning of an interpreting andtranslation service is much more cost-effective if commissioning is multi-sectoral - involving Health; Social Care;Housing; Police; Job Centre Plus;Education and the Voluntary Sector.

Funding for interpreting services is oftenperceived and experienced as problematic, andwhilst organisations are required to review theirpractices little guidance is given regarding how tobalance priorities, and interpreting services areoften abandoned on the basis of cost (McPakeand Johnstone, 2002). Arrangements thus oftenremain ad hoc and therefore more costly, thusreinforcing the perception of the insurmountablecosts. This in part is due to an undervaluing of therole of the interpreter and failure to understandthe complexity of the skills involved; but it is alsothe result of a failure to adopt the more inclusiveoptions of language support available.

The development of a comprehensive, sociallyinclusive language support strategy is dependentupon the third sector. Where commissioners findservice users difficult to engage with, especially ifparticularly marginalized or suspicious of statutoryagencies, third sector agencies and communityorganisations can provide in-reach andengagement. Local communities will provide thelinguistic expertise to supply interpreters to meetthat community’s specific language needs(languages, dialects, cultural groups). Bilingualstaff (administrative, auxiliary and clinical) willneed to be recruited from local communities.Local agencies hold the knowledge and data thatcommissioners require in order to identify theappropriate commissioning strategies. Thirdsector agencies also have access to fundingstreams that support an inclusive approach, andare part of wider organizations, offering a ‘one-stop’ service approach.

Commissioners often find engagement with thethird sector difficult when provider agencies aresmall, staffed with volunteers, are specific tocertain groups within communities and have littleability for long term strategic planning. Thirdsector agencies themselves find procurementpractices are not flexible enough to meet theirparticular needs and many report NHSprocurement processes to be over complicated.They have limited capacity to complete bids to thestandard required and in competition with nationalcompanies. Their existing funding is often shortterm and from multiple sources with specificoutcomes expected from that funding stream.Often third sector providers are completelyexcluded in the initial research and design stagesof procurement (DH, 2010)

However, it is through third sector agencies thatmany community interpreting services areprovided. Even those agencies offering BSL andare 85% not for profit, are often charitableagencies dependent upon donations, and anycentral funding received is inadequate to meetcosts and is often cut year on year (Perez andWilson, 2006). Yet they provide services thatstatutory bodies should themselves be providingto meet service user needs and legalrequirements. Central government, statutorybodies and local government need to recognisethat provision of language support for BSL andminority languages is a legitimate and necessarycost.

Contractual frameworks options need toincorporate multi-agency provision and multi-agency commissioning. A range of agencies will berequired to provide different elements of alanguage support strategy and multiple agencieswill need to have access to the various optionsavailable. Thus procurement and contracting mustbe flexible and sustainable as lead contractingarrangements will involve multiple funding streams,and a variety of differing contractual arrangements.

A long term commitment to socially inclusivelanguage support is essential; particularly whenconsidering work-force development options andcapacity development for providers. Capacity

5.2 Procurement and contractualapproaches

52


Case Study 13 – Local Multi-Agency Partnership

Translation and Interpreting Project (TIP) (ISCRE)

Contact: Annie Chow – Translation and Interpreting Project [email protected]

TIP works closely with multi-agency partners in order to facilitate services needed by public serviceproviders and service users who are not fluent in English language. It is particularly important in mentalhealth cases as patients tend to fall back on their mother tongues when they are mentally unwell.

Mrs. Z who was 50 years old had been suffering from mental illness for a long time. Her family did notrecognize her illness and did not seek medical help for some time. Mrs. Z was lucky to be saved by apasser-by who witnessed her walking into the sea and called the police. Mrs. Z suffered fromSchizophrenia; she demonstrated severe symptoms which included serious self harm while she wasbeing treated in a mental health hospital.

With the help of her interpreter, doctors were able to properly assess her mental status. After year-longtreatment, she was well enough to be discharged. Her children, however, cannot look after their mumat home due to their work commitments. She was offered a place in a residential mental health carehome in order to build a positive and meaningful future for herself. Her care was the responsibility of

TIP provided the same interpreter for each visit. This was seen as important by the mental healthspecialists who wanted continuity to help build trust between the interpreter and the patient in thepatient’s best interests. Additionally this continuity was helpful for the agencies. Because of the impactof the patient’s illness on her needs, the residential home requested a flexible 24/7 telephoneinterpreting service provided by the same interpreter. Through its track record of building strongrelationships and flexibility with its interpreters TIP was able to provide all the services requested by theservice providers.

Over the 3 years the agencies and TIP have been involved with the patient, she has done very wellbuilding a more positive future for herself.

Suffolk Mental Health Partnership Trust, Suffolk County Council and NHS Suffolk.

building in the third sector is fundamental todeveloping language support services as theexpertise required rests within the communitiesthemselves; this means a commitment to pick uplong term funding where both commissioning andservice provision can be responsive to changingneeds over time.

The NHS procurement hub can itself be verycostly and time consuming and the timing ofcommissioning rounds might not correspond withthe timing of applications for some of the shortterm, ad hoc funding sources available to thirdsector agencies (Comic Relief, Lottery etc). Aflexible ‘design and build’ approach is essential(DH, 2010). This may have a number of featuresand advantages including:

services designed around users needs;potential users, or communities of users,

‘Design and build’

••

involved in service development at all stagesand a panel of local expertise can be created toguide broader communication strategies;it supports the localization agenda allowingsmall local agencies a better chance tocompete in the tendering processes as it isfrom these that the people with the languageexpertise have to be drawn;contractual arrangements commission for‘capacity’ rather than units of activity;support is provided for agencies to do long termstrategic planning rather than short-termismbased on insecure year by year funding;services can be more flexible and innovativeand accessibility criteria for service users arebroadened;data can be collected to inform futurecommissioning and service development.(DH 2010).

•

•

•

•

•


53

‘The Compact’

Partnership approaches

Commissioning around ‘Touch points’

The Compact (DH, 2007) is an agreementbetween the Government and the voluntary andcommunity sector in England which provides aframework and guiding principles for effectivepartnership. It commits Government bodies toworking towards longer term fundingarrangements with third sector organisations, 3years being the accepted period with options toextend where appropriate.

Bringing third sector and statutory servicestogether in partnerships to collaborate in theprovision of jointly-provided areas of service suchas advocacy workers or in the provision of co-located, integrated and one-stop services.

Commissioners will need to identify andunderstand key service ‘touch points’ (DH, 2010),where service users actually present to accessservices. This might be through inappropriatepresentations at A&E for non emergency needs orit might be appropriate use of a walk-in centre.Understanding why service users present toservices where and how they do, will enablecommissioners to develop improved patientpathways. More importantly, ‘touch points’ offer anopportunity to target language supportinterventions. With inappropriate presentations inA&E for example, quick access to telephoneinterpreters might help facilitate quicker

throughput and ensure provision of healthinformation to redirect subsequent contacts moreappropriately along with the opportunity to refer toa bilingual support service to provide ongoinghealth information and support. Additionalservices could be built around a walk in centre toprovide a wider range of health interventions,reciprocal arrangements between health andother services or a point of access for languagesupport options.

Commissioners might wish to considerincentivizing mainstream services to work withservice users requiring language support or tomake reasonable adjustments. The DDA definesdiscrimination in a number of ways and outlinesfour specific types of discrimination: directdiscrimination, failure to make reasonableadjustment, disability-related discrimination andvictimisation. It is unlawful for service providers totreat someone less favourably because of theirdisability, and this requires them to make“reasonable adjustments” to service provision. Aservice does not have to be impossible to usebefore a service provider has to make changes:they also have to make changes when it isunreasonably difficult. Service providers shouldbe thinking ahead and continually looking at theway they provide services, the physical featuresof their premises and services, and how they canmake improvements for disabled people.

Reasonable adjustments to existing ormainstream services

54


Table 5

Reasonable adjustments for language support

All audiences •

Deaf peopleand hard ofhearing, deafblind.

Non Englishspeakers

Blind andvisually-impaired

Older people

Learning

Speechimpairment

Use of plain EnglishInformation easy to read and simpleInform of different methods of provisionBe aware of cultural differencesMake reasonable adjustmentsStaff aware of duties and have the practical know-how on how to behave, how towrite, communicate, present displays, avoid certain typefaces, etc... and largerfont.Staff guidelines – with training to make the guidelines more meaningful

Speech to text for hard of hearing. (transcription of the word onto a screen)Languages include BSL, Makaton, deaf manual, deaf blind manual and moreTypetalk (funded by BT) to communicate with hearing people and vice-versa,through the operator translating the spoken word and textSupport for people with learning disabilities to arrange their bookingsInternet signers to explain services are provided and how to access them andwhat users’ rights are

Sight translating or verbal interpretation of documentsPictures and symbols

Or learning disability

•••••

•

•••••••

••

••••

•••

••

•disabilities

••

BSL interpretersLip speakersHearing loopsMinicom

Foreign Language InterpretersTranslators

Large PrintBrailleAudio cassettes

Look at visual impairment, mobility impairment and hearing impairment

Plain English, short sentences, large print, use pictures-photos, information onaudio tapes, write in symbols (Rebus) - using symbols to support words and‘Easy-read’ format

Text phonesTypetalk (funded by BT) to communicate with hearing people and vice-versa,through the operator translating the spoken word and text


55

Collaborative commissioning approaches

Workforce development

Commissioners might find that service usersaccess services across a number of areaboundaries or a wide range of different areas ofprovision. Thus the needs of their particular areamight be better served by a specialist serviceincorporating a range of language supportmodels. Commissioning of an interpreting andtranslation service is much more cost effective ifcommissioning is multi-sectoral, involving health,social care, housing, police, Job Centre Plus,education and the voluntary sector.

Most community interpreting service providersrecruit self employed freelance interpreters.Workforce development initiatives need to worktowards long term sustainability and retention ofan interpreting workforce by offering support forprofessional development and training and careeroptions (e.g. specialist interpreters employed inmental health services). Mainstream servicesshould be supported to recruit bilingual staff andthis might mean commissioning English languagetraining and writing skills support for those staff inpartnership with education facilities.

With a wide range of options available in thesocial inclusion model the best service solutionwill depend upon a number of factors, including

5.3 Mapping existing services andfunding

existing service provision, changing needs andfunding streams available. The most effectiveapproaches to mapping services and identifyingfunding are those which collaborate closely withexisting service providers, service users and localcommunities. Inclusive approaches such asadvocates, bilingual staff etc opens up a widerrange of funding opportunities to addresslanguage support needs imaginatively. Partners incommissioning and provision of language supportcan agree funding streams to support contractsfrom many different sources.Funding sources might be local, short term,through European initiatives, or centralgovernment.• The Department of Health (DH, 2009) has

issued guidance for commissioners on the useof grants in place of commercial contracting

• NHS can use General Medical Services (GMS),various Personal Medical Services (PMS)options and Enhanced Service Agreements tointegrate language support options within GPpractices, Dental Surgeries and communityservices;

• Education: colleges and universities haveaccess to funding to support training ofinterpreters, training of bilingual staff inadministration or professional roles such ascounseling and for research (including localbursaries).

• Home Office funding streams for dispersalneed to include support for local costs ofinterpreting for NHS services.

56


Case Study 14 – Occupational health and safety

Ipswich & Suffolk Council for Racial Equality (ISCRE)

Contact: Jane Basham, ISCRE [email protected]

A Lithuanian female in her 40’s who had been in the UK 5 years, sending money home to support herteenage son who lived with her parents. Spoke very little English, working 12 hour shifts 6 days aweek. She experienced an accident at work, which left her unable to return to work. The employer didnot offer letters in her own language about her continued absence from work. She was not in theUnion and did not appear to understand the role of a Union.

On arrival at ISCRE offices with her paperwork she was living in a hostel, along with drug users andalcohol users. We engaged an interpreter immediately. She was apparently receiving a small amountof benefit, very stressed and really confused about her work status - she thought she had beensacked. The injury to her arm was apparent, despite it being about 6 months old. Review of thepaperwork showed that she was being asked to attend Occupational Health by the employer for anassessment with a view to terminating her contract. In addition she had paperwork that indicated shehad sought legal advice about her injury at work. There was no evidence of any interpreter and aletter from the law firm suggested she would be unlikely to win a Personal Injury claim. Reviewing thepaperwork regarding the injury the investigation felt unsatisfactory. This was not however her priority.

Additionally she was experiencing other health problems and again she did not appear to have anycorrespondence on this in any language other than English. She was due to have a procedure at thehospital and was really fearful and unsure what it would entail. This was what had prompted her tocome to us. We called the hospital who agreed to ensure an interpreter was present at the preoperation appointment. We wrote to the GP and Hospital to determine whether interpreters had beenused on all occasions, describing her complete lack of understanding of what was going to happen toher. We rang the work place to ensure that that Occupational Health met with her with an interpreter.They refused to commission a professional and agreed to use a work colleague who spoke someEnglish.

Because of her subsequent hospital procedure she felt unwell enough to pursue any complaintagainst the employer or the law firm. Eventually we lost contact with her as she was towards the endliving in poor conditions and leading a chaotic lifestyle but understand she returned to Lithuania.

This shows the human costs of not embedding the removal of the barrier of language every time it isrequired. There are additional costs too:• The potentially dangerous work environment has not been addressed

The loss of income led this woman into an environment that she became influenced by, thatexacerbated her health problemsThe discriminatory impact of accessing justice for a potential Personal Injury claimThe costs associated with organisations like ISCRE who paid for interpreters in order tounderstand her issues and to be able to offer her the right support and guidanceThe fear of not fully understanding what your GP or Consultant is telling you

•

••

•


57

SECTION 6:

MonitoringPerformance

6.

6.1 Key performance indicators

...with language support provisionactually emanating from the communitywhich it serves it as a fundamental pre-requisite to have meaningfulcommunity participation at all levels.

Table 6

In specifying what type of services to include in acommunication support strategy, commissionerswill need to assure themselves that not only therange of services provided is appropriate, but thatthis is supported by a rigorous evidence base.Good evidence is not easily available for a newarea of service development so it is important thatcommissioners are clear regarding the outcomesrequired in each service area and standards to beachieved.

The commissioning of an interpreting andtranslation service will require consideration of thefollowing service performance indicators,management and monitoring.

1. Background and history2. Scope of the service3. Telephone, BSL and Lipspeaking, face-to-

face foreign language interpreting, writtentranslations

4. Service availability5. Special requests6. Additional services: Braille, audio

translations, large script, etc.7. Customer service support8. Booking processes9. Management information

10. Selection and development of interpreters

Service provision for translation andinterpreting

Service level agreement / tenderspecification headings

11. Training12. Publicity materials13. Quality control14. Complaints15. Disaster recovery16. Upsurge or variations of demand17. Research for development18. Confidentiality and code of conduct19. Referees20. Partnership working21. Payment and cost of service

• Call centre to be staffed 24 hours per day/7days per week/365 days per year[99%] of all calls answered within [20] seconds[1%] of all calls answered within [60] seconds

[99%] of all requests booked

[90%] of all emergencies – interpreters arrivewithin [1] hour (need for local servicedevelopment)[90%] of all emergencies – interpreters arrivewithin [5] hours

[x%] of all standard language face to faceinterpreters travel [x] miles (depends upon localsituation)Ability to recruit and train interpreters to meetlocal gaps in provisionLook at usage statistics:Cannot provide interpreter/language/unmetneedHad to provide interpreters from furtherdistance

Each booking needs to show languagequalification/level of training of interpreter usedTranslators must have a qualification intranslation (not interpretation)100% compliance with quality standardsagreed in the SLAAbility to provide interpreters trained inparticularly complex areas of the NHS e.g.

Service Provision Standards for interpretingprovision

Call Centre

Bookings filled

Speed of response

Cost control – ability to reduce mileage costs

Quality of services delivered

••

•

•

•

•

•

••

•

•

•

•

•

58


Mental Health, Drugs and Alcohol. Expert staffcan train locally-based interpreters in areas ofexpertise. In Mental Health, interpreters mustbe fully confident in simultaneous interpreting(which is tested in the DPSI qualification).Customer satisfaction feedbackComplaints/incident resolutionIdentifying when “complaints of the samenature” reoccur and reviewReview training and CPD targets with suppliersat each review meeting for face to faceinterpreters

100% timeliness of submission of monitoringand management information100% accuracy and completeness ofmanagement and monitoring information100% accuracy of ID codes100% accuracy of invoices (and ability to checkand verify: must be audit-trackable).

Staff surveysService user surveys% of complaints/total bookings and resolutionsatisfaction

Depending upon contracts, suppliers may beoffering added-value services. In order toimplement them, a guarantee of value isrequired to ensure efficiency.

Co-ordination and management is a key issuewhere there are multiple commissioning partners,commissioning services from a range ofproviders, in order to provide interpreting andtranslation to a number of services. Partnerorganisations will save a considerable amount oftime and money if a coordinating/managementbody is utilised to manage the complexities ofdelivery, ensure the success, efficiency and costeffectiveness of provision.

Tenders and reviews performance with partnerson an ongoing basisProduces SLAs and Partnership Agreementsand pays for legal consultation fees as and whennecessary through a pooled partnership budgetReviews contracts quarterly on behalf of all itspartners

•••

•

•

•

••

•••

•

•

•

•

Management Information

Customer satisfaction

Additional services and innovation

A managing/coordinating body:

•

•

•

•

•

•

•

Provides written annual reports and ensuresstandardized and consistent reporting from allproviders/suppliersCommunicates with providers/suppliers as andwhen necessary to ensure best value,consistency and qualityDevelops champions in service providers tosupport staff in each service and link with themanagement team/coordinating bodyTrains staff in local situations, booking systems,working with interpreters, choosing betweendifferent options of language supportMonitors on a yearly basis:- Service delivery – usage, contract

compliance, top languages per area/service,gaps in provision, average unit costs

- Recruitment and training of interpreters- Quality assurance and quality control- Feedback received from staff, interpreters

and users, yearly reviews of customersatisfaction

- Areas for improvement- Current and future development work and

targets

Services need to be managed. The most complexand potentially more expensive services will beface to face. As part of commissioning guidelines,these performance indicators solely concern themonitoring of performance of commissionedsuppliers.These do not measure:

the ability of the NHS’s organisation to meetpatient’s safety through PSI&T servicesinternal efficiency – staff making an effectiveuse of services

It is however important to point out that not onlysuppliers but staff themselves contribute to theeffectiveness of the delivery of the contracts.

Good partnership working provides for more thanbasic monitoring for data collection or managing ofprocesses. A range of patient issues and needscan be identified (e.g. not being able to access aparticular service), shifts and changes withincommunities can be responded to (e.g. sudden‘removals’ of asylum seekers or increasingnumbers of family joining individuals in a particularcommunity), tensions and misunderstandings canquickly be addressed (e.g. confidentiality and trust)and community cohesion issues highlighted (e.g.increasing homelessness).

Partnership working


59

Case Study 15 – Partnership Working

INTRAN Partnership

Contact: The NHS group by emailing [email protected], or David Hewer, NHS INTRANChair, at the same email address

A group of 9 NHS agencies* meet to benchmark and monitor internal performance, shareexperiences of good practice and prevent duplication. All partner agencies access services through aregional commissioning framework and expect therefore, to receive the same level of qualityservices. Each agency appoints a PSI&T champion that acts as the critical link between theorganisation, staff and patients. The champions rely on extensive analyses of quantitative andqualitative data to identify developmental needs and to inform future decision-making. In-depthanalyses are provided centrally prior to meetings taking place.Working in partnership helps problem-solve, increase the in-depth knowledge of individualchampions (who are themselves responsible for justifying the needs for such services on behalf oftheir organisation), gain good ideas, increase NHS staff efficiency, reduce the amount of wasted stafftime when communicating with non-English speakers and sometimes to share costs. Partnershipworking has:• identified gaps in efficiencies, higher usage needs and solutions for addressing them

shared good practice and has therefore been able to improve servicesresearched situations where face-to-face interpreting is essential and situations where telephoneinterpreting could be used more extensivelydeveloped common guidelines and systems on the effective use of PSI&T servicesregularly reviewed the effectiveness of “access points”. For example, acute and mental healthtrusts have worked constructively with primary care agencies to improve patient access andremove barriers at primary care level. This could be something as simple as a surgery informing ahospital of a patient’s need for an interpreterset up controls to make sure that all PSI&T services meet the audit trail requirementscreated a library of translated resources at NHS Norfolk to share with partners without costidentified awareness raising needs by comparing high users to non-usersenabled discussions to be held when usage is significant in some departments in one hospital andnot in othersin instances where acute trust hospitals see patients that could have been looked after at primarycare level, the NHS Norfolk champion consulted the surgeries in question to raise their awarenessof the need for them to access PSI&T services to help reduce preventable demands for secondaryservicesin order to save costs, held discussions relating to the value and required mechanisms in highusage areas of booking an interpreter regularly. Two partners have implemented regular clinicswith interpreters where patients report a high level of satisfaction for the clinical care they receive

Members of the sub-group include:

James Paget University Hospitals NHS Foundation TrustNHS Great Yarmouth and WaveneyNHS NorfolkNorfolk Community Health and Care (about to join the group)Norfolk Drugs and Alcohol AgencyNorfolk and Norwich University Hospitals NHS Foundation TrustNorfolk and Waveney Mental Healthcare NHS TrustQueen Elizabeth Hospital King's Lynn NHS Foundation TrustWest Suffolk Hospital NHS Trust

••

••

••••

•

•

•••••••••

*

60


6.2 Service inclusion model evaluation

It is of vital importance that a process ofevaluation of language support services isinstituted and takes place on an ongoing basis.There are often difficulties reported with regard tothe credibility and trust between ethnic minorityservice users and service providers. Evaluationand monitoring can play an important part inaddressing such difficulties. Communityinvolvement in monitoring and evaluating serviceprovision is a useful means to increaseconfidence in the services being provided.Furthermore, with language support provisionderiving from the community itself, it is afundamental pre-requisite to have meaningfulcommunity participation at all levels. Despite this,it is often the case that there are few systems andprocedures for quality assurance of languagesupport, and monitoring take-up, user satisfactionand operational efficiency are poorly addressed.

Monitoring of services would depend largely uponthe type of service being provided (primary care,community services etc) and upon the form oflanguage support offered (bilingual staff, linkworkers etc). For mainstream servicescommissioners might wish to align somemeasures to the reasonable adjustments theywish service providers to make.

(DH, 2009) as opposed totarget setting and enforcement. This wouldinvolve ongoing monitoring, service user andcommunity consultation via a steering group andperiodic external evaluation by an independent

‘Design and build’approaches to service quality and outcomes, anddevelopment and improvement require ‘risksharing agreements’

agent with expertise in the fields of equal accessand language service provision. Suchindependent evaluation should generaterecommendations for service improvement.

Each agency will have its own internal ways ofseeking user feedback. It is important to point outthat:• New ways of approaching service user

feedback are required for those with limitedEnglish proficiencySuppliers will not seek to retrieve feedbackfrom service users. For example, if a feedbackcard was completed and given to theinterpreter, the likelihood of hearing aboutanything negative would be nil.Agencies could produce simple userquestionnaires translated in top languages.Agencies could be pro-active at promoting thePALS service to their patients.Agencies could have regular surveys, bylooking at statistics and identifying regular staffusers who have contact with the same patients.In such case, they could target their effortsthrough that member of staff.Agencies could produce simple informationleafletsMystery shopping exercisesFocus groups

Service user feedback

•

•

•

•

•

••

“Using photos in this way was fun andreally showed me that I am not aloneas other refugees have the sameproblems and experiences.”16 year old Afghan service user (Stallabrass, 2005)

Table 7Quick Feedback from Service User

Thank you for your time!Translation and Interpreting Project (ISCRE)

Did the interpreter: Yes No

Arrive on time?

Dress appropriately?

Behave impartially?

Show professionalism?

Meet your requirement?

Comment:


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Staff feedback:Staff are also users of the service and thus it isessential to act upon their feedback:• Website facility – to communicate with staff-

users and invite them to complete thequantitative/qualitative survey on the staffwebsite, in order to monitor quantitativelysatisfaction for each commissioned agency andto receive comments and good ideas in thequalitative sectionSuppliers can contact a sample of staff usersevery month and results can be sent to thechampionTargeting staff users through IT surveys, like‘surveymonkey’The champion can support staff who seem tomake ineffective use of the services (if billshigher than should be)

•

•

•

6.3 Reporting performance

In order to coordinate a number of commissioningpartners, different providers for different areas ofservice and the number of service providers usinglanguage support careful consideration will berequired regarding:

The creation of champions within these areasto support staff and service users and provideinformation and experience from the groundlevel to commissioners;Designation of a named lead withincommissioning partners;The most useful and influential place to reportto in order to continue the development oflanguage support provision;Reference to equality and diversity monitoring;Reponses to exception reporting, incidents andcomplaints andWhich particular information and data to collect.

•

•

•

••

•

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Case Study 16 - Monitoring

NHS Peterborough

Contact: Geeta Pankhania NHS Peterborough [email protected]

The NHS has a key Access Target and a statutory duty under the equalities legislation to ensure NHSservices are accessible in compliance with race, gender and disability in particular. Provision ofinterpretation and translation for patients accessing primary and community services (including faceto face for non verbal communications) has been provided by NHS Peterborough for the last 15years. This has been managed trough a central budget for interpretation whilst translation ofinformation has been paid for by individual service areas.Over the last 4 years the need has grown with the increase of diversity in Peterborough and influx ofasylum seekers, refugees and new arrivals in the city. Our population has grown from 153,000 to164,000 currently, with over 100 languages spoken in the city. Approximately 5 years ago our budgetwas exceeding £300,000. Our users have been Primary Care (all GP surgeries, Dentists, Opticiansand Pharmacies), the Walk-In Centre, and Peterborough Community Services. In addition we providefor a Counselling Service with Primary Care referrals, community midwifery services at GP surgeriesand Children’s Centres. All hospital based services are paid for by the hospital contract.Following for the first time a tender process for interpretation and achieving a joint 3 year contractwith NHS Peterborough and Peterborough City Council, the usage was monitored closely for thefollowing elements: quarterly trends of usage for both face to face and telephone interpreting, brokendown by each GP practice or service area e.g. health visiting etc.; location of interpreters, number ofbookings per month and on costs, length of time face to face interpreters were used etc Variations inuse were found and poor use of face to face for short lengths of time which proved to be costly.Following robust monitoring an executive decision was taken to achieve efficiency in use and in costwith an understanding of and commitment to interpreting service provision. Explicit criteria weredeveloped to aid decision making between face to face and telephone interpreting in primary carewith detailed monitoring of face to face use. Through these criteria savings of approximately 50%were achieved (06/07 £305K reduced 08/09 to £153K and 09/10 to £121.5K). HSP also supportedservice areas with one off payment to install telephone lines in dental consultation rooms, providedhands free loud speaking telephone handsets and training in how to use telephone interpretation in avariety of ways and settings and information packs.Important features included:• Good relationships with providers of interpretation services and their cooperation

Good relationships and communications with service usersTop level understanding of the service and supportRobust monitoring systems both from providers of service and commissioner perspective forreporting purposes and responding to Freedom of Information requestsAdapting the service to suit the provider and using ID codes split by each service area, GP practice

etc to enable robust monitoringEnsuring interpretation and translation policies are in place as point of reference. (NHSP policies arepending review until the current tender process is over)

•••

•


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SECTION 7:

7. RecommendationsAcknowledging the case for change

Assessing your local needs andpriorities

Identifying suitable service solutions

Defining and specifying services basedon best practice

• Make communication and language supportcentral to the way care is providedDevelop a clear conceptual framework thatdescribes the differing contexts of languagesupport and recognises the complexities ofcommunicating across language and culturesand allows the professional to achieve effectivecommunication

Collect a range of data not only to identifycommunity languages but more specifically todescribe language support needsCollect, collate and interpret data andinformation in partnership with localcommunities and third sector agenciesEnsure detailed and quality ethnic andlanguage monitoring in all services, includinginterpreting and translation services

Start from the point of view of those whocommunicate in forms other than spoken orwritten English and consider multiplecommunication approaches that will giveservice users choice and take into account theirconcerns, experiences, aspirations and lifestyleDevelop commissioning partnerships withcommunity organisations, voluntary sectoragencies and interpreting services which arecrucial to community needs assessment anddecision making regarding language supportprovisionCreate a language support strategy whichincludes a locally based interpreting andtranslation service with and for localcommunities and ensures every servicecommissioned includes reasonableadjustments and a wide range of options forlanguage support provision

Apply the conceptual framework forunderstanding language needs and the

•

•

•

•

•

•

•

•

language support strategy to every servicedeveloped.Consider the full range of options that areavailable for delivering language support.Decide what outcomes each individual serviceshould deliver and consider how languagesupport options available will support thoseoutcomes for BME communities.

Work in partnership with the education sectorsrequired to develop language skill in localcommunities, provide training and professionaldevelopment for interpreters and support healthstaff training and developmentFamiliarise all NHS staff with language supportoptions available, sources of translatedinformation accessible, the work of otherorganisations locally and nationally that canhelp support service users, legislation,guidelines and policiesEnsure all services users are aware of theoptions available to them and empower them toparticipate in the development and provision ofsupport options and identifying developingneeds and new ideasWork with service providers in health, housing,social care and in the third/voluntary sector toco-ordinate their work together for individualpatients and for communities, share theprovision of link, support and advocacy workersand collaborate on the provision of interpretingand translation services

Actively seek feedback from individuals,communities and staff who are all users oflanguage supportCreate guidelines and policies with clearstandards with means for their monitoring andevaluationEnsure the employment, training, assessmentand deployment of interpreters and translatorsmeets minimum best practice standards toensure safety, efficacy and quality ofinterpreting.Apply robust monitoring systems essential tofacilitating cost effective provision of languagesupportBuild in evaluation of commissioning, planning,service development and delivery from the start

•

•

•

•

•

•

•

•

•

•

•

Working with and developing providers

Monitoring performance

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Glossary

ACL Adult & Community Learning (Suffolk County Council)

APS Annual Population Survey

BME Black and Minority Ethnic

BSL British Sign Language

CINTRA Cambridge Interpreting and Translation

CRB Criminal Records Bureau

CSV Community Service Volunteers

DCSF Department for Children, Schools and Families now Department for Education

DDA Disability Discrimination Act

DH Department of Health

DPS Diploma in Public Service Interpreting

DRE Delivering Race Equality

EELGA East of England Local Government Association

ER Electoral Register

ESA Employment and Support Allowance

ESOL English for Speakers of Other Languages

FOI Freedom of Information (requests)

PLAB Professional and Linguistic Assessments Board (for medical practitioners)

HES Hospital Episode Statistics

HESA Higher Education Statistics Agency

HITS Herts Interpreting and Translation Service

HPA Health Protection Agency

HSA Health & Safety Executive

IAPTS Improving Access to Psychological Therapies Services

ICOCO Institute of Community Cohesion

INTRAN Multi-agency partnership providing language support services throughout the Eastern Region

IPS International Passenger Survey

ISCRE Ipswich & Suffolk Council for Racial Equality

LFS Labour Force Survey

MECAN Minority Ethnic Community Action Network

MHMDS Mental Health Minimum Dataset

Nis National Indicators

NINo National Insurance Number (Registration Data)

NRPSI National Register of Public Service Interpreters

NTA National Treatment Agency

ODPM Office of the Deputy Prime Minister

ONS Office for National Statistics

PALs Patient Advice & Liaison Services

PHOs Public Health Observatories

PLASC Pupil Level Annual School Census

PROMs Patient-Reported Outcome Measures

PSI&T Public Service Interpretation & Translation

QIPP Quality, Innovation, Productivity & Prevention

SRSF Suffolk Refugee Support Forum

TIP Translating & Interpreting Project (Ipswich & Suffolk Council for Racial Equality)

WRS Worker Registration Scheme


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Appendix 1

Regional and national resources

Policy Guidance, Research andSupport

Training and Education

The Scottish Translation, Interpreting andCommunication ForumThe Forum aims to promote good practice in theuse of interpreting, translating and communicationsupport to people whose first language is notEnglish. It also aims to develop high professionalstandards in the use, management and deliveryof interpreting and communication support inScotland. http://www.stics.org.uk/

8 Wellington MewsWellington StreetCambridgeCB1 1HWContact:Mrs Jill Wilkinson01223 346 [email protected]

48 High StreetHemel HempsteadHertsHP1 3AFContact:Mr Ian McKenzie01442 867 212interpreting@communityactiondacorum.org.ukwww.hertsinterpreting.org

INTRAN is a multi agency public sectorpartnership providing language support servicesthroughout the Eastern Region.http://www.intran.org/cms

Working with Interpreters

CINTRA Ltd

Herts Interpreting and Translation Service

INTRAN Partnership

Practical guidelines:- Cost effectivenesshttp://www.intran.org/cms/BestPractice/CostEffectiveness.html- Using interpreters wiselyhttp://www.intran.org/cms/StaffSupport/UsingInterpretersWisely.html- Using translators wiselyhttp://www.intran.org/cms/StaffSupport/UsingTranslatorsWisely.html

Refugee Council provides training for serviceproviders who work with refugees and migrantcommunities and for the communities themselvesand Refugee Community Organisations.http://www.refugeecouncil.org.uk/

TIP provides training for service providers whowork with interpreters, to support best practicewhen using interpreters in Suffolk and a widergeographical area if requested.Contact:Annie ChowProject [email protected]://www.iscre.org.uk/Translation%20&%20Interpreting%20Project.asp?nid=189&pid=185

Diploma in Public Service Interpreting – courseproviders and examination centres in the East ofEngland

York Street CampusLutonLU2 0EZContact:Mr David Farrer0158 256 [email protected]

Refugee Council

Translation and Interpreting Project (ISCRE)

Training of Interpreters

Barnfield College

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CINTRA Ltd

Herts Interpreting and Translation Service

Language Solutions GY

University of Bedfordshire

Chartered Institute of Linguists

8 Wellington MewsWellington StreetCambridgeCB1 1HWContact:Mrs Jill Wilkinson01223 346 [email protected]/Health/Local Government

48 High StreetHemel HempsteadHertsHP1 3AFContact:Mr Ian McKenzie01442 867 212interpreting@communityactiondacorum.org.ukwww.hertsinterpreting.orgHealth/Local Government (Part-time course)

124 King StreetGreat YarmouthNorfolkNR30 2PQContact:Costa Ricardo01493 855 [email protected]

Bedford CampusPolehill AvenueBedfordMK41 9EAContact:Ms Laure Scott01234 793 [email protected]

Website with further information on the Diploma inPublic Service Interpreting:http://www.iol.org.uk/qualifications/exams_dpsi.asp

Interpreting and Translation Services

CINTRA (Cambridge Interpreting andTranslation)

Herts Interpreting and Translation Service(HITS)

INTRAN Partnership

Cintra provides interpreting and translationservices to public and private sector partners inthe UK. CINTRA specialise in providing highlytrained, qualified and security vetted interpreters(in person or by telephone) 24 hours a day, everyday of the year.

8 Wellington Mews, Wellington Street, CambridgeCB1 1HWTelephone: 01223 346870Fax: 01223 309923General email [email protected] email [email protected]: http://www.cintra.org.uk

HITS provide language support services(telephone and face-to-face interpreting,translation, audio recordings and languageassessments) for Health Trusts, Local Authorities,non-statutory sector organisations, commercialand private partners throughout Hertfordshire,Buckinghamshire, Milton Keynes, Oxfordshireand beyond.

48 High Street, Hemel Hempstead, Herts HP13AFTelephone: 01442 867212 (24 hours a day -

seven days a week)0845 4500273 (during office hours)

Fax: 01442 239775E-mail:[email protected]:http://www.hertsinterpreting.org/index.html

INTRAN is a multi agency public sectorpartnership providing language support servicesthroughout the Eastern Region.http://www.intran.org/cms


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National Register of Public ServiceInterpreters (NRPSI)

On Line Sign language IntepretingSignTranslate GP and SignTranslate Hospital

Translation and Interpreting Project (TIP)

More details can be found on

Arthritis Care

NRPSI provides public service organisations, andagencies that they may work through, with aregister of professional, qualified and qualityassured interpreters.The Register lists interpreters who have satisfiedentry criteria in terms of qualifications andexperience, and are subject to a Code ofProfessional Conduct.Public service organisations and agencies thatthey may work through can obtain access to theNational Register via a subscription service. If youwish to subscribe, please go tohttp://www.nrpsi.co.uk/subscription/index.htm

Websites to allow access to BSL interpreting viawebcam link and a talking signing medicalphrasebook of some 500 commonly used phrasesin a medical consultation. This facility is alsooffered for 12 foreign languages including: Arabic,French, Gujarati, Korean, Polish, Portuguese,Punjabi, Somali, Spanish, Turkish and Urdu.http://www.signtranslate.com/programs.php?page=programs

A community-led flexible service within theIpswich and Suffolk Council for Racial Equality(ISCRE), TIP provides interpreting and translationservices to the public, private and voluntarysector in Suffolk and across the UK. This includesaccess to BSL signers.

ISCRE, 46a St Matthew’s Street, Ipswich IP1 3EPTel: 01473 408111/400082Bookings email: [email protected]: www.iscre.org.uk

http://helplines.community.officelive.com/default.aspx

0808 800 4050Monday – Friday 10am – 4pmInterpreting Servicehttp://www.arthritiscare.org.uk/PublicationsandResources/Someonetotalkto/Helpline/Aboutthehelpline

Helplines

Alzheimer Society Helpline

Asthma UK Adviceline

Autism Helpline

Diabetes UK Careline:

Epilepsy

Family Planning Association

0845 300 0336Monday – Friday 8.30am – 6.30pmInterpreting Servicehttp://www.alzheimers.org.uk/site/scripts/documents.php?categoryID=200273

08457 010203Monday to Friday 9am -5pmInterpreting servicehttp://www.asthma.org.uk/how_we_help/adviceline/

0845 070 4004Monday to Friday 10am-4pmInterpreting servicehttp://www.escis.org.uk/Entry/View/The_National_Autistic_Society_Autism_Helpline/20690

0845 120 2960Interpreting servicehttp://www.diabetes.org.uk/How_we_help/Careline/

0808 800 2200Monday to Friday 10am-4pm (6pm on aThursday)Interpreting servicehttp://www.epilepsy.org.uk/services/freephone.html

0845 122 8690Monday to Friday 9am to 6pmhttp://www.fpa.org.uk/Helpandadvice/FPAhelplines


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McMillan & Cancerbackup

Meningitis Research Foundation

Saneline

Smoking

0808 800 1234Monday to Friday 9am-8pmOver 100 languages, ask nurse for an interpreterAlso has helplines in a number of languages:

Arabic 0808 800 0130Bengali 0808 800 0131Chinese 0808 800 0132French 0808 800 0133Greek 0808 800 0134Gujarati 0808 800 0135Hindi 0808 800 0136Polish 0808 800 0137Punjabi 0808 800 0138Turkish 0808 800 0139Urdu 0808 800 0140Vietnamese 0808 800 0141

http://www.macmillan.org.uk/HowWeCanHelp/TalkToUs/Talktous.aspx

0808 800 334424hr helplineInterpreting servicehttp://www.meningitis.org/helping-you/freefone-24-hour-helpline

Every day 365 days per year 6am – 11pmhttp://www.sane.org.uk/News/View/205

NHS Asian Tobacco helpline:Urdu 0800 169 0881Punjabi 0800 169 0882Hindi 0800 169 0883Guajarati 0800 169 0884Bengali 0800 169 0885

Tuesday 1pm-9pm

Asian Quitline:Bengali 0800 00 22 44 Monday 1pm-9pmGuajarati 0800 00 22 55 Tuesday 1pm-9pmHindi 0800 00 22 66 Wednesday 1pm-9pmPunjabi 0800 00 22 77 Thursday 1pm-9pmUrdu 0800 00 22 88 Sunday 1pm-9pmTurkish/Kurdish0800 00 22 99 Thursday & Sunday 1pm-9pmhttp://smokefree.nhs.uk/questions/south-asian-tobacco-use/


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Appendix 2

Bedford and Central Bedfordshire

Cambridgeshire

Local BME and Community Agencies

The projects are listed under their relevantcounty or unitary council base:

Bedford Refugee and Asylum Seeker Support(BRASS)

BME Voice Bedford

The Learning Partnership

Polish British Integration Centre (PBIC)

Below is a list of projects working with asylumseekers, refugees and/or migrant workers. Theinformation is being shared as a sign of goodpractice. Should you wish to find out moreinformation about any of the projects, pleasecontact them directly.

(area covered by Bedfordshire New MigrationPartnership)

offers practical advice to refugees andasylum seekers (not counselling). Address: 27bTavistock Street, Bedford MK40 2RB, Tel: 01234211381, Email: [email protected], Website:http://www.brassbedford.org.uk

makes a contribution toempowering local BME community members tobecome active citizens, influencing local decision-making, with more representation, participationand consultation for the delivery of accessibleservices. Contact: Jasmin Nessa,[email protected]

works with migrantworkers through the Transqual project and theTrain to Gain ESOL Project. Address: 1 SunbeamRoad, Woburn Road Industrial Estate, Kempston,Bedfordshire MK42 7BZ, Tel: 01234 857637,Email: [email protected]. Website:www.learningincommunities.co.uk

aimsto support vulnerable migrants to attend cultureawareness courses with embedded ESOL.Address: Bradgate Road, Bedford, MK40 3DE.Tel: 01234 358100. Email: [email protected] Thise-mail address is being protected from spambots.You need JavaScript enabled to view it

(area covered by theCambridgeshire Migrant Workers & AsylumSeekers and Refugees Network and by theFenland Diversity Forum)

Cambridge Refugee and Migrant Support

The East of England Polish CommunityOrganisation

The Ferry Project

Fenland CAB Migrant Workers Project

The Rosmini Centre

is aproject run by the Cambridge Ethnic CommunityForum providing a first point of contact for asylumseekers, refugees and migrant workers inCambridge City. The project offers advice andsupport with a range of issues and freecounselling services and English language tuition.Address: 62-64 Victoria Road, Cambridge, CB43DU, Tel: 01223 315877 Website:http://www.cecf.co.uk/crms.html

is a voluntary group that providesinformation and support to the Polish communityin Cambridge and the surrounding areas.Services include a “one-stop-shop” in DomPolonia providing assistance with filling forms,translating documents; information on self-employment, employment rights, educationissues and benefits. Address: 231 ChestertonRoad, Cambridge, CB4 1AS, Tel: 07914 49 33 52,Email: [email protected], Website:http://eepco.co.uk

works with the housingcompany Luminus Group to provide housing andskills training for single homeless people.Address: 16 - 24 Mill Close, Wisbech Tel: 01945461106 (Female), Tel: 01945 589905 (Male),SOFA Project: 01945 467596.

supports migrant workers in rural areas. Drop-insessions in Portuguese. Address: 12 ChurchMews, Wisbech, Cambs, PE13 1HL. Tel: 01945464367. Email: [email protected]

provides guidance andsupport for newly arriving and established migrantworkers, offering help with translation, form filling,and family learning opportunities.Address: Rosmini Centre CommunityDevelopment Manager, 69 Queens Road,Wisbech, Cambs, PE13 2PH Tel: 01945 474422,Email: [email protected]

(area covered by Essex Multi AgencyForum)

Integration Support Services (ISS) is a non-profitmaking charity for ethnic minorities, refugees,migrants and other isolated communities, basedin Harlow. Its purpose is to make a positivecontribution to the communities in which it worksand serve to improve the life of both immigrant

Essex


70

communities and the indigenous populationthrough education, support services and welfaresupport. Address: 2 Wych Elm, Harlow, Essex,CM20 1QP, Tel: 01279 639442; Website:http://www.integrationsupportservices.org.uk/index.php

aims to improve the quality of life ofpeople of all ages from migrant communities, tofacilitate integration, promote understanding andreduce isolation in the UK and abroad, andenable migrant communities to maintain their owncultures and heritage. Address: Braintree DistrictCouncil, Causeway House, Bocking End,Braintree, CM7 9HB, Tel: 07976 071722, Email:[email protected], Website:http://revirevi.co.uk/index.html

supports Black and MinorityEthnic (BME) people who live in the Colchesterand Tendring areas. Address: Winsley’s House,High Street, Colchester, Essex, CO1 1UG, Tel:01206 769789 and 01206 50047, Email:[email protected], Website:http://www.tacmep.org.uk

(area covered by HertfordshireMigrant Workers Multi Agency Forum)

is a local umbrellaorganisation which provides a circle of support tovoluntary organisations and community groups,as well as delivering a number of services thatsupport identified community need. The CAD hasmanaged the “Meeting the Information andEconomic Needs of Migrants” (MINEM) project.Address: 48 High Street, Hemel Hempstead,Herts, HP1 3AF. Tel: 01442 253935. Website:http://www.dacorumcvs.org.uk/

is based aroundthe Polish Saturday school. The communities fromWelwyn and Hatfield are going to join an educationproject for children from different parts of thecounty. Contacts: Chair of the Polish Community:Ula Bowdler, Email: [email protected];Head of the Polish Saturday School: Iza Fraser,Email: [email protected]

Contact: Betty [email protected]

REVI (Real and Enthusiastic Voice ofIntegration)

TACMEP (Tendring and Colchester MinorityEthnic Partnership)

Community Action Dacorum

Polish Community in St. Albans

Portuguese Community in Bishop’s Stortford

Hertfordshire

Stevenage Polish Association

Welwyn Hatfield Ethnic Minority Group(WHEMG)

Welwyn Hatfield Polish Forum

Bedfordshire African Community Centre(BACC)

Centre for All Families Positive Health(CAFPH)

British Red Cross

Luton Training & Mentoring (LTM)

runs drop-insessions twice a month in Stevenage Fire Stationand ESOL classes in cooperation with NorthHertfordshire College, Contact: MalgorzataPoczatek, E–mail: [email protected],Website: www.spa.socjum.pl

Contact: Moreen Pascal, WHEMGStrategic Manager, [email protected]

runs ESOLclasses, organises meetings with guest speakersand is planning to open Polish Saturday Schooland Mother and Toddler Group. Contacts: MichalSiewniak, [email protected] ; OlaGoral, [email protected]

(area covered by Luton New MigrationPartnership)

aims to empower, support and assistindividuals and minority groups from the Africancontinent including asylum seekers, migrantworkers and refugees living in Luton and Bedfordareas. Address: The Basement, Aldwyck House,Upper George Street, Luton, Beds, LU1 2RB.Telephone: 01582 484807. Email:[email protected],[email protected], Website:www.africancentre.org.uk/

is a specific service that is peer-led andall efforts are made to involve people living withHIV/AIDS, including asylum seekers andrefugees, in the development and improvement ofservices at all levels. Address: Kingham House,Unit 1, Kingham Way, Luton LU2 7RG, Tel: 01582726 061, Website: www.cafph.org/

The work undertaken by theRed Cross in this area includes providing supportto refugees and asylum seekers. BedfordshireArea Office, 232 Dunstable Road, Luton, Tel:01582 589080, Website: www.redcross.org.uk

aims to look atproviding free customised mentoring support toNEET (Not in Education, Employment or Training)young people aged 14-19 and vulnerable adultsthroughout Luton and Bedfordshire with the help ofqualified, trained and experienced mentors. Address:Luton Training & Mentoring, Community Enterprise &

Luton


71

Resource Centre, The Moakes, Luton, LU3 3QB, Tel:01582 848488, Email: [email protected]: www.lutonmentor.com/

(area covered by Norwich AsylumSeeker and Refugee Forum, Norfolk MigrantWorkers Forum, West Norfolk Diversity Forum,Great Yarmouth GYROS Multi-Agency Forum)

- the project acts as a liaison betweenthe local churches and migrant communities sothat they may have their needs met and integratein the local society; it focuses on the Brecklandarea. Email: Jorge Damesceno,[email protected]

is a meeting groupwhich engages with community members with theaim of representing the voice of asylum seekersand refugees within the Norwich Asylum Seekerand Refugee Forum. Its objectives are to promotelocal and regional policy based on well-informedasylum issues and to produce knowledgeable,skilful and confident community representatives.Address: c/o Red Cross Refugee ResourceCentre, 44-46 St. Augustine’s Street, Norwich,NR3 3AD, Tel: 01603 623041, Email:[email protected]

- thiscommunity programme offers projects for youngpeople, competitions, a library project and varioustraining and workshop opportunities. Address: 14Princes Street, Norwich, NR3 1AE, Tel: 01603877177, Email: [email protected],Website: www.newwritingpartnership.org.uk

is acommunity development and empowermentorganisation working across the boroughs ofGreat Yarmouth and Waveney. Communities aresupported through a whole range of services andprojects. Address: Electra House, 32 SouthtownRoad, Great Yarmouth, NR31 0DU. Tel: 01493656372, Email: [email protected],

Website: http://www.communityconnections.org.uk

aims to bring together the different BlackMinority groups of Great Yarmouth and promotegood relations within the wider communitythrough social and cultural events. Address: 52a,Deneside, Great Yarmouth, NR30 2HL. Tel:01493 851598, Email: [email protected]

Amigos

Asylum Voice (Norwich)

City of Refuge/New Writing Partnership

Community Connections (Great Yarmouth)

Great Yarmouth International Association(GYIA)

Norfolk

Great Yarmouth PortugueseAssociation/Herois del Mar

GYROS (Great Yarmouth Refugee Outreach &Support)

Kings Lynn Area Resettlement Support(KLARS)

META@Keystone

Mid-Norfolk Association (MNA)

NEAD (Norfolk Education & Action forDevelopment):

- one of the group'skey roles is to encourage Portuguese communitymembers to pursue education and training and toimprove their English. The “Boca em Boca”newsletter also provides information and help withaccess to advice and services. Address: c/o CaféArroz dos, 31 King Street, Great Yarmouth.

provides settlement and integrationservices to newcomers to the UK and is the mainpoint of contact in Great Yarmouth for asylumseekers, refugees and migrant workers needingadvice, information or support. Address: 52ADeneside, Great Yarmouth NR30 2HL, Tel. 01493745260, Email: [email protected],Website: www.gyros.org.uk

provides advice and information formigrant workers, asylum seekers and refugees.There are four drop-in sessions every week,where newcomers can get information in English,Portuguese, Russian, Polish and Lithuanian.Address: 14 Tuesday Market Place, King’s Lynn,Norfolk, PE30 1JN, Tel: 07916 201729, Email:[email protected], Website:http://www.klarskl.org.uk/

- META drop-in is a face-to-face information and support service staffed bymigrant workers to help mobile communitiessettle down quickly and effectively. META staffprovide support in 7 languages. The META hotlineis a telephone service providing information tomigrant workers in the Eastern region. Address:Keystone Development Trust, The Limes, 32Bridge Street, Thetford, Norfolk IP24 3AG, Tel:01842 754 639, Email:[email protected], Website:http://www.keystonetrust.org.uk/META/

- projectsinclude “Portuguese school for all”, ESOL classesand youth club activities. Contact:[email protected]

NEAD is a developmenteducation centre working across the easternregion. NEAD promotes awareness and action onlocal and global justice and equality issuesincluding community cohesion, migration anddiversity. The World Voices programme trains and


72

guides local people with backgrounds in othercountries to share their culture in schoolsAddress: Charing Cross Centre, 17-19 St JohnMaddermarket, Norwich, NR2 1DN. Tel: 01603610993, Email: [email protected], Website:www.nead.org.uk

providedservices to asylum seekers, refugees and otherethnic minorities and runs a variety of projectswhich reflect the diversity of its clients. Address:48 St Augustine’s Street, Norwich NR3 3AD, Tel:01603 632816, Email: [email protected],Website:http://www.interfacelearning.org.uk/new_routes.html

Great Yarmouth confidential clinicalservice offes information, advice, assessment,needle exchange, counselling and support foranyone who has an alcohol or drug problem or isconcerned about a relative, friend or colleague.NORCAS also offers counselling services forgambling clients. Some bilingual support isavailable to Portuguese speakers. Address: 59North Quay, Great Yarmouth, NR30 1JB, Tel:01493 857249, Email:[email protected], Website:http://www.norcas.org.uk/

aims to foster social cohesion amongstthe scattered African persons or groups in Norfolkand thus mitigate any feelings or effects ofisolation, social exclusion or racial abuse.Address: 47 Winchester Tower, Vauxhall Street,Norwich, NR2 2SE, Tel: 01603 625470, Email:[email protected], Website: http://www.n-a-c-a.org.uk

is a community group for Frenchspeaking people, especially refugees from Africa.Address: c/o MENTER, 19 Muspole StreetNorwich, NR3 1DJ, Email: [email protected]

- createdfor young people aged 12 - 19 from non-European Union countries who are currently livingin the United Kingdom. The project providesorientation, integration and education. ContactFairlie Winship, Project Co-ordinator Email:[email protected], Tel: 07825 630941

Address: c/oSt Martins Housing Trust, 35 Bishopgate,

New Routes Integration Project

NORCAS

Norfolk African Community Association(NACA)

NORFRESA (Norwich French SpeakersAssociation)

Norwich International Youth Project

Norwich Lithuanian Association

Norwich, NR1 4AA, Tel: 01603 667706, Email:[email protected]

is an independent charity covering thecounty of Norfolk. It works in partnership withcommunities, local, regional and nationalstatutory & voluntary bodies to address issues ofinequality and discrimination. NNREC providesfree advice & information about racialdiscrimination and harassment, equalopportunities and the promotion of good racerelations. Address: North Wing, County Hall,Martineau Lane Norwich NR1 2DH, Tel: 01603611644, Email: [email protected], Website:http://www.nnrec.org.uk/

offers adrop-in service on Mondays and Fridays wherevolunteers are able to provide support and helpwith practical problems. Address: 44-46 St.Augustine’s Street, Norwich, NR3 3AD. Tel:01603 623041, Email: [email protected]

runs drop-in surgeries and cultural activities for migrantnewcomers in the Breckland area and producesthe “Gossip” newspaper. Contact:[email protected]

in Great Yarmouth supportsthe development of a programme linking localresidents, including migrant workers, into training,volunteering and employment pathways. Address:The Neighbourhood Centre, 143 King Street,Great Yarmouth, Norfolk NR30 2PQ, Tel: 01493845925, Email: [email protected],Website: http://www.nvs-gy.org.uk/

aims toincrease the visibility of the migrant Chinesecommunity and to promote cultural activities.Address: 38 Reffley Lane, Kings Lynn PE30 3EQ.

(area covered by PeterboroughMulti-Agency Forum)

provides support toelderly Caribbean people and activities for youngpeople. Address: Millennium Centre, DickensStreet, PE1 5DG, Tel: 01733 562663.

Norwich & Norfolk Racial Equality Council(NNREC)

Red Cross Refugee Orientation Project

Support and integration of Migrantspromoting Legal Equality (SIMPLE)

Voluntary Norfolk

West Norfolk Chinese Association

African Caribbean Forum

Peterborough


73

Bissau-Guinean Association

British Red Cross Refugee Services

Czech and Slovak Community Organisation

Daman Community of Peterborough

Ethiopian and Eritrean Community Association

Lithuanian Community Association

New Link

Peterborough Portuguese Association

Peterborough African CommunityOrganisation (PACO)

c/o New Link,Lincoln Road Centre, 439 Lincoln Road,Peterborough, PE1 2PE, Tel: 01733 864311,Email [email protected]

coordinates services for asylum seekers andrefugees living in the East of England. Address:Brassey Close, Peterborough, PE1 2AZ, Tel:01733 557472, Email: [email protected]

c/o New Link, Lincoln Road Centre, 439 LincolnRoad, Peterborough, PE1 2PE, Tel: 01733864311, Email: [email protected]

(Portuguese community) c/o New Link, LincolnRoad Centre, 439 Lincoln Road, Peterborough,PE1 2PE, Tel: 01733 864311, Email:[email protected]

c/o New Link, Lincoln Road Centre, 439 LincolnRoad, Peterborough, PE1 2PE, Tel: 01733

864311, Email: [email protected]

c/o NewLink, Lincoln Road Centre, 439 Lincoln Road,Peterborough, PE1 2PE, Tel: 01733 864311,Email: [email protected]

is Peterborough City Council's asylumand migration service. It aims at creating a newmodel for managing new arrivals in the UK.Individual projects have been established inPeterborough to achieve this aim. Address: 439,Lincoln Road Peterborough England PE1 2PE,Tel: 01733 864305, Email:[email protected], Website:http://www.peterborough.gov.uk/page-3838

facilitates ESOL classes in Peterborough.Address: 128 Gladstone Street, Peterborough,PE1 2BL, Email: [email protected]

was set up as a means oftackling isolation. PACO addresses this issue byfacilitating contact between people with commonorigins who came to settle in Peterborough.Address: 439, Lincoln Road PeterboroughEngland PE1 2PE, Tel: 01733742801, Website:http://www.pacouk.org/

Peterborough Community Group Forum

Peterborough Women’s Centre

Poor African Refugee Community Association(PARCA)

Somali Community of Peterborough

Anglo- Chinese Cultural Exchange

aimsto increase discussion and information exchangeand to provide a more effective voice forcommunity groups, organisations andassociations in the wider community. Address: c/oNew Link, Lincoln Road Centre, 439 LincolnRoad, Peterborough, PE1 2PE, Tel: 01733864311, Email: [email protected]

focuses onraising awareness of women's issues, rights,education and personal development, and alsopromotes interagency links. Courses offeredinclude ESOL, ESOL for ICT, and there is a pilotgroup for refugee women. Address: 69-71Broadway, Peterborough, PE1 1SY, Tel: 01733311564 or 311568, Email:[email protected], Website:http://www.peterboroughwomenscentre.org.uk/

aims to work towards the full integrationof refugees and asylum seekers. Projects andactivities cover provision of general informationand advice, signposting and referral services,help with training and job search. Address: UnityHall, Northfield Road, Peterborough, PE1 3QH,Tel: 01733 310091, Email: [email protected]@poor-refugee.org, Website: http://www.poor-refugee.org/

offersadvice and support for the Somali community inPeterborough and signposts for housing andeducation services. Address: c/o New Link,Lincoln Road Centre, 439 Lincoln Road,Peterborough, PE1 2PE, Tel: 01733 742801,Email: [email protected], Website:http://scopeuk.org/

(area covered by Suffolk Forum forRefugees, Asylum Seekers and Migrants)

promotesChinese and British cultures and exchangesdetails and learning about everyday lives of thetwo groups. It is hoped that by engaging in theexchange of cultures and arts, understandingbetween the two groups will grow and strengthen.Address: C/o Ipswich Community Radio, CSVMedia Clubhouse, Ipswich, IP1 1RS, Tel: 01473225312/078 67614349

Suffolk


74

Bangladeshi Support Centre

The Basis Project

British Red Cross

CSV Media

Ipswich and Suffolk Council for RacialEquality (ISCRE)

providesinformation, help and support in a culturallysensitive environment; advances the education ofindividuals and the community as a whole;empowers the individual and community andprovides various types of education & recreationaltraining, workshops, and activities for people fromthe Black and Minority Ethnic background.Address: Bangladeshi Support Centre, Ipswich,IP1 3BE, Tel: 01473 400081 Email:[email protected], Website:www.bscentre.org.uk

is an England-wide servicegiving one-to-one support to refugee communityorganisations (RCOs) to help them manage,develop and sustain their organisation. Thecontact person for the East of England is ShpetimAlimeta, Tel: 01473 297 912, Email:

[email protected]

- the work undertaken by theRed Cross in this area includes providing supportto refugees and asylum seekers from their centrein Chevallier Street. Address: 15 Chevallier St,Ipswich, IP1 2PF, Tel: 01473 219260, Website:www.redcross.org.uk

The Clubhouse in Ipswich is a largedigital multimedia centre with music andcommunity art facilities. Amongst CSV's activitiesis work with Millennium Volunteers, the hosting ofIpswich Community Radio and provision ofinformation, and advice and guidance sessions.Address: The Point, 120 Princes Street, Ipswich,IP1 1RS, Tel: 01473 418014, Email:[email protected], Website:http://www.csv.org.uk/Get+Trained/Media+Training/Media+Clubhouse+Ipswich.htm

provides information, adviceand support of a non-financial nature toindividuals and families who have experienced, orare experiencing, racialdiscrimination/harassment or race-relateddifficulties. They also provide training to serviceproviders. Address: 46A St Matthew's Street,Ipswich IP11TE, Tel: 01473 408111, Website:www.onesuffolk.co.uk/ipswichandsuffolkcouncilforracialequality/

Ipswich Suffolk Indian Association

JIMAS (Jamait Ihyaa Minhaaj Al-Sunnah)

Karibu African Women's Support Group

Lowestoft International Support Group

The Refugee Council

Suffolk Refugee Support Forum

Suffolk Inter Faith Resource (SIFRE)

Address:PO Box 757 Ipswich, IP1 9ND Tel: 0844 8844824,Email: [email protected], Website:www.onesuffolk.co.uk/isia

Address: PO Box 24, Ipswich, IP3 8ED Tel: 01473251578, Email: [email protected]

givesinformation and advice to their members,provides help and support and signposts to otherservice providers and also runs different activitiesfor children. Address: 2nd Floor, 1 Cornhill,Ipswich, IP1 1DD, Tel: 01473 289330; 07757 660833, Email: [email protected], Website:www.karibuawsg.org

is asmall organisation run by volunteers, whichsupports refugees through providing free Englishclasses and a help and information service fromtheir office. Address: 15 Surrey Street, Lowestoft,NR32 1LJ, Tel: 01502 501444, Email:[email protected]

- the East of EnglandAsylum and Refugee Integration Service, basedin Ipswich, helps asylum seekers and refugees inSuffolk, Norfolk, Essex, Cambridge, Bedfordshire,and Hertfordshire. Address: First Floor, 4-8Museum Street, Ipswich IP1 1HT, Tel: 01473297900, Website: www.refugeecouncil.org.uk

runs a drop-inadvice and advocacy service for anyone toreceive free advice and support on a broad rangeof subjects from housing and employment to howto make friends and learn English. Address: 38St. Matthews Street, Ipswich IP1 3EP, Tel: 01473400785, Email: [email protected]

wasestablished in 1994 by a group of peoplerepresenting the faiths and cultures of the residentsof Ipswich and Suffolk. Their intent is to promoteunderstanding between people of different faiths.Address: Long Street Building, University CampusSuffolk, Rope Walk, Ipswich IP4 1LT, Tel: 01473343661, Email: [email protected], Website:http://www.sifre.org.uk/


75

The Ipswich Polish Club provides advice in legaland community matters, financial and employmentsupport and all general matters. Address: 57 StMargaret’s Street, Ipswich, IP4 2AX, Email:[email protected], Website:http://www.theipswichpolishclub.co.uk/facilities.htm

Waveney Ethnic Minority Project (WEMP) is avoice for Waveney’s BME population and wasformed in recognition of the emergence of a morediverse Waveney community. Contact: DouglasMhizha-Shayanewako, Tel: 07785 383670, Email:[email protected]

Appendix 3

EQUALITY IMPACT ASSESSMENT: Commissioning framework for language support guidelines

Name of project/policy/strategy (hereafter referred to as “initiative”):

Provide a brief summary (bullet points) of the aims of the initiative and main activities

Project/Policy Manager:Date:

This stage establishes whether a proposed initiative will have an impacton any particular group of people or community – i.e. on the grounds of race

(incl. religion/faith), gender (incl. sexual orientation), age, disability, or whether it is “equalityneutral” (i.e. have no effect either positive or negative). In the case of gender, considerwhether men and women are affected differently.

Q 1. Who will benefit from this initiative? Is there likely to be a positive impact on specificgroups/communities (whether or not they are the intended beneficiaries), and if so, how?is it clear at this stage that it will be equality “neutral”? i.e. will have no particular effect onany group.

Q 2. Is there likely to be an adverse impact on one or more minority/under-represented orcommunity groups as a result of this initiative? If so, who may be affected and why?

is it clear at this stage that it will be equality “neutral”?

Q 3. Is the impact of the initiative – whether positive or negative - significant enough towarrant a more detailed assessment If not, will there be monitoring and review to assess theimpact over a period time? Briefly (bullet points) give reasons for your answer and any stepsyou are taking to address particular issues, including any consultation with staff or externalgroups/agencies.

To produce commissioning guidelines for language support services

: The aimof these guidelines is to support commissioners in the development of coherent and robust evidencebased language support and interpreting / translation strategies and policies, which can be used todeliver culturally competent service provision.

Simon How1/12/10

The main group to benefit from this initiative are community members whose first language is notEnglish and who would have found communicating with their healthcare profession in English achallenge. The expected benefits to this particular group are to overcome the challenges detailed inAppendix 1.However by easing some of the pressure on local services it is expected that there will be a smallpositive impact on the community as a whole, in addition to an increase in community cohesion.In this way the initiative is expected to have a positive impact on equality.

There is not expected to be an adverse impact to other groups as a result of this initiative

A detailed assessment is not required as negative impacts are not expected. However thoseimplementing guidelines at a local level are encouraged to monitor and assess both the expectedbenefits and any adverse impacts not foreseen.

from an equalityperspective

Or

Or


76

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