Policy guidance for cross-cultural communication: learning from the RESTORE journey

Kate O’Donnell, Nicola Burns, Frances MairGeneral Practice & Primary Care, University of Glasgow

Today’s presentation.

• To describe rationale for this work.• To outline the methods.• To present key findings.• To present our policy recommendations.

Background.

Increasing migration worldwide. “Super-diversity” (Vertovec, 2007).Health systems need to recognise and respond to this. http://www.global-migration.info/

Population Flows in Europe, 2005 – 2010.

http://www.global-migration.info/

Europe.

In 2013 for EU-27

20.4 million (4.1%) citizens from outwith EU-27.

13.7 million internal migrants.

160-180 languages.

But, not just about language ….

Non-verbal communication.Shared understanding.Cultural understanding.

RESTORE: REsearch into implementation STrategies to support patients of different ORigins and language backgrounds in a variety of European primary care settings. http://www.fp7restore.eu/

Funded by the European Commission FP7 Health Programme, contract number 257258.

Aims of RESTORE.

• Identify and map guidelines and training initiatives designed to support cross-cultural communication in European primary care.

• Select and, where necessary adapt, a set of G/Tis for implementation.• Map the co-design and implementation journey, involving multiple

stakeholders.• Identify and map the impact of health care policy on that journey.• Draft policy recommendations to support cross-cultural communication.

Rationale for our policy work.

• Different health care systems, migrant rights and policies impact on the way in which migrants and health care professionals encounter and interact with each other.

• Importance of policy environments in which RESTORE implementation journeys were situated.

Migration

Policy

External forces

Health care system

Task 7.1• Description of migration profile in each RESTORE country.• Description of health care system in each RESTORE country.

Task 7.2

• Identification and analysis of policy relating to language and communication in primary care setting for migrants at EU and RESTORE country level.

Task 7.3

• Qualitative interviews with EU and national stakeholders; analysis of policy-relevant data from WPs 3 to 6.

• Synthesis of data generated across Tasks 7.1 to 7.3.

Policies must address at least one of the following

Primary care and migrant health issues

Language and/or cultural competence in migrant health

Language and/or cultural competence in primary care

Country case

summaries

Migration profiles & health system review

Policy analysis

Elite stakeholder interviews & CAPES

Recommendations

Data synthesis.

Key questions1. Where in the policy environment is cross-cultural communication situated?

2. What does the policy environment consider in relation to cross-cultural communication? 3. At what level are these policies operating and how?

4. Where policy does exist, what monitoring is taking place? Are the results of monitoring being used within primary care?5. Does the primary care structure support the implementation of such policies?

6. What resources are in place to support policies on cross-cultural communication? 7. Do countries with established diverse communities have better policy support for cross-cultural communication?8. Are there other wider factors which support/hinder the implementation of policy?

Overarching findings

• Rapid and increasing diversity of migrant populations in all countries.• Rights to health care entitlement (and language support) varies across

countries and across migrant status.• Primary care, as a system, varied across countries.• Migrants’ knowledge of primary care also varies – may be important in

countries with strong primary care systems.• Health care policy for cross-cultural communication often focuses on

interpreting; little attention paid to cultural communication.• Wider pressures – austerity, health system reorganisation – has major

impact on health of migrants.

Statement Legal frameworks and Acts help to frame migrants rights, but often do not give them any legal rights to language support

The evidence Charter of Fundamental Rights of the European Union and Council of Europe state rights to access health care, but recognise language barriers. However, legal enactment lies at Member State level.Little evidence this has occurred. For example, while the 2010 UK Equality Act (covering both England and Scotland) provides a legal framework for public bodies to pursue equality, there is no legal right to provide interpreting support for patients. Thus interpreting and translating services are not always prioritised.

Recommendation Council of Europe recommendation that professional interpreters be used to ensure effective communication for migrants should be upheld and enshrined as a legal requirement across member States.

Statement The location of policies to support cross-cultural communication may be situated in several different policy arenas.

The evidence Legal rulings in several RESTORE countries, e.g. Austria, enshrine the rights of patients to be able to give informed consent. In the UK, the need for doctors to communicate effectively with all patients was explicitly raised by the General Medical Council’s Good Medical Practice guidance as a professional requirement.Interviewees in Ireland recognised that effective communication was also tied to person-centred care and informed consent.

Recommendation Situating support and enabling cross-culture communication may be better placed within patient safety legislation.

Statement Wider political and health system challenges can render cross-cultural communication “invisible”.

The evidence In Greece, the economic crisis and austerity measures pushed on any concerns about cross-cultural communication; instead, focus was on access.In England, extensive health system re-organisation led to a lack of clarity about who was responsible for providing and funding interpreting services.Wider structural determinants were acknowledged in Irish Intercultural Health Strategy, but austerity measures removed opportunities to move from strategy to action.

Recommendation The right to effective communication, through an interpreter, is as fundamental a right to good health as the right of access to health care. This needs to be protected in difficult times, such as economic downturns or major re-organisation.

Statement Increasing diversity of the workforce will improve cross-cultural communication.

The evidence In several countries, increasing the diversity of the workforce was seen as a strategy to improve cross-cultural communication.While this may be regarded as a useful adjunct, it is at odds with previous international work advocating use of trained, professional interpreters to facilitate communication.

Recommendation Support for cross-cultural communication should not rely on increasing the diversity of the workforce to provide interpreting and communication support.

European Union• The Council of Europe recommendation that professional interpreters be

used to ensure effective communication for migrants should be upheld and enshrined as a legal requirement across Member States.

• In order to address the right to informed consent, health systems will have to address interpreting rights. Member States should consider making access to an interpreter a legal right.

• Member states should move to align their rights to entitlement for migrant populations, improving access to health care – as well as to language support - between countries for all migrant groups.

• The right to effective communication, through an interpreter, is as fundamental a right to good health care as the right of access to health care. This needs to be protected in difficult times, such as economic downturns or major re-organisation.

National Government/Health service

• National health systems need to ensure that patients can communicate adequately to ensure that patient safety is maintained at all times. Situating support and enabling cross-culture communication may this be better placed with patient safety legislation in each country.

• National health systems need to engage with all providers of care – including social insurance and private insurance organisations) – to address who funds what, for whom and when.

• A strong primary care system provides a setting which facilitates the use of professional interpreters due to its structural advantages. Additional requirements such as resourcing and the removal of financial barriers to patient access must also be addressed.

• Support for cross-cultural communication should not rely on increasing the diversity of health system’s workforce in order to provide interpreting support.

• Health systems need to recognise that the needs of established BME groups within each country may not align with those of newer migrant groups. In particular, capturing data on minority ethnic use of health care does not equate to migrants’ use of health care.

• Host countries need to find ways of informing migrants about the health care system they may wish to use in a way that acknowledges the impact of previous experience. This needs to ensure that migrants do not feel stigmatised when they do access health care.

Professional bodies/Universities

• Cultural competence, and working with interpreters, needs to become a key component of undergraduate and postgraduate training across all health care professions.

Research community

• The role of community interpreters, who could both interpret and act as a cultural guide or advocate, needs to be further developed and evaluated.

• If a goal is to improve staff cultural competence, attention must be paid to how this is provided, funded and – of particular importance – assessed.

• Research is needed into the cost-effectiveness of providing interpreters, from a health system and societal perspective.

The start of a new journey …..

• Dissemination of the recommendations:• Council of Europe; EU Commissioners; WHO; IOM.• Government and health service level in partner countries.• Professional bodies.