A large proportion of people living in Ireland do not speak English as their first language. Sarah Gallagher investigates the challenges this poses to healthcare access and whether interpretation services need to be improved
According to the Central Statistics Office, the number of Irish residents who speak a language other than English or Irish at home increased by 19 per cent between 2011 and 2016, a rise of nearly 98,000 people. Ireland has seen huge diversification of its population in recent years and one result of this is the significant increase in foreign language speakers.
In 2017, the Immigrant Council of Ireland (ICI) published the report Language and Migration in Ireland. Of the participants who had difficulties understanding English in certain situations, medical institutions posed the biggest challenge, according to the report. Participants reported problems comprehending technical language and professionals speaking quickly. Some reported that they could not communicate their problems effectively to healthcare professionals. This means that the provision of well-structured interpretation services within the healthcare setting is especially important.
The regulation of translation and interpretation services is challenging and requires a “whole-of-Government approach”, according to a leading researcher in the field.
Dr Mary Phelan (PhD), Lecturer in Spanish and Translation at Dublin City University (DCU) and Chairperson of the Irish Translators’ and Interpreters’ Association, believes the system for interpretation in hospitals, and other areas, is flawed. She considers that regulation should recognise that in a country as small as Ireland, interpreters are not likely to specialise and, instead, work in a number of different settings.
“You need to give people time to get qualified,” Dr Phelan told the Medical Independent (MI). “… You need to give [trainers] time to train the people, you need to get trainers for different languages; that can be very complicated to do… you can’t do all that overnight.”
In addition to being well trained, interpreters need to be well paid, Dr Phelan said. She believes if there was an incentive in place to be trained, interpreters would probably be more likely to undergo training.
“There’s no point in somebody just setting up a course and hoping that interpreters will do it, because why would they do it?” Dr Phelan said. “Why would they go to the expense of paying for a course and doing a course if there isn’t something at the end of it?”
Dr Phelan was part of a HSE-commissioned working group which wrote a report in 2018 that identified barriers and ‘levers’ to implementing trained interpreters in healthcare consultations in Ireland.
Levers included the possibility that technology can provide access to interpretation in rural and remote areas; that patients can feel trust in trained interpreters; and that “emphasising clinical risk resonates with the importance placed by HSE management on quality and risk”. Some of the barriers identified were the lack of resources for a comprehensive interpreting service; the lack of political will for a whole-of-Government response; the lack of training and certification of interpreters; racism and ethnocentrism; the lack of training for staff to work with trained interpreters; and poor working conditions for interpreters.
Ms Fiona Finn, who works with Nasc, a Cork-based NGO for migrants and refugees, works primarily with newly-arrived Syrian refugees. She also believes that regulation is required among medical interpretation services in Ireland.
“In the UK, it’s very highly regulated; it is a specific qualification, so you cannot set yourself up as an interpreter unless you have this very specific qualification,” Ms Finn told MI. “At the moment [in Ireland], you have agencies who are employing people in the local community to come and interpret for them. So even when the service is available, the quality of the service then can be very patchy; quality assurance isn’t there.”
She also highlighted a specific area of healthcare in which access for migrants and refugees is extremely difficult. “The other … chronic issue for that particular group, as well, is access to mental healthcare services, and the availability of translators in that context.” In Ms Finn’s experience, interpretation services for mental healthcare are more difficult to access than physical healthcare, because of how skilled an interpreter has to be in that situation.
“It’s not as simple as repeating verbatim what someone has said,” she explained.
National Intercultural Health Strategy
Measures have been taken by the HSE to improve problems in the area of interpretation, through its 2007-2012 National Intercultural Health Strategy (NIHS), and the second NIHS 2018-2023. The latter strategy was due to begin in early 2018, but commenced in early 2019. A HSE representative told MI that the launch was “scheduled at a time to ensure that there was maximum participation”.
The HSE said that translation and interpretation services are to be overseen by the HSE’s Intercultural Health Governance Group. The second NIHS lists multiple aims that are intended to mitigate communication problems between doctor and patient. Among these is the strategic objective of “developing a model for interpreting provision across the HSE”. Under this objective are strategic actions, which include the need to “provide training to staff in working effectively with interpreters,” and “finalise an appropriate model for the phased implementation of interpreting provision across the HSE”.
A HSE spokesperson told this newspaper that implementing the 2018 working group report “would require a Government decision and have implications across a number of Government departments”.
“In the interim, the HSE requires that any interpreting service is provided by reputable companies, and constantly monitors feedback,” according to the spokersperson.
In response to a query from MI about whether it would address the lack of regulation in patient interpretation services, the Department responded: “This is an operational matter, how the HSE decide to recruit their translators is a matter for them to decide.”
Dr Maitiú Ó Tuathail uses interpreters on a regular basis. He is a GP member of the Safetynet service, which delivers medical care to vulnerable populations, including migrants and refugees.
Safetynet’s Mobile Health and Screening Unit (MHSU) is a healthcare service that travels the country to fulfil the healthcare needs of disadvantaged populations, and Dr Ó Tuathail is its clinical lead. When working in this unit, Dr Ó Tuathail uses interpretation services “every single day” because of the number of languages spoken by Safetynet’s patients.
There is a group of about 10 interpreters working with agencies who are regularly hired by Safetynet, and whose interpreting skills are “very, very good,” according to Dr Ó Tuathail.
While there are quality services available to the Safetynet team, these services come at a price. According to its website, Safetynet receives funds from a number of bodies, including the HSE Social Inclusion Unit. Dr Ó Tuathail told this newspaper the HSE does not directly fund the provision of interpreting services to Safetynet.
“It’s probably the biggest cost that Safetynet faces outside of salaries, in terms of the migrant side of Safetynet… we have a team of one GP and two nurses, and that would be three interpreters, and then we would also have to use phone interpreters for people who come from other nationalities,” he said. “… We would use interpreters at least three days a week, so it’s a significant expense to Safetynet.”
Also, Dr Ó Tuathail pointed out he does not find using online translation tools like Google Translate helpful in a medical setting. He describes the method as “totally unsafe” and says that it “really should be totally discouraged — that’s the worst option.”
Dr Ó Tuathail added that the HSE Social Inclusion Unit does directly fund some interpreters for a small number of GPs, specifically in areas with high refugee populations like Waterford, and Ballaghaderreen, Co Roscommon. “To be honest, it’s what we should have always expected but I think it is a very welcome development, because I think the language barrier is a significant issue for GPs,” he said. “But in some cases, GPs are having to either use relatives [of patients] or actually have to pay for their own interpreting services, and neither of those are right.”
A GP from Ballaghaderreen said that the HSE does pay for interpreters to provide interpretation during visits to his GP practice. Dr Martin Garvey, who works at Willow Brook Medical Centre in Ballaghaderreen, told MI that the HSE provides such services to his practice through a Galway-based interpretation and translation company called Context.
Dr Garvey said that “the area would have a large number of families that settled in the environs who got work through the meat factory in Ballyhaunis during the 1980s”. He said the services are satisfactory.
“The patients get to know them, and they will often act as intermediary between the patients and the hotel and pharmacy,” he said.
Dr Garvey described the interpretors as “very obliging”.
According to Dr Ó Tuathail, “what we’re seeing more and more is this particular department of the HSE, the HSE Social Inclusion, they are either providing face-to-face interpreters or phone interpreting services to these GPs, which is a relatively new development. But I have to say for the GPs providing the service, it’s a very welcome development.”
However, Dublin GP and former IMO President Dr Ray Walley said that while there are interpretation services available to GPs in Ireland, information about them is not circulated often enough. This leads many GPs to believe they are not in place.
“I don’t think this exists but there should be a pack… handed out by every primary care GP unit, to every incoming GP [to tell them] ‘this is something available nationally, this is something available locally.’ But I’m not aware of that happening.”
A HSE spokesperson confirmed there is no “set national policy or centrally-held budget for interpretation services for GPs” and that “funding for same is managed locally at Community Healthcare Organisation (CHO) level”. They stated that when GPs require interpretation services, funding must be requested from existing resources within the CHO, and “GPs are advised to contact their relevant local HSE office”.
In general, hospitals and health clinics pay for their own interpretation services from their allocated budgets, according to the spokesperson.
Ms Teresa Buczkowska is Integration Team Co-ordinator with the ICI. Previously, she worked as a Polish-English interpreter with an interpretation agency. The agency would call her when someone nearby needed an interpreter, and often it was a Polish-speaking patient with a hospital appointment.
While she no longer interprets as a job, she hears anecdotes about the quality of services through her position in the ICI. She identifies persistent flaws in the interpreting system, and does not believe that it is improving.
Ms Buczkowska told MI that though she is confident in her English, she should have been screened or trained before commencing work for the agency. “Nobody really checked my qualifications as an interpreter, nobody checked my working standards and ethics, and also funnily enough, nobody checked my level of English,” she said. “And obviously, interpreting in medical situations, you need a little bit of knowledge about technical terminology — in relation to illnesses and diseases, and medical procedures, and nobody really checked that… I wasn’t even given a training [sic] in this area.”
Ms Buczkowska has heard people complaining to the ICI that, sometimes, there is no interpreter for them at a hospital visit, after calling to check that one would be provided. “They arrived for the appointment and there was nobody there, so the appointment couldn’t go ahead.
“I mean, it was a choice of the patient… whether they wanted to go ahead or not,” she said, “and they decided not to go ahead because of the concern that they might not understand everything that’s being said to them, and they said that they wanted to reschedule.
“Still, we don’t really have any attempts to provide standards in the interpretation, so people are still using friends, families; sometimes I’ve heard even about situations when adult parents are using underage children for the interpretation.” Ms Buczkowska said this is ethically unsound.
Family and friends
Dr Ó Tuathail also finds using family and friends as interpreters to be inappropriate, calling it “the second-worst option” after Google Translate. “GPs always need to be mindful of things like domestic violence and [issues] like that, and they’re things you really can’t look out for if you’re using either a friend or a family member as an interpreter.”
Dr Walley finds the interpretation services that are accessible through the HSE to be useful. “I have found the system, when I use it, timely, accessible and good.” However, he uses it as a “back-up service”, largely relying on family, friends and people living locally to interpret. He finds using interpreters “impersonal”. However, Dr Walley uses family and friends with caution, as he is aware of social and cultural issues that can create significant issues between patients and family members.
Mr Niall Rooney, legal counsel with Medisec, said that assuming express consent has been given by the patient, Medisec’s position is there is no issue of confidentiality or data protection regulations with bringing a friend or family member to translate a medical appointment. He also said that it is important to note that sometimes, in this context, there will be times when it is inappropriate for at least certain friends or family members to act as interpreter.
“The choice of relative to act as interpreter can be challenging in cases of suspected abuse or undue influence, and equally it may not be appropriate for a minor to act as interpreter in certain situations, such as where the mental health of a parent is being discussed or an intimate examination is required,” he said. “We would urge our members to consider each situation on its merits and to exercise their best judgement.”
Mr Rooney said that “while professional interpreters are not always readily available, many of the communication difficulties experienced by our members can be addressed satisfactorily by taking practical steps.”
These practical steps include using plain English when communicating with patients, using an “appropriate web-based translation service”, asking patients to bring a family member along to an appointment, or asking them to write down symptoms and medications.