Written communications about radiology appointments are routinely sent in English only from NHS Trusts, not accounting for the needs of the patient’s first language, warns a new report from the Healthcare Safety Investigation Branch (HSIB).
The HSIB came to this conclusion after undertaking an investigation into written patient communications generated by systems that book patients in for clinical investigations such as diagnostic tests and scans (X-ray, CT or MRI). The NHS may use paper-based or fully electronic systems or a combination of the two (hybrid) and the communications sent to patients will include date, time, location of their appointment and the actions they need to take for the appointment.
The report emphasises that, for patients whose first language is not English, there is a risk that they may not attend the appointment or, if they aren’t able to understand a specific requirement this could prevent the procedure taking place and it being cancelled on the day. There is then additional risk that the patient can be ‘lost to follow-up’ – they aren’t tracked, and appointments aren’t rescheduled. All of this can lead to a delay in diagnosis and timely care.
The safety impact of sending communications solely in English was seen in the reference case HSIB examined. A 3-year-old child of Romanian ethnicity was booked in for an MRI to check for and ‘rule out’ cancer. In the case, the family travelled to two appointments that were then cancelled because there was a fasting requirement for the scan (as it was under general anaesthetic). The family had not been able to recognise this specific need because both letters had been sent in English. There was also an 11-week gap between the first and second appointment as the radiology booking team did not receive confirmation of the need to book another. The third appointment (scheduled a day after the second cancelled one) went ahead and the MRI confirmed the child did have cancer. Despite treatment, the disease progressed, and the child sadly died.
HSIB conducted a search of a national incident database, which revealed that 34 incidents in a year (March 2021-February 2022) had been related to issues of keeping track of patients rather than due to a lack of capacity to undertake clinical investigations. In several of those cases, the patient’s treatment options and prognosis was adversely affected by the delay. The search showed that these incidents were reported across the country in different disciplines, indicating that this is a widespread issue and not related to a single trust.
The national investigation examined the wider context of clinical investigation booking systems failures. As it progressed, it was clear that there was a particular issue relating to written communication and community languages. This was evidenced through detailed analysis of the reference case, visits to trusts and interviews with NHS staff and national organisations.
- All the Trusts that HSIB spoke to said that they provided interpretation services for face-to-face, telephone and video appointments. However, none of them routinely provided written communications, in relation to appointments, in languages other than English.
- NHS staff were quoted as saying the expectation was that “a family member or neighbour” would translate letters for patients. NHS England guidance for translation services in primary care suggests that this not good practice and ‘strongly discouraged.’ Whilst this is not replicated in NHS guidance on written communications, many felt this principle should still apply.
- The investigation identified that the NHS Accessible Information Standard excludes non-English language interpretation and translation (other than for disability) and there is no comparable standard for non-English written communications.
- Information on the language needs of patients are inconsistently captured or not recorded at all. For example, all the letters seen by the investigation were generated by booking systems that didn’t have options to select to translate into a different language. There is a national system with patient demographic data which can populate electronic patient records. This can include written communications preferences. However, the investigation identified that quite often information is not there or is outdated.
- There can be a disconnect between the perceptions of senior Trust staff and administrative staff that are speaking to patients daily. In one Trust the investigation spoke to, the senior governance team asserted that they had little demand for letters to be translated as their patient population were predominantly white British. However, administration staff in the same Trust told HSIB that they would make calls to patients and find that they were unable to communicate in English. This happened several times a week.
- There are concerns around cost, feasibility and additional resources needed to translate written communications. The investigation highlighted that non-attendance to appointments is also costly and consumes resources in an already pressured environment. The report sets out an example of a Trust that had noticed a disparity between white British patients and ethnic minority patients in non-attendance for respiratory appointments. The Trust had run a pilot scheme with interventions to reduce this. As well as improving patient care, the Trust told HSIB that the ‘saving in terms of clinical time far exceeded the investment required to reduce the non-attendance rate.’
The report sets out the views and perceptions at a national level. The Equality and Human Rights Commission (EHRC) considered that HSIB’s investigation highlighted a ‘gap that needs to be remedied urgently’. When asked about the NHS Accessibility Standard, some individuals in national organisations considered that not including community languages within this standard was a missed opportunity. It would ensure this area of inequality was highlighted and was something trusts were measured against. NHS England told the investigation that there were future plans to scope the issues around community languages, including interpretation and translation.
As a result of the investigation, one recommendation has been made to NHS England on developing and implementing a standard for healthcare providers on supplying written appointment information in languages other than English.
Matt Mansbridge, National Investigator, said: “Our investigation shows that the translation of written communications poses a particular risk for patients if their first language is not English. When compared to services provided for face-to-face appointments, the gap in provision is clear. Unfortunately, that gap has the potential to create delays in diagnosis – sometimes for conditions that are life-changing or life threatening. Multiple changes and cancellations and confusion over what people need to do for appointments is also distressing for patients, who may already be anxious about undergoing radiology scans or tests.
“Some Trusts are implementing changes to their written communications, and we have acknowledged that there is immense pressure and backlogs within radiology departments. However, the NHS does have a duty to ensure that services reflect and are tailored to the needs of all their patients, their families, and carers. Having a consistent translation service that covers all communication supports the patient experience, could reduce the number of missed appointments, and saves cost and resource This is why we made a recommendation specifically on creating a standard that covers written communications in other languages – it is a step forward in ensuring that every patient has the access they need to tests, treatment and follow-up care.”
View the full report here.
