Even though you might not notice them at first, you will see them if you walk into the outpatient waiting area of any major hospital in London on a weekday morning. With her mother sitting motionless next to her, a girl, perhaps thirteen, is half-tucked into her school uniform and using a cracked phone to scroll through Google Translate. A boy who doesn’t know the word for “dialysis” in Sylheti is translating a consultant’s remarks regarding his grandfather’s kidneys, pausing every few seconds. These scenes have an odd politeness. No one says anything. With a gentle smile, the nurses continue their work.
This is one of the more subdued aspects of the contemporary NHS, and it coexists awkwardly with the official guidelines. There is a framework. The obligations under the law are obvious. Nevertheless, a child who ought to be in double maths is frequently the most trustworthy interpreter in the room throughout London.
In the UK, about a million people speak little or no English. That statistic has been used so frequently that it has lost its impact, but it shouldn’t. Individuals who are unable to follow a clinician’s instructions are more likely to receive an incorrect diagnosis, miss appointments, and wind up in A&E with an illness that should have been discovered sooner. Speaking with general practitioners in east London, it seems like everyone is aware of this, but nobody is quite sure how to address it. Budgets for translations are limited. There are wait times for phone interpreting lines. By default, written correspondence is still sent in English.
The cost of all of this became extremely clear after the HSSIB investigation a few years ago. A referral for a child’s MRI scan that required general anesthesia was given to a Romanian-speaking family. More or less, the spoken interpretation was successful. The written letter did not; it was sent in English and stated the date and time, but it made no mention of the need to fast. The scan was canceled. The system lost the referral. Eleven weeks went by.
The same thing occurred when the next appointment was scheduled. A day later, the scan was completed. The youngster passed away. The report was cautious to note that the system failure was the point, even though early detection might not have altered the result. A letter in the wrong language, a hybrid booking platform that couldn’t handle anything but English, and no policy telling staff to think twice.
Reading the results from HSSIB and Lord Darzi’s September 2024 investigation, I was struck by how frequently these failures occur in the same postcodes. In short, those who are most in need receive the least amount of care, according to Darzi’s straightforward explanation of the inverse care law. In reality, that means a teenager translating an oncology consultation while attempting to maintain her composure for the benefit of her mother in places like Newham or Tower Hamlets. It refers to a fourteen-year-old learning vocabulary such as “biopsy” prior to his GCSE biology class.
The patchwork is intended to be fixed by the NHS England framework, which was released this year. It is now officially required of commissioners and ICBs to provide consistent, excellent translations for both spoken and written materials. It remains to be seen if that permeates a bustling district hospital in Hounslow. Trusts are overextended. The acquisition of interpreting services is not uniform. Certain boroughs consistently employ formal language, while others subtly rely on the person who shows up with the patient.
This is something that Britain is reluctant to examine. Coordination of services around patient and family needs is mentioned in the NHS Constitution. For hundreds of thousands of people, the coordinating is actually done by family members, many of whom have not yet reached puberty. Healthtech investors are constantly promoting AI translation tools as the solution; perhaps some of those will be useful. However, a parent’s face cannot be read by a phone app. It is something that a child can, does, and brings home.
Until someone determines that the cost of not fixing it is greater than the cost of fixing it, it is difficult to avoid the conclusion that this will continue to occur. The framework is a first step. Money, willpower, and the awkward question of who gets heard in a hospital that is supposed to listen to everyone will determine whether it develops into anything more.
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