Bridging the divide

COMMUNITIES across the country are becoming increasingly multicultural. More than 300 languages are said to be spoken in London schools alone and over 7.5 per cent of the total UK population were born abroad.

The trend has had an inevitable impact on UK healthcare provision. Indeed, the significance of language and cultural differences between doctor and patient is such that the BMA has identified them as “the most important barriers to healthcare in Britain”. So how does this affect the role of the practice manager?

At Woodside Health Centre in the north of Glasgow, the patient list is diverse and a growing number of patients speak little or no English. During their GP consultations they require a translator and a double slot is allocated to allow extra time for communication. The most common languages requiring translation are Cantonese, Mandarin, Farsi, Arabic, Punjabi, Urdu and Portuguese.

Manager Cari Blackwood says the main challenges facing the practice arise when patients fail to attend appointments and also in booking interpreters.

She says: “These patients are booked in for a double consultation so when they do not attend that wastes a lot of valuable time. Another problem can occur if the reception staff are busy and forget to book an interpreter or when the interpreter or GP is running late.

“Things are fine when everything runs to schedule but that doesn’t always happen in general practice so a patient might be left waiting for an interpreter or the interpreter has to leave mid-way through a consultation to attend another appointment.”

FLEXIBLE AND FAIR

Despite the occasional problem, Cari says running a multicultural practice does not require much more work than any other practice. “Flexibility and fairness are crucial,” she says.

“We had one instance where a female patient wearing a full veil objected to being asked to briefly remove it to allow staff to verify her identity when registering her. In the end she agreed to remove her veil briefly during her consultation with the GP. You have to be prepared to work around these issues.”

Cari ensures practice leaflets on topics such as contraceptives, smear tests, bowel screening and child vaccinations are available in some of the most commonly spoken languages. The practice also included patients who speak English as a second language in a recent questionnaire exercise to find out their opinion of the services provided, which gave useful feedback.

She adds: “It’s important not to treat patients from other countries differently. Everyone at our practice is treated the same. When registering, for example, all patients have to show their passport and have their ID checked. Managers should make sure practice staff are familiar with the protocols and procedures and that they are applied universally.”

Gorbals Health Centre in Glasgow serves a large multicultural community, with a migrant population including patients from Somalia and other African states. Kathleen Diamond and Janette McMillan share managerial duties at the centre as well as at the practice in nearby Croftfoot Road.

They find the task of communicating with non-English speaking patients and arranging interpreters to be a time-consuming one.

Kathleen says: “We looked at the work of receptionists at both sites and found the staff at the Gorbals centre took around three times as long to do simple tasks such as booking appointments. They are having to constantly repeat themselves and ask if the patient needs an interpreter and then they have to book the interpreter.”

The managers have found many of these patients come from countries affected by war and require treatment for complex health problems including mental health issues.

Janette says: “They present with everything and anything. It’s very varied. There’s a lot of abuse and mental health issues. Some come from war torn areas where they may have watched their family members suffer.”

And there is the additional consideration of patients’ immigration status. BMA guidance Access to health care for asylum seekers and refused asylum seekers – guidance for doctors states that practices are not required to check the identity or immigration status of people registering to join their lists and prospective patients are not obliged to provide evidence in this regard. While practices are not forbidden from doing so, the BMA advises they proceed with caution to avoid discriminating against particular groups of patients.

CULTURAL COMPETENCE

Communication is key within any multicultural practice and it is important that staff are “culturally competent”, which means they know how to effectively interact with patients from different cultural backgrounds.

Many NHS trusts or health boards have practical information available for staff, such as the Cultural Competency Toolkit (www.tinyurl.com/6knxtlk) from West London Mental Health Trust. The booklet aims to fill the gaps in knowledge regarding the culture, customs and practices of ethnic minority patients and highlights the importance of being aware of cultural differences. It urges staff to find out as much as they can about the needs of ethnic minority patients and to try to understand the differences in their values and lifestyles.

One simple example highlights how people of south Asian origins are generally not accustomed to routinely saying ‘please’ and ‘thank you’ – a custom that could be misinterpreted in the UK for rudeness or ingratitude.

The toolkit offers tips to healthcare staff when speaking to patients with little or no English. It recommends speaking slowly and clearly without using jargon or acronyms and without raising your voice. It underlines the importance of regularly checking the patient is following what you are saying but advises against asking “Do you understand” or “Is that all right?” as the answer will almost always be yes. The guidance explains: “Yes is often the first word someone learns in a foreign language, but does not necessarily indicate that they understand.”

Staff are also advised to be aware that people who speak English as a second language may be less able to remember large chunks of information. The guidance recommends providing a simple note for the patient to refer to once they have left.

PATIENT EXPECTATIONS

Recent research suggests there is still room for improvement in the provision of primary care services to patients born abroad. One study suggests a number of practices in England are not meeting the expectations of some of these patients. The latest English General Practice Patient Survey published in September 2011 in BMJ Quality & Safety has found that some patients from minority ethnic groups are not satisfied with NHS primary care services.

Despite efforts to provide a healthcare system that offers universal coverage, the research shows satisfaction is particularly low among people from south Asian and Chinese backgrounds, as well as younger patients and those in poorer health.

Bangladeshi, Pakistani, Indian and Chinese patients gave their practices significantly lower scores for professional communication than either white British or black patients. Researchers say the fact that patients from these ethnic backgrounds tended to be clustered in generally low performing practices accounted for half of this difference for south Asian patients and for 14 per cent of that for Chinese patients.

The authors argue: “Substantial ethnic differences in patient experience exist in a national healthcare system providing universal coverage. If the overall performance of low-performing practices were improved (as is the goal of a series of major UK Government policy initiatives), this would also help improve the patient experiences of south Asian and Chinese patients.”

The research serves as a timely reminder to managers to ensure all the necessary practice systems are in place and that staff are equipped with the right skills to care for the growing multicultural community.

 Joanne Curran is associate editor of publications at MDDUS