Pharmacies and language access

Written by Peter Bates with assistance from Mohammad Mashayekhi

Summary

Some pharmacy patients in England do not speak English. National policy declares that interpreting services should be available in community pharmacies and this position has been reinforced by the UK Government. In contrast, some local pharmacists believe that they have no access to interpreting and translation services and so rely on Google Translate (similar devices are available). Without proper language access in pharmacies, the problems of concordance escalate and this population will be at increased risk. This is dangerous to individuals and increases waste and inequality, but it seems difficult to find out what is happening to improve the situation.

After considerable investigation, I found one local pharmacy that has language access and then, around 100 emails later, was informed that a local healthcare provider offers a language access service to one or two pharmacists in my area – those pharmacy practices that are housed within health centres, but there does not appear to be a list indicating where they are. The feedback I have received to my inquiries suggests that language access to community pharmacy across England is patchy at best, poorly understood and the level of unmet need is unknown.

The need

In the 2011 census, the Office of National Statistics found that 1.3% of the population of England and Wales did not speak English very well, and 0.3% did not speak English at all. If this old estimate is applied to the city of Nottingham, it suggests that over 4,000 people would benefit from language access services.

Evidence from academic research is clear that health outcomes improve when language access is provided (Diamond et al 2019) and that interpreting services need to be good quality (Rayment Jones et al 2021) to reduce the likelihood of dosing errors, under-utilisation of prescribed medication and adverse drug events (Alhomoud et al 2016).

Doctors of the World offer some leaflets about health in more than 50 languages, which is helpful but does not replace an interpreter in a clinical conversation with an individual patient.

In Lincolnshire, there is no language access service for pharmacy, optometry or dentistry or even any funding for interpretation and translation services, so each pharmacy is left to develop their own system. This shortfall has been identified, but discussions are at an early stage.

There is no reason to think that people who not speak English fare any better than d/Deaf people. A 2012 study found that ‘one-third of deaf people left GP consultations uncertain about their condition and a third were unclear about how to take medication or had actually taken the wrong dosage.’

Healthwatch Manchester reported that patients from three communities where English is not their first language found pharmacies to be the health facility they relied upon most during the COVID-19 pandemic. In Gateshead, a survey of Arabic speakers found that GPs were most likely to offer language access, followed by dentists, then opticians, hospital staff, community nurses and last on the list came pharmacists – the group who were least likely to offer an interpreter. In contrast, the biggest need in Sheffield is reported as the difficulty of obtaining interpreters for GP appointments.

Healthwatch Essex noted that interpreters are available via the telephone in GP surgeries and hospitals, but patients may find that the service is not ideal, since (i) the interpreter is not always trained to work in health settings and so information can be literally translated rather than delivered in a way that is informative and comforting for the patient, and (ii) despite the range of languages (over 200) offered by contracted services, there are occasions when confusion is caused as the interpreter speaks a different dialect to the person. Similar findings were unearthed by Healthwatch Gateshead who reported that interpreters sometimes failed to attend appointments or were late, and may not be competent in the particular dialect that was needed.

The situation may be different in the community, since GPs are often running an hour or more late, so an interpreter would need to stand ready for a lengthy time period or would need to take up one of the limited number of fixed time appointments which the doctor can offer. It may be the case that fixed time appointments are more readily available with a pharmacist. Those who investigate the quality of healthcare provision may with to explore the cost attached to these arrangements and the number of failed appointments that were intended to include interpreters caused by excessive waiting times.

People who do not speak English may be invisible in priority-setting systems too. For example, Healthwatch South Tees set their work priorities through community intelligence received through their engagement, information and signposting activities and the need for language access to community pharmacy has not been raised with them. Healthwatch St Helens say ‘this is not an issue that has ever been raised with us’. This may indicate that needs are being well met, or alternatively, that this group are so profoundly excluded that their needs remain unrecognised across the system.

What should be happening?

The Accessible Information Standard requires NHS organisations to reduce health inequalities by removing barriers to its services and taking the following steps:

Identify the communication and information needs of those who use their service.
Record a person’s communication and information needs clearly and consistently on record, recording their needs not why they have those needs, for example ‘requires a BSL interpreter’ not ‘person is deaf’.
Have a consistent flagging system so that it is immediately clear whether the person has a communication or information need.
Share a person’s information and communication needs where appropriate. For example, a GP referring a patient to a hospital including that a deafblind manual interpreter is needed in the referral letter so that the hospital can arrange it.
Meet the communication and information needs identified. For example, send an appointment letter in braille or book an interpreter for an appointment.

Guidance for commissioners: Interpreting and Translation Services in Primary Care was published in 2018 by NHS England and declares:

Patients should be able to access primary care services in a way that ensures their language and communication requirements do not prevent them receiving the same quality of healthcare as others.
Whilst not being able to speak English is not a ‘protected characteristic’ defined under the Equality Act 2010, section 13G of the National Health Service Act 2006 states that NHS England, ‘in the exercise of its functions, must have regard to the need to reduce inequalities between patients with respect to: their ability to access health services and the outcomes achieved for them by the provision of health services.
Reliance on family, friends or unqualified interpreters is strongly discouraged and would not be considered good practice.
Automated on-line translating systems or services such as “Google-translate” should be avoided as there is no assurance of the quality of the translations.
Professionals and primary care staff may use their language and communication skills to assist patients in making appointments or identifying communication requirements, (language brokering) but should not, other than where immediate and necessary treatment is required, take on the role of an interpreter unless this is part of their defined job role and they are qualified to do so. Staff trained and used as interpreters must be covered by indemnity insurance (where clinical staff are bilingual they should use their professional judgement to decide whether they are able to competently communicate with the patient).
Interpretation and translation should be provided free at the point of delivery, be of a high quality, accessible and responsive to a patient’s linguistic needs
Patients should not be asked to pay for interpreting services or to provide their own interpreter.
Where an interpreter is required the primary care provider is responsible for ensuring one is booked.
Data monitoring should include measurements that support future service planning… Number of appointments… language provided… where the service was provided (e.g. …pharmacy)

In relation to point five above, it has been suggested that in multicultural urban areas, patients who do not speak English find their way to bilingual pharmacists, who then ensure that the patient receives help, where necessary setting aside the instructions set out in this point. For example, Healthwatch Leicester and Leicestershire commented that ‘we have a very diverse population in the city and most of the pharmacies will have people who can help where there is need for help regarding different languages’. Shop assistants rather than qualified pharmacists may be pressed into service. This means that pharmacists do use their professional judgement, do not confine their engagement to ‘immediate and necessary treatment’, do not have interpreting written as a distinct element of their job role, are not qualified in interpreting and are not specifically covered by indemnity insurance for issues arising from their language access role. This may be true and if so it would be evidence of a commendable commitment to patient-centred care, but we have not found any evidence of the skewing of the population who attend a bilingual pharmacist or any agency that has collated or distributed information about where bilingual pharmacists are to be found.

Parliamentary Under-Secretary of State for Patient Safety and Primary Care, Maria Caulfield, confirmed that language access services should be available to community pharmacies in her letter dated 9 November 2021.

Local Health and Wellbeing Boards are required to produce and publish a Pharmaceutical Needs Assessment paying attention to “what languages are spoken each day”. During the coronavirus pandemic, this duty was suspended, and the next assessment is due in April 2022.

Healthwatch Tameside promote a number of principles in terms of the use of interpreters:

People who need to use interpreting services in the course of their care and treatment should have equivalent treatment to people who do not use interpreters. This includes timeliness – especially access to unplanned (urgent or emergency) care and access to routine interpretation when being treated as an inpatient (e.g. during ward rounds).
It is normally not appropriate for a family member or friend to act as an interpreter, especially in a health and care context. This is not only because the friend or family member may not be a trained interpreter. It is also about privacy and dignity – they must not feel forced to share sensitive personal information with a family member or friend.
People who need an interpreter should have an opportunity for a family member or friend to join them at their appointment – if this family member or friend already understands their situation and health/care need. This can help the person to feel supported and also allow for the interpreter to receive additional clarification if required. This is very much optional – a reminder for services not to deny a trusted friend to be part of the session, if the patient wants them there.
NHS service providers need to be mindful of their statutory duties under the Equality Act 2010, and also the expectations of the NHS EDS2 (Equality and Diversity Scheme, 2^nd iteration).
In order to meet their obligations to hear feedback from all sections of the community, Healthwatch Tameside has access to their own interpretation and translation services, independent of the NHS.

Action by NHS E&I regional teams

NHS England and NHS Improvement (NHS E&I) have seven regional offices in England.

North West has commissioned three organisations to provide services that community pharmacies can use: Language Line Solutions (telephone interpreting), Global Accent (face to face interpreting) and Action on Hearing Loss (British Sign Language interpreters).
East of England established regional contract with Language Empire from November 2021 that covers all Primary Care contractor groups: Dentists, GPs, Opticians and Pharmacies.
South West has contracted with D.A. Languages Limited, who provide spoken face-to-face interpreting, telephone interpreting, translation and transcription services and British Sign Language interpreting to Pharmacy, Optometry and Dental Practices. All locations should have received an email from D.A. Languages explaining how they can access the service.
Midlands does not currently have any contracts for language access services to pharmacies. In the period to summer 2021, no invoices for interpreting services had been submitted by community pharmacies in this region. Regional offices have a duty to provide a list to enable pharmacies to fulfil their signposting duties, but this does not appear to be available. The Deputy Head of Primary Care Commissioning for the Midlands has responsibility for Pharmacy, Optometry and Dentistry and has confirmed that invoices for these services will be paid and a more comprehensive solution is under development.
South East provides interpretation services for pharmacies to assist in patient consultations in line with national guidelines. Any NHS pharmacy can request the service but take up is quite low across the region – which indicates that either there is little demand, or that pharmacists are not taking up the opportunity.
Anna Ladd at North East and Yorkshire is planning to audit interpreting services and find out about its take-up and impact to inform commissioning decisions (email inquiry sent 14/12/21)
That leaves London where the provision is as yet unknown (inquiry sent 7/12/21).

A neglected issue

There are several reasons for believing that patients are sometimes locked out, including the following:

There is no information about language access or competence in the Community Pharmacy Workforce Survey undertaken in 2021. The Centre for Pharmacy Workforce Studies explored language skills amongst migrant pharmacists employed in the NHS around 2014 but has not looked at language access for patients.
The Community Pharmacy Contractual Framework sets out the core services that must be provided when working for the NHS yet this does not include an obligation to provide a language access service. There is no reference to interpreting services in the Community Pharmacy Contractual Framework 5-year deal: year 4 (2022 to 2023) and year 5 (2023 to 2024). The need for pharmacy patients to have language access has not found its way through to the Pharmaceutical Needs Assessment framework for local population and there are no references to language or interpreter services in the Nottinghamshire PNA documents. On 23 November 2021, I was notified that the matter will be raised at the next meeting of the Nottinghamshire Local Pharmacy Committee.
NHS England and NHS Improvement can commission pharmacies on a local basis to provide a Language Access Service. This is an optional ‘enhanced’ service, which commissioners may establish in some rather than all pharmacies as set out in paragraph 14 of the Pharmaceutical Services (Advanced and Enhanced Services) (England) Directions 2013. Pharmacies without a language access service have a duty to signpost patients to those that do.
The national negotiating body, the Pharmaceutical Services Negotiating Committee, provides a list of advanced and enhanced services commissioned in local areas, but no language access services appeared in its list dated 21 September 2021.
A written inquiry to the 18 community pharmacies in postcode areas NG1 and NG2 during July 2021 asking for information about language access yielded no replies. Inquiring further afield is hampered by the lack of email addresses in the General Pharmaceutical Council’s register. Anecdotally pharmacists often rely on Google Translate or a family member, demonstrating their concern for the patient by setting aside NHS guidance in the absence of other options.
The chair of Nottinghamshire Local Pharmacy Committee indicated in September 2022 that they would welcome a service but explain that they are not a commissioning organisation.
NHS 111 have access to interpreters but will not help with pharmacy issues and may misdirect patients by asserting that community pharmacies do have language access services when they don’t.
Inquiries to the local Clinical Commissioning Group, Sustainability and Transformation Partnership and Integrated Care System reveal that language access is not widely understood. The matter has never come to the attention of the Chief Executive of the Dispensing Doctors Association and does not appear to have been directly tackled by local Healthwatch organisations.
Healthwatch Leeds have been told that community pharmacies, despite being NHS services, do not have access to translation at present and would welcome it. Local commissioners are considering the merits of providing language access at a small number of pharmacies in some target areas, using Winter Access Funds.
Boots ran a pilot project in a few of its pharmacies around the country in 2019, but this has been discontinued.

Could family doctors do it?

According to the Dispensing Doctor’s Association, almost four million patients in England and Wales receive dispensing services from their General Practitioner rather than a pharmacist and 15% of the 7,000 GP practices provide this service. The main reason given for doctors to dispense is the rural location, where the patient lives more than a mile away from a pharmacist, but another permitted reason can be where where the patient has satisfied the Primary Care Organisation that they would have serious difficulty in obtaining any necessary drugs or appliances from a chemist by reason of inadequacy of means of communication.

Some 320,000 people live in the city of Nottingham but only one GP practice appears in the list of Dispensing Practices (Table 2) published by NHS Digital. The website for that GP practice indicates that dispensing is only available from its rural branch rather than in the city, and only for patients living more than a mile from a chemist, saying nothing about provision for patients who face communication challenges.

We might predict that (i) patients who do not speak English are more likely to be found in urban rather than rural settings; (ii) people who do not speak English would have some difficulty in mounting an argument to satisfy the Primary Care Organisation of their need to be looked after by a dispensing doctor; (iii) workload pressure on GPs is so high that few family doctors would be willing to take on this additional role, and so (iv) both GP and pharmacist would prefer pharmacists to have a language access service provided directly. Healthwatch Worcestershire observe that there is no right of appeal on the decision to deny patients access to a Dispensing Doctor.

So whilst in theory and in the absence of a better solution, it might at first glance appear to be entirely reasonable to ask GPs to dispense to patients who do not speak English, in practice this is a non-starter, since established Dispensing Practices are almost entirely located in isolated rural settings. The Local Medical Committee simply referred my inquiry to the Local Pharmacy Committee.

Finally here, we note that one way to manage excess demand for healthcare is to nudge people with common ailments away from medical practices and into community pharmacies. One might imagine the patient who does not speak English following the crowd to their pharmacy where they are told that language access is not available, so they should make their way to the doctor’s surgery since interpreters are available there. On arrival, they find that the surgery has introduced an intercom access system. Notices written in English direct the bewildered patient towards online and telephone booking systems replete with complex decision trees and several minutes of general recorded information.

The contribution of Healthwatch

Healthwatch have a role in scrutiny of NHS performance, but their catalogue of report titles suggests that they have not yet examined the provision of language access services in pharmacies. They have done some work in relation to pharmacy access by d/Deaf people and people with learning disabilities and also addressed the question of access to other primary care services by people who do not speak much English. Email addresses for Healthwatch are listed here and an inquiry was sent to all 149 local Healthwatch organisations in England during November and December 2021, yielding the following responses:

The findings from various Healthwatch teams already mentioned in this webpage emphasise the importance of language access in pharmacies.
Healthwatch Liverpool are collecting views to feed into their local Pharmaceutical Needs Assessment as are Healthwatch Worcestershire. Healthwatch Liverpool have met one person who has used a language access service in a community pharmacy. the Pharmacy Network representative at Healthwatch has emailed all community pharmacists with the code for them to use when booking a Language Line interpreter to make sure that the information is at their fingertips.
Healthwatch Central Bedfordshire and Healthwatch Bedford Borough jointly facilitated a Focus Group with people from the D/deaf community on 20^th November 2021. The group were to be asked about access to health and social care services, the impact of digital deprivation and discrimination, what services they have used and what challenges they face, plus their thoughts on how services can be improved. They kindly agreed to include pharmacies in their purview.
Healthwatch Lewisham reported on the difficulties that d/Deaf people experience in gaining access to interpreters.
Healthwatch teams in Hackney, Norfolk and Reading are participating in a project run by Healthwatch England (contact Lily Bishop) which is investigating the experiences of people who have communication challenges and need to attend an NHS appointment in the absence of a friend, relative or interpreter. Such situations are covered by the provisions of the Accessible Information Standard. They have not looked specifically at language access to pharmacies, have not come across anything relevant and expect to report by mid March 2022.
Healthwatch Enfield report that “There is a need to audit the take up of translation services in relation to primary care access…” Healthwatch Shropshire will add the issue to the topics they check out at pharmacies during their Enter and View assessments in 2022.
The following Healthwatch teams declared that they have not done any work on this issue but offered to explore the matter: Bexley, Birmingham, Brent, Bristol, Bury, Carlisle, Central Bedfordshire, Devon, Halton, Havering, Leeds, North Yorkshire and Shropshire. The following responded to an inquiry by indicating simply that they had not looked into this matter in their local area, although several of them kindly provided information that was helpful to this inquiry: Healthwatch Bromley, Cambridgeshire & Peterborough, the City of London, Derby, Ealing, East Sussex, the Isle of Wight, Islington, Newham, Redbridge, Sefton, Sheffield, Southampton, South Gloucestershire, South Tees, Stockport, Swindon, Trafford, Wakefield, Walsall, Waltham Forest, Wandsworth, Warwickshire and York.

Rays of hope

On the bright side, as mentioned above, Nottingham CityCare Partnership CiC have said that interpreters who attend a consultation with a GP will sometimes stay on and accompany the patient to the pharmacy. However, this will only happen when the pharmacist is housed in the health centre rather than on the High Street, and it is an unfunded act of goodwill.

NHS E&I (Midlands) have indicated that they intend to put a contract in place for all community pharmacies across the region.

The pharmacy at Nottingham’s large general hospital, the Queen’s Medical Centre, is open to the public as well as serving patients who are being treated at the hospital, and has access to telephone interpreters through its contract as an NHS Trust. Patients with language support needs can use this hospital pharmacy as if it were a community pharmacy.