INTRODUCTION
It is well recognised that language is central to good communication in all clinical consultations. The national focus on clinical staff being fluent in English is important and proportionate. Recently, a midwife was suspended from the UK Nursing and Midwifery Council Register because of deficient competency in English1 until she is able to demonstrate that she has reached the necessary standard of English for safe practice.2
The General Medical Council (GMC) similarly expects all licensed doctors to:
‘… have the necessary knowledge of the English language to provide a good standard of practice and care in the UK.’3
For those European doctors who are not required by the GMC to pass a national English language test, the current GMC guidance states that:
‘To practise safely in the UK doctors must have sufficient knowledge of English.’4
So why, in Central Midlands, has NHS England felt it necessary to develop guidance for clinicians who may be tempted to consult in languages other than English? The answer lies in the language competencies of our international recruits to general practice in Lincolnshire and the patients who consult them.
THE NEED FOR A FLEXIBLE APPROACH
Lincolnshire, a predominantly rural county in the East Midlands of England, where recruitment and retention of GPs has long been a significant challenge to delivery for the NHS, is the site of an innovative collaborative approach to international recruitment into general practice.
Since 2016, the Lincolnshire Local Medical Committee, working with NHS England and Health Education England (HEE), has recruited a cohort of 26 doctors from several European Union countries, all of whom were trained in family practice in their home countries and eligible for entry to the GMC’s GP Register. Each was appointed to work as a salaried GP in a practice in the county, on a standard 3-year contract of employment. Following an intense period of campus-based training in Poland, the doctors moved to begin life as Lincolnshire GPs, some bringing their families with them.
As a consequence of their lack of NHS primary care experience and to ensure the safety of patients, NHS England, through the national Performers List Regulations, applied conditions on each doctor to allow for a period of suitable supervision and assessment, and the doctors’ participation in ongoing development opportunities.
The pilot scheme includes the triangulation of evidence from different sources to provide assurance that each doctor reaches the standard required for independent practice in UK general practice, and, in this case, often in rural, dispensing, UK general practice. The whole programme is subject to independent academic evaluation, which will in time be published.
DEVELOPING GUIDANCE
One of the assessment methods used is the provision, to the Local Medical Committee and NHS England, of monthly supervision reports by the workplace supervisor, an experienced GP. In one particular area of practice it was observed that doctors were receiving an interesting range of feedback from their workplace supervisors; that is, on the topic of consultations in languages other than English. For example, in one case a supervisor had rebuked one of the international recruits for consulting in his mother tongue when the patient was a native speaker of the same language. Another supervisor reported that English-speaking patients were troubled to hear their doctors speaking to one another in a foreign language in their presence. Until then we had not thought of this as a controversial issue, but now it seemed it needed to be addressed. Clearly, in accordance with GMC expectations, it is not only of paramount importance that international graduates working in the UK health system have excellent English to ensure safe healthcare provision, but it is also worth considering the times when a consultation might best be conducted in another language in which the doctor is competent.
As a result, the author, clinical lead for the pilot, decided, with encouragement from the International Recruitment Pilot Project Board, to draft some advice for workplace supervisors and for the international recruits themselves about the appropriateness, or otherwise, of consulting in and using languages other than English, while seeing and treating patients in the NHS in England.
The foremost principle applied was that every consultation should be conducted in a manner that is respectful of the patient’s background and culture, and best meets their clinical needs. Indeed, the GMC’s Good Medical Practice requires us to communicate effectively with our patients. It says:
‘You must give patients the information they want or need to know in a way they can understand. You should make sure that arrangements are made, wherever possible, to meet patients’ language and communication needs.’3
In a county like Lincolnshire, where a GP’s registered patients come from many different countries, many of them speaking a European language other than English as their mother tongue, on occasion it may well be the best option for doctor and patient to communicate in their mutually most comfortable language. Having said that, it is essential that all medical records and correspondence are kept in English so that they are accessible to all the other clinicians who may need to access them, whose language competence may be restricted to English. Also, where it is important for an English-speaking carer or other third party present in the consulting room to understand the contents of a consultation, it is critical that the consulting clinician explains the consultation clearly to that person.
It was deemed unacceptably discourteous for health professionals to speak to one another in the presence of a patient in a language other than English, when the patient concerned does not understand that language.
The resulting advice, summarised in Box 1, was circulated to international GPs and their workplace supervisors, and, anecdotally, has been found to be helpful. Feedback from HEE East Midlands is that such guidance would be equally relevant to doctors and other clinical professionals working anywhere in the NHS. The same principles apply to communication with patients in any language, including signing, and is certainly not an exclusive issue for doctors from Europe, nor solely an issue for primary care.
Principles
When it is OK
The doctor and patient share a common mother (or other mutually fluent) tongue and both find it easier to communicate with each other in that language. The doctor can add value to the consultation by accommodating the patient’s language needs, which may include signing. The consultation is patient-led. Check at the start of the consultation which language the patient would prefer for their consultation and make a note of that in the patient record. The entry made in the clinical record must be to the same standard as any other clinical consultation, regardless of the language used during the consultation. Where an accompanying person is the patient’s carer, the doctor should ensure that they explain the consultation and any actions needed in the language the accompanying person understands. When it is not OK
If asked by a carer or other accompanying person, not the patient, unless the patient lacks capacity: the patient themselves must, wherever feasible, be empowered to choose the language of consultation when more than one option is possible. For any member of the primary care team to speak with another in the presence of any patient in a language other than English that the patient does not understand. To use when a doctor agrees to video consultations for future review with their clinical supervisor, unless the supervisor is also fluent in that language.
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Box 1. Consulting in a language other than English
The Lincolnshire guidance is now available at NHS England (https://www.england.nhs.uk/mids-east/our-work/guidance-and-information/) and hopefully it will be found useful to others working among groups of health and social care professionals, patients, and service users, who increasingly come from a diversity of backgrounds and bring with them similarly diverse language skills to be embraced and, on occasion, deployed appropriately in the UK NHS context.
Acknowledgments
The author is grateful for the encouragement of the Project Board for the International Recruitment Pilot, chaired by Aly Rashid, NHS England Medical Director for Central Midlands, Nigel Scarborough, Primary Care Dean, HEE East Midlands, and to those practices involve in the Lincolnshire International Recruitment Pilot who responded to our invitation for comments and improvements.
Notes
Provenance
Freely submitted; externally peer reviewed.
- © British Journal of General Practice 2019