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Written on 27th April 2023 by Susan Brown

A report by the healthcare watchdog, HSIB, has warned that written communications used by NHS booking systems may result in diagnosis and treatment delays for non-English speaking patients with serious or life-threatening conditions.

HSIB’s report, Clinical investigation booking systems failures: written communications in community languages, followed an investigation into the safety risks of written communications generated by the systems used by NHS trusts to book patient appointments for clinical investigations, such as diagnostic tests, x-rays and scans, when those communications do not account for the needs of the non-English speaking (or reading) patient.

HSIB identified that whereas face-to-face appointments are often interpreted, standard booking system letters offering appointments and giving instructions for diagnostic appointments are not translated. This results in confusion,  cancellations and delays in diagnosis and treatment of patients with potentially life-changing or life-threatening conditions.

HSIB’s reference event - delays in diagnosis of child’s cancer

HSIB’s report highlighted the experience of a Romanian family whose three-year-old child died from cancer after misunderstandings and errors in communication about a diagnostic MRI scan led to delays in diagnosis and treatment. The hospital trust’s booking system generated a letter, written in English, which was sent to the family giving an appointment for the MRI scan. The family recognised some of the appointment details, such as the date, time and location of the scan, but did not understand the fasting instructions saying that the child should not eat or drink before the scan, which was to be performed under general anaesthetic. They attended twice for scans which were then cancelled because the child had eaten. There was also an 11-week delay following the first appointment as the radiology booking team did not receive confirmation that another scan needed to be booked. When the MRI scan finally took place it confirmed that the child had cancer, but treatment was unsuccessful and the child died.

HSIB calls for NHS written communications to meet the needs of all patients

HSIB’s report highlights that census data from 2021 shows that 4.1 million people (7.1% of the population) in England and Wales could speak English but not as their main language. A further 880,000 people (or 1.5%) could not speak English well and 161,000 (0.3%) could not speak English at all. In 2019, the Organisation for Economic Co-operation and Development (OECD) reported low literacy skills in 16.4% of adults in England.   

HSIB point out that although there is no standard requirement for provision of non-English-language interpretation or translation (unless for disability), the NHS’s constitution says that patients must be ‘at the heart of everything the NHS does’, and that NHS services ‘must reflect, and should be coordinated around and tailored to, the needs and preferences of patients, their families and their carers’.  NICE guidance on communications for patients with cancer says that appropriate information should be provided ‘in terms of language, ability and culture’. However, HSIB found that the NHS needs to do more to meet the needs of patients who cannot read and fully understand standard written booking system communications to avoid cost of cancellations and harm from lack of follow-up and diagnostic or treatment delay.

HSIB’s findings included:

  • Written communications from NHS trusts about radiology appointments are routinely sent in (only) English, and do not account for the patients with a different first language.  All NHS trusts interviewed by HSIB said that they provided interpretation services for face-to-face, telephone and video appointments, but  none routinely provided written communications about appointments in non-English languages.
  • Healthcare staff expect written appointment information that is sent to patients to be translated by the patient’s family or friend, even though this is ‘strongly discouraged’ in NHS England guidance for translation services in primary care (such as by GPs). 
  • Patients’ language needs are not always clearly understood, with differing national guidance about whether the patient’s communication needs should be recorded. Information about the patient’s preferred form of written communication is often not entered into the national NHS patient information system. 
  • Senior NHS trust staff do not take into account the experience of administrative staff when assessing and testing electronic booking systems before implementation. HSIB heard from a trust’s senior governance team that they had little demand for letters to be translated as most of their patients were white British, whereas the administration staff in the same trust reported making several calls each week to patients who could not communicate in English.
  • Concerns about the cost, feasibility and resources needed to translate written communications did not take into account the greater cost of unattended appointments.  HSIB reported the improvements in patient care and savings in clinical time experienced by a trust which had implemented interventions to reduce the disparity between white British patients and ethnic minority patients in non-attendance for respiratory appointments.  
  • HSIB identified that confusion about the requirements for appointments leads to additional costs of rebooking appointments and may also result in delayed patient care.

HSIB’s findings have been endorsed by the Equality and Human Rights Commission (EHRC) which considered that this investigation has highlighted a ‘gap that needs to be remedied urgently’.

HSIB has made a safety recommendation that NHS England now develops and implements a standard for healthcare providers on providing written appointment information for patients in languages other than English. Meanwhile NHS England has advised that there are future plans to explore the issues around ‘community languages’, including interpretation and translation.

Delays in diagnosis and treatment

HSIB’s investigation revealed that booking system written communications which fail to take into account the language needs of patients are having a widespread safety impact across multiple disciplines of healthcare in different trusts across the country. HSIB’s search of the national database for serious safety incidents in healthcare revealed that from March 2021 to February 2022, there had been 34 incidents related to issues with keeping track of patients (via follow up) rather than any lack of capacity to perform clinical investigations. In several of those incidents, the patient’s treatment options and prognosis had been adversely affected by the delay.

Delays in investigations and scans for any healthcare condition cause additional worry and stress for patients and their families at what is already a difficult time. For some, the harm that results from delays caused by preventable communication errors is catastrophic, leading to the death of a patient who should have been saved, or to a lifetime of disability, psychological injury and pain.

If the NHS is to meet the challenges of these difficult times, it must address inequalities at all levels and stages of patient care. Boyes Turner welcome the findings of HSIB’s investigation, in the hope that it will result in changes which reduce delays and avoidable harm in patient care.

If you have been severely injured as a result of medical negligence, or have been contacted by HSIB/HSSIB, CQC or NHS Resolution, you can talk to one of our solicitors, free and confidentially, for advice on how to respond or make a claim, by contacting us.