Introduction
This investigation focuses on the systems used by healthcare providers to book patient appointments for clinical investigations, such as diagnostic tests and scans. Clinical investigation booking systems are used throughout the NHS to support the delivery of patient care. Healthcare services use either paper-based or fully electronic systems, or a combination of the two (hybrid systems), that communicate to patients the time, date and location of their appointment. These systems also produce information for patients about actions they need to take to prepare for their appointment. Written patient communication is a key output of clinical investigation booking systems.
The investigation seeks to examine why patients are sometimes ‘lost’ to booking systems, leading to delays in clinical investigations. It also examines the safety implications of patient communications produced by booking systems not following the needs of the patient. To explore the issues involved, the investigation used the following real patient safety incident, referred to as ‘the reference event’.
This interim bulletin highlights a safety risk identified by the investigation to date and presents a safety observation for the attention of NHS care providers.
Reference event
A child of Romanian background was referred for an MRI scan which required a general anaesthetic. A scan was booked, and a letter was sent to the child’s parents. The Trust where the scan would take place knew about the family’s Romanian background and their need for translation services when they attended appointments. However, all written communication was sent in English.
The family were able to understand the key details in the written information, such as the time, date and location of the scan, but did not understand the implications for the child not eating or drinking (fasting) for a certain amount of time before the scan. When they went to the Trust for the scan appointment, the child had not fasted. This meant the scan could not be completed and was cancelled.
Following the cancellation, the MRI scan was not rebooked for 11 weeks as the referral was lost in the booking system. When it was rebooked, a further letter was sent with the appointment details, including the need for fasting. The child was brought to the scheduled scan appointment, but again had not fasted. The scan was cancelled and rebooked for the following day, when it was carried out.
This period of care had an impact on the family, who had to travel to the Trust, which was some distance from their home, on two occasions without the scan being carried out. They also experienced anxiety and distress while waiting for a diagnosis. There was also an impact on the Trust’s time and resources, as available scan slots were not used.
During face-to-face appointments at the Trust, the child and their family received translation support. This support was not replicated in written communications such as appointment letters and pre-appointment instructions. The investigation was informed that the Trust’s hybrid booking system did not support the production of appointment letters in languages other than English, and that there was no Trust policy stating that staff should consider translating written documents.
National context
In 2012, the Department of Health stated:
‘For those of us who need support in accessing information, health and care professionals as ‘information givers’ have a vital role. Professionals need excellent communication skills for sharing information and for communicating with us in ways that the person receiving care can understand. This includes thinking about language and interpretation support and ensuring that all communications are in formats that each of us – as the individual recipient of the care – can understand.’ (Department of Health, 2012)
The provision of non-English language interpretation or translation (for reasons other than disability) is out of the scope of the Accessible Information Standard (NHS England, 2017). However, one of the guiding principles of the NHS, as reflected in the NHS Constitution (Department of Health and Social Care, 2021), is that ‘the patient will be at the heart of everything we do’, including that care ‘should be coordinated around and tailored to, the needs and preferences of patients, their families and their carers’.
National guidance exists which states:
‘If a patient requires interpreting and translation to access appointments and health-related information, they will also likely require interpreting and translation services for other communications with health services. This includes booking, cancelling and rescheduling appointments, and reading appointment letters.’ (Office for Health Improvement and Disparities, 2017)
However, further guidance cautions that:
‘Reliance on family, friends or unqualified interpreters is strongly discouraged and would not be considered good practice.’ (NHS England, 2018)
Emerging safety risk
The investigation has identified issues with written communication to non-English speaking patients and their families.
The investigation has found that trusts have relied on patients having access to friends or family who can translate written communications for them. The expectation to use friends or family for this purpose means that patients may have no choice other than to share private and personal information which they ordinarily would not. This reliance can create opportunities for misunderstandings, or issues of control where relationships or cultural influences may influence the information passed on.
HSIB has identified translation options being used by other industries that have a need to communicate to customers, users or patients.
These include embedded translation functions within commonly used word processing software applications, which will translate a document as it is created. HSIB is also aware of services such as gov.uk Notify, a platform that public services can use to send text messages, emails and letters which includes the option of translated communications. The investigation has not assessed these approaches for validity of translation or compatibility with systems currently used in trusts. However, their existence demonstrates that the translation of written communication for patients may be both possible and feasible. Such translation enables more robust information sharing while enhancing patient support and experience. It also reduces the waste of resources that occurs when patients attend for an appointment, but the planned procedure cannot go ahead.
HSIB makes the following safety observation
Safety observation O/2022/198:
It may be beneficial for NHS care providers to explore options for the translation of written appointment communications, including pre-attendance guidance, for patients whose preferred written language is not English.
References
Department of Health (2012) The power of information: putting all of us in control of the health and care information we need. Available at https://assets.publishing.service.gov.uk/ government/uploads/system/uploads/attachment_ data/file/213689/dh_134205.pdf (Accessed 22 September 2022).
Department of Health and Social Care (2021) The NHS Constitution for England. Available at https://www.gov.uk/government/publications/the-nhs-constitution-for-england/the-nhs-constitution-for-england (Accessed 12 October 2022).
NHS England (2017) Accessible information: specification v.1.1. Available at https://www. england.nhs.uk/wp-content/uploads/2017/08/ accessilbe-info-specification-v1-1.pdf (Accessed 25 October 2022).
NHS England (2018) Guidance for commissioners: interpreting and translation services in primary care. Available at https://www.england.nhs.uk/ wp-content/uploads/2018/09/guidance-for-commissioners-interpreting-and-translation-services-in-primary-care.pdf (Accessed 30 September 2022).
Office for Health Improvement and Disparities (2017) Language interpreting and translation: migrant health guide. Available at https://www.gov.uk/guidance/language-interpretation-migrant-health-guide (Accessed 30 September 2022).