The experience of the Covid-19 pandemic has highlighted a number of significant issues in our healthcare system. Much focus has been placed on inequitable outcomes, particularly for Maori and Pacific populations . We know about this inequity because we collect data.
There is an important sector of our population for which we have very limited data but which, intuitively, must have inferior health care; those with a language barrier. Although there are bilingual suppliers in general, this is the group of people who have limited English proficiency (LEP).
How can a clinician provide good care if he can’t talk to his patient?
How many interpreters do we need?
We have very imprecise information on the number of people likely to need the services of an interpreter. The census asks about language and 1.9% (4.4% in Auckland) are known to speak only one language other than English. These people cannot do without an interpreter. There are still 16% (27% in Auckland) who speak two or more languages but not Maori or New Zealand Sign Language. Most of this group will speak English and another language, but an unknown number of these people do not speak enough English to receive adequate health care. Australia has a similar number of migrants and their census (2016) asks more useful questions. 3.5% answered that they spoke another language and English not at all well, 17% spoke another language and English well or very well and 6.4% did not answer. A reasonable estimate of the number of people who would need an interpreter for a consultation would be 5% of the population. If this were applied to New Zealand, that would be 235,000 people.
Use of interpreter
The government does not collect data on the use of interpreters. I have contacted all DHBs, interpreter providers and the Department of Business Innovation and Employment (MBIE) language assistance program to try to establish what is currently being provided. Data are of poor quality but there were at least 250,000 interpreted consultations per year in DHBs and primary care. We do not know what average number of consultations per year can be expected. However, given that the person with the highest number of interpreted consultations in Nelson had 69 consultations in one year, a rate of one interpreted consultation per person per year for all health care is clearly insufficient.
Code of rights of health and disability users
Right 5 gives the right to effective communication. Where necessary and reasonably practicable, this includes the right to a competent interpreter. When the rights code was established, most interpretations were done in person and this was the reason for the “reasonably practical” qualification. It is very difficult for a clinician to assess the competence of an interpreter, other than knowing their training and certification. Now, with the availability of professional telephone and video interpreters, it is no longer tenable in most cases not to hire a professional interpreter.
Interpreters provided and funded at the hospital
The problem of inequality due to the language barrier can be largely solved by the provision of interpreters and the MBIE has a language assistance program. They engaged Ezispeak to provide interpreting services to the core public service 24/7. In the health sector, this means that all hospitals have access to interpreters. The predominant modality is telephone interpretation, but this has recently been extended to in-person interpretation.
Unfunded Primary Care Interpreters
The Ezispeak service is not available for primary care. In primary care, there is no explicit budget for interpretation services and primary health care organizations (PHOs) are expected to enter into their own contracts with language service providers. There is a small budget for ‘Access Enhancement Services’ (AIS) which is only available to Maori, Pacific and people in deprivation index quintile 5 (the most deprived quintile ). Access to interpreters differs across the country. The three Auckland DHBs and Nelson DHBs fund primary care interpreting from the DHB budget (and in Nelson’s case a contribution from PHO SIA funding). Given that a large portion of those who need an interpreter live in Auckland, that’s fine. However, this is a classic case of postcode health care; quality of access determined by where you live.
Even with full funding, Australia has low use of interpreters in primary care and has come up with strategies to improve this. Without adequate funding, our adoption in New Zealand is likely to be much worse.
Interpreters and COVID-19
Due to the epidemic nature of Covid-19, if one person receives poor care due to lack of an interpreter, it can have a major effect on the whole community.
We know that the Delta outbreak in Auckland has occurred significantly in the Pacific community. What we don’t know is what proportion of those affected did not speak English. However, the outbreak could only be brought under control once providers in the Pacific Community received the resources to address these issues. South Auckland GP Dr Api Talemaitoga said:
During the first lockdown, he says some patients were telling their GP they had received a call, ‘from someone they don’t know from a place they’ve never heard of, talking about palagi about things they don’t understand, ‘and I just said yes so they hang up the phone’”.
Now that there is significant Covid-19 in the community, a new need has been identified. The health system has relied on primary care to care for most of these people. Much of this care is delivered remotely. Patient care providers who do not have congruent language clinicians told the Department of Health they were unable to do so without interpreters.
Fully funded interpreters for COVID-19 patients in primary care
As a result, the Ministry of Health has announced an initiative to fully fund interpretation for primary care services caring for people suffering from Covid-19.
Like the approach of funding Pacific Services to carry out contact tracing, this is because the nature of Covid-19 is that inequities in access have consequences not just for the affected community, but for the whole of the 5 million team.
Why don’t we fund primary care interpreters all the time?
If funded interpreting is necessary to provide satisfactory care for patients with Covid-19, why is it not available to provide care for all other conditions?
New Zealand has accepted refugees from around the world for the past 30 years. On arrival most do not speak English. Nelson DHB introduced its interpretation of funded primary care following the acceptance of refugees in the area. But what about refugees outside of Auckland and Nelson?
An important question addressed by the Royal Commission of Inquiry into the Terrorist Attack on Christchurch Masijida was the importance of social inclusion. They identified that both the perpetrator and the victims would have benefited from greater social inclusion. It is not possible for someone with limited English proficiency to be socially included without interpreters.
Australia has had a fully funded national interpreting service for 50 years. Why are we taking so long to provide this essential basic service in primary care?