How inequality creates sick people and sick

communities and why migrants are particularly at

risk

RCGP Clinical Champion for Social Inclusion Clinical Reader in Primary Care Research amp GP

Primary Care Clinical Sciencespsgillbhamacuk

Provide an overview

bull Inequalities

bull Migration

bull Focus on Cardiovascular Disease

bull Some challenges and solutions

Provide an overview

bull Inequalities

bull Migration

bull Focus on Cardiovascular Disease

bull Some challenges and solutions

lsquoIf we believe that men have any personal rights at all as human beings they have an absolute right to such measure of good health as society and society alone is able to give themrsquo

Aristotle (gt 2000 years ago)

Reviews of socially stratified health inequalities

1980 The Black Report drew attention to the marked differences in morbidity and mortality rates between individuals in the top and bottom social groups

1998 The Acheson Report showed that although these rates had fallen in all social groups the differences in rates at the top and bottom of the social scale had increased

Inequalities widening

West Midlands - The Increasing Gap in Life Expectancy

70

72

74

76

78

80

82

84

91-93 92-94 93-95 94-96 95-97 96-98 97-99 98-00 99-01 00-02 01-03 02-04 03-05

Lif

e E

xp

ect

an

cy -

Years

Gap between Local Authorities with Highest and Lowest Female Life Expectancy

Gap between Local Authorities with Highest and Lowest Male Life Expectancy

33 years

38 years

40 years

49 years

2005 DH Tackling Health Inequalities A Programme for Action confirmed lsquodespite improvements the gap in health outcomes between those at the top and bottom ends of the social scale remains large and in some areas continues to widenrsquo

2010 Marmot Review Fair Society Healthy Lives identified social inequalities as root causes of health inequalities

In t e r n a t io n a l m ig r a t io n

bull This is not new

bull Since very dawn of humanity people have migrated

bull 191 million people may now live outside their country of birth over 13 million of them refugees

bull Globalisation has transformed demographic structure of large cities

bull Expansion of European Union

Migration phases framework

Migration to UK

Know little about the first people who inhabited Britain except that they were from else where ndash immigrants

This is NOT new

Before 1066

1000-150 BC Celts

43-410 AD Romans

800-1000 AD Danes

1066 Normans

1066-1900

1555-1833 Slaves from West Africa

1830-1860 Irish migration

1900 -

1933-45 Refugees from the Third Reich

1948-71 Caribbean

1950-71 West Africa Hong Kong ISC

1968-76 East African Asians

1990 - Eastern Europeans refugees amp asylum seekers

C H DB r e a s t c a n c e r

Muller-Nordhorn J et al Eur Heart J 2008 0ehm604v2-11

Age-standardized mortality from cardiovascular disease ie ischaemic heart disease and cerebrovascular disease combined in European regions (men age group 45-74 years year

2000)

SMR for IHD in men (20-74 yrs)

Bangladeshi 151 ( 136-167)

Pakistani 148 (138-158)

Indian 142 (137-147)

Irish 124 (120-127)

White 100

Caribbean 62 (58-67)

Chinese 44 (36-54)

Gill in httpwwwhcnabhamacukseriesbemgframehtm

Possible explanations for the excess CHD risk amongst BMEGs include

possible differential susceptibility to established risk factors (hypertension hyperlipidaemia smoking diabetes) along with exposure to ldquoemergingrdquo risk factors (insulin resistance early life factors racism factor X) and migration

BC BA I P B C I General

Men 25 21 20 29 40 21 30 24

Women 24 10 5 5 2 8 26 23

Self-reported cigarette smoking status by minority ethnic group and sex HSE 2004

Societal influencesIndividual psychology

Biology

Activity environment

Individual activity

Food Consumption

Food Production

Some health care challengeshellip

05

2 5

Childhood Old AgeMiddle Age

Symptoms

No Symptoms

Symptom threshold

SECONDARY

PREVENTION

PRIMARY PREVENTION

CHD Prevention optionsCHD Prevention options

Natural Course of CHD

Natural Course of CHD

Hanlon Capewell et al 1997

0

200

400

600

800

1970

1973

1976

1979

1982

1985

1988

1991

1994

1997

2000

SourceWHO statistics 2005 Men aged 35 - 74 Standardised

Per 100000Per 100000

USA

CHD mortality rates started falling long before effective treatments used widely

Goldman amp Cook 1984 Annals Int Med 1984 101825) Beaglehole 1986 BMJ 1986 292 33

CABGrArr ThrombolysisrArr StatinsrArr

New Zealand

Studies indicate that approximately 45ndash75 of the recent fall in CVD deaths in industrialised countries was as a result of prevention activities

Around 25ndash45 of the decrease was due to treatment

Capewell Heart 2009941105

Julian Tudor Hart Glyncorrwg

Disease register screening and management of CVD

Inverse Care Law (1971)

The availability of good medical care tends to vary inversely with the need for it in the population served

hellipconsultations in deprived areas

time constraints greater morbidity less patient enablement greater practitioner stress

RCGP Scotland Time to Care Health inequalities deprivation and General Practice in Scotland

Prof Graham Watt lsquoIn at the Deep Endrsquo

Secondary Care

Pharmacist

Primary Care

Dentist

LA

SELF CARE

Voluntary sector

Social Worker

Provision of Health Care

90

Common Barriers to Access

Low levels of cultural competency in staff

Case complexity diagnostic and other

overshadowing

Negative previous experiences of

services

Health not a priority

Communicationlanguage and literacy

Inflexible processesIncluding registration and

Appointment systems

Transport and other costs

Lack of understanding ofrsquosystemrsquo rights and

responsibilities

Discriminationstigmatisation

Challenges ndash language diversity

bull Overcoming language barriers to health care is a global challenge

bull 6500 languages spoken in the world

bull US - 31 million residents unable to speak English fluently with over half of these non-English speakers speaking Spanish and 15 million people speaking 24 different languages bull Recent research identifying more than 300 languages excluding dialects spoken by children at home indicates that London may be the most linguistically diverse city in the world

Current provision of interpreting

Mixed and patchy provisionhellip

bull Family friends

bull Health professional

bull Professional interpreters (face-to-face advocates)

bull Technology (telephone videoconferencing)

bull very little data available on how many individuals are out there unable to consult in English

bull sohellip

Objectives to document the

bull number of general practice consultations occurring in a language other than English

bull use of interpreting services

Gill et al (2011) The Unmet Need for Interpreting Provision in UK Primary Care PLoS ONE 6(6) e20837

Methodology

bull All 70 practices invited

bull Data collection given week in June 2009

bull Random allocation of session

bull Consultation record sheet

Results

bull 77122 (63) eligible practitioners (73 GPs 4 advanced nurse practitioners)

bull 4170 practices (59)

bull 1008 consultations

bull 1 abandoned due to language problems

Note Swine Flu epidemic during study period

The Consultations

717 Consultations in English

290 other languages (1 missing data)

57 relativefriend interpreted

6 professional interpreter (5 in same practice)

No relationship between Practitioner characteristics and need for interpreting

Consultation language

GP proficiency

None Basic Mod High N

Arabic Arabic 0 0 0 10 10 Bengali Bengali 5 7 10 18 40 BengaliEnglish Bengali 0 4 0 0 4 Gujerati Gujerati 0 1 0 2 3 Hindi Hindi 1 2 6 4 13 HindiPunjabi Punjabi 0 2 1 0 3 Katchi Katchi 0 0 1 0 1 Mirpuri Mirpuri 13 0 0 0 13 Punjabi Punjabi 1 3 19 20 43 Urdu Urdu 1 4 13 71 89 UrduEnglish Urdu 0 0 0 3 3 UrduHindi Urdu 0 0 2 0 2 UrduPunjabi Urdu 0 0 0 1 1 Not stated - - - - 4 21 23 52 129 229

Language used in consultation (where other than English)

Conclusions

bull Range of languages spoken by patients compared to practitioners unsurprising

bull Strategies used to overcome language barriers

bull Worrying consultations conducted where practitioner declared only basicno proficiency

bull High number communicating in patients preferred language

bull Use of professional interpreters (6 consultations)

bull increase evidence base of how individuals negotiate their way into and within health care identifying and developing standardised datasets for monitoring access and ensure that we donrsquot exclude minority groups from research

Ethnic recording mandatory within secondary care since 1995 and urgent need to include it within primary care as well eg through Quality and Outcomes framework

- new registrations

- Directly Enhanced Service

Reviews of socially stratified health inequalities

1980 The Black Report drew attention to the marked differences in morbidity and mortality rates between individuals in the top and bottom social groups

1998 The Acheson Report showed that although these rates had fallen in all social groups the differences in rates at the top and bottom of the social scale had increased

Inequalities widening

West Midlands - The Increasing Gap in Life Expectancy

70

72

74

76

78

80

82

84

91-93 92-94 93-95 94-96 95-97 96-98 97-99 98-00 99-01 00-02 01-03 02-04 03-05

Lif

e E

xp

ect

an

cy -

Years

Gap between Local Authorities with Highest and Lowest Female Life Expectancy

Gap between Local Authorities with Highest and Lowest Male Life Expectancy

33 years

38 years

40 years

49 years

2005 DH Tackling Health Inequalities A Programme for Action confirmed lsquodespite improvements the gap in health outcomes between those at the top and bottom ends of the social scale remains large and in some areas continues to widenrsquo

2010 Marmot Review Fair Society Healthy Lives identified social inequalities as root causes of health inequalities

In t e r n a t io n a l m ig r a t io n

bull This is not new

bull Since very dawn of humanity people have migrated

bull 191 million people may now live outside their country of birth over 13 million of them refugees

bull Globalisation has transformed demographic structure of large cities

bull Expansion of European Union

Migration phases framework

Migration to UK

Know little about the first people who inhabited Britain except that they were from else where ndash immigrants

This is NOT new

Before 1066

1000-150 BC Celts

43-410 AD Romans

800-1000 AD Danes

1066 Normans

1066-1900

1555-1833 Slaves from West Africa

1830-1860 Irish migration

1900 -

1933-45 Refugees from the Third Reich

1948-71 Caribbean

1950-71 West Africa Hong Kong ISC

1968-76 East African Asians

1990 - Eastern Europeans refugees amp asylum seekers

C H DB r e a s t c a n c e r

Muller-Nordhorn J et al Eur Heart J 2008 0ehm604v2-11

Age-standardized mortality from cardiovascular disease ie ischaemic heart disease and cerebrovascular disease combined in European regions (men age group 45-74 years year

2000)

SMR for IHD in men (20-74 yrs)

Bangladeshi 151 ( 136-167)

Pakistani 148 (138-158)

Indian 142 (137-147)

Irish 124 (120-127)

White 100

Caribbean 62 (58-67)

Chinese 44 (36-54)

Gill in httpwwwhcnabhamacukseriesbemgframehtm

Possible explanations for the excess CHD risk amongst BMEGs include

possible differential susceptibility to established risk factors (hypertension hyperlipidaemia smoking diabetes) along with exposure to ldquoemergingrdquo risk factors (insulin resistance early life factors racism factor X) and migration

BC BA I P B C I General

Men 25 21 20 29 40 21 30 24

Women 24 10 5 5 2 8 26 23

Self-reported cigarette smoking status by minority ethnic group and sex HSE 2004

Societal influencesIndividual psychology

Biology

Activity environment

Individual activity

Food Consumption

Food Production

Some health care challengeshellip

05

2 5

Childhood Old AgeMiddle Age

Symptoms

No Symptoms

Symptom threshold

SECONDARY

PREVENTION

PRIMARY PREVENTION

CHD Prevention optionsCHD Prevention options

Natural Course of CHD

Natural Course of CHD

Hanlon Capewell et al 1997

0

200

400

600

800

1970

1973

1976

1979

1982

1985

1988

1991

1994

1997

2000

SourceWHO statistics 2005 Men aged 35 - 74 Standardised

Per 100000Per 100000

USA

CHD mortality rates started falling long before effective treatments used widely

Goldman amp Cook 1984 Annals Int Med 1984 101825) Beaglehole 1986 BMJ 1986 292 33

CABGrArr ThrombolysisrArr StatinsrArr

New Zealand

Studies indicate that approximately 45ndash75 of the recent fall in CVD deaths in industrialised countries was as a result of prevention activities

Around 25ndash45 of the decrease was due to treatment

Capewell Heart 2009941105

Julian Tudor Hart Glyncorrwg

Disease register screening and management of CVD

Inverse Care Law (1971)

The availability of good medical care tends to vary inversely with the need for it in the population served

hellipconsultations in deprived areas

time constraints greater morbidity less patient enablement greater practitioner stress

RCGP Scotland Time to Care Health inequalities deprivation and General Practice in Scotland

Prof Graham Watt lsquoIn at the Deep Endrsquo

Secondary Care

Pharmacist

Primary Care

Dentist

LA

SELF CARE

Voluntary sector

Social Worker

Provision of Health Care

90

Common Barriers to Access

Low levels of cultural competency in staff

Case complexity diagnostic and other

overshadowing

Negative previous experiences of

services

Health not a priority

Communicationlanguage and literacy

Inflexible processesIncluding registration and

Appointment systems

Transport and other costs

Lack of understanding ofrsquosystemrsquo rights and

responsibilities

Discriminationstigmatisation

Challenges ndash language diversity

bull Overcoming language barriers to health care is a global challenge

bull 6500 languages spoken in the world

bull US - 31 million residents unable to speak English fluently with over half of these non-English speakers speaking Spanish and 15 million people speaking 24 different languages bull Recent research identifying more than 300 languages excluding dialects spoken by children at home indicates that London may be the most linguistically diverse city in the world

Current provision of interpreting

Mixed and patchy provisionhellip

bull Family friends

bull Health professional

bull Professional interpreters (face-to-face advocates)

bull Technology (telephone videoconferencing)

bull very little data available on how many individuals are out there unable to consult in English

bull sohellip

Objectives to document the

bull number of general practice consultations occurring in a language other than English

bull use of interpreting services

Gill et al (2011) The Unmet Need for Interpreting Provision in UK Primary Care PLoS ONE 6(6) e20837

Methodology

bull All 70 practices invited

bull Data collection given week in June 2009

bull Random allocation of session

bull Consultation record sheet

Results

bull 77122 (63) eligible practitioners (73 GPs 4 advanced nurse practitioners)

bull 4170 practices (59)

bull 1008 consultations

bull 1 abandoned due to language problems

Note Swine Flu epidemic during study period

The Consultations

717 Consultations in English

290 other languages (1 missing data)

57 relativefriend interpreted

6 professional interpreter (5 in same practice)

No relationship between Practitioner characteristics and need for interpreting

Consultation language

GP proficiency

None Basic Mod High N

Arabic Arabic 0 0 0 10 10 Bengali Bengali 5 7 10 18 40 BengaliEnglish Bengali 0 4 0 0 4 Gujerati Gujerati 0 1 0 2 3 Hindi Hindi 1 2 6 4 13 HindiPunjabi Punjabi 0 2 1 0 3 Katchi Katchi 0 0 1 0 1 Mirpuri Mirpuri 13 0 0 0 13 Punjabi Punjabi 1 3 19 20 43 Urdu Urdu 1 4 13 71 89 UrduEnglish Urdu 0 0 0 3 3 UrduHindi Urdu 0 0 2 0 2 UrduPunjabi Urdu 0 0 0 1 1 Not stated - - - - 4 21 23 52 129 229

Language used in consultation (where other than English)

Conclusions

bull Range of languages spoken by patients compared to practitioners unsurprising

bull Strategies used to overcome language barriers

bull Worrying consultations conducted where practitioner declared only basicno proficiency

bull High number communicating in patients preferred language

bull Use of professional interpreters (6 consultations)

bull increase evidence base of how individuals negotiate their way into and within health care identifying and developing standardised datasets for monitoring access and ensure that we donrsquot exclude minority groups from research

Ethnic recording mandatory within secondary care since 1995 and urgent need to include it within primary care as well eg through Quality and Outcomes framework

- new registrations

- Directly Enhanced Service

Inequalities widening

West Midlands - The Increasing Gap in Life Expectancy

70

72

74

76

78

80

82

84

91-93 92-94 93-95 94-96 95-97 96-98 97-99 98-00 99-01 00-02 01-03 02-04 03-05

Lif

e E

xp

ect

an

cy -

Years

Gap between Local Authorities with Highest and Lowest Female Life Expectancy

Gap between Local Authorities with Highest and Lowest Male Life Expectancy

33 years

38 years

40 years

49 years

2005 DH Tackling Health Inequalities A Programme for Action confirmed lsquodespite improvements the gap in health outcomes between those at the top and bottom ends of the social scale remains large and in some areas continues to widenrsquo

2010 Marmot Review Fair Society Healthy Lives identified social inequalities as root causes of health inequalities

In t e r n a t io n a l m ig r a t io n

bull This is not new

bull Since very dawn of humanity people have migrated

bull 191 million people may now live outside their country of birth over 13 million of them refugees

bull Globalisation has transformed demographic structure of large cities

bull Expansion of European Union

Migration phases framework

Migration to UK

Know little about the first people who inhabited Britain except that they were from else where ndash immigrants

This is NOT new

Before 1066

1000-150 BC Celts

43-410 AD Romans

800-1000 AD Danes

1066 Normans

1066-1900

1555-1833 Slaves from West Africa

1830-1860 Irish migration

1900 -

1933-45 Refugees from the Third Reich

1948-71 Caribbean

1950-71 West Africa Hong Kong ISC

1968-76 East African Asians

1990 - Eastern Europeans refugees amp asylum seekers

C H DB r e a s t c a n c e r

Muller-Nordhorn J et al Eur Heart J 2008 0ehm604v2-11

Age-standardized mortality from cardiovascular disease ie ischaemic heart disease and cerebrovascular disease combined in European regions (men age group 45-74 years year

2000)

SMR for IHD in men (20-74 yrs)

Bangladeshi 151 ( 136-167)

Pakistani 148 (138-158)

Indian 142 (137-147)

Irish 124 (120-127)

White 100

Caribbean 62 (58-67)

Chinese 44 (36-54)

Gill in httpwwwhcnabhamacukseriesbemgframehtm

Possible explanations for the excess CHD risk amongst BMEGs include

possible differential susceptibility to established risk factors (hypertension hyperlipidaemia smoking diabetes) along with exposure to ldquoemergingrdquo risk factors (insulin resistance early life factors racism factor X) and migration

BC BA I P B C I General

Men 25 21 20 29 40 21 30 24

Women 24 10 5 5 2 8 26 23

Self-reported cigarette smoking status by minority ethnic group and sex HSE 2004

Societal influencesIndividual psychology

Biology

Activity environment

Individual activity

Food Consumption

Food Production

Some health care challengeshellip

05

2 5

Childhood Old AgeMiddle Age

Symptoms

No Symptoms

Symptom threshold

SECONDARY

PREVENTION

PRIMARY PREVENTION

CHD Prevention optionsCHD Prevention options

Natural Course of CHD

Natural Course of CHD

Hanlon Capewell et al 1997

0

200

400

600

800

1970

1973

1976

1979

1982

1985

1988

1991

1994

1997

2000

SourceWHO statistics 2005 Men aged 35 - 74 Standardised

Per 100000Per 100000

USA

CHD mortality rates started falling long before effective treatments used widely

Goldman amp Cook 1984 Annals Int Med 1984 101825) Beaglehole 1986 BMJ 1986 292 33

CABGrArr ThrombolysisrArr StatinsrArr

New Zealand

Studies indicate that approximately 45ndash75 of the recent fall in CVD deaths in industrialised countries was as a result of prevention activities

Around 25ndash45 of the decrease was due to treatment

Capewell Heart 2009941105

Julian Tudor Hart Glyncorrwg

Disease register screening and management of CVD

Inverse Care Law (1971)

The availability of good medical care tends to vary inversely with the need for it in the population served

hellipconsultations in deprived areas

time constraints greater morbidity less patient enablement greater practitioner stress

RCGP Scotland Time to Care Health inequalities deprivation and General Practice in Scotland

Prof Graham Watt lsquoIn at the Deep Endrsquo

Secondary Care

Pharmacist

Primary Care

Dentist

LA

SELF CARE

Voluntary sector

Social Worker

Provision of Health Care

90

Common Barriers to Access

Low levels of cultural competency in staff

Case complexity diagnostic and other

overshadowing

Negative previous experiences of

services

Health not a priority

Communicationlanguage and literacy

Inflexible processesIncluding registration and

Appointment systems

Transport and other costs

Lack of understanding ofrsquosystemrsquo rights and

responsibilities

Discriminationstigmatisation

Challenges ndash language diversity

bull Overcoming language barriers to health care is a global challenge

bull 6500 languages spoken in the world

bull US - 31 million residents unable to speak English fluently with over half of these non-English speakers speaking Spanish and 15 million people speaking 24 different languages bull Recent research identifying more than 300 languages excluding dialects spoken by children at home indicates that London may be the most linguistically diverse city in the world

Current provision of interpreting

Mixed and patchy provisionhellip

bull Family friends

bull Health professional

bull Professional interpreters (face-to-face advocates)

bull Technology (telephone videoconferencing)

bull very little data available on how many individuals are out there unable to consult in English

bull sohellip

Objectives to document the

bull number of general practice consultations occurring in a language other than English

bull use of interpreting services

Gill et al (2011) The Unmet Need for Interpreting Provision in UK Primary Care PLoS ONE 6(6) e20837

Methodology

bull All 70 practices invited

bull Data collection given week in June 2009

bull Random allocation of session

bull Consultation record sheet

Results

bull 77122 (63) eligible practitioners (73 GPs 4 advanced nurse practitioners)

bull 4170 practices (59)

bull 1008 consultations

bull 1 abandoned due to language problems

Note Swine Flu epidemic during study period

The Consultations

717 Consultations in English

290 other languages (1 missing data)

57 relativefriend interpreted

6 professional interpreter (5 in same practice)

No relationship between Practitioner characteristics and need for interpreting

Consultation language

GP proficiency

None Basic Mod High N

Arabic Arabic 0 0 0 10 10 Bengali Bengali 5 7 10 18 40 BengaliEnglish Bengali 0 4 0 0 4 Gujerati Gujerati 0 1 0 2 3 Hindi Hindi 1 2 6 4 13 HindiPunjabi Punjabi 0 2 1 0 3 Katchi Katchi 0 0 1 0 1 Mirpuri Mirpuri 13 0 0 0 13 Punjabi Punjabi 1 3 19 20 43 Urdu Urdu 1 4 13 71 89 UrduEnglish Urdu 0 0 0 3 3 UrduHindi Urdu 0 0 2 0 2 UrduPunjabi Urdu 0 0 0 1 1 Not stated - - - - 4 21 23 52 129 229

Language used in consultation (where other than English)

Conclusions

bull Range of languages spoken by patients compared to practitioners unsurprising

bull Strategies used to overcome language barriers

bull Worrying consultations conducted where practitioner declared only basicno proficiency

bull High number communicating in patients preferred language

bull Use of professional interpreters (6 consultations)

bull increase evidence base of how individuals negotiate their way into and within health care identifying and developing standardised datasets for monitoring access and ensure that we donrsquot exclude minority groups from research

Ethnic recording mandatory within secondary care since 1995 and urgent need to include it within primary care as well eg through Quality and Outcomes framework

- new registrations

- Directly Enhanced Service

2005 DH Tackling Health Inequalities A Programme for Action confirmed lsquodespite improvements the gap in health outcomes between those at the top and bottom ends of the social scale remains large and in some areas continues to widenrsquo

2010 Marmot Review Fair Society Healthy Lives identified social inequalities as root causes of health inequalities

In t e r n a t io n a l m ig r a t io n

bull This is not new

bull Since very dawn of humanity people have migrated

bull 191 million people may now live outside their country of birth over 13 million of them refugees

bull Globalisation has transformed demographic structure of large cities

bull Expansion of European Union

Migration phases framework

Migration to UK

Know little about the first people who inhabited Britain except that they were from else where ndash immigrants

This is NOT new

Before 1066

1000-150 BC Celts

43-410 AD Romans

800-1000 AD Danes

1066 Normans

1066-1900

1555-1833 Slaves from West Africa

1830-1860 Irish migration

1900 -

1933-45 Refugees from the Third Reich

1948-71 Caribbean

1950-71 West Africa Hong Kong ISC

1968-76 East African Asians

1990 - Eastern Europeans refugees amp asylum seekers

C H DB r e a s t c a n c e r

Muller-Nordhorn J et al Eur Heart J 2008 0ehm604v2-11

Age-standardized mortality from cardiovascular disease ie ischaemic heart disease and cerebrovascular disease combined in European regions (men age group 45-74 years year

2000)

SMR for IHD in men (20-74 yrs)

Bangladeshi 151 ( 136-167)

Pakistani 148 (138-158)

Indian 142 (137-147)

Irish 124 (120-127)

White 100

Caribbean 62 (58-67)

Chinese 44 (36-54)

Gill in httpwwwhcnabhamacukseriesbemgframehtm

Possible explanations for the excess CHD risk amongst BMEGs include

possible differential susceptibility to established risk factors (hypertension hyperlipidaemia smoking diabetes) along with exposure to ldquoemergingrdquo risk factors (insulin resistance early life factors racism factor X) and migration

BC BA I P B C I General

Men 25 21 20 29 40 21 30 24

Women 24 10 5 5 2 8 26 23

Self-reported cigarette smoking status by minority ethnic group and sex HSE 2004

Societal influencesIndividual psychology

Biology

Activity environment

Individual activity

Food Consumption

Food Production

Some health care challengeshellip

05

2 5

Childhood Old AgeMiddle Age

Symptoms

No Symptoms

Symptom threshold

SECONDARY

PREVENTION

PRIMARY PREVENTION

CHD Prevention optionsCHD Prevention options

Natural Course of CHD

Natural Course of CHD

Hanlon Capewell et al 1997

0

200

400

600

800

1970

1973

1976

1979

1982

1985

1988

1991

1994

1997

2000

SourceWHO statistics 2005 Men aged 35 - 74 Standardised

Per 100000Per 100000

USA

CHD mortality rates started falling long before effective treatments used widely

Goldman amp Cook 1984 Annals Int Med 1984 101825) Beaglehole 1986 BMJ 1986 292 33

CABGrArr ThrombolysisrArr StatinsrArr

New Zealand

Studies indicate that approximately 45ndash75 of the recent fall in CVD deaths in industrialised countries was as a result of prevention activities

Around 25ndash45 of the decrease was due to treatment

Capewell Heart 2009941105

Julian Tudor Hart Glyncorrwg

Disease register screening and management of CVD

Inverse Care Law (1971)

The availability of good medical care tends to vary inversely with the need for it in the population served

hellipconsultations in deprived areas

time constraints greater morbidity less patient enablement greater practitioner stress

RCGP Scotland Time to Care Health inequalities deprivation and General Practice in Scotland

Prof Graham Watt lsquoIn at the Deep Endrsquo

Secondary Care

Pharmacist

Primary Care

Dentist

LA

SELF CARE

Voluntary sector

Social Worker

Provision of Health Care

90

Common Barriers to Access

Low levels of cultural competency in staff

Case complexity diagnostic and other

overshadowing

Negative previous experiences of

services

Health not a priority

Communicationlanguage and literacy

Inflexible processesIncluding registration and

Appointment systems

Transport and other costs

Lack of understanding ofrsquosystemrsquo rights and

responsibilities

Discriminationstigmatisation

Challenges ndash language diversity

bull Overcoming language barriers to health care is a global challenge

bull 6500 languages spoken in the world

bull US - 31 million residents unable to speak English fluently with over half of these non-English speakers speaking Spanish and 15 million people speaking 24 different languages bull Recent research identifying more than 300 languages excluding dialects spoken by children at home indicates that London may be the most linguistically diverse city in the world

Current provision of interpreting

Mixed and patchy provisionhellip

bull Family friends

bull Health professional

bull Professional interpreters (face-to-face advocates)

bull Technology (telephone videoconferencing)

bull very little data available on how many individuals are out there unable to consult in English

bull sohellip

Objectives to document the

bull number of general practice consultations occurring in a language other than English

bull use of interpreting services

Gill et al (2011) The Unmet Need for Interpreting Provision in UK Primary Care PLoS ONE 6(6) e20837

Methodology

bull All 70 practices invited

bull Data collection given week in June 2009

bull Random allocation of session

bull Consultation record sheet

Results

bull 77122 (63) eligible practitioners (73 GPs 4 advanced nurse practitioners)

bull 4170 practices (59)

bull 1008 consultations

bull 1 abandoned due to language problems

Note Swine Flu epidemic during study period

The Consultations

717 Consultations in English

290 other languages (1 missing data)

57 relativefriend interpreted

6 professional interpreter (5 in same practice)

No relationship between Practitioner characteristics and need for interpreting

Consultation language

GP proficiency

None Basic Mod High N

Arabic Arabic 0 0 0 10 10 Bengali Bengali 5 7 10 18 40 BengaliEnglish Bengali 0 4 0 0 4 Gujerati Gujerati 0 1 0 2 3 Hindi Hindi 1 2 6 4 13 HindiPunjabi Punjabi 0 2 1 0 3 Katchi Katchi 0 0 1 0 1 Mirpuri Mirpuri 13 0 0 0 13 Punjabi Punjabi 1 3 19 20 43 Urdu Urdu 1 4 13 71 89 UrduEnglish Urdu 0 0 0 3 3 UrduHindi Urdu 0 0 2 0 2 UrduPunjabi Urdu 0 0 0 1 1 Not stated - - - - 4 21 23 52 129 229

Language used in consultation (where other than English)

Conclusions

bull Range of languages spoken by patients compared to practitioners unsurprising

bull Strategies used to overcome language barriers

bull Worrying consultations conducted where practitioner declared only basicno proficiency

bull High number communicating in patients preferred language

bull Use of professional interpreters (6 consultations)

bull increase evidence base of how individuals negotiate their way into and within health care identifying and developing standardised datasets for monitoring access and ensure that we donrsquot exclude minority groups from research

Ethnic recording mandatory within secondary care since 1995 and urgent need to include it within primary care as well eg through Quality and Outcomes framework

- new registrations

- Directly Enhanced Service

In t e r n a t io n a l m ig r a t io n

bull This is not new

bull Since very dawn of humanity people have migrated

bull 191 million people may now live outside their country of birth over 13 million of them refugees

bull Globalisation has transformed demographic structure of large cities

bull Expansion of European Union

Migration phases framework

Migration to UK

Know little about the first people who inhabited Britain except that they were from else where ndash immigrants

This is NOT new

Before 1066

1000-150 BC Celts

43-410 AD Romans

800-1000 AD Danes

1066 Normans

1066-1900

1555-1833 Slaves from West Africa

1830-1860 Irish migration

1900 -

1933-45 Refugees from the Third Reich

1948-71 Caribbean

1950-71 West Africa Hong Kong ISC

1968-76 East African Asians

1990 - Eastern Europeans refugees amp asylum seekers

C H DB r e a s t c a n c e r

Muller-Nordhorn J et al Eur Heart J 2008 0ehm604v2-11

Age-standardized mortality from cardiovascular disease ie ischaemic heart disease and cerebrovascular disease combined in European regions (men age group 45-74 years year

2000)

SMR for IHD in men (20-74 yrs)

Bangladeshi 151 ( 136-167)

Pakistani 148 (138-158)

Indian 142 (137-147)

Irish 124 (120-127)

White 100

Caribbean 62 (58-67)

Chinese 44 (36-54)

Gill in httpwwwhcnabhamacukseriesbemgframehtm

Possible explanations for the excess CHD risk amongst BMEGs include

possible differential susceptibility to established risk factors (hypertension hyperlipidaemia smoking diabetes) along with exposure to ldquoemergingrdquo risk factors (insulin resistance early life factors racism factor X) and migration

BC BA I P B C I General

Men 25 21 20 29 40 21 30 24

Women 24 10 5 5 2 8 26 23

Self-reported cigarette smoking status by minority ethnic group and sex HSE 2004

Societal influencesIndividual psychology

Biology

Activity environment

Individual activity

Food Consumption

Food Production

Some health care challengeshellip

05

2 5

Childhood Old AgeMiddle Age

Symptoms

No Symptoms

Symptom threshold

SECONDARY

PREVENTION

PRIMARY PREVENTION

CHD Prevention optionsCHD Prevention options

Natural Course of CHD

Natural Course of CHD

Hanlon Capewell et al 1997

0

200

400

600

800

1970

1973

1976

1979

1982

1985

1988

1991

1994

1997

2000

SourceWHO statistics 2005 Men aged 35 - 74 Standardised

Per 100000Per 100000

USA

CHD mortality rates started falling long before effective treatments used widely

Goldman amp Cook 1984 Annals Int Med 1984 101825) Beaglehole 1986 BMJ 1986 292 33

CABGrArr ThrombolysisrArr StatinsrArr

New Zealand

Studies indicate that approximately 45ndash75 of the recent fall in CVD deaths in industrialised countries was as a result of prevention activities

Around 25ndash45 of the decrease was due to treatment

Capewell Heart 2009941105

Julian Tudor Hart Glyncorrwg

Disease register screening and management of CVD

Inverse Care Law (1971)

The availability of good medical care tends to vary inversely with the need for it in the population served

hellipconsultations in deprived areas

time constraints greater morbidity less patient enablement greater practitioner stress

RCGP Scotland Time to Care Health inequalities deprivation and General Practice in Scotland

Prof Graham Watt lsquoIn at the Deep Endrsquo

Secondary Care

Pharmacist

Primary Care

Dentist

LA

SELF CARE

Voluntary sector

Social Worker

Provision of Health Care

90

Common Barriers to Access

Low levels of cultural competency in staff

Case complexity diagnostic and other

overshadowing

Negative previous experiences of

services

Health not a priority

Communicationlanguage and literacy

Inflexible processesIncluding registration and

Appointment systems

Transport and other costs

Lack of understanding ofrsquosystemrsquo rights and

responsibilities

Discriminationstigmatisation

Challenges ndash language diversity

bull Overcoming language barriers to health care is a global challenge

bull 6500 languages spoken in the world

bull US - 31 million residents unable to speak English fluently with over half of these non-English speakers speaking Spanish and 15 million people speaking 24 different languages bull Recent research identifying more than 300 languages excluding dialects spoken by children at home indicates that London may be the most linguistically diverse city in the world

Current provision of interpreting

Mixed and patchy provisionhellip

bull Family friends

bull Health professional

bull Professional interpreters (face-to-face advocates)

bull Technology (telephone videoconferencing)

bull very little data available on how many individuals are out there unable to consult in English

bull sohellip

Objectives to document the

bull number of general practice consultations occurring in a language other than English

bull use of interpreting services

Gill et al (2011) The Unmet Need for Interpreting Provision in UK Primary Care PLoS ONE 6(6) e20837

Methodology

bull All 70 practices invited

bull Data collection given week in June 2009

bull Random allocation of session

bull Consultation record sheet

Results

bull 77122 (63) eligible practitioners (73 GPs 4 advanced nurse practitioners)

bull 4170 practices (59)

bull 1008 consultations

bull 1 abandoned due to language problems

Note Swine Flu epidemic during study period

The Consultations

717 Consultations in English

290 other languages (1 missing data)

57 relativefriend interpreted

6 professional interpreter (5 in same practice)

No relationship between Practitioner characteristics and need for interpreting

Consultation language

GP proficiency

None Basic Mod High N

Arabic Arabic 0 0 0 10 10 Bengali Bengali 5 7 10 18 40 BengaliEnglish Bengali 0 4 0 0 4 Gujerati Gujerati 0 1 0 2 3 Hindi Hindi 1 2 6 4 13 HindiPunjabi Punjabi 0 2 1 0 3 Katchi Katchi 0 0 1 0 1 Mirpuri Mirpuri 13 0 0 0 13 Punjabi Punjabi 1 3 19 20 43 Urdu Urdu 1 4 13 71 89 UrduEnglish Urdu 0 0 0 3 3 UrduHindi Urdu 0 0 2 0 2 UrduPunjabi Urdu 0 0 0 1 1 Not stated - - - - 4 21 23 52 129 229

Language used in consultation (where other than English)

Conclusions

bull Range of languages spoken by patients compared to practitioners unsurprising

bull Strategies used to overcome language barriers

bull Worrying consultations conducted where practitioner declared only basicno proficiency

bull High number communicating in patients preferred language

bull Use of professional interpreters (6 consultations)

bull increase evidence base of how individuals negotiate their way into and within health care identifying and developing standardised datasets for monitoring access and ensure that we donrsquot exclude minority groups from research

Ethnic recording mandatory within secondary care since 1995 and urgent need to include it within primary care as well eg through Quality and Outcomes framework

- new registrations

- Directly Enhanced Service

Migration phases framework

Migration to UK

Know little about the first people who inhabited Britain except that they were from else where ndash immigrants

This is NOT new

Before 1066

1000-150 BC Celts

43-410 AD Romans

800-1000 AD Danes

1066 Normans

1066-1900

1555-1833 Slaves from West Africa

1830-1860 Irish migration

1900 -

1933-45 Refugees from the Third Reich

1948-71 Caribbean

1950-71 West Africa Hong Kong ISC

1968-76 East African Asians

1990 - Eastern Europeans refugees amp asylum seekers

C H DB r e a s t c a n c e r

Muller-Nordhorn J et al Eur Heart J 2008 0ehm604v2-11

Age-standardized mortality from cardiovascular disease ie ischaemic heart disease and cerebrovascular disease combined in European regions (men age group 45-74 years year

2000)

SMR for IHD in men (20-74 yrs)

Bangladeshi 151 ( 136-167)

Pakistani 148 (138-158)

Indian 142 (137-147)

Irish 124 (120-127)

White 100

Caribbean 62 (58-67)

Chinese 44 (36-54)

Gill in httpwwwhcnabhamacukseriesbemgframehtm

Possible explanations for the excess CHD risk amongst BMEGs include

possible differential susceptibility to established risk factors (hypertension hyperlipidaemia smoking diabetes) along with exposure to ldquoemergingrdquo risk factors (insulin resistance early life factors racism factor X) and migration

BC BA I P B C I General

Men 25 21 20 29 40 21 30 24

Women 24 10 5 5 2 8 26 23

Self-reported cigarette smoking status by minority ethnic group and sex HSE 2004

Societal influencesIndividual psychology

Biology

Activity environment

Individual activity

Food Consumption

Food Production

Some health care challengeshellip

05

2 5

Childhood Old AgeMiddle Age

Symptoms

No Symptoms

Symptom threshold

SECONDARY

PREVENTION

PRIMARY PREVENTION

CHD Prevention optionsCHD Prevention options

Natural Course of CHD

Natural Course of CHD

Hanlon Capewell et al 1997

0

200

400

600

800

1970

1973

1976

1979

1982

1985

1988

1991

1994

1997

2000

SourceWHO statistics 2005 Men aged 35 - 74 Standardised

Per 100000Per 100000

USA

CHD mortality rates started falling long before effective treatments used widely

Goldman amp Cook 1984 Annals Int Med 1984 101825) Beaglehole 1986 BMJ 1986 292 33

CABGrArr ThrombolysisrArr StatinsrArr

New Zealand

Studies indicate that approximately 45ndash75 of the recent fall in CVD deaths in industrialised countries was as a result of prevention activities

Around 25ndash45 of the decrease was due to treatment

Capewell Heart 2009941105

Julian Tudor Hart Glyncorrwg

Disease register screening and management of CVD

Inverse Care Law (1971)

The availability of good medical care tends to vary inversely with the need for it in the population served

hellipconsultations in deprived areas

time constraints greater morbidity less patient enablement greater practitioner stress

RCGP Scotland Time to Care Health inequalities deprivation and General Practice in Scotland

Prof Graham Watt lsquoIn at the Deep Endrsquo

Secondary Care

Pharmacist

Primary Care

Dentist

LA

SELF CARE

Voluntary sector

Social Worker

Provision of Health Care

90

Common Barriers to Access

Low levels of cultural competency in staff

Case complexity diagnostic and other

overshadowing

Negative previous experiences of

services

Health not a priority

Communicationlanguage and literacy

Inflexible processesIncluding registration and

Appointment systems

Transport and other costs

Lack of understanding ofrsquosystemrsquo rights and

responsibilities

Discriminationstigmatisation

Challenges ndash language diversity

bull Overcoming language barriers to health care is a global challenge

bull 6500 languages spoken in the world

bull US - 31 million residents unable to speak English fluently with over half of these non-English speakers speaking Spanish and 15 million people speaking 24 different languages bull Recent research identifying more than 300 languages excluding dialects spoken by children at home indicates that London may be the most linguistically diverse city in the world

Current provision of interpreting

Mixed and patchy provisionhellip

bull Family friends

bull Health professional

bull Professional interpreters (face-to-face advocates)

bull Technology (telephone videoconferencing)

bull very little data available on how many individuals are out there unable to consult in English

bull sohellip

Objectives to document the

bull number of general practice consultations occurring in a language other than English

bull use of interpreting services

Gill et al (2011) The Unmet Need for Interpreting Provision in UK Primary Care PLoS ONE 6(6) e20837

Methodology

bull All 70 practices invited

bull Data collection given week in June 2009

bull Random allocation of session

bull Consultation record sheet

Results

bull 77122 (63) eligible practitioners (73 GPs 4 advanced nurse practitioners)

bull 4170 practices (59)

bull 1008 consultations

bull 1 abandoned due to language problems

Note Swine Flu epidemic during study period

The Consultations

717 Consultations in English

290 other languages (1 missing data)

57 relativefriend interpreted

6 professional interpreter (5 in same practice)

No relationship between Practitioner characteristics and need for interpreting

Consultation language

GP proficiency

None Basic Mod High N

Arabic Arabic 0 0 0 10 10 Bengali Bengali 5 7 10 18 40 BengaliEnglish Bengali 0 4 0 0 4 Gujerati Gujerati 0 1 0 2 3 Hindi Hindi 1 2 6 4 13 HindiPunjabi Punjabi 0 2 1 0 3 Katchi Katchi 0 0 1 0 1 Mirpuri Mirpuri 13 0 0 0 13 Punjabi Punjabi 1 3 19 20 43 Urdu Urdu 1 4 13 71 89 UrduEnglish Urdu 0 0 0 3 3 UrduHindi Urdu 0 0 2 0 2 UrduPunjabi Urdu 0 0 0 1 1 Not stated - - - - 4 21 23 52 129 229

Language used in consultation (where other than English)

Conclusions

bull Range of languages spoken by patients compared to practitioners unsurprising

bull Strategies used to overcome language barriers

bull Worrying consultations conducted where practitioner declared only basicno proficiency

bull High number communicating in patients preferred language

bull Use of professional interpreters (6 consultations)

bull increase evidence base of how individuals negotiate their way into and within health care identifying and developing standardised datasets for monitoring access and ensure that we donrsquot exclude minority groups from research

Ethnic recording mandatory within secondary care since 1995 and urgent need to include it within primary care as well eg through Quality and Outcomes framework

- new registrations

- Directly Enhanced Service

Migration to UK

Know little about the first people who inhabited Britain except that they were from else where ndash immigrants

This is NOT new

Before 1066

1000-150 BC Celts

43-410 AD Romans

800-1000 AD Danes

1066 Normans

1066-1900

1555-1833 Slaves from West Africa

1830-1860 Irish migration

1900 -

1933-45 Refugees from the Third Reich

1948-71 Caribbean

1950-71 West Africa Hong Kong ISC

1968-76 East African Asians

1990 - Eastern Europeans refugees amp asylum seekers

C H DB r e a s t c a n c e r

Muller-Nordhorn J et al Eur Heart J 2008 0ehm604v2-11

Age-standardized mortality from cardiovascular disease ie ischaemic heart disease and cerebrovascular disease combined in European regions (men age group 45-74 years year

2000)

SMR for IHD in men (20-74 yrs)

Bangladeshi 151 ( 136-167)

Pakistani 148 (138-158)

Indian 142 (137-147)

Irish 124 (120-127)

White 100

Caribbean 62 (58-67)

Chinese 44 (36-54)

Gill in httpwwwhcnabhamacukseriesbemgframehtm

Possible explanations for the excess CHD risk amongst BMEGs include

possible differential susceptibility to established risk factors (hypertension hyperlipidaemia smoking diabetes) along with exposure to ldquoemergingrdquo risk factors (insulin resistance early life factors racism factor X) and migration

BC BA I P B C I General

Men 25 21 20 29 40 21 30 24

Women 24 10 5 5 2 8 26 23

Self-reported cigarette smoking status by minority ethnic group and sex HSE 2004

Societal influencesIndividual psychology

Biology

Activity environment

Individual activity

Food Consumption

Food Production

Some health care challengeshellip

05

2 5

Childhood Old AgeMiddle Age

Symptoms

No Symptoms

Symptom threshold

SECONDARY

PREVENTION

PRIMARY PREVENTION

CHD Prevention optionsCHD Prevention options

Natural Course of CHD

Natural Course of CHD

Hanlon Capewell et al 1997

0

200

400

600

800

1970

1973

1976

1979

1982

1985

1988

1991

1994

1997

2000

SourceWHO statistics 2005 Men aged 35 - 74 Standardised

Per 100000Per 100000

USA

CHD mortality rates started falling long before effective treatments used widely

Goldman amp Cook 1984 Annals Int Med 1984 101825) Beaglehole 1986 BMJ 1986 292 33

CABGrArr ThrombolysisrArr StatinsrArr

New Zealand

Studies indicate that approximately 45ndash75 of the recent fall in CVD deaths in industrialised countries was as a result of prevention activities

Around 25ndash45 of the decrease was due to treatment

Capewell Heart 2009941105

Julian Tudor Hart Glyncorrwg

Disease register screening and management of CVD

Inverse Care Law (1971)

The availability of good medical care tends to vary inversely with the need for it in the population served

hellipconsultations in deprived areas

time constraints greater morbidity less patient enablement greater practitioner stress

RCGP Scotland Time to Care Health inequalities deprivation and General Practice in Scotland

Prof Graham Watt lsquoIn at the Deep Endrsquo

Secondary Care

Pharmacist

Primary Care

Dentist

LA

SELF CARE

Voluntary sector

Social Worker

Provision of Health Care

90

Common Barriers to Access

Low levels of cultural competency in staff

Case complexity diagnostic and other

overshadowing

Negative previous experiences of

services

Health not a priority

Communicationlanguage and literacy

Inflexible processesIncluding registration and

Appointment systems

Transport and other costs

Lack of understanding ofrsquosystemrsquo rights and

responsibilities

Discriminationstigmatisation

Challenges ndash language diversity

bull Overcoming language barriers to health care is a global challenge

bull 6500 languages spoken in the world

bull US - 31 million residents unable to speak English fluently with over half of these non-English speakers speaking Spanish and 15 million people speaking 24 different languages bull Recent research identifying more than 300 languages excluding dialects spoken by children at home indicates that London may be the most linguistically diverse city in the world

Current provision of interpreting

Mixed and patchy provisionhellip

bull Family friends

bull Health professional

bull Professional interpreters (face-to-face advocates)

bull Technology (telephone videoconferencing)

bull very little data available on how many individuals are out there unable to consult in English

bull sohellip

Objectives to document the

bull number of general practice consultations occurring in a language other than English

bull use of interpreting services

Gill et al (2011) The Unmet Need for Interpreting Provision in UK Primary Care PLoS ONE 6(6) e20837

Methodology

bull All 70 practices invited

bull Data collection given week in June 2009

bull Random allocation of session

bull Consultation record sheet

Results

bull 77122 (63) eligible practitioners (73 GPs 4 advanced nurse practitioners)

bull 4170 practices (59)

bull 1008 consultations

bull 1 abandoned due to language problems

Note Swine Flu epidemic during study period

The Consultations

717 Consultations in English

290 other languages (1 missing data)

57 relativefriend interpreted

6 professional interpreter (5 in same practice)

No relationship between Practitioner characteristics and need for interpreting

Consultation language

GP proficiency

None Basic Mod High N

Arabic Arabic 0 0 0 10 10 Bengali Bengali 5 7 10 18 40 BengaliEnglish Bengali 0 4 0 0 4 Gujerati Gujerati 0 1 0 2 3 Hindi Hindi 1 2 6 4 13 HindiPunjabi Punjabi 0 2 1 0 3 Katchi Katchi 0 0 1 0 1 Mirpuri Mirpuri 13 0 0 0 13 Punjabi Punjabi 1 3 19 20 43 Urdu Urdu 1 4 13 71 89 UrduEnglish Urdu 0 0 0 3 3 UrduHindi Urdu 0 0 2 0 2 UrduPunjabi Urdu 0 0 0 1 1 Not stated - - - - 4 21 23 52 129 229

Language used in consultation (where other than English)

Conclusions

bull Range of languages spoken by patients compared to practitioners unsurprising

bull Strategies used to overcome language barriers

bull Worrying consultations conducted where practitioner declared only basicno proficiency

bull High number communicating in patients preferred language

bull Use of professional interpreters (6 consultations)

bull increase evidence base of how individuals negotiate their way into and within health care identifying and developing standardised datasets for monitoring access and ensure that we donrsquot exclude minority groups from research

Ethnic recording mandatory within secondary care since 1995 and urgent need to include it within primary care as well eg through Quality and Outcomes framework

- new registrations

- Directly Enhanced Service

Before 1066

1000-150 BC Celts

43-410 AD Romans

800-1000 AD Danes

1066 Normans

1066-1900

1555-1833 Slaves from West Africa

1830-1860 Irish migration

1900 -

1933-45 Refugees from the Third Reich

1948-71 Caribbean

1950-71 West Africa Hong Kong ISC

1968-76 East African Asians

1990 - Eastern Europeans refugees amp asylum seekers

C H DB r e a s t c a n c e r

Muller-Nordhorn J et al Eur Heart J 2008 0ehm604v2-11

Age-standardized mortality from cardiovascular disease ie ischaemic heart disease and cerebrovascular disease combined in European regions (men age group 45-74 years year

2000)

SMR for IHD in men (20-74 yrs)

Bangladeshi 151 ( 136-167)

Pakistani 148 (138-158)

Indian 142 (137-147)

Irish 124 (120-127)

White 100

Caribbean 62 (58-67)

Chinese 44 (36-54)

Gill in httpwwwhcnabhamacukseriesbemgframehtm

Possible explanations for the excess CHD risk amongst BMEGs include

possible differential susceptibility to established risk factors (hypertension hyperlipidaemia smoking diabetes) along with exposure to ldquoemergingrdquo risk factors (insulin resistance early life factors racism factor X) and migration

BC BA I P B C I General

Men 25 21 20 29 40 21 30 24

Women 24 10 5 5 2 8 26 23

Self-reported cigarette smoking status by minority ethnic group and sex HSE 2004

Societal influencesIndividual psychology

Biology

Activity environment

Individual activity

Food Consumption

Food Production

Some health care challengeshellip

05

2 5

Childhood Old AgeMiddle Age

Symptoms

No Symptoms

Symptom threshold

SECONDARY

PREVENTION

PRIMARY PREVENTION

CHD Prevention optionsCHD Prevention options

Natural Course of CHD

Natural Course of CHD

Hanlon Capewell et al 1997

0

200

400

600

800

1970

1973

1976

1979

1982

1985

1988

1991

1994

1997

2000

SourceWHO statistics 2005 Men aged 35 - 74 Standardised

Per 100000Per 100000

USA

CHD mortality rates started falling long before effective treatments used widely

Goldman amp Cook 1984 Annals Int Med 1984 101825) Beaglehole 1986 BMJ 1986 292 33

CABGrArr ThrombolysisrArr StatinsrArr

New Zealand

Studies indicate that approximately 45ndash75 of the recent fall in CVD deaths in industrialised countries was as a result of prevention activities

Around 25ndash45 of the decrease was due to treatment

Capewell Heart 2009941105

Julian Tudor Hart Glyncorrwg

Disease register screening and management of CVD

Inverse Care Law (1971)

The availability of good medical care tends to vary inversely with the need for it in the population served

hellipconsultations in deprived areas

time constraints greater morbidity less patient enablement greater practitioner stress

RCGP Scotland Time to Care Health inequalities deprivation and General Practice in Scotland

Prof Graham Watt lsquoIn at the Deep Endrsquo

Secondary Care

Pharmacist

Primary Care

Dentist

LA

SELF CARE

Voluntary sector

Social Worker

Provision of Health Care

90

Common Barriers to Access

Low levels of cultural competency in staff

Case complexity diagnostic and other

overshadowing

Negative previous experiences of

services

Health not a priority

Communicationlanguage and literacy

Inflexible processesIncluding registration and

Appointment systems

Transport and other costs

Lack of understanding ofrsquosystemrsquo rights and

responsibilities

Discriminationstigmatisation

Challenges ndash language diversity

bull Overcoming language barriers to health care is a global challenge

bull 6500 languages spoken in the world

bull US - 31 million residents unable to speak English fluently with over half of these non-English speakers speaking Spanish and 15 million people speaking 24 different languages bull Recent research identifying more than 300 languages excluding dialects spoken by children at home indicates that London may be the most linguistically diverse city in the world

Current provision of interpreting

Mixed and patchy provisionhellip

bull Family friends

bull Health professional

bull Professional interpreters (face-to-face advocates)

bull Technology (telephone videoconferencing)

bull very little data available on how many individuals are out there unable to consult in English

bull sohellip

Objectives to document the

bull number of general practice consultations occurring in a language other than English

bull use of interpreting services

Gill et al (2011) The Unmet Need for Interpreting Provision in UK Primary Care PLoS ONE 6(6) e20837

Methodology

bull All 70 practices invited

bull Data collection given week in June 2009

bull Random allocation of session

bull Consultation record sheet

Results

bull 77122 (63) eligible practitioners (73 GPs 4 advanced nurse practitioners)

bull 4170 practices (59)

bull 1008 consultations

bull 1 abandoned due to language problems

Note Swine Flu epidemic during study period

The Consultations

717 Consultations in English

290 other languages (1 missing data)

57 relativefriend interpreted

6 professional interpreter (5 in same practice)

No relationship between Practitioner characteristics and need for interpreting

Consultation language

GP proficiency

None Basic Mod High N

Arabic Arabic 0 0 0 10 10 Bengali Bengali 5 7 10 18 40 BengaliEnglish Bengali 0 4 0 0 4 Gujerati Gujerati 0 1 0 2 3 Hindi Hindi 1 2 6 4 13 HindiPunjabi Punjabi 0 2 1 0 3 Katchi Katchi 0 0 1 0 1 Mirpuri Mirpuri 13 0 0 0 13 Punjabi Punjabi 1 3 19 20 43 Urdu Urdu 1 4 13 71 89 UrduEnglish Urdu 0 0 0 3 3 UrduHindi Urdu 0 0 2 0 2 UrduPunjabi Urdu 0 0 0 1 1 Not stated - - - - 4 21 23 52 129 229

Language used in consultation (where other than English)

Conclusions

bull Range of languages spoken by patients compared to practitioners unsurprising

bull Strategies used to overcome language barriers

bull Worrying consultations conducted where practitioner declared only basicno proficiency

bull High number communicating in patients preferred language

bull Use of professional interpreters (6 consultations)

bull increase evidence base of how individuals negotiate their way into and within health care identifying and developing standardised datasets for monitoring access and ensure that we donrsquot exclude minority groups from research

Ethnic recording mandatory within secondary care since 1995 and urgent need to include it within primary care as well eg through Quality and Outcomes framework

- new registrations

- Directly Enhanced Service

C H DB r e a s t c a n c e r

Muller-Nordhorn J et al Eur Heart J 2008 0ehm604v2-11

Age-standardized mortality from cardiovascular disease ie ischaemic heart disease and cerebrovascular disease combined in European regions (men age group 45-74 years year

2000)

SMR for IHD in men (20-74 yrs)

Bangladeshi 151 ( 136-167)

Pakistani 148 (138-158)

Indian 142 (137-147)

Irish 124 (120-127)

White 100

Caribbean 62 (58-67)

Chinese 44 (36-54)

Gill in httpwwwhcnabhamacukseriesbemgframehtm

Possible explanations for the excess CHD risk amongst BMEGs include

possible differential susceptibility to established risk factors (hypertension hyperlipidaemia smoking diabetes) along with exposure to ldquoemergingrdquo risk factors (insulin resistance early life factors racism factor X) and migration

BC BA I P B C I General

Men 25 21 20 29 40 21 30 24

Women 24 10 5 5 2 8 26 23

Self-reported cigarette smoking status by minority ethnic group and sex HSE 2004

Societal influencesIndividual psychology

Biology

Activity environment

Individual activity

Food Consumption

Food Production

Some health care challengeshellip

05

2 5

Childhood Old AgeMiddle Age

Symptoms

No Symptoms

Symptom threshold

SECONDARY

PREVENTION

PRIMARY PREVENTION

CHD Prevention optionsCHD Prevention options

Natural Course of CHD

Natural Course of CHD

Hanlon Capewell et al 1997

0

200

400

600

800

1970

1973

1976

1979

1982

1985

1988

1991

1994

1997

2000

SourceWHO statistics 2005 Men aged 35 - 74 Standardised

Per 100000Per 100000

USA

CHD mortality rates started falling long before effective treatments used widely

Goldman amp Cook 1984 Annals Int Med 1984 101825) Beaglehole 1986 BMJ 1986 292 33

CABGrArr ThrombolysisrArr StatinsrArr

New Zealand

Studies indicate that approximately 45ndash75 of the recent fall in CVD deaths in industrialised countries was as a result of prevention activities

Around 25ndash45 of the decrease was due to treatment

Capewell Heart 2009941105

Julian Tudor Hart Glyncorrwg

Disease register screening and management of CVD

Inverse Care Law (1971)

The availability of good medical care tends to vary inversely with the need for it in the population served

hellipconsultations in deprived areas

time constraints greater morbidity less patient enablement greater practitioner stress

RCGP Scotland Time to Care Health inequalities deprivation and General Practice in Scotland

Prof Graham Watt lsquoIn at the Deep Endrsquo

Secondary Care

Pharmacist

Primary Care

Dentist

LA

SELF CARE

Voluntary sector

Social Worker

Provision of Health Care

90

Common Barriers to Access

Low levels of cultural competency in staff

Case complexity diagnostic and other

overshadowing

Negative previous experiences of

services

Health not a priority

Communicationlanguage and literacy

Inflexible processesIncluding registration and

Appointment systems

Transport and other costs

Lack of understanding ofrsquosystemrsquo rights and

responsibilities

Discriminationstigmatisation

Challenges ndash language diversity

bull Overcoming language barriers to health care is a global challenge

bull 6500 languages spoken in the world

bull US - 31 million residents unable to speak English fluently with over half of these non-English speakers speaking Spanish and 15 million people speaking 24 different languages bull Recent research identifying more than 300 languages excluding dialects spoken by children at home indicates that London may be the most linguistically diverse city in the world

Current provision of interpreting

Mixed and patchy provisionhellip

bull Family friends

bull Health professional

bull Professional interpreters (face-to-face advocates)

bull Technology (telephone videoconferencing)

bull very little data available on how many individuals are out there unable to consult in English

bull sohellip

Objectives to document the

bull number of general practice consultations occurring in a language other than English

bull use of interpreting services

Gill et al (2011) The Unmet Need for Interpreting Provision in UK Primary Care PLoS ONE 6(6) e20837

Methodology

bull All 70 practices invited

bull Data collection given week in June 2009

bull Random allocation of session

bull Consultation record sheet

Results

bull 77122 (63) eligible practitioners (73 GPs 4 advanced nurse practitioners)

bull 4170 practices (59)

bull 1008 consultations

bull 1 abandoned due to language problems

Note Swine Flu epidemic during study period

The Consultations

717 Consultations in English

290 other languages (1 missing data)

57 relativefriend interpreted

6 professional interpreter (5 in same practice)

No relationship between Practitioner characteristics and need for interpreting

Consultation language

GP proficiency

None Basic Mod High N

Arabic Arabic 0 0 0 10 10 Bengali Bengali 5 7 10 18 40 BengaliEnglish Bengali 0 4 0 0 4 Gujerati Gujerati 0 1 0 2 3 Hindi Hindi 1 2 6 4 13 HindiPunjabi Punjabi 0 2 1 0 3 Katchi Katchi 0 0 1 0 1 Mirpuri Mirpuri 13 0 0 0 13 Punjabi Punjabi 1 3 19 20 43 Urdu Urdu 1 4 13 71 89 UrduEnglish Urdu 0 0 0 3 3 UrduHindi Urdu 0 0 2 0 2 UrduPunjabi Urdu 0 0 0 1 1 Not stated - - - - 4 21 23 52 129 229

Language used in consultation (where other than English)

Conclusions

bull Range of languages spoken by patients compared to practitioners unsurprising

bull Strategies used to overcome language barriers

bull Worrying consultations conducted where practitioner declared only basicno proficiency

bull High number communicating in patients preferred language

bull Use of professional interpreters (6 consultations)

bull increase evidence base of how individuals negotiate their way into and within health care identifying and developing standardised datasets for monitoring access and ensure that we donrsquot exclude minority groups from research

Ethnic recording mandatory within secondary care since 1995 and urgent need to include it within primary care as well eg through Quality and Outcomes framework

- new registrations

- Directly Enhanced Service

Muller-Nordhorn J et al Eur Heart J 2008 0ehm604v2-11

Age-standardized mortality from cardiovascular disease ie ischaemic heart disease and cerebrovascular disease combined in European regions (men age group 45-74 years year

2000)

SMR for IHD in men (20-74 yrs)

Bangladeshi 151 ( 136-167)

Pakistani 148 (138-158)

Indian 142 (137-147)

Irish 124 (120-127)

White 100

Caribbean 62 (58-67)

Chinese 44 (36-54)

Gill in httpwwwhcnabhamacukseriesbemgframehtm

Possible explanations for the excess CHD risk amongst BMEGs include

possible differential susceptibility to established risk factors (hypertension hyperlipidaemia smoking diabetes) along with exposure to ldquoemergingrdquo risk factors (insulin resistance early life factors racism factor X) and migration

BC BA I P B C I General

Men 25 21 20 29 40 21 30 24

Women 24 10 5 5 2 8 26 23

Self-reported cigarette smoking status by minority ethnic group and sex HSE 2004

Societal influencesIndividual psychology

Biology

Activity environment

Individual activity

Food Consumption

Food Production

Some health care challengeshellip

05

2 5

Childhood Old AgeMiddle Age

Symptoms

No Symptoms

Symptom threshold

SECONDARY

PREVENTION

PRIMARY PREVENTION

CHD Prevention optionsCHD Prevention options

Natural Course of CHD

Natural Course of CHD

Hanlon Capewell et al 1997

0

200

400

600

800

1970

1973

1976

1979

1982

1985

1988

1991

1994

1997

2000

SourceWHO statistics 2005 Men aged 35 - 74 Standardised

Per 100000Per 100000

USA

CHD mortality rates started falling long before effective treatments used widely

Goldman amp Cook 1984 Annals Int Med 1984 101825) Beaglehole 1986 BMJ 1986 292 33

CABGrArr ThrombolysisrArr StatinsrArr

New Zealand

Studies indicate that approximately 45ndash75 of the recent fall in CVD deaths in industrialised countries was as a result of prevention activities

Around 25ndash45 of the decrease was due to treatment

Capewell Heart 2009941105

Julian Tudor Hart Glyncorrwg

Disease register screening and management of CVD

Inverse Care Law (1971)

The availability of good medical care tends to vary inversely with the need for it in the population served

hellipconsultations in deprived areas

time constraints greater morbidity less patient enablement greater practitioner stress

RCGP Scotland Time to Care Health inequalities deprivation and General Practice in Scotland

Prof Graham Watt lsquoIn at the Deep Endrsquo

Secondary Care

Pharmacist

Primary Care

Dentist

LA

SELF CARE

Voluntary sector

Social Worker

Provision of Health Care

90

Common Barriers to Access

Low levels of cultural competency in staff

Case complexity diagnostic and other

overshadowing

Negative previous experiences of

services

Health not a priority

Communicationlanguage and literacy

Inflexible processesIncluding registration and

Appointment systems

Transport and other costs

Lack of understanding ofrsquosystemrsquo rights and

responsibilities

Discriminationstigmatisation

Challenges ndash language diversity

bull Overcoming language barriers to health care is a global challenge

bull 6500 languages spoken in the world

bull US - 31 million residents unable to speak English fluently with over half of these non-English speakers speaking Spanish and 15 million people speaking 24 different languages bull Recent research identifying more than 300 languages excluding dialects spoken by children at home indicates that London may be the most linguistically diverse city in the world

Current provision of interpreting

Mixed and patchy provisionhellip

bull Family friends

bull Health professional

bull Professional interpreters (face-to-face advocates)

bull Technology (telephone videoconferencing)

bull very little data available on how many individuals are out there unable to consult in English

bull sohellip

Objectives to document the

bull number of general practice consultations occurring in a language other than English

bull use of interpreting services

Gill et al (2011) The Unmet Need for Interpreting Provision in UK Primary Care PLoS ONE 6(6) e20837

Methodology

bull All 70 practices invited

bull Data collection given week in June 2009

bull Random allocation of session

bull Consultation record sheet

Results

bull 77122 (63) eligible practitioners (73 GPs 4 advanced nurse practitioners)

bull 4170 practices (59)

bull 1008 consultations

bull 1 abandoned due to language problems

Note Swine Flu epidemic during study period

The Consultations

717 Consultations in English

290 other languages (1 missing data)

57 relativefriend interpreted

6 professional interpreter (5 in same practice)

No relationship between Practitioner characteristics and need for interpreting

Consultation language

GP proficiency

None Basic Mod High N

Arabic Arabic 0 0 0 10 10 Bengali Bengali 5 7 10 18 40 BengaliEnglish Bengali 0 4 0 0 4 Gujerati Gujerati 0 1 0 2 3 Hindi Hindi 1 2 6 4 13 HindiPunjabi Punjabi 0 2 1 0 3 Katchi Katchi 0 0 1 0 1 Mirpuri Mirpuri 13 0 0 0 13 Punjabi Punjabi 1 3 19 20 43 Urdu Urdu 1 4 13 71 89 UrduEnglish Urdu 0 0 0 3 3 UrduHindi Urdu 0 0 2 0 2 UrduPunjabi Urdu 0 0 0 1 1 Not stated - - - - 4 21 23 52 129 229

Language used in consultation (where other than English)

Conclusions

bull Range of languages spoken by patients compared to practitioners unsurprising

bull Strategies used to overcome language barriers

bull Worrying consultations conducted where practitioner declared only basicno proficiency

bull High number communicating in patients preferred language

bull Use of professional interpreters (6 consultations)

bull increase evidence base of how individuals negotiate their way into and within health care identifying and developing standardised datasets for monitoring access and ensure that we donrsquot exclude minority groups from research

Ethnic recording mandatory within secondary care since 1995 and urgent need to include it within primary care as well eg through Quality and Outcomes framework

- new registrations

- Directly Enhanced Service

SMR for IHD in men (20-74 yrs)

Bangladeshi 151 ( 136-167)

Pakistani 148 (138-158)

Indian 142 (137-147)

Irish 124 (120-127)

White 100

Caribbean 62 (58-67)

Chinese 44 (36-54)

Gill in httpwwwhcnabhamacukseriesbemgframehtm

Possible explanations for the excess CHD risk amongst BMEGs include

possible differential susceptibility to established risk factors (hypertension hyperlipidaemia smoking diabetes) along with exposure to ldquoemergingrdquo risk factors (insulin resistance early life factors racism factor X) and migration

BC BA I P B C I General

Men 25 21 20 29 40 21 30 24

Women 24 10 5 5 2 8 26 23

Self-reported cigarette smoking status by minority ethnic group and sex HSE 2004

Societal influencesIndividual psychology

Biology

Activity environment

Individual activity

Food Consumption

Food Production

Some health care challengeshellip

05

2 5

Childhood Old AgeMiddle Age

Symptoms

No Symptoms

Symptom threshold

SECONDARY

PREVENTION

PRIMARY PREVENTION

CHD Prevention optionsCHD Prevention options

Natural Course of CHD

Natural Course of CHD

Hanlon Capewell et al 1997

0

200

400

600

800

1970

1973

1976

1979

1982

1985

1988

1991

1994

1997

2000

SourceWHO statistics 2005 Men aged 35 - 74 Standardised

Per 100000Per 100000

USA

CHD mortality rates started falling long before effective treatments used widely

Goldman amp Cook 1984 Annals Int Med 1984 101825) Beaglehole 1986 BMJ 1986 292 33

CABGrArr ThrombolysisrArr StatinsrArr

New Zealand

Studies indicate that approximately 45ndash75 of the recent fall in CVD deaths in industrialised countries was as a result of prevention activities

Around 25ndash45 of the decrease was due to treatment

Capewell Heart 2009941105

Julian Tudor Hart Glyncorrwg

Disease register screening and management of CVD

Inverse Care Law (1971)

The availability of good medical care tends to vary inversely with the need for it in the population served

hellipconsultations in deprived areas

time constraints greater morbidity less patient enablement greater practitioner stress

RCGP Scotland Time to Care Health inequalities deprivation and General Practice in Scotland

Prof Graham Watt lsquoIn at the Deep Endrsquo

Secondary Care

Pharmacist

Primary Care

Dentist

LA

SELF CARE

Voluntary sector

Social Worker

Provision of Health Care

90

Common Barriers to Access

Low levels of cultural competency in staff

Case complexity diagnostic and other

overshadowing

Negative previous experiences of

services

Health not a priority

Communicationlanguage and literacy

Inflexible processesIncluding registration and

Appointment systems

Transport and other costs

Lack of understanding ofrsquosystemrsquo rights and

responsibilities

Discriminationstigmatisation

Challenges ndash language diversity

bull Overcoming language barriers to health care is a global challenge

bull 6500 languages spoken in the world

bull US - 31 million residents unable to speak English fluently with over half of these non-English speakers speaking Spanish and 15 million people speaking 24 different languages bull Recent research identifying more than 300 languages excluding dialects spoken by children at home indicates that London may be the most linguistically diverse city in the world

Current provision of interpreting

Mixed and patchy provisionhellip

bull Family friends

bull Health professional

bull Professional interpreters (face-to-face advocates)

bull Technology (telephone videoconferencing)

bull very little data available on how many individuals are out there unable to consult in English

bull sohellip

Objectives to document the

bull number of general practice consultations occurring in a language other than English

bull use of interpreting services

Gill et al (2011) The Unmet Need for Interpreting Provision in UK Primary Care PLoS ONE 6(6) e20837

Methodology

bull All 70 practices invited

bull Data collection given week in June 2009

bull Random allocation of session

bull Consultation record sheet

Results

bull 77122 (63) eligible practitioners (73 GPs 4 advanced nurse practitioners)

bull 4170 practices (59)

bull 1008 consultations

bull 1 abandoned due to language problems

Note Swine Flu epidemic during study period

The Consultations

717 Consultations in English

290 other languages (1 missing data)

57 relativefriend interpreted

6 professional interpreter (5 in same practice)

No relationship between Practitioner characteristics and need for interpreting

Consultation language

GP proficiency

None Basic Mod High N

Arabic Arabic 0 0 0 10 10 Bengali Bengali 5 7 10 18 40 BengaliEnglish Bengali 0 4 0 0 4 Gujerati Gujerati 0 1 0 2 3 Hindi Hindi 1 2 6 4 13 HindiPunjabi Punjabi 0 2 1 0 3 Katchi Katchi 0 0 1 0 1 Mirpuri Mirpuri 13 0 0 0 13 Punjabi Punjabi 1 3 19 20 43 Urdu Urdu 1 4 13 71 89 UrduEnglish Urdu 0 0 0 3 3 UrduHindi Urdu 0 0 2 0 2 UrduPunjabi Urdu 0 0 0 1 1 Not stated - - - - 4 21 23 52 129 229

Language used in consultation (where other than English)

Conclusions

bull Range of languages spoken by patients compared to practitioners unsurprising

bull Strategies used to overcome language barriers

bull Worrying consultations conducted where practitioner declared only basicno proficiency

bull High number communicating in patients preferred language

bull Use of professional interpreters (6 consultations)

bull increase evidence base of how individuals negotiate their way into and within health care identifying and developing standardised datasets for monitoring access and ensure that we donrsquot exclude minority groups from research

Ethnic recording mandatory within secondary care since 1995 and urgent need to include it within primary care as well eg through Quality and Outcomes framework

- new registrations

- Directly Enhanced Service

Possible explanations for the excess CHD risk amongst BMEGs include

possible differential susceptibility to established risk factors (hypertension hyperlipidaemia smoking diabetes) along with exposure to ldquoemergingrdquo risk factors (insulin resistance early life factors racism factor X) and migration

BC BA I P B C I General

Men 25 21 20 29 40 21 30 24

Women 24 10 5 5 2 8 26 23

Self-reported cigarette smoking status by minority ethnic group and sex HSE 2004

Societal influencesIndividual psychology

Biology

Activity environment

Individual activity

Food Consumption

Food Production

Some health care challengeshellip

05

2 5

Childhood Old AgeMiddle Age

Symptoms

No Symptoms

Symptom threshold

SECONDARY

PREVENTION

PRIMARY PREVENTION

CHD Prevention optionsCHD Prevention options

Natural Course of CHD

Natural Course of CHD

Hanlon Capewell et al 1997

0

200

400

600

800

1970

1973

1976

1979

1982

1985

1988

1991

1994

1997

2000

SourceWHO statistics 2005 Men aged 35 - 74 Standardised

Per 100000Per 100000

USA

CHD mortality rates started falling long before effective treatments used widely

Goldman amp Cook 1984 Annals Int Med 1984 101825) Beaglehole 1986 BMJ 1986 292 33

CABGrArr ThrombolysisrArr StatinsrArr

New Zealand

Studies indicate that approximately 45ndash75 of the recent fall in CVD deaths in industrialised countries was as a result of prevention activities

Around 25ndash45 of the decrease was due to treatment

Capewell Heart 2009941105

Julian Tudor Hart Glyncorrwg

Disease register screening and management of CVD

Inverse Care Law (1971)

The availability of good medical care tends to vary inversely with the need for it in the population served

hellipconsultations in deprived areas

time constraints greater morbidity less patient enablement greater practitioner stress

RCGP Scotland Time to Care Health inequalities deprivation and General Practice in Scotland

Prof Graham Watt lsquoIn at the Deep Endrsquo

Secondary Care

Pharmacist

Primary Care

Dentist

LA

SELF CARE

Voluntary sector

Social Worker

Provision of Health Care

90

Common Barriers to Access

Low levels of cultural competency in staff

Case complexity diagnostic and other

overshadowing

Negative previous experiences of

services

Health not a priority

Communicationlanguage and literacy

Inflexible processesIncluding registration and

Appointment systems

Transport and other costs

Lack of understanding ofrsquosystemrsquo rights and

responsibilities

Discriminationstigmatisation

Challenges ndash language diversity

bull Overcoming language barriers to health care is a global challenge

bull 6500 languages spoken in the world

bull US - 31 million residents unable to speak English fluently with over half of these non-English speakers speaking Spanish and 15 million people speaking 24 different languages bull Recent research identifying more than 300 languages excluding dialects spoken by children at home indicates that London may be the most linguistically diverse city in the world

Current provision of interpreting

Mixed and patchy provisionhellip

bull Family friends

bull Health professional

bull Professional interpreters (face-to-face advocates)

bull Technology (telephone videoconferencing)

bull very little data available on how many individuals are out there unable to consult in English

bull sohellip

Objectives to document the

bull number of general practice consultations occurring in a language other than English

bull use of interpreting services

Gill et al (2011) The Unmet Need for Interpreting Provision in UK Primary Care PLoS ONE 6(6) e20837

Methodology

bull All 70 practices invited

bull Data collection given week in June 2009

bull Random allocation of session

bull Consultation record sheet

Results

bull 77122 (63) eligible practitioners (73 GPs 4 advanced nurse practitioners)

bull 4170 practices (59)

bull 1008 consultations

bull 1 abandoned due to language problems

Note Swine Flu epidemic during study period

The Consultations

717 Consultations in English

290 other languages (1 missing data)

57 relativefriend interpreted

6 professional interpreter (5 in same practice)

No relationship between Practitioner characteristics and need for interpreting

Consultation language

GP proficiency

None Basic Mod High N

Arabic Arabic 0 0 0 10 10 Bengali Bengali 5 7 10 18 40 BengaliEnglish Bengali 0 4 0 0 4 Gujerati Gujerati 0 1 0 2 3 Hindi Hindi 1 2 6 4 13 HindiPunjabi Punjabi 0 2 1 0 3 Katchi Katchi 0 0 1 0 1 Mirpuri Mirpuri 13 0 0 0 13 Punjabi Punjabi 1 3 19 20 43 Urdu Urdu 1 4 13 71 89 UrduEnglish Urdu 0 0 0 3 3 UrduHindi Urdu 0 0 2 0 2 UrduPunjabi Urdu 0 0 0 1 1 Not stated - - - - 4 21 23 52 129 229

Language used in consultation (where other than English)

Conclusions

bull Range of languages spoken by patients compared to practitioners unsurprising

bull Strategies used to overcome language barriers

bull Worrying consultations conducted where practitioner declared only basicno proficiency

bull High number communicating in patients preferred language

bull Use of professional interpreters (6 consultations)

bull increase evidence base of how individuals negotiate their way into and within health care identifying and developing standardised datasets for monitoring access and ensure that we donrsquot exclude minority groups from research

Ethnic recording mandatory within secondary care since 1995 and urgent need to include it within primary care as well eg through Quality and Outcomes framework

- new registrations

- Directly Enhanced Service

BC BA I P B C I General

Men 25 21 20 29 40 21 30 24

Women 24 10 5 5 2 8 26 23

Self-reported cigarette smoking status by minority ethnic group and sex HSE 2004

Societal influencesIndividual psychology

Biology

Activity environment

Individual activity

Food Consumption

Food Production

Some health care challengeshellip

05

2 5

Childhood Old AgeMiddle Age

Symptoms

No Symptoms

Symptom threshold

SECONDARY

PREVENTION

PRIMARY PREVENTION

CHD Prevention optionsCHD Prevention options

Natural Course of CHD

Natural Course of CHD

Hanlon Capewell et al 1997

0

200

400

600

800

1970

1973

1976

1979

1982

1985

1988

1991

1994

1997

2000

SourceWHO statistics 2005 Men aged 35 - 74 Standardised

Per 100000Per 100000

USA

CHD mortality rates started falling long before effective treatments used widely

Goldman amp Cook 1984 Annals Int Med 1984 101825) Beaglehole 1986 BMJ 1986 292 33

CABGrArr ThrombolysisrArr StatinsrArr

New Zealand

Studies indicate that approximately 45ndash75 of the recent fall in CVD deaths in industrialised countries was as a result of prevention activities

Around 25ndash45 of the decrease was due to treatment

Capewell Heart 2009941105

Julian Tudor Hart Glyncorrwg

Disease register screening and management of CVD

Inverse Care Law (1971)

The availability of good medical care tends to vary inversely with the need for it in the population served

hellipconsultations in deprived areas

time constraints greater morbidity less patient enablement greater practitioner stress

RCGP Scotland Time to Care Health inequalities deprivation and General Practice in Scotland

Prof Graham Watt lsquoIn at the Deep Endrsquo

Secondary Care

Pharmacist

Primary Care

Dentist

LA

SELF CARE

Voluntary sector

Social Worker

Provision of Health Care

90

Common Barriers to Access

Low levels of cultural competency in staff

Case complexity diagnostic and other

overshadowing

Negative previous experiences of

services

Health not a priority

Communicationlanguage and literacy

Inflexible processesIncluding registration and

Appointment systems

Transport and other costs

Lack of understanding ofrsquosystemrsquo rights and

responsibilities

Discriminationstigmatisation

Challenges ndash language diversity

bull Overcoming language barriers to health care is a global challenge

bull 6500 languages spoken in the world

bull US - 31 million residents unable to speak English fluently with over half of these non-English speakers speaking Spanish and 15 million people speaking 24 different languages bull Recent research identifying more than 300 languages excluding dialects spoken by children at home indicates that London may be the most linguistically diverse city in the world

Current provision of interpreting

Mixed and patchy provisionhellip

bull Family friends

bull Health professional

bull Professional interpreters (face-to-face advocates)

bull Technology (telephone videoconferencing)

bull very little data available on how many individuals are out there unable to consult in English

bull sohellip

Objectives to document the

bull number of general practice consultations occurring in a language other than English

bull use of interpreting services

Gill et al (2011) The Unmet Need for Interpreting Provision in UK Primary Care PLoS ONE 6(6) e20837

Methodology

bull All 70 practices invited

bull Data collection given week in June 2009

bull Random allocation of session

bull Consultation record sheet

Results

bull 77122 (63) eligible practitioners (73 GPs 4 advanced nurse practitioners)

bull 4170 practices (59)

bull 1008 consultations

bull 1 abandoned due to language problems

Note Swine Flu epidemic during study period

The Consultations

717 Consultations in English

290 other languages (1 missing data)

57 relativefriend interpreted

6 professional interpreter (5 in same practice)

No relationship between Practitioner characteristics and need for interpreting

Consultation language

GP proficiency

None Basic Mod High N

Arabic Arabic 0 0 0 10 10 Bengali Bengali 5 7 10 18 40 BengaliEnglish Bengali 0 4 0 0 4 Gujerati Gujerati 0 1 0 2 3 Hindi Hindi 1 2 6 4 13 HindiPunjabi Punjabi 0 2 1 0 3 Katchi Katchi 0 0 1 0 1 Mirpuri Mirpuri 13 0 0 0 13 Punjabi Punjabi 1 3 19 20 43 Urdu Urdu 1 4 13 71 89 UrduEnglish Urdu 0 0 0 3 3 UrduHindi Urdu 0 0 2 0 2 UrduPunjabi Urdu 0 0 0 1 1 Not stated - - - - 4 21 23 52 129 229

Language used in consultation (where other than English)

Conclusions

bull Range of languages spoken by patients compared to practitioners unsurprising

bull Strategies used to overcome language barriers

bull Worrying consultations conducted where practitioner declared only basicno proficiency

bull High number communicating in patients preferred language

bull Use of professional interpreters (6 consultations)

bull increase evidence base of how individuals negotiate their way into and within health care identifying and developing standardised datasets for monitoring access and ensure that we donrsquot exclude minority groups from research

Ethnic recording mandatory within secondary care since 1995 and urgent need to include it within primary care as well eg through Quality and Outcomes framework

- new registrations

- Directly Enhanced Service

Societal influencesIndividual psychology

Biology

Activity environment

Individual activity

Food Consumption

Food Production

Some health care challengeshellip

05

2 5

Childhood Old AgeMiddle Age

Symptoms

No Symptoms

Symptom threshold

SECONDARY

PREVENTION

PRIMARY PREVENTION

CHD Prevention optionsCHD Prevention options

Natural Course of CHD

Natural Course of CHD

Hanlon Capewell et al 1997

0

200

400

600

800

1970

1973

1976

1979

1982

1985

1988

1991

1994

1997

2000

SourceWHO statistics 2005 Men aged 35 - 74 Standardised

Per 100000Per 100000

USA

CHD mortality rates started falling long before effective treatments used widely

Goldman amp Cook 1984 Annals Int Med 1984 101825) Beaglehole 1986 BMJ 1986 292 33

CABGrArr ThrombolysisrArr StatinsrArr

New Zealand

Studies indicate that approximately 45ndash75 of the recent fall in CVD deaths in industrialised countries was as a result of prevention activities

Around 25ndash45 of the decrease was due to treatment

Capewell Heart 2009941105

Julian Tudor Hart Glyncorrwg

Disease register screening and management of CVD

Inverse Care Law (1971)

The availability of good medical care tends to vary inversely with the need for it in the population served

hellipconsultations in deprived areas

time constraints greater morbidity less patient enablement greater practitioner stress

RCGP Scotland Time to Care Health inequalities deprivation and General Practice in Scotland

Prof Graham Watt lsquoIn at the Deep Endrsquo

Secondary Care

Pharmacist

Primary Care

Dentist

LA

SELF CARE

Voluntary sector

Social Worker

Provision of Health Care

90

Common Barriers to Access

Low levels of cultural competency in staff

Case complexity diagnostic and other

overshadowing

Negative previous experiences of

services

Health not a priority

Communicationlanguage and literacy

Inflexible processesIncluding registration and

Appointment systems

Transport and other costs

Lack of understanding ofrsquosystemrsquo rights and

responsibilities

Discriminationstigmatisation

Challenges ndash language diversity

bull Overcoming language barriers to health care is a global challenge

bull 6500 languages spoken in the world

bull US - 31 million residents unable to speak English fluently with over half of these non-English speakers speaking Spanish and 15 million people speaking 24 different languages bull Recent research identifying more than 300 languages excluding dialects spoken by children at home indicates that London may be the most linguistically diverse city in the world

Current provision of interpreting

Mixed and patchy provisionhellip

bull Family friends

bull Health professional

bull Professional interpreters (face-to-face advocates)

bull Technology (telephone videoconferencing)

bull very little data available on how many individuals are out there unable to consult in English

bull sohellip

Objectives to document the

bull number of general practice consultations occurring in a language other than English

bull use of interpreting services

Gill et al (2011) The Unmet Need for Interpreting Provision in UK Primary Care PLoS ONE 6(6) e20837

Methodology

bull All 70 practices invited

bull Data collection given week in June 2009

bull Random allocation of session

bull Consultation record sheet

Results

bull 77122 (63) eligible practitioners (73 GPs 4 advanced nurse practitioners)

bull 4170 practices (59)

bull 1008 consultations

bull 1 abandoned due to language problems

Note Swine Flu epidemic during study period

The Consultations

717 Consultations in English

290 other languages (1 missing data)

57 relativefriend interpreted

6 professional interpreter (5 in same practice)

No relationship between Practitioner characteristics and need for interpreting

Consultation language

GP proficiency

None Basic Mod High N

Arabic Arabic 0 0 0 10 10 Bengali Bengali 5 7 10 18 40 BengaliEnglish Bengali 0 4 0 0 4 Gujerati Gujerati 0 1 0 2 3 Hindi Hindi 1 2 6 4 13 HindiPunjabi Punjabi 0 2 1 0 3 Katchi Katchi 0 0 1 0 1 Mirpuri Mirpuri 13 0 0 0 13 Punjabi Punjabi 1 3 19 20 43 Urdu Urdu 1 4 13 71 89 UrduEnglish Urdu 0 0 0 3 3 UrduHindi Urdu 0 0 2 0 2 UrduPunjabi Urdu 0 0 0 1 1 Not stated - - - - 4 21 23 52 129 229

Language used in consultation (where other than English)

Conclusions

bull Range of languages spoken by patients compared to practitioners unsurprising

bull Strategies used to overcome language barriers

bull Worrying consultations conducted where practitioner declared only basicno proficiency

bull High number communicating in patients preferred language

bull Use of professional interpreters (6 consultations)

bull increase evidence base of how individuals negotiate their way into and within health care identifying and developing standardised datasets for monitoring access and ensure that we donrsquot exclude minority groups from research

Ethnic recording mandatory within secondary care since 1995 and urgent need to include it within primary care as well eg through Quality and Outcomes framework

- new registrations

- Directly Enhanced Service

Some health care challengeshellip

05

2 5

Childhood Old AgeMiddle Age

Symptoms

No Symptoms

Symptom threshold

SECONDARY

PREVENTION

PRIMARY PREVENTION

CHD Prevention optionsCHD Prevention options

Natural Course of CHD

Natural Course of CHD

Hanlon Capewell et al 1997

0

200

400

600

800

1970

1973

1976

1979

1982

1985

1988

1991

1994

1997

2000

SourceWHO statistics 2005 Men aged 35 - 74 Standardised

Per 100000Per 100000

USA

CHD mortality rates started falling long before effective treatments used widely

Goldman amp Cook 1984 Annals Int Med 1984 101825) Beaglehole 1986 BMJ 1986 292 33

CABGrArr ThrombolysisrArr StatinsrArr

New Zealand

Studies indicate that approximately 45ndash75 of the recent fall in CVD deaths in industrialised countries was as a result of prevention activities

Around 25ndash45 of the decrease was due to treatment

Capewell Heart 2009941105

Julian Tudor Hart Glyncorrwg

Disease register screening and management of CVD

Inverse Care Law (1971)

The availability of good medical care tends to vary inversely with the need for it in the population served

hellipconsultations in deprived areas

time constraints greater morbidity less patient enablement greater practitioner stress

RCGP Scotland Time to Care Health inequalities deprivation and General Practice in Scotland

Prof Graham Watt lsquoIn at the Deep Endrsquo

Secondary Care

Pharmacist

Primary Care

Dentist

LA

SELF CARE

Voluntary sector

Social Worker

Provision of Health Care

90

Common Barriers to Access

Low levels of cultural competency in staff

Case complexity diagnostic and other

overshadowing

Negative previous experiences of

services

Health not a priority

Communicationlanguage and literacy

Inflexible processesIncluding registration and

Appointment systems

Transport and other costs

Lack of understanding ofrsquosystemrsquo rights and

responsibilities

Discriminationstigmatisation

Challenges ndash language diversity

bull Overcoming language barriers to health care is a global challenge

bull 6500 languages spoken in the world

bull US - 31 million residents unable to speak English fluently with over half of these non-English speakers speaking Spanish and 15 million people speaking 24 different languages bull Recent research identifying more than 300 languages excluding dialects spoken by children at home indicates that London may be the most linguistically diverse city in the world

Current provision of interpreting

Mixed and patchy provisionhellip

bull Family friends

bull Health professional

bull Professional interpreters (face-to-face advocates)

bull Technology (telephone videoconferencing)

bull very little data available on how many individuals are out there unable to consult in English

bull sohellip

Objectives to document the

bull number of general practice consultations occurring in a language other than English

bull use of interpreting services

Gill et al (2011) The Unmet Need for Interpreting Provision in UK Primary Care PLoS ONE 6(6) e20837

Methodology

bull All 70 practices invited

bull Data collection given week in June 2009

bull Random allocation of session

bull Consultation record sheet

Results

bull 77122 (63) eligible practitioners (73 GPs 4 advanced nurse practitioners)

bull 4170 practices (59)

bull 1008 consultations

bull 1 abandoned due to language problems

Note Swine Flu epidemic during study period

The Consultations

717 Consultations in English

290 other languages (1 missing data)

57 relativefriend interpreted

6 professional interpreter (5 in same practice)

No relationship between Practitioner characteristics and need for interpreting

Consultation language

GP proficiency

None Basic Mod High N

Arabic Arabic 0 0 0 10 10 Bengali Bengali 5 7 10 18 40 BengaliEnglish Bengali 0 4 0 0 4 Gujerati Gujerati 0 1 0 2 3 Hindi Hindi 1 2 6 4 13 HindiPunjabi Punjabi 0 2 1 0 3 Katchi Katchi 0 0 1 0 1 Mirpuri Mirpuri 13 0 0 0 13 Punjabi Punjabi 1 3 19 20 43 Urdu Urdu 1 4 13 71 89 UrduEnglish Urdu 0 0 0 3 3 UrduHindi Urdu 0 0 2 0 2 UrduPunjabi Urdu 0 0 0 1 1 Not stated - - - - 4 21 23 52 129 229

Language used in consultation (where other than English)

Conclusions

bull Range of languages spoken by patients compared to practitioners unsurprising

bull Strategies used to overcome language barriers

bull Worrying consultations conducted where practitioner declared only basicno proficiency

bull High number communicating in patients preferred language

bull Use of professional interpreters (6 consultations)

bull increase evidence base of how individuals negotiate their way into and within health care identifying and developing standardised datasets for monitoring access and ensure that we donrsquot exclude minority groups from research

Ethnic recording mandatory within secondary care since 1995 and urgent need to include it within primary care as well eg through Quality and Outcomes framework

- new registrations

- Directly Enhanced Service

05

2 5

Childhood Old AgeMiddle Age

Symptoms

No Symptoms

Symptom threshold

SECONDARY

PREVENTION

PRIMARY PREVENTION

CHD Prevention optionsCHD Prevention options

Natural Course of CHD

Natural Course of CHD

Hanlon Capewell et al 1997

0

200

400

600

800

1970

1973

1976

1979

1982

1985

1988

1991

1994

1997

2000

SourceWHO statistics 2005 Men aged 35 - 74 Standardised

Per 100000Per 100000

USA

CHD mortality rates started falling long before effective treatments used widely

Goldman amp Cook 1984 Annals Int Med 1984 101825) Beaglehole 1986 BMJ 1986 292 33

CABGrArr ThrombolysisrArr StatinsrArr

New Zealand

Studies indicate that approximately 45ndash75 of the recent fall in CVD deaths in industrialised countries was as a result of prevention activities

Around 25ndash45 of the decrease was due to treatment

Capewell Heart 2009941105

Julian Tudor Hart Glyncorrwg

Disease register screening and management of CVD

Inverse Care Law (1971)

The availability of good medical care tends to vary inversely with the need for it in the population served

hellipconsultations in deprived areas

time constraints greater morbidity less patient enablement greater practitioner stress

RCGP Scotland Time to Care Health inequalities deprivation and General Practice in Scotland

Prof Graham Watt lsquoIn at the Deep Endrsquo

Secondary Care

Pharmacist

Primary Care

Dentist

LA

SELF CARE

Voluntary sector

Social Worker

Provision of Health Care

90

Common Barriers to Access

Low levels of cultural competency in staff

Case complexity diagnostic and other

overshadowing

Negative previous experiences of

services

Health not a priority

Communicationlanguage and literacy

Inflexible processesIncluding registration and

Appointment systems

Transport and other costs

Lack of understanding ofrsquosystemrsquo rights and

responsibilities

Discriminationstigmatisation

Challenges ndash language diversity

bull Overcoming language barriers to health care is a global challenge

bull 6500 languages spoken in the world

bull US - 31 million residents unable to speak English fluently with over half of these non-English speakers speaking Spanish and 15 million people speaking 24 different languages bull Recent research identifying more than 300 languages excluding dialects spoken by children at home indicates that London may be the most linguistically diverse city in the world

Current provision of interpreting

Mixed and patchy provisionhellip

bull Family friends

bull Health professional

bull Professional interpreters (face-to-face advocates)

bull Technology (telephone videoconferencing)

bull very little data available on how many individuals are out there unable to consult in English

bull sohellip

Objectives to document the

bull number of general practice consultations occurring in a language other than English

bull use of interpreting services

Gill et al (2011) The Unmet Need for Interpreting Provision in UK Primary Care PLoS ONE 6(6) e20837

Methodology

bull All 70 practices invited

bull Data collection given week in June 2009

bull Random allocation of session

bull Consultation record sheet

Results

bull 77122 (63) eligible practitioners (73 GPs 4 advanced nurse practitioners)

bull 4170 practices (59)

bull 1008 consultations

bull 1 abandoned due to language problems

Note Swine Flu epidemic during study period

The Consultations

717 Consultations in English

290 other languages (1 missing data)

57 relativefriend interpreted

6 professional interpreter (5 in same practice)

No relationship between Practitioner characteristics and need for interpreting

Consultation language

GP proficiency

None Basic Mod High N

Arabic Arabic 0 0 0 10 10 Bengali Bengali 5 7 10 18 40 BengaliEnglish Bengali 0 4 0 0 4 Gujerati Gujerati 0 1 0 2 3 Hindi Hindi 1 2 6 4 13 HindiPunjabi Punjabi 0 2 1 0 3 Katchi Katchi 0 0 1 0 1 Mirpuri Mirpuri 13 0 0 0 13 Punjabi Punjabi 1 3 19 20 43 Urdu Urdu 1 4 13 71 89 UrduEnglish Urdu 0 0 0 3 3 UrduHindi Urdu 0 0 2 0 2 UrduPunjabi Urdu 0 0 0 1 1 Not stated - - - - 4 21 23 52 129 229

Language used in consultation (where other than English)

Conclusions

bull Range of languages spoken by patients compared to practitioners unsurprising

bull Strategies used to overcome language barriers

bull Worrying consultations conducted where practitioner declared only basicno proficiency

bull High number communicating in patients preferred language

bull Use of professional interpreters (6 consultations)

bull increase evidence base of how individuals negotiate their way into and within health care identifying and developing standardised datasets for monitoring access and ensure that we donrsquot exclude minority groups from research

Ethnic recording mandatory within secondary care since 1995 and urgent need to include it within primary care as well eg through Quality and Outcomes framework

- new registrations

- Directly Enhanced Service

0

200

400

600

800

1970

1973

1976

1979

1982

1985

1988

1991

1994

1997

2000

SourceWHO statistics 2005 Men aged 35 - 74 Standardised

Per 100000Per 100000

USA

CHD mortality rates started falling long before effective treatments used widely

Goldman amp Cook 1984 Annals Int Med 1984 101825) Beaglehole 1986 BMJ 1986 292 33

CABGrArr ThrombolysisrArr StatinsrArr

New Zealand

Studies indicate that approximately 45ndash75 of the recent fall in CVD deaths in industrialised countries was as a result of prevention activities

Around 25ndash45 of the decrease was due to treatment

Capewell Heart 2009941105

Julian Tudor Hart Glyncorrwg

Disease register screening and management of CVD

Inverse Care Law (1971)

The availability of good medical care tends to vary inversely with the need for it in the population served

hellipconsultations in deprived areas

time constraints greater morbidity less patient enablement greater practitioner stress

RCGP Scotland Time to Care Health inequalities deprivation and General Practice in Scotland

Prof Graham Watt lsquoIn at the Deep Endrsquo

Secondary Care

Pharmacist

Primary Care

Dentist

LA

SELF CARE

Voluntary sector

Social Worker

Provision of Health Care

90

Common Barriers to Access

Low levels of cultural competency in staff

Case complexity diagnostic and other

overshadowing

Negative previous experiences of

services

Health not a priority

Communicationlanguage and literacy

Inflexible processesIncluding registration and

Appointment systems

Transport and other costs

Lack of understanding ofrsquosystemrsquo rights and

responsibilities

Discriminationstigmatisation

Challenges ndash language diversity

bull Overcoming language barriers to health care is a global challenge

bull 6500 languages spoken in the world

bull US - 31 million residents unable to speak English fluently with over half of these non-English speakers speaking Spanish and 15 million people speaking 24 different languages bull Recent research identifying more than 300 languages excluding dialects spoken by children at home indicates that London may be the most linguistically diverse city in the world

Current provision of interpreting

Mixed and patchy provisionhellip

bull Family friends

bull Health professional

bull Professional interpreters (face-to-face advocates)

bull Technology (telephone videoconferencing)

bull very little data available on how many individuals are out there unable to consult in English

bull sohellip

Objectives to document the

bull number of general practice consultations occurring in a language other than English

bull use of interpreting services

Gill et al (2011) The Unmet Need for Interpreting Provision in UK Primary Care PLoS ONE 6(6) e20837

Methodology

bull All 70 practices invited

bull Data collection given week in June 2009

bull Random allocation of session

bull Consultation record sheet

Results

bull 77122 (63) eligible practitioners (73 GPs 4 advanced nurse practitioners)

bull 4170 practices (59)

bull 1008 consultations

bull 1 abandoned due to language problems

Note Swine Flu epidemic during study period

The Consultations

717 Consultations in English

290 other languages (1 missing data)

57 relativefriend interpreted

6 professional interpreter (5 in same practice)

No relationship between Practitioner characteristics and need for interpreting

Consultation language

GP proficiency

None Basic Mod High N

Arabic Arabic 0 0 0 10 10 Bengali Bengali 5 7 10 18 40 BengaliEnglish Bengali 0 4 0 0 4 Gujerati Gujerati 0 1 0 2 3 Hindi Hindi 1 2 6 4 13 HindiPunjabi Punjabi 0 2 1 0 3 Katchi Katchi 0 0 1 0 1 Mirpuri Mirpuri 13 0 0 0 13 Punjabi Punjabi 1 3 19 20 43 Urdu Urdu 1 4 13 71 89 UrduEnglish Urdu 0 0 0 3 3 UrduHindi Urdu 0 0 2 0 2 UrduPunjabi Urdu 0 0 0 1 1 Not stated - - - - 4 21 23 52 129 229

Language used in consultation (where other than English)

Conclusions

bull Range of languages spoken by patients compared to practitioners unsurprising

bull Strategies used to overcome language barriers

bull Worrying consultations conducted where practitioner declared only basicno proficiency

bull High number communicating in patients preferred language

bull Use of professional interpreters (6 consultations)

bull increase evidence base of how individuals negotiate their way into and within health care identifying and developing standardised datasets for monitoring access and ensure that we donrsquot exclude minority groups from research

Ethnic recording mandatory within secondary care since 1995 and urgent need to include it within primary care as well eg through Quality and Outcomes framework

- new registrations

- Directly Enhanced Service

Studies indicate that approximately 45ndash75 of the recent fall in CVD deaths in industrialised countries was as a result of prevention activities

Around 25ndash45 of the decrease was due to treatment

Capewell Heart 2009941105

Julian Tudor Hart Glyncorrwg

Disease register screening and management of CVD

Inverse Care Law (1971)

The availability of good medical care tends to vary inversely with the need for it in the population served

hellipconsultations in deprived areas

time constraints greater morbidity less patient enablement greater practitioner stress

RCGP Scotland Time to Care Health inequalities deprivation and General Practice in Scotland

Prof Graham Watt lsquoIn at the Deep Endrsquo

Secondary Care

Pharmacist

Primary Care

Dentist

LA

SELF CARE

Voluntary sector

Social Worker

Provision of Health Care

90

Common Barriers to Access

Low levels of cultural competency in staff

Case complexity diagnostic and other

overshadowing

Negative previous experiences of

services

Health not a priority

Communicationlanguage and literacy

Inflexible processesIncluding registration and

Appointment systems

Transport and other costs

Lack of understanding ofrsquosystemrsquo rights and

responsibilities

Discriminationstigmatisation

Challenges ndash language diversity

bull Overcoming language barriers to health care is a global challenge

bull 6500 languages spoken in the world

bull US - 31 million residents unable to speak English fluently with over half of these non-English speakers speaking Spanish and 15 million people speaking 24 different languages bull Recent research identifying more than 300 languages excluding dialects spoken by children at home indicates that London may be the most linguistically diverse city in the world

Current provision of interpreting

Mixed and patchy provisionhellip

bull Family friends

bull Health professional

bull Professional interpreters (face-to-face advocates)

bull Technology (telephone videoconferencing)

bull very little data available on how many individuals are out there unable to consult in English

bull sohellip

Objectives to document the

bull number of general practice consultations occurring in a language other than English

bull use of interpreting services

Gill et al (2011) The Unmet Need for Interpreting Provision in UK Primary Care PLoS ONE 6(6) e20837

Methodology

bull All 70 practices invited

bull Data collection given week in June 2009

bull Random allocation of session

bull Consultation record sheet

Results

bull 77122 (63) eligible practitioners (73 GPs 4 advanced nurse practitioners)

bull 4170 practices (59)

bull 1008 consultations

bull 1 abandoned due to language problems

Note Swine Flu epidemic during study period

The Consultations

717 Consultations in English

290 other languages (1 missing data)

57 relativefriend interpreted

6 professional interpreter (5 in same practice)

No relationship between Practitioner characteristics and need for interpreting

Consultation language

GP proficiency

None Basic Mod High N

Arabic Arabic 0 0 0 10 10 Bengali Bengali 5 7 10 18 40 BengaliEnglish Bengali 0 4 0 0 4 Gujerati Gujerati 0 1 0 2 3 Hindi Hindi 1 2 6 4 13 HindiPunjabi Punjabi 0 2 1 0 3 Katchi Katchi 0 0 1 0 1 Mirpuri Mirpuri 13 0 0 0 13 Punjabi Punjabi 1 3 19 20 43 Urdu Urdu 1 4 13 71 89 UrduEnglish Urdu 0 0 0 3 3 UrduHindi Urdu 0 0 2 0 2 UrduPunjabi Urdu 0 0 0 1 1 Not stated - - - - 4 21 23 52 129 229

Language used in consultation (where other than English)

Conclusions

bull Range of languages spoken by patients compared to practitioners unsurprising

bull Strategies used to overcome language barriers

bull Worrying consultations conducted where practitioner declared only basicno proficiency

bull High number communicating in patients preferred language

bull Use of professional interpreters (6 consultations)

bull increase evidence base of how individuals negotiate their way into and within health care identifying and developing standardised datasets for monitoring access and ensure that we donrsquot exclude minority groups from research

Ethnic recording mandatory within secondary care since 1995 and urgent need to include it within primary care as well eg through Quality and Outcomes framework

- new registrations

- Directly Enhanced Service

Julian Tudor Hart Glyncorrwg

Disease register screening and management of CVD

Inverse Care Law (1971)

The availability of good medical care tends to vary inversely with the need for it in the population served

hellipconsultations in deprived areas

time constraints greater morbidity less patient enablement greater practitioner stress

RCGP Scotland Time to Care Health inequalities deprivation and General Practice in Scotland

Prof Graham Watt lsquoIn at the Deep Endrsquo

Secondary Care

Pharmacist

Primary Care

Dentist

LA

SELF CARE

Voluntary sector

Social Worker

Provision of Health Care

90

Common Barriers to Access

Low levels of cultural competency in staff

Case complexity diagnostic and other

overshadowing

Negative previous experiences of

services

Health not a priority

Communicationlanguage and literacy

Inflexible processesIncluding registration and

Appointment systems

Transport and other costs

Lack of understanding ofrsquosystemrsquo rights and

responsibilities

Discriminationstigmatisation

Challenges ndash language diversity

bull Overcoming language barriers to health care is a global challenge

bull 6500 languages spoken in the world

bull US - 31 million residents unable to speak English fluently with over half of these non-English speakers speaking Spanish and 15 million people speaking 24 different languages bull Recent research identifying more than 300 languages excluding dialects spoken by children at home indicates that London may be the most linguistically diverse city in the world

Current provision of interpreting

Mixed and patchy provisionhellip

bull Family friends

bull Health professional

bull Professional interpreters (face-to-face advocates)

bull Technology (telephone videoconferencing)

bull very little data available on how many individuals are out there unable to consult in English

bull sohellip

Objectives to document the

bull number of general practice consultations occurring in a language other than English

bull use of interpreting services

Gill et al (2011) The Unmet Need for Interpreting Provision in UK Primary Care PLoS ONE 6(6) e20837

Methodology

bull All 70 practices invited

bull Data collection given week in June 2009

bull Random allocation of session

bull Consultation record sheet

Results

bull 77122 (63) eligible practitioners (73 GPs 4 advanced nurse practitioners)

bull 4170 practices (59)

bull 1008 consultations

bull 1 abandoned due to language problems

Note Swine Flu epidemic during study period

The Consultations

717 Consultations in English

290 other languages (1 missing data)

57 relativefriend interpreted

6 professional interpreter (5 in same practice)

No relationship between Practitioner characteristics and need for interpreting

Consultation language

GP proficiency

None Basic Mod High N

Arabic Arabic 0 0 0 10 10 Bengali Bengali 5 7 10 18 40 BengaliEnglish Bengali 0 4 0 0 4 Gujerati Gujerati 0 1 0 2 3 Hindi Hindi 1 2 6 4 13 HindiPunjabi Punjabi 0 2 1 0 3 Katchi Katchi 0 0 1 0 1 Mirpuri Mirpuri 13 0 0 0 13 Punjabi Punjabi 1 3 19 20 43 Urdu Urdu 1 4 13 71 89 UrduEnglish Urdu 0 0 0 3 3 UrduHindi Urdu 0 0 2 0 2 UrduPunjabi Urdu 0 0 0 1 1 Not stated - - - - 4 21 23 52 129 229

Language used in consultation (where other than English)

Conclusions

bull Range of languages spoken by patients compared to practitioners unsurprising

bull Strategies used to overcome language barriers

bull Worrying consultations conducted where practitioner declared only basicno proficiency

bull High number communicating in patients preferred language

bull Use of professional interpreters (6 consultations)

bull increase evidence base of how individuals negotiate their way into and within health care identifying and developing standardised datasets for monitoring access and ensure that we donrsquot exclude minority groups from research

Ethnic recording mandatory within secondary care since 1995 and urgent need to include it within primary care as well eg through Quality and Outcomes framework

- new registrations

- Directly Enhanced Service

Inverse Care Law (1971)

The availability of good medical care tends to vary inversely with the need for it in the population served

hellipconsultations in deprived areas

time constraints greater morbidity less patient enablement greater practitioner stress

RCGP Scotland Time to Care Health inequalities deprivation and General Practice in Scotland

Prof Graham Watt lsquoIn at the Deep Endrsquo

Secondary Care

Pharmacist

Primary Care

Dentist

LA

SELF CARE

Voluntary sector

Social Worker

Provision of Health Care

90

Common Barriers to Access

Low levels of cultural competency in staff

Case complexity diagnostic and other

overshadowing

Negative previous experiences of

services

Health not a priority

Communicationlanguage and literacy

Inflexible processesIncluding registration and

Appointment systems

Transport and other costs

Lack of understanding ofrsquosystemrsquo rights and

responsibilities

Discriminationstigmatisation

Challenges ndash language diversity

bull Overcoming language barriers to health care is a global challenge

bull 6500 languages spoken in the world

bull US - 31 million residents unable to speak English fluently with over half of these non-English speakers speaking Spanish and 15 million people speaking 24 different languages bull Recent research identifying more than 300 languages excluding dialects spoken by children at home indicates that London may be the most linguistically diverse city in the world

Current provision of interpreting

Mixed and patchy provisionhellip

bull Family friends

bull Health professional

bull Professional interpreters (face-to-face advocates)

bull Technology (telephone videoconferencing)

bull very little data available on how many individuals are out there unable to consult in English

bull sohellip

Objectives to document the

bull number of general practice consultations occurring in a language other than English

bull use of interpreting services

Gill et al (2011) The Unmet Need for Interpreting Provision in UK Primary Care PLoS ONE 6(6) e20837

Methodology

bull All 70 practices invited

bull Data collection given week in June 2009

bull Random allocation of session

bull Consultation record sheet

Results

bull 77122 (63) eligible practitioners (73 GPs 4 advanced nurse practitioners)

bull 4170 practices (59)

bull 1008 consultations

bull 1 abandoned due to language problems

Note Swine Flu epidemic during study period

The Consultations

717 Consultations in English

290 other languages (1 missing data)

57 relativefriend interpreted

6 professional interpreter (5 in same practice)

No relationship between Practitioner characteristics and need for interpreting

Consultation language

GP proficiency

None Basic Mod High N

Arabic Arabic 0 0 0 10 10 Bengali Bengali 5 7 10 18 40 BengaliEnglish Bengali 0 4 0 0 4 Gujerati Gujerati 0 1 0 2 3 Hindi Hindi 1 2 6 4 13 HindiPunjabi Punjabi 0 2 1 0 3 Katchi Katchi 0 0 1 0 1 Mirpuri Mirpuri 13 0 0 0 13 Punjabi Punjabi 1 3 19 20 43 Urdu Urdu 1 4 13 71 89 UrduEnglish Urdu 0 0 0 3 3 UrduHindi Urdu 0 0 2 0 2 UrduPunjabi Urdu 0 0 0 1 1 Not stated - - - - 4 21 23 52 129 229

Language used in consultation (where other than English)

Conclusions

bull Range of languages spoken by patients compared to practitioners unsurprising

bull Strategies used to overcome language barriers

bull Worrying consultations conducted where practitioner declared only basicno proficiency

bull High number communicating in patients preferred language

bull Use of professional interpreters (6 consultations)

bull increase evidence base of how individuals negotiate their way into and within health care identifying and developing standardised datasets for monitoring access and ensure that we donrsquot exclude minority groups from research

Ethnic recording mandatory within secondary care since 1995 and urgent need to include it within primary care as well eg through Quality and Outcomes framework

- new registrations

- Directly Enhanced Service

Prof Graham Watt lsquoIn at the Deep Endrsquo

Secondary Care

Pharmacist

Primary Care

Dentist

LA

SELF CARE

Voluntary sector

Social Worker

Provision of Health Care

90

Common Barriers to Access

Low levels of cultural competency in staff

Case complexity diagnostic and other

overshadowing

Negative previous experiences of

services

Health not a priority

Communicationlanguage and literacy

Inflexible processesIncluding registration and

Appointment systems

Transport and other costs

Lack of understanding ofrsquosystemrsquo rights and

responsibilities

Discriminationstigmatisation

Challenges ndash language diversity

bull Overcoming language barriers to health care is a global challenge

bull 6500 languages spoken in the world

bull US - 31 million residents unable to speak English fluently with over half of these non-English speakers speaking Spanish and 15 million people speaking 24 different languages bull Recent research identifying more than 300 languages excluding dialects spoken by children at home indicates that London may be the most linguistically diverse city in the world

Current provision of interpreting

Mixed and patchy provisionhellip

bull Family friends

bull Health professional

bull Professional interpreters (face-to-face advocates)

bull Technology (telephone videoconferencing)

bull very little data available on how many individuals are out there unable to consult in English

bull sohellip

Objectives to document the

bull number of general practice consultations occurring in a language other than English

bull use of interpreting services

Gill et al (2011) The Unmet Need for Interpreting Provision in UK Primary Care PLoS ONE 6(6) e20837

Methodology

bull All 70 practices invited

bull Data collection given week in June 2009

bull Random allocation of session

bull Consultation record sheet

Results

bull 77122 (63) eligible practitioners (73 GPs 4 advanced nurse practitioners)

bull 4170 practices (59)

bull 1008 consultations

bull 1 abandoned due to language problems

Note Swine Flu epidemic during study period

The Consultations

717 Consultations in English

290 other languages (1 missing data)

57 relativefriend interpreted

6 professional interpreter (5 in same practice)

No relationship between Practitioner characteristics and need for interpreting

Consultation language

GP proficiency

None Basic Mod High N

Arabic Arabic 0 0 0 10 10 Bengali Bengali 5 7 10 18 40 BengaliEnglish Bengali 0 4 0 0 4 Gujerati Gujerati 0 1 0 2 3 Hindi Hindi 1 2 6 4 13 HindiPunjabi Punjabi 0 2 1 0 3 Katchi Katchi 0 0 1 0 1 Mirpuri Mirpuri 13 0 0 0 13 Punjabi Punjabi 1 3 19 20 43 Urdu Urdu 1 4 13 71 89 UrduEnglish Urdu 0 0 0 3 3 UrduHindi Urdu 0 0 2 0 2 UrduPunjabi Urdu 0 0 0 1 1 Not stated - - - - 4 21 23 52 129 229

Language used in consultation (where other than English)

Conclusions

bull Range of languages spoken by patients compared to practitioners unsurprising

bull Strategies used to overcome language barriers

bull Worrying consultations conducted where practitioner declared only basicno proficiency

bull High number communicating in patients preferred language

bull Use of professional interpreters (6 consultations)

bull increase evidence base of how individuals negotiate their way into and within health care identifying and developing standardised datasets for monitoring access and ensure that we donrsquot exclude minority groups from research

Ethnic recording mandatory within secondary care since 1995 and urgent need to include it within primary care as well eg through Quality and Outcomes framework

- new registrations

- Directly Enhanced Service

Secondary Care

Pharmacist

Primary Care

Dentist

LA

SELF CARE

Voluntary sector

Social Worker

Provision of Health Care

90

Common Barriers to Access

Low levels of cultural competency in staff

Case complexity diagnostic and other

overshadowing

Negative previous experiences of

services

Health not a priority

Communicationlanguage and literacy

Inflexible processesIncluding registration and

Appointment systems

Transport and other costs

Lack of understanding ofrsquosystemrsquo rights and

responsibilities

Discriminationstigmatisation

Challenges ndash language diversity

bull Overcoming language barriers to health care is a global challenge

bull 6500 languages spoken in the world

bull US - 31 million residents unable to speak English fluently with over half of these non-English speakers speaking Spanish and 15 million people speaking 24 different languages bull Recent research identifying more than 300 languages excluding dialects spoken by children at home indicates that London may be the most linguistically diverse city in the world

Current provision of interpreting

Mixed and patchy provisionhellip

bull Family friends

bull Health professional

bull Professional interpreters (face-to-face advocates)

bull Technology (telephone videoconferencing)

bull very little data available on how many individuals are out there unable to consult in English

bull sohellip

Objectives to document the

bull number of general practice consultations occurring in a language other than English

bull use of interpreting services

Gill et al (2011) The Unmet Need for Interpreting Provision in UK Primary Care PLoS ONE 6(6) e20837

Methodology

bull All 70 practices invited

bull Data collection given week in June 2009

bull Random allocation of session

bull Consultation record sheet

Results

bull 77122 (63) eligible practitioners (73 GPs 4 advanced nurse practitioners)

bull 4170 practices (59)

bull 1008 consultations

bull 1 abandoned due to language problems

Note Swine Flu epidemic during study period

The Consultations

717 Consultations in English

290 other languages (1 missing data)

57 relativefriend interpreted

6 professional interpreter (5 in same practice)

No relationship between Practitioner characteristics and need for interpreting

Consultation language

GP proficiency

None Basic Mod High N

Arabic Arabic 0 0 0 10 10 Bengali Bengali 5 7 10 18 40 BengaliEnglish Bengali 0 4 0 0 4 Gujerati Gujerati 0 1 0 2 3 Hindi Hindi 1 2 6 4 13 HindiPunjabi Punjabi 0 2 1 0 3 Katchi Katchi 0 0 1 0 1 Mirpuri Mirpuri 13 0 0 0 13 Punjabi Punjabi 1 3 19 20 43 Urdu Urdu 1 4 13 71 89 UrduEnglish Urdu 0 0 0 3 3 UrduHindi Urdu 0 0 2 0 2 UrduPunjabi Urdu 0 0 0 1 1 Not stated - - - - 4 21 23 52 129 229

Language used in consultation (where other than English)

Conclusions

bull Range of languages spoken by patients compared to practitioners unsurprising

bull Strategies used to overcome language barriers

bull Worrying consultations conducted where practitioner declared only basicno proficiency

bull High number communicating in patients preferred language

bull Use of professional interpreters (6 consultations)

bull increase evidence base of how individuals negotiate their way into and within health care identifying and developing standardised datasets for monitoring access and ensure that we donrsquot exclude minority groups from research

Ethnic recording mandatory within secondary care since 1995 and urgent need to include it within primary care as well eg through Quality and Outcomes framework

- new registrations

- Directly Enhanced Service

Common Barriers to Access

Low levels of cultural competency in staff

Case complexity diagnostic and other

overshadowing

Negative previous experiences of

services

Health not a priority

Communicationlanguage and literacy

Inflexible processesIncluding registration and

Appointment systems

Transport and other costs

Lack of understanding ofrsquosystemrsquo rights and

responsibilities

Discriminationstigmatisation

Challenges ndash language diversity

bull Overcoming language barriers to health care is a global challenge

bull 6500 languages spoken in the world

bull US - 31 million residents unable to speak English fluently with over half of these non-English speakers speaking Spanish and 15 million people speaking 24 different languages bull Recent research identifying more than 300 languages excluding dialects spoken by children at home indicates that London may be the most linguistically diverse city in the world

Current provision of interpreting

Mixed and patchy provisionhellip

bull Family friends

bull Health professional

bull Professional interpreters (face-to-face advocates)

bull Technology (telephone videoconferencing)

bull very little data available on how many individuals are out there unable to consult in English

bull sohellip

Objectives to document the

bull number of general practice consultations occurring in a language other than English

bull use of interpreting services

Gill et al (2011) The Unmet Need for Interpreting Provision in UK Primary Care PLoS ONE 6(6) e20837

Methodology

bull All 70 practices invited

bull Data collection given week in June 2009

bull Random allocation of session

bull Consultation record sheet

Results

bull 77122 (63) eligible practitioners (73 GPs 4 advanced nurse practitioners)

bull 4170 practices (59)

bull 1008 consultations

bull 1 abandoned due to language problems

Note Swine Flu epidemic during study period

The Consultations

717 Consultations in English

290 other languages (1 missing data)

57 relativefriend interpreted

6 professional interpreter (5 in same practice)

No relationship between Practitioner characteristics and need for interpreting

Consultation language

GP proficiency

None Basic Mod High N

Arabic Arabic 0 0 0 10 10 Bengali Bengali 5 7 10 18 40 BengaliEnglish Bengali 0 4 0 0 4 Gujerati Gujerati 0 1 0 2 3 Hindi Hindi 1 2 6 4 13 HindiPunjabi Punjabi 0 2 1 0 3 Katchi Katchi 0 0 1 0 1 Mirpuri Mirpuri 13 0 0 0 13 Punjabi Punjabi 1 3 19 20 43 Urdu Urdu 1 4 13 71 89 UrduEnglish Urdu 0 0 0 3 3 UrduHindi Urdu 0 0 2 0 2 UrduPunjabi Urdu 0 0 0 1 1 Not stated - - - - 4 21 23 52 129 229

Language used in consultation (where other than English)

Conclusions

bull Range of languages spoken by patients compared to practitioners unsurprising

bull Strategies used to overcome language barriers

bull Worrying consultations conducted where practitioner declared only basicno proficiency

bull High number communicating in patients preferred language

bull Use of professional interpreters (6 consultations)

bull increase evidence base of how individuals negotiate their way into and within health care identifying and developing standardised datasets for monitoring access and ensure that we donrsquot exclude minority groups from research

Ethnic recording mandatory within secondary care since 1995 and urgent need to include it within primary care as well eg through Quality and Outcomes framework

- new registrations

- Directly Enhanced Service

Challenges ndash language diversity

bull Overcoming language barriers to health care is a global challenge

bull 6500 languages spoken in the world

bull US - 31 million residents unable to speak English fluently with over half of these non-English speakers speaking Spanish and 15 million people speaking 24 different languages bull Recent research identifying more than 300 languages excluding dialects spoken by children at home indicates that London may be the most linguistically diverse city in the world

Current provision of interpreting

Mixed and patchy provisionhellip

bull Family friends

bull Health professional

bull Professional interpreters (face-to-face advocates)

bull Technology (telephone videoconferencing)

bull very little data available on how many individuals are out there unable to consult in English

bull sohellip

Objectives to document the

bull number of general practice consultations occurring in a language other than English

bull use of interpreting services

Gill et al (2011) The Unmet Need for Interpreting Provision in UK Primary Care PLoS ONE 6(6) e20837

Methodology

bull All 70 practices invited

bull Data collection given week in June 2009

bull Random allocation of session

bull Consultation record sheet

Results

bull 77122 (63) eligible practitioners (73 GPs 4 advanced nurse practitioners)

bull 4170 practices (59)

bull 1008 consultations

bull 1 abandoned due to language problems

Note Swine Flu epidemic during study period

The Consultations

717 Consultations in English

290 other languages (1 missing data)

57 relativefriend interpreted

6 professional interpreter (5 in same practice)

No relationship between Practitioner characteristics and need for interpreting

Consultation language

GP proficiency

None Basic Mod High N

Arabic Arabic 0 0 0 10 10 Bengali Bengali 5 7 10 18 40 BengaliEnglish Bengali 0 4 0 0 4 Gujerati Gujerati 0 1 0 2 3 Hindi Hindi 1 2 6 4 13 HindiPunjabi Punjabi 0 2 1 0 3 Katchi Katchi 0 0 1 0 1 Mirpuri Mirpuri 13 0 0 0 13 Punjabi Punjabi 1 3 19 20 43 Urdu Urdu 1 4 13 71 89 UrduEnglish Urdu 0 0 0 3 3 UrduHindi Urdu 0 0 2 0 2 UrduPunjabi Urdu 0 0 0 1 1 Not stated - - - - 4 21 23 52 129 229

Language used in consultation (where other than English)

Conclusions

bull Range of languages spoken by patients compared to practitioners unsurprising

bull Strategies used to overcome language barriers

bull Worrying consultations conducted where practitioner declared only basicno proficiency

bull High number communicating in patients preferred language

bull Use of professional interpreters (6 consultations)

bull increase evidence base of how individuals negotiate their way into and within health care identifying and developing standardised datasets for monitoring access and ensure that we donrsquot exclude minority groups from research

Ethnic recording mandatory within secondary care since 1995 and urgent need to include it within primary care as well eg through Quality and Outcomes framework

- new registrations

- Directly Enhanced Service

Current provision of interpreting

Mixed and patchy provisionhellip

bull Family friends

bull Health professional

bull Professional interpreters (face-to-face advocates)

bull Technology (telephone videoconferencing)

bull very little data available on how many individuals are out there unable to consult in English

bull sohellip

Objectives to document the

bull number of general practice consultations occurring in a language other than English

bull use of interpreting services

Gill et al (2011) The Unmet Need for Interpreting Provision in UK Primary Care PLoS ONE 6(6) e20837

Methodology

bull All 70 practices invited

bull Data collection given week in June 2009

bull Random allocation of session

bull Consultation record sheet

Results

bull 77122 (63) eligible practitioners (73 GPs 4 advanced nurse practitioners)

bull 4170 practices (59)

bull 1008 consultations

bull 1 abandoned due to language problems

Note Swine Flu epidemic during study period

The Consultations

717 Consultations in English

290 other languages (1 missing data)

57 relativefriend interpreted

6 professional interpreter (5 in same practice)

No relationship between Practitioner characteristics and need for interpreting

Consultation language

GP proficiency

None Basic Mod High N

Arabic Arabic 0 0 0 10 10 Bengali Bengali 5 7 10 18 40 BengaliEnglish Bengali 0 4 0 0 4 Gujerati Gujerati 0 1 0 2 3 Hindi Hindi 1 2 6 4 13 HindiPunjabi Punjabi 0 2 1 0 3 Katchi Katchi 0 0 1 0 1 Mirpuri Mirpuri 13 0 0 0 13 Punjabi Punjabi 1 3 19 20 43 Urdu Urdu 1 4 13 71 89 UrduEnglish Urdu 0 0 0 3 3 UrduHindi Urdu 0 0 2 0 2 UrduPunjabi Urdu 0 0 0 1 1 Not stated - - - - 4 21 23 52 129 229

Language used in consultation (where other than English)

Conclusions

bull Range of languages spoken by patients compared to practitioners unsurprising

bull Strategies used to overcome language barriers

bull Worrying consultations conducted where practitioner declared only basicno proficiency

bull High number communicating in patients preferred language

bull Use of professional interpreters (6 consultations)

bull increase evidence base of how individuals negotiate their way into and within health care identifying and developing standardised datasets for monitoring access and ensure that we donrsquot exclude minority groups from research

Ethnic recording mandatory within secondary care since 1995 and urgent need to include it within primary care as well eg through Quality and Outcomes framework

- new registrations

- Directly Enhanced Service

Objectives to document the

bull number of general practice consultations occurring in a language other than English

bull use of interpreting services

Gill et al (2011) The Unmet Need for Interpreting Provision in UK Primary Care PLoS ONE 6(6) e20837

Methodology

bull All 70 practices invited

bull Data collection given week in June 2009

bull Random allocation of session

bull Consultation record sheet

Results

bull 77122 (63) eligible practitioners (73 GPs 4 advanced nurse practitioners)

bull 4170 practices (59)

bull 1008 consultations

bull 1 abandoned due to language problems

Note Swine Flu epidemic during study period

The Consultations

717 Consultations in English

290 other languages (1 missing data)

57 relativefriend interpreted

6 professional interpreter (5 in same practice)

No relationship between Practitioner characteristics and need for interpreting

Consultation language

GP proficiency

None Basic Mod High N

Arabic Arabic 0 0 0 10 10 Bengali Bengali 5 7 10 18 40 BengaliEnglish Bengali 0 4 0 0 4 Gujerati Gujerati 0 1 0 2 3 Hindi Hindi 1 2 6 4 13 HindiPunjabi Punjabi 0 2 1 0 3 Katchi Katchi 0 0 1 0 1 Mirpuri Mirpuri 13 0 0 0 13 Punjabi Punjabi 1 3 19 20 43 Urdu Urdu 1 4 13 71 89 UrduEnglish Urdu 0 0 0 3 3 UrduHindi Urdu 0 0 2 0 2 UrduPunjabi Urdu 0 0 0 1 1 Not stated - - - - 4 21 23 52 129 229

Language used in consultation (where other than English)

Conclusions

bull Range of languages spoken by patients compared to practitioners unsurprising

bull Strategies used to overcome language barriers

bull Worrying consultations conducted where practitioner declared only basicno proficiency

bull High number communicating in patients preferred language

bull Use of professional interpreters (6 consultations)

bull increase evidence base of how individuals negotiate their way into and within health care identifying and developing standardised datasets for monitoring access and ensure that we donrsquot exclude minority groups from research

Ethnic recording mandatory within secondary care since 1995 and urgent need to include it within primary care as well eg through Quality and Outcomes framework

- new registrations

- Directly Enhanced Service

Methodology

bull All 70 practices invited

bull Data collection given week in June 2009

bull Random allocation of session

bull Consultation record sheet

Results

bull 77122 (63) eligible practitioners (73 GPs 4 advanced nurse practitioners)

bull 4170 practices (59)

bull 1008 consultations

bull 1 abandoned due to language problems

Note Swine Flu epidemic during study period

The Consultations

717 Consultations in English

290 other languages (1 missing data)

57 relativefriend interpreted

6 professional interpreter (5 in same practice)

No relationship between Practitioner characteristics and need for interpreting

Consultation language

GP proficiency

None Basic Mod High N

Arabic Arabic 0 0 0 10 10 Bengali Bengali 5 7 10 18 40 BengaliEnglish Bengali 0 4 0 0 4 Gujerati Gujerati 0 1 0 2 3 Hindi Hindi 1 2 6 4 13 HindiPunjabi Punjabi 0 2 1 0 3 Katchi Katchi 0 0 1 0 1 Mirpuri Mirpuri 13 0 0 0 13 Punjabi Punjabi 1 3 19 20 43 Urdu Urdu 1 4 13 71 89 UrduEnglish Urdu 0 0 0 3 3 UrduHindi Urdu 0 0 2 0 2 UrduPunjabi Urdu 0 0 0 1 1 Not stated - - - - 4 21 23 52 129 229

Language used in consultation (where other than English)

Conclusions

bull Range of languages spoken by patients compared to practitioners unsurprising

bull Strategies used to overcome language barriers

bull Worrying consultations conducted where practitioner declared only basicno proficiency

bull High number communicating in patients preferred language

bull Use of professional interpreters (6 consultations)

bull increase evidence base of how individuals negotiate their way into and within health care identifying and developing standardised datasets for monitoring access and ensure that we donrsquot exclude minority groups from research

Ethnic recording mandatory within secondary care since 1995 and urgent need to include it within primary care as well eg through Quality and Outcomes framework

- new registrations

- Directly Enhanced Service

Results

bull 77122 (63) eligible practitioners (73 GPs 4 advanced nurse practitioners)

bull 4170 practices (59)

bull 1008 consultations

bull 1 abandoned due to language problems

Note Swine Flu epidemic during study period

The Consultations

717 Consultations in English

290 other languages (1 missing data)

57 relativefriend interpreted

6 professional interpreter (5 in same practice)

No relationship between Practitioner characteristics and need for interpreting

Consultation language

GP proficiency

None Basic Mod High N

Arabic Arabic 0 0 0 10 10 Bengali Bengali 5 7 10 18 40 BengaliEnglish Bengali 0 4 0 0 4 Gujerati Gujerati 0 1 0 2 3 Hindi Hindi 1 2 6 4 13 HindiPunjabi Punjabi 0 2 1 0 3 Katchi Katchi 0 0 1 0 1 Mirpuri Mirpuri 13 0 0 0 13 Punjabi Punjabi 1 3 19 20 43 Urdu Urdu 1 4 13 71 89 UrduEnglish Urdu 0 0 0 3 3 UrduHindi Urdu 0 0 2 0 2 UrduPunjabi Urdu 0 0 0 1 1 Not stated - - - - 4 21 23 52 129 229

Language used in consultation (where other than English)

Conclusions

bull Range of languages spoken by patients compared to practitioners unsurprising

bull Strategies used to overcome language barriers

bull Worrying consultations conducted where practitioner declared only basicno proficiency

bull High number communicating in patients preferred language

bull Use of professional interpreters (6 consultations)

bull increase evidence base of how individuals negotiate their way into and within health care identifying and developing standardised datasets for monitoring access and ensure that we donrsquot exclude minority groups from research

Ethnic recording mandatory within secondary care since 1995 and urgent need to include it within primary care as well eg through Quality and Outcomes framework

- new registrations

- Directly Enhanced Service

The Consultations

717 Consultations in English

290 other languages (1 missing data)

57 relativefriend interpreted

6 professional interpreter (5 in same practice)

No relationship between Practitioner characteristics and need for interpreting

Consultation language

GP proficiency

None Basic Mod High N

Arabic Arabic 0 0 0 10 10 Bengali Bengali 5 7 10 18 40 BengaliEnglish Bengali 0 4 0 0 4 Gujerati Gujerati 0 1 0 2 3 Hindi Hindi 1 2 6 4 13 HindiPunjabi Punjabi 0 2 1 0 3 Katchi Katchi 0 0 1 0 1 Mirpuri Mirpuri 13 0 0 0 13 Punjabi Punjabi 1 3 19 20 43 Urdu Urdu 1 4 13 71 89 UrduEnglish Urdu 0 0 0 3 3 UrduHindi Urdu 0 0 2 0 2 UrduPunjabi Urdu 0 0 0 1 1 Not stated - - - - 4 21 23 52 129 229

Language used in consultation (where other than English)

Conclusions

bull Range of languages spoken by patients compared to practitioners unsurprising

bull Strategies used to overcome language barriers

bull Worrying consultations conducted where practitioner declared only basicno proficiency

bull High number communicating in patients preferred language

bull Use of professional interpreters (6 consultations)

bull increase evidence base of how individuals negotiate their way into and within health care identifying and developing standardised datasets for monitoring access and ensure that we donrsquot exclude minority groups from research

Ethnic recording mandatory within secondary care since 1995 and urgent need to include it within primary care as well eg through Quality and Outcomes framework

- new registrations

- Directly Enhanced Service

Consultation language

GP proficiency

None Basic Mod High N

Arabic Arabic 0 0 0 10 10 Bengali Bengali 5 7 10 18 40 BengaliEnglish Bengali 0 4 0 0 4 Gujerati Gujerati 0 1 0 2 3 Hindi Hindi 1 2 6 4 13 HindiPunjabi Punjabi 0 2 1 0 3 Katchi Katchi 0 0 1 0 1 Mirpuri Mirpuri 13 0 0 0 13 Punjabi Punjabi 1 3 19 20 43 Urdu Urdu 1 4 13 71 89 UrduEnglish Urdu 0 0 0 3 3 UrduHindi Urdu 0 0 2 0 2 UrduPunjabi Urdu 0 0 0 1 1 Not stated - - - - 4 21 23 52 129 229

Language used in consultation (where other than English)

Conclusions

bull Range of languages spoken by patients compared to practitioners unsurprising

bull Strategies used to overcome language barriers

bull Worrying consultations conducted where practitioner declared only basicno proficiency

bull High number communicating in patients preferred language

bull Use of professional interpreters (6 consultations)

bull increase evidence base of how individuals negotiate their way into and within health care identifying and developing standardised datasets for monitoring access and ensure that we donrsquot exclude minority groups from research

Ethnic recording mandatory within secondary care since 1995 and urgent need to include it within primary care as well eg through Quality and Outcomes framework

- new registrations

- Directly Enhanced Service

Conclusions

bull Range of languages spoken by patients compared to practitioners unsurprising

bull Strategies used to overcome language barriers

bull Worrying consultations conducted where practitioner declared only basicno proficiency

bull High number communicating in patients preferred language

bull Use of professional interpreters (6 consultations)

bull increase evidence base of how individuals negotiate their way into and within health care identifying and developing standardised datasets for monitoring access and ensure that we donrsquot exclude minority groups from research

Ethnic recording mandatory within secondary care since 1995 and urgent need to include it within primary care as well eg through Quality and Outcomes framework

- new registrations

- Directly Enhanced Service

bull increase evidence base of how individuals negotiate their way into and within health care identifying and developing standardised datasets for monitoring access and ensure that we donrsquot exclude minority groups from research

Ethnic recording mandatory within secondary care since 1995 and urgent need to include it within primary care as well eg through Quality and Outcomes framework

- new registrations

- Directly Enhanced Service

Ethnic recording mandatory within secondary care since 1995 and urgent need to include it within primary care as well eg through Quality and Outcomes framework

- new registrations

- Directly Enhanced Service

THANK YOU

• How inequality creates sick people and sick communities and why migrants are particularly at risk
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• Inequalities widening
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• BC BA I P B C I General Men 25 21 20 29 40 21 30 24 Women 24 10 5 5 2 8 26 23
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• CHD mortality rates started falling long before effective treatments used widely
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• Common Barriers to Access
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