Email updates

Keep up to date with the latest news and content from BMC Public Health and BioMed Central.

Open Access Research article

Access to interpreting services in England: secondary analysis of national data

Paramjit S Gill*, Aparna Shankar, Terry Quirke and Nick Freemantle

Author Affiliations

School of Health and Population Sciences, University of Birmingham, Birmingham, UK

For all author emails, please log on.

BMC Public Health 2009, 9:12  doi:10.1186/1471-2458-9-12

The electronic version of this article is the complete one and can be found online at:

Received:16 August 2008
Accepted:12 January 2009
Published:12 January 2009

© 2009 Gill et al; licensee BioMed Central Ltd.

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.



Overcoming language barriers to health care is a global challenge. There is great linguistic diversity in the major cities in the UK with more than 300 languages, excluding dialects, spoken by children in London alone. However, there is dearth of data on the number of non-English speakers for planning effective interpreting services. The aim was to estimate the number of people requiring language support amongst the minority ethnic communities in England.


Secondary analysis of national representative sample of subjects recruited to the Health Surveys for England 1999 and 2004.


298,432 individuals from the four main minority ethnic communities (Indian, Pakistani, Bangladeshi and Chinese) who may be unable to communicate effectively with a health professional. This represents 2,520,885 general practice consultations per year where interpreting services might be required.


Effective interpreting services are required to improve access and health outcomes of non-English speakers and thereby facilitate a reduction in health inequalities.


Overcoming language barriers to health care is a global challenge. [1-3] In the US over 24 million residents are unable to speak English fluently, with over 55 million residents speaking a language other than English. [4] In urban Australia language services are required in up to 100 different languages reflecting enormous linguistic diversity. [5] The UK is a diverse society with 7.9% of the population from Black and other minority ethnic groups.[6] This is a heterogeneous group with different migration and settlement patterns, culture, religion, and languages spoken. 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. [7]

It is obvious that high-quality medical care requires effective communication between patient and health professional. [8] The complexity of linguistic diversity is illustrated with a report that found that many doctors working in primary care in the UK are themselves not native English speakers and communicate with their patients, originally from the Indian subcontinent, in one of a range of Asian languages.[9] An obvious benefit of this is the shared understanding and knowledge of health beliefs and expectations from health care professionals. [10] However, when faced with English-speaking health professionals, patients with no functional English will require interpreting services. This may often include informal interpreters such as family members [11] although this can be problematic when faced with embarrassing issues or when the informal interpreter's language skills are poor. [11] While even good quality professional interpreting will not completely remove the language barrier, effective communication can be achieved and has been shown to lead to improved care [12], comparable to that received by English-speaking patients. [13]

Currently no national data exist on the number of non-English speakers in the UK and there is a need to estimate this to plan effective interpreting services. The aim of this study was to estimate the number of people requiring language support amongst the minority ethnic communities.


The present analysis combined data from the Health Survey for England 1999 [14] and 2004 [15]. Both surveys included boost samples from ethnic minority groups and the current analysis focussed on four minority ethnic groups (Indians, Pakistanis, Bangladeshis and Chinese). The surveys use a multi-stage, stratified probability sampling design. Primary sampling units (postcode sector in 1999 and census wards in 2004) were stratified based on the proportion of resident individuals from ethnic minorities. The probability of each unit being selected was proportional to the number of addresses within the unit. Screening of addresses and focussed enumeration (in areas where there was a smaller proportion of minority ethnic residents) was carried out to identify individuals for inclusion in the survey. In 2004, in addition to the minority ethnic boost sample, a further Chinese boost sample was obtained by screening the electoral register for individuals with 'Chinese-sounding' surnames. In 1999, the Chinese sample was recruited solely by re-contacting individuals who participated in the 1998 Health and Lifestyles of the Chinese Population in England survey. [16] Further information on the methodology used in the surveys is available elsewhere. [14,15]

Participants were asked how well they spoke English (self-report). Response options included 'very well', 'fairly well', 'slightly' and 'not at all'. The proportion of participants who responded 'slightly' or 'not at all' was calculated for participants aged 16 years and above by age category (16–34, 35–54 and 55+), ethnic group and sex. The analyses were weighted to correct for differing selection probabilities. This proportion was applied to data for England from the Census 2001 [17] to provide an estimate of the number of individuals in the population from these groups who are unable to converse in English. This was then multiplied by the annual contact rate for GP consultations based on the HSE 1999 [14] to provide an estimate of the number of GP consultations per year for these minority groups where interpreting services are likely to be required.


Eight thousand and forty one participants were included in this analysis (47.4% male). We estimated that there are 298,432 individuals from these ethnic groups in the population who are unable to converse in English (Tables 1 and 2). The proportion of individuals unable to speak English increases with age and fewer women speak English. Based on average annual contact rate by sex, age group and ethnicity, we estimated that annually 2,520,885 general practitioner consultations for individuals from these ethnic groups are likely to require interpreting services. The issue is particularly important for women and older individuals as they also report higher consultation rates.

Table 1. Percentage of male individuals who speak little or no English, estimates of the number in England and the number of annual GP consultations by age and ethnic group in 1999 and 2004

Table 2. Percentage of female individuals who speak little or no English, estimates of the number in England and the number of annual GP consultations by age and ethnic group in 1999 and 2004


This study shows that nearly 300,000 adults from the four main ethnic communities in England and Wales have no functional English to communicate with their health professional. Even though these communities have been resident in the UK for over 30 years, the differences by ethnic group partly reflect the different migration patterns. [6] An inability to communicate in English can create barriers, misunderstandings and misconceptions in patient-health professional relationships [8] and patients themselves repeatedly highlight ineffective communication as cause of unsatisfactory experiences of health services. [18] Further, patients are unlikely to be able to participate in and contribute fully to their local community. [19] Despite this, fluency in English is not routinely documented as part of ethnic monitoring. [20]

Estimates of the number of individuals unable to converse in English vary widely, from 400,000 to 1.2 million. [20] With recent migration of other communities this number is likely to be even higher. [21] Further, as our estimates are based on 2001 Census data, ethnic group populations have grown and the Office of National Statistics has now produced experimental population estimates by ethnic group. [22] Our estimate is slightly lower than that reported by Carr-Hill et al [19] whose sample was smaller with 925 Punjabi, Bengali and Chinese speakers and 173 subjects from 4 refugee groups.

There is a great need for effective interpreting services across the country and provision is patchy with access restricted to health professionals. Some of this interpreting is provided by informal interpreters such as family members [11] and general practitioners. [9] However, the latter are due to retire within the next few years and further increasing demand for interpreting services. [23]

It is estimated that the additional costs (English Language Difficulties Adjustment) of providing medical services to patients who do not speak English is £29/person. [6] This adjustment grossly underestimates the number of non-English speakers and fails to highlight the scale and distribution of this population. In our present study, we used consultation rates from the HSE, which are self-reported and may be an underestimate [6,24,25]. There is a need to map the distribution of non-English speakers, hence inclusion of language spoken as part of the new Census dataset. [6,20] This will then ensure the appropriate and effective provision of interpreting services within the UK and through this, improved access and health outcomes for migrants with subsequent reduction in health inequalities. [26]


We have highlighted the unmet need for interpreting services within four minority ethnic communities and with increased international migration; demand for effective interpreting will continue to rise.

Competing interests

The authors declare that they have no competing interests.

Authors' contributions

PG initiated the study, supervised its conduct and analysis and drafted the paper with all authors. AS and NF produced the analysis plan. AS and TQ did the statistical analysis. PG is the guarantor.


We thank the Data Archive and the depositors of the information for permission to use the data. Material from the Health Survey for England is Crown Copyright and has been made available by the Office for National Statistics, the Joint Health Surveys Unit of Social and Community Planning Research, and the Department of Epidemiology and Public Health at University College, London.


  1. Chang PH, Fortier JB: Language barriers to health care: an overview.

    Journal of Health Care for the Poor and Undeserved 1998, 9:S5-S20. OpenURL

  2. Jones D, Gill P: Breaking down language barriers.

    BMJ 1998, 316:1476. PubMed Abstract | Publisher Full Text | PubMed Central Full Text OpenURL

  3. Green AR, Ngo-Metzger Q, Legedza AT, Massagli MP, Phillips RS, Iezzoni LI: Interpreter services, language concordance, and health care quality. Experiences of Asian Americans with limited English proficiency.

    J Gen Int Med 2005, 20:1050-6. Publisher Full Text OpenURL

  4. U.S. Census Bureau [] webcite

    (accessed 7/11/08)

  5. Ozolins U: Interpreting and Translation in Australia. In Current issues and international comparisons. Melbourne: Language Australia; 1998. OpenURL

  6. Gill PS, Kai J, Bhopal RS, Wild S: Health Care Needs Assessment: Black and Minority Ethnic Groups. In Health Care Needs Assessment. The epidemiologically based needs assessment reviews. Third Series. Edited by Raftery J. Abingdon: Radcliffe Medical Press Ltd; 2007. OpenURL

  7. Baker P, Everseley J: Multilingual Capital. In The languages of London's schoolchildren and their relevance to economic, social and educational policies. London: Battlebridge publications; 2000. OpenURL

  8. Stewart M: Effective patient-physician communication and health: a review.

    Can Med Assoc J 1995, 152:1423-33. OpenURL

  9. Alexander Z: Study of Black, Asian and Ethnic Minority Issues. London: Department of Health; 1999.

  10. Free C: Transcultural communication and ethnic comparisons in the experience of services.

    Br J Gen Pract 2005, 55(514):339-340. PubMed Abstract | Publisher Full Text | PubMed Central Full Text OpenURL

  11. Free C, Green J, Bhavnani V, Newman A: Bilingual young people's experiences of interpreting in primary care: a qualitative study.

    Br J Gen Pract 2003, 53(492):530-535. PubMed Abstract | Publisher Full Text | PubMed Central Full Text OpenURL

  12. Karliner LS, Jacobs EA, Chen A, Mutha S: Do Professional Interpreters Improve Clinical Care?

    Health Serv Res 2007, 42(2):727-754. PubMed Abstract | Publisher Full Text OpenURL

  13. Tocher TM, Larson E: Quality of diabetes care for non-English-speaking patients: a comparative study.

    The Western Journal of Medicine 1998, 168:504-12. PubMed Abstract | PubMed Central Full Text OpenURL

  14. Erens B, Primatesta P, Prior G: The Health Survey for England. In The Health of Minority Ethnic Groups'99. Methodology & Documentation. Volume 2. London: The Stationery Office; 2001. OpenURL

  15. Sproston K, Mindell J: The Health Survey for England. In The Health of Minority Ethnic Groups 2004. Methodology & Documentation. Volume 2. London: The Stationery Office; 2006. OpenURL

  16. Sproston K, Pitson L, Whitfield G, Walker E: Health and lifestyles of the Chinese population in England. HEA:London; 1999.

  17. Office for National Statistics [] webcite

    (accessed 7/11/08)

  18. Lakhani M: No Patient Left Behind: how can we ensure world class primary care for black and minority ethnic people? Department of Health; 2008.

  19. Carr-Hill R, Passingham S, Wolf A, Kent N: Lost opportunities: the language skills of linguistic minorities in England and Wales. London: Basic Skills Agency; 1996. PubMed Abstract | Publisher Full Text | PubMed Central Full Text OpenURL

  20. Aspinall P: Why the next census needs to ask about language.

    BMJ 2005, 331:363-4. PubMed Abstract | Publisher Full Text | PubMed Central Full Text OpenURL

  21. A Profile of Immigrant Populations in the 21st Century: Data from OECD Countries

    OECD 2008. OpenURL

  22. National Statistics [] webcite

    (accessed 7/11/08)

  23. Taylor DH, Esmail A: Retrospective analysis of census data on general practitioners who qualified in South Asia: who will replace them as they retire?

    BMJ 1999, 318:306-310. PubMed Abstract | Publisher Full Text | PubMed Central Full Text OpenURL

  24. Bhandari A, Wagner T: Self-reported utilization of health care services: improving measurement and accuracy.

    Med Care Res Rev 2006, 63:217-35. PubMed Abstract | Publisher Full Text OpenURL

  25. Ritter PL, Stewart AL, Kaymaz H, Sobel DS, Block DA, Lorig KR: Self-reports of health care utilization compared to provider records.

    J Clin Epidimiol 2001, 54:136-41. Publisher Full Text OpenURL

  26. Marmot M: Achieving health equity: from root causes to fair outcomes.

    The Lancet 2007, 370:1153-1163. Publisher Full Text OpenURL

Pre-publication history

The pre-publication history for this paper can be accessed here: