Sign of the times

Deaf patients have specific communication needs. Following on from last month's article about interpretation, Channa Panagamuwa and coauthors consider the role of sign language interpreters and the legal obligation of doctors to provide them

Britain's Deaf community, like many other minority groups, has a language and a culture of its own. But unlike hearing minorities, access to the majority language and culture is limited by disability. Access to society is also severely limited by prejudice and a lack of understanding of Deaf people, their language, and their culture.

Language of the British Deaf community

Have you ever tried to access healthcare services in a country where you don't speak the language? How do you explain what's wrong - by gesture or drawing? How confident do you feel to consent to an operation, take prescribed drugs, or accept that you are "OK"?

For Deaf people who use British Sign Language (BSL), access to health services is almost always in another language. It is a common misconception that BSL is a visual representation of English and that it follows the grammar and word order of English and simply substitutes signs for words. This is not the case. Much of the grammar and intonation of BSL are to be found in facial expressions and mouth patterns, and the sign order and structure of the language follow different rules.¹ This is why a Deaf BSL user's written English may look "foreign" and ungrammatical.

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For many Deaf BSL users, English is therefore a second or even a third language. Communication via pen and paper, while useful for basic short exchanges, is not appropriate or safe for conducting medical consultations or obtaining consent. As with users of other minority languages, the solution to this is to communicate through an interpreter.

Some Deaf people may require additional or alternative communication services to a BSL-English interpreter - for example, a Deaf person with minimal language skills may require a specialist interpreter to work either instead of, or alongside, a BSL-English interpreter.

What is a BSL-English interpreter?

BSL-English interpreters are trained accredited professionals. They have undergone training and assessment in both languages, in cultural mediation and in interpreting. In England and Wales interpreters are registered with the Independent Registration Panel (IRP) or are members of the Association of Sign Language Interpreters (ASLI). In Scotland, interpreters are registered with the Scottish Association of Sign Language Interpreters (SASLI).

Although interpreters are bound by a code of ethics, which includes impartiality and confidentiality, friends and relatives are not. Sadly, hearing children of Deaf parents are often used to "interpret" during medical consultations. This is obviously dangerous for the patient and also places inappropriate responsibility on the child. Alongside ethical considerations, with sign language we cannot assume that friends and relatives of a Deaf person can sign to a sufficient level. For medical consultations, it is essential that someone with the proper level of interpreting skills - not a member of staff with a basic knowledge of BSL - is used.² While it is extremely helpful when NHS staff can conduct basic conversations in BSL, as with medicine a little knowledge can be dangerous if the person is not aware of their limitations.

A professional duty

"We as a profession have a duty to maintain a good standard of practice and care towards our patients." The General Medical Council (GMC) requires its doctors to³:

• Respect the rights of patients to be fully involved in decisions about their care
• Give patients information in a form they can understand
• Listen to patients and respect their views
• Respect patients' dignity and privacy
• Recognise the limits of your professional competence.

It is difficult to see how the above can be achieved when doctor and patient do not use the same language.

The GMC standards and ethics committee also made the following statement: "Make arrangements wherever possible to meet particular language and communication needs, for example, through translations, and independent interpreters."⁴

A legal duty

Since 1999 there has been a legal requirement on service providers to make "reasonable adjustments" to ensure their services are accessible to disabled people. One example of a "reasonable adjustment" listed by the Disability Discrimination Act is the provision of sign language interpreters.⁵ A further extension to the Disability Discrimination Act in October 2004 requires that physical features of surgeries and hospitals also be made accessible. For deaf people this could include the use of visual information displays for calling patients from a waiting room.

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How to book a BSL-English interpreter

Deaf people use a range of communication services, so you should always try to find out the patient's preferred means of communication. If you are unable to sign, ensure that your face is clearly visible and speak clearly. Alternatively, write it down in plain English and use visual pictures where appropriate.

If you need a BSL-English interpreter:

• Check with your department, primary care trust, or hospital trust whether they have a central booking system or a contract for the provision of interpreting services
• If you need to book an interpreter directly, ensure that you are booking an IRP or SASLI registered or ASLI member (box 3 gives contact details)
• Bear in mind that there is a shortage of interpreters and allow as much time as possible when booking
• Try to be flexible with the appointment date and time.

Conclusion

The provision of BSL-English interpreters is not only a professional duty and legal obligation but also fundamental to providing a safe and accessible health service for deaf people.

Channa Panagamuwa, (hearing) specialist registrar in otolaryngology, Leicester Royal Infirmary, Leicester
Email: channa.panagamuwa@virgin.net

Kate Wellman, (hearing) British sign language-English interpreter, London
Email: kate.wellman@zen.co.uk

Marije Davidson, (deaf) legal policy officer, RNID, London
Email: Davidson@famdav.eclipse.co.uk


studentBMJ 2005;13:177-220 May ISSN 0966-6494

1. Sutton-Spence R, Woll B. The linguistics of British Sign Language - an introduction. Cambridge: Cambridge University Press, 1999.
2. Department of Health. Doubly disabled: Equality for disabled people in the new NHS access to services.
3. General Medical Council. Good edical practice. London: GMC Publications, 1998.
4. GMC standards and ethics committee. Seeking patients' consent: Ethical considerations (Core Document). London: GMC Press, November.
5. Disability Rights Commission, RNID, British Deaf Association. Guidance on providing British sign language/English interpreters under the Disability Discrimination Act 1995. For employers, trade organisations and service providers. London: RNID, 2004
6. RNID. A simple cure. A national report into deaf and hard of hearing people's experiences of the NHS. London: RNID, 2004.