Access to care: identifying the barriers for Bangladeshi communities in West London
“I don’t want to burden anybody else”
Following our engagement with members of local Bangladeshi communities on tackling vaccine hesitancy, our latest work explores the access challenges preventing people from receiving the healthcare they need.
Lots of the work we do involves speaking to people in the community about a specific issue. This could be having conversations with young people about local mental health support, working with people who have lived experience of being a patient at a particular hospital or exploring the views of people who use home care services. Often through this work and the conversations we have, important issues are highlighted that don’t fit into the main piece of work but that nevertheless need addressing.
Over the last year, we spent time with members of the Bangladeshi communities in Westminster and Kensington & Chelsea, exploring vaccine hesitancy and the barriers many Bangladeshi people face to getting vaccinated. For this important piece of work, we produced a report and a set of recommendations with local community members to help the NHS and the local councils improve their service to ensure that Bangladeshi people feel more comfortable getting vaccinated if they can. However, this work highlighted serious access issues for Bangladeshi people that stretch much further than vaccine hesitancy. In this article, we’ll explore some of the important issues that were highlighted.
Barriers to health and social care access
The people we engaged with described a range of barriers which make it difficult for them to access health and social care services. These include a lack of available interpreting services, the often complicated and confusing structure of NHS primary care for patients, poor healthcare access routes for those who do not or cannot use digital health tools, and a lack of trust in health and social care services.
Issue one: Interpreting services
Many of the Bangladeshi people we engaged with discussed issues with interpreting services in primary care settings. A significant number of participants were not aware that they are entitled to request an interpreter for GP or hospital appointments and that the NHS or GP surgery have an obligation to provide someone. Almost all the people we engaged with were unaware of Language Line, a translation tool available for people accessing NHS 111 and GP services on the phone.
There are two major issues with primary care interpreting services. One, many people who need to use interpreting services don’t know they exist. Two, many services that GP surgeries have an obligation to provide either don’t work very well, or don’t work at all. Some participants told us that a lack of interpreters at GP practices has led them to make otherwise unnecessary trips to A&E in order to receive care.
“If it’s urgent, I go to A&E because they don’t have interpreters at the GP practice at short notice.”
Poorly functioning interpreting mean treatment and care is often delayed for those who need it. One person told us GP practice appointments need to be booked an extra two weeks in advance in order to arrange for an interpreter to be present. Meanwhile, they are waiting to receive care.
This leads to a stressful and challenging experience for people who need an interpreter to access healthcare. One participant’s story demonstrates the impact these issues have on patients. They told us they went to see their GP with an urgent concern but were turned away because the GP practice could not provide an interpreter. The practice advised them to go to A&E. At A&E, they were sent back to their GP to arrange a referral to see a specialist at the hospital. However, the reason they were in A&E was because they could not get an appointment with their GP. This participant told us their experience was very distressing.
Issue two: Poor healthcare routes outside digital health tools
When we began this long-term engagement work in 2021, many GP practices were still operating by appointment only and patients were not able to walk in and book appointments or speak to practice staff in person. Some participants told us this lack of in-person availability created distance between them, their family, and their GP practice. Although many GP practices are now more open, many rely much more heavily on digital and remote access tools, such as their website, an app or telephone triage, than they did before the pandemic began.
One issue many participants consistently mentioned was telephone triage. For many people who have English as an additional language, communicating is even more difficult over the phone. Many participants expressed frustration that at times the only appointments they have been offered have either been online or over the telephone. Some people told us this meant they were unable to access services care as a result.
Digital health tools have similar access issues. Many of the challenges raised by participants during this programme of engagement were issues we had already explored at length in a report on NHS digital healthcare access in 2021. Some participants told us they cannot use digital tools to access health services because they do not know how to use the technology. Other people told us that even though they speak and understand English to some extent, they cannot write in English, and therefore cannot use online healthcare tools.
“I can speak English, but I cannot write in English. Sometimes, my daughter-in-law has to help me online.”
One participant told us that they felt the growing reliance of primary care providers on digital tools was taking away independence and privacy from some members of their family.
“My mum doesn’t have access to a computer and doesn’t know how to arrange an appointment using her phone. She is being asked to do things she cannot do.”
Issue three: The complicated structure of primary care for patients
We have already heard the story of a patient who was turned away from a GP practice due to a lack of available interpreters, only to also be sent away from A&E with the advice to request that their GP refers them to a specialist back at the hospital. For many people who don’t speak English or who have English as an additional language, the complicated and complex structure of primary care services, and the lack of coordination between them, means they are forced to go through a host of tiring additional steps in order to get treatment.
GP practices, for instance, offer different types of consultations which are often based solely on a patient’s clinical needs. Frequently, no thought is given to the non-clinical needs of a patient, such as language barriers, hearing or visual impairments, technological literacy, or cost. One participant told us that receiving care over the phone from their GP was challenging due to the long timeframe GP practices give for when they will call. The participant said that the lack of a specific appointment time made it very difficult for them to arrange for a family member to be present to interpret.
Some participants told us that the number of contacts they or their family members need to get the help they need is much larger for those with additional accessibility needs. Consider, for example, someone who doesn’t speak English or have access to a computer and who has hurt their leg. They do not know that patients are able to self-refer themselves to a physiotherapist because they cannot access this information online. This person instead has to get a family member to help them speak to a GP receptionist to arrange an appointment with a GP, wait for a GP appointment and arrange for an interpreter to be present to get a referral to see a physiotherapist, and then wait for a physiotherapy appointment and arrange for another interpreter to be present at this appointment.
Delayed help
These access issues mean many people either delay getting the treatment and care they need or abandon it altogether. Most participants we spoke to told us they have delayed seeking treatment because they felt it would be too difficult or challenging to access their GP.
“My mum could have just phoned and spoken in her native tongue or in simple English at an appointment [with an interpreter]. Now she is saying ‘maybe I don’t need to see a doctor.’”
Many participants told us that getting care takes longer because they are dependent on other people for help accessing services. For instance, some participants told us of examples of people having to wait for a family member to be available for help with making appointments, ordering repeat prescriptions, interpreting during an appointment, or translating information.
On top of this, some participants told us about the pride they or their family members feel and their wish to remain independence. Many participants told us they do not want to be a burden on others.
“Especially in the Bangladeshi community, our parents and our grandparents are reliant on us and our extended family to help them. But they also take it on themselves. They say, ‘oh, I don’t want to burden anybody else.’”
What needs to change?
When we released our 2021 report on digital health and access issues, we developed a comprehensive set of recommendations for NHS and local council service providers and decision makers. These set out the steps they should take to ensure primary care services are as accessible as possible. Sadly, over a year later, many of these recommendations have not been acted on or implemented. Our recommendations remain as relevant now as they were then.
One: Face-to-face appointments and consultations
GPs and all NHS services in Westminster and Kensington & Chelsea should adhere to UK Health Security Agency Recommendation 4 that states that patients should be consulted on their needs and preferences for face-to-face appointments. Where it is not possible to offer this, patients should be provided with clear explanations on the reasons why this decision was made and what their alternatives are.
Two: Signposting
Public Health teams in Westminster and Kensington & Chelsea should promote information on local health services, including details about self-referral routes where applicable, accessibility, and interpreting services in public places such as pharmacies, GP surgeries, libraries, community centres, sports centres, walk-in clinics, schools, and higher and further education colleges
Three: Local public health messaging
Local Public Health bodies should involve local people and community groups to produce local public health information.
Four: Interpreting services
All GP practices and other NHS services within Westminster and Kensington & Chelsea should promote and make available interpreting services at each point of need, for all patients who request this service.