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The link worker has a crucial role

Dr Joshua Hill describes how his inner-city practice meets non-English speakers' healthcare needs.

Dr Joshua Hill
Dr Joshua Hill

I am an inner city GP in Tottenham, north London. It is 9am and my heart sinks as I realise there is a long, computerised list of non-English speaking patients stretching out before me.

I contemplate a string of misunderstandings, huge lists of problems and lengthy diatribes in languages I don't understand.

I will be stressed out when surgery ends, and at least one patient will not have been satisfied with their consultation.

My practice sees many Turkish and Kurdish patients unable to describe their symptoms in English. Happily, much of the stress and dissatisfaction I have just described is a thing of the past - we have access to the services of Sivel Hulusi.

She is the Turkish-speaking link worker for North Middlesex Hospital and local GP surgeries. Ms Hulusi says that with a good link worker present during a consultation with a patient who cannot speak English, there is no reason why the consultation should not run smoothly and professionally.

Switching on a light
She enjoys her job. She likes people and gains satisfaction from helping them. For patients, she says the presence of a skilled link worker can be like switching on a light in a dark room.

'Thank you, I finally know what's wrong with me after all these years,' is something she hears often. She also receives the thanks of doctors who have been struggling to help but have missed something vital in the patient's history, or been caught out by a cultural issue.

I was troubled by the seeming lack of patient satisfaction among my Kurdish patients over how I dealt with perfectly routine problems. When I asked Ms Hulusi for advice, she said: 'You don't examine them enough.'

I protested that an examination is not always necessary and told her: 'We only have 10 minutes per patient.' However, I began to spend more time 'laying on hands'.

This resulted in an overwhelming increase in patients' confidence. I was now behaving as they expected a doctor to behave - and saving time for both them and I by avoiding repeat consultations.

Sometimes patients need an explanation for the doctor's behaviour, for example, if he or she consults a textbook during a consultation. Ms Hulusi says some patients interpret this as incompetence on the doctor's part, so she explains to them that 'It is just the doctor being careful'.

Ethnic minority patients - especially recent arrivals to the UK - frequently need an explanation of how the NHS works. Private healthcare systems, often the only form of healthcare provision back home, tend to over-investigate patients.

As a result, they come to the UK expecting the doctor to automatically send them for tests and costly investigations. When this does not happen they are disappointed.

Also, the issue of somatisation is tackled head-on in the UK rather than being implicitly encouraged with the 'rewards' of ever more invasive procedures.

Are explanations like those of Ms Hulusi's ethnic stereotyping or sensible advice? I would argue the latter and believe that providing clinicians with this sort of guidance is where link workers come into their own.

Cultural misunderstandings and communication difficulties are their bread and butter, so it is worth listening to their suggestions.

It is also important to ask link workers for their opinions because they may not necessarily volunteer them.

Lost in translation
Ms Hulusi translates everything the patient says word for word without giving her own opinions or summarising what is being said.

'You often run into problems when the link worker does their own summarising or ventures opinions which are not those of the doctor,' she says, adding that this happens a lot according to the feedback she gets from patients and doctors.

Over-summarising will ring true with some GPs, who will be familiar with a patient talking for a full minute, only for the link worker to turn to the doctor and say 'he can't sleep' or 'her head hurts'.

This is equally frustrating for the patients, because they know that this is happening.

More dangerous is when the doctor's advice is changed when relayed to the patient. Or when link workers venture opinions rather than translating what the doctor says. Of course, a link worker is entitled to have an opinion, but it should be identified as such.

Ms Hulusi advises reporting adverse incidents to which the link worker may have contributed to their employer.

NHS trusts spend £55 million a year on translation services. Primary care organisations and hospitals will probably try to cut costs by targeting link worker provision. And one former minister has been quoted as saying that translating services should be cut to encourage immigrants to learn English.

Employing link workers is a significant cost, so it is unlikely that an average GP practice would be able to fund their services. But it would be a great loss to the NHS and to the diverse communities we serve if we had to struggle on without them.

  • Dr Joshua Hill is a GP in north London.


  • My surgery, the Morris House Group Practice in Tottenham, and all other GP surgeries in our PCT, NHS Haringey, are served by the link worker office at the local hospital.
  • This arrangement has been in place for more than 15 years.
  • Kurdish (Turkish speakers) and Turkish patients are our biggest ethnic group.
  • Turkish-speaking link worker Ms Sivel Hulusi spends two mornings a week at my practice.
  • During each session she translates for about 10 patients who have been booked at staggered intervals.
  • Link workers for different nationalities can be booked by our receptionists if it is likely that a patient will need one, or if a patient requests a translator.
  • The service is promoted in our practice leaflet (in Turkish and other languages) and by word of mouth.

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