Blog by Mike Etkind, Volunteer Panel Member, Healthwatch Bucks
I’ve found myself volunteering in various health capacities since retiring from a non-health job a couple of years ago. This has included a role advising on readability and plain English writing.
In this blog I’m giving brief insight into two activities:
- reviewing 15 documents from local health and social care providers and writing a report for Healthwatch Bucks;
- advising on patient-facing materials for various medical research projects.
There are 152 local Healthwatch bodies in England with a combined budget from Government, via local authorities, of £26m. Each local Healthwatch exercises statutory powers to
- find out what people want from health and social care and
- share these views with those running services to help make them better.
I joined Healthwatch Bucks as a volunteer on their advisory panel. They were then consulted by the local healthcare trust on its revision of each of the 80 existing maternity leaflets it has.
Having had experience of plain English writing in my civil service career (yes, I know, plain English often isn’t an attribute of Government publications!), I offered to comment on a few of the leaflets. As a result, I produced a 2-page guide for the maternity service – in summary:
Page 1: Three steps to a good leaflet:
- Decide who you want to read it;
- Decide what the purpose of the leaflet is;
- Decide what your readers want or need to know.
Page 2: Advice on clear writing
- Know the average reading age of the UK population is said to be 9 years old. The Sun writes for a reading age of 8.
- Assume if more people read and understand the leaflets, there should be fewer queries and less anxiety.
- It’s not about dumbing down, or being patronising, or not saying what needs to be said.
- Top tips with examples: Use everyday words and short sentences, be personal, try reading your text aloud, less is more, etc.
One thing led to another. Healthwatch Bucks persuaded me to lead a project to review 15 items published by the local healthcare trust, clinical commissioning group, and county council social services department. We consulted the three bodies and came up with a selection of items, including consultation papers, patient leaflets, reports for public meetings, an admissions agreement, a bulletin on the integrated care system, a strategy document, and a complaints policy.
The review had two elements. For each item (or part thereof), I put it through the Flesch-Kincaid readability algorithm available via Microsoft Word. Next I attempted some redrafting and provided an assessment of each item.
Why Flesch-Kincaid? Because it’s readily available on Word and easy to use. Because it’s a useful entry-level tool to get non-professional writers thinking of readability. And because the results can provide useful headlines which focus and influence management decisions.
In the case of the Healthwatch Bucks work, the finding was that just one of the 15 items secured a Flesch-Kincaid readability score of >60. This is said by some to represent plain English.
I’m pretty sure it was this ‘one out of 15’ headline finding, presented using a RAG rating (see below), which led to the review being taken seriously at senior level. In their responses, all three organisations committed to take forward all six recommendations in the report and we have already seen evidence of action being taken.
But, of course, readers of this blog will well know that it’s possible to get a high Flesch-Kincaid score by writing complete garbage with short words and short sentences. Likewise, poorly structured or poorly targeted text can still emerge unscathed from Flesch-Kincaid scrutiny. So there are risks that, in non-professional hands, a good score will erroneously be seen as “job done”.
Having applied Flesch-Kincaid, the second stage was to redraft part or all of the documents to show what improvements were possible. I accompanied each revision with an analysis of the main types of improvement made: whether restructuring, refocusing for the assumed target audience, simplifying language, etc. Underpinning several of the recommendations was a distinction between leaflets aimed at public/patients and documents produced for consultation, public awareness or co-production. The report suggests it’s unrealistic to expect the latter to be written entirely in plain English, but the pay-back is that all such documents ought to have a plain English summary at the beginning.
The report was published in June 2018 and included a modified version of the two-page guide produced for maternity services.
Patient Public Involvement (PPI) in research
There are opportunities for members of the public to be PPI volunteers for all sorts of health-related research. Projects I have been involved with include research into whether and how people keep information about their medication on their person; possible use of electrical impulses to improve the performance of surgeons; the effects on kidney patients of taking aspirin to reduce heart attack and stroke risk; and the development of improved methods of assessing potential dementia sufferers. The PPI role is, in essence, to try to reflect what patients and the public would think, so as to help the researchers plan and deliver their project.
I have also reviewed three funding applications for the National Institute for Health Research. PPI reviewers are asked, in particular, to focus on the sections in each application containing a plain English summary and details of how the researchers propose engaging patients and the public.
With much research requiring members of the public to participate – whether in trialling medication or techniques, or just sharing their insights into their particular condition or circumstances – the materials produced need to be clear and understandable. I have found that researchers may not have the training to produce accessible material, nor have access to support to help them do so. The same applies to those writing funding applications. Of the three I reviewed, only one produced a plain English summary that was clear and concise from the perspective of a non-expert reader.
One interesting issue emerged from an NIHR review. The plain English summary for this application stated that service users had been involved in drafting it. However, in my view, it was too long, lacked a clear narrative and contained many complex sentences. It is, I’m sure, difficult for researchers to find a mix of patients or service users willing to volunteer their time. But this instance does, for me, suggest the need for caution in relying too heavily on volunteers who may be very close to the issues, perhaps because they have extensive lived experience, or otherwise are not representative of the general population.
From the above experiences, I will tentatively offer the following thoughts.
- Professional members of PIF are well-placed to advise and create materials that are clear and understandable to most patients and the public. But it seems a lot of materials are not produced by people with this professional skill-set.
- To enable those without high-level writing skills to produce readable materials, it is important they have access to short, basic guidance, rather than the sort of lengthy style guides, etc that organisations can produce and, I suspect, are left on the shelf unread or undigested. Likewise, if training is available, it should be tailored: not to turn a professional midwife or social worker into a highly capable author, but to briefly introduce simple, basic principles that can be easily and reliably assimilated.
- Health and social services organisations can favour creating and updating their own bespoke material even when there are opportunities to deploy (with or without customising) materials produced by charities and other involved bodies, which are often produced with considerable attention to accessibility.
- In relation to public sector health and social care organisations, I don’t know what training their comms specialists typically have on writing or editing patient/public focused materials. In my ignorance, I merely ask whether this is something that might need addressing?
- The NHS’s own agenda is about self-care, patient responsibility and illness prevention/well-being. To succeed, patients and the public need to understand the messages and information they are getting. Furthermore, poor communication using complex and lengthy documents hampers co-production as well as being time-wasting for health and social care professionals and administrators and everyone else. Which leads me to see readability as a core issue, not a luxury add-on.
- Given the importance now given to PPI in health research (see foreword to the NIHR’s Patient and public involvement in health and social care research: A handbook for researchers), researchers should have training in public-focused writing or access to expertise within their research organisations.
This blog is written purely in a personal capacity and doesn’t necessarily represent the views of any organisations I have mentioned.
Posted on Tuesday, 27th November 2018