Highly usable websites, inclusive and accessible content – all coming to a GP website near you

Well, this is very welcome…

Future NHS page with the ‘creating a highly usable and accessible GP Website for patients’ guide, and ‘Patient-user research to support’

In the last few weeks there are some super updates to the guidance from NHS Digital and NHS England that will help GP practices to create inclusive content and usable websites. It should also make lives easier for people who need to use the ‘Digital front door’, aka GP practice websites.

I’m talking about the updates to the NHS Digital service manual, Content style guide and the ‘Creating a highly usable and accessible GP Website’ from NHS England’s user research team, Dominic Vallely and Emmy Graham. We’ll be exploring the content style guide and the ways in which practices communicate with patients in a joint event with Nexer Digital on the 12^th October 22 (have a peek on Twitter at #LettersHack).

If you’ve followed my other GP website blogs ….

You’ll realise that I have a bit of thing for GP websites. In my day job, I sit at the intersection between policy makers, NHS commissioners, specialists in inclusive and accessible research and service design, product suppliers and the people in practices who try and make sense of it all, to provide services to us as patients in the NHS. It’s a nice place to sit. I don’t need to be a specialist, I don’t need to have the technical know-how, and although I do know a fair bit about General Practice, service improvement and delivery, we all have experiences as patients that we can lean on and learn from. This guidance brings much of that knowledge into one place.

This is why the guides are so helpful….

GP Practices have a myriad of contract requirements to meet, in fact there are 10 pages of items listed in the ‘highly usable website guide’. Many of them are iterations of earlier contract requirements, it’s no wonder practice teams are confused – I’m confused by much of it too. The GP website supplier market is large, as is the online consultation market and each supplier clearly wants to do the best for their clients – the practices. But occasionally and possibly due to the market competition, these suppliers sometimes focus a bit too much on their own branding and product and not quite enough on the usability of their product, either from a General Practice team perspective or the intended end user, i.e. the patient. They may forget that their product needs to be connected to another NHS service and so needs to conform to the standards and style of the NHS brand, which is trusted and researched to reach as many people as possible. Often, the user is confused when they access information online and get diverted off to a supplier’s platform, or suddenly the page no longer looks like their GP practice or even an NHS service.

Home page from NHS Digital service manual showing the Standard for creating health content

Colours matter, language and content matters, the user’s journey matters, the technical layout matters. For the practice teams who have a million other things to do, simple ‘how to’ instructions and examples help enormously and these guides offer sample layouts with ‘things to include’ and just as importantly, things ‘not to include and say’.

Hilary Stephenson, Managing Director at Nexer Digital says,

‘It’s great to see the convergence of user centred design standards and technical platforms across the NHS and their vendor network. Sadly, in our work we have seen real issues with the core usability and accessibility of websites, consultation platforms and apps used for digital engagement. This feels like such a missed opportunity at a time where digital inclusion is vital for patients, their families and those delivering services under immense pressure. Anything that provides practical guidance, which is evidenced by user research and makes things more inclusive, from content design through to platform configuration, will improve the experience for patients, clinicians and administrative teams.’
Hilary Stephenson, Managing Director at Nexer Digital

Now the work starts….

There are over 6500 GP practices in England, just over 900 in Scotland, almost 400 in Wales and over 300 in Northern Ireland, each serving their average registered population of 9000 people. That’s a lot of people to reach to reduce the variation of experience for users and for practice teams who provide information. We have incorporated this guidance along with simple advice, hints and tips into an easy-to-use system called the Digital journey planner (DJP). The first module; Patient Communications deals with Websites, Social Media and Messaging, The second module; GP Online Services covers everything that practice teams need to know to provide a good online service and make that easy for patients to use. If you are getting ready for patients having full online access to their medical records later this year, it’s a must. Our next module, due for release at end of Sept will be Digital Inclusion.

Map showing location of practices in England using the Digital Journey Planner. Blue dots have Foundation access, green dots are practices with Enhanced support from Redmoor Health to embed digital service delivery. Aug 2022.

So far 10% of practices are using this system in England currently and we aim for 25% before the end of the year. At Redmoor Health we work with practice teams to help improve digital knowledge, skills, confidence and competence and offer support in terms of training, coaching, advice and share best practice resources that save practices time when searching for help. These guides are essential learning tools to embed in the DJP, so they are easy to find and stand alongside practical hints and tips when to use. Some areas have already commissioned Redmoor Health to carry out reviews across all their practice websites, just to get a feel for the scale of the problem and ideas how to help. Others have offered incentive schemes for practices to have the time and space to make the changes, so we anticipate this as a big opportunity to improve, standardise and simplify access to information.

The suppliers….

Good suppliers have been using these standards for some time and have already created NHS style guided website templates, that meet the accessibility and usability needs of users and practice teams. Others recognise that they need to encourage practices to move away from old legacy systems, personalised styles and ‘whizzy websites’ to be more consistent, and to simplify the user journey. I’m quite sure many more will now take on these recommendations following the detailed patient user research that informed the guide. I spoke to a few to get their views of the research and guidance.

Iatro Practice 365 have already produced a simple version and template for practice teams to know what to add to their website. Thomas Porteus said,

‘We’ve been behind the NHS Service Design Toolkit since we started, it’s been a pleasure to work with NHS teams openly and to be able to contribute our own code back to the project for the good of all NHS organisations. The guidance is a really great point of reference for practices wondering where to start, and what to avoid’
Thomas Porteus, CEO and Founder of Iatro

Tim Green, co-founder of GPsurgery.net, commented:

“As advocates for patient-friendly, accessible websites since we began working with GP surgeries in 2004, we warmly welcome this new evidence-based guidance from the NHS Digital First Primary Care team. Clearly focused on simplifying the patient journey, the guidance offers practical advice and tips for practices and commissioners aiming to improve patient experience, reduce digital inequalities and remove barriers to access for patients with disabilities.“
Tim Green, co-founder of GPsurgery.net

Dillon Sykes, NHS Partnerships Manager and Joe McGrath, Product Manager for Livi have been developing the full patient journey via their website platform to connect to the NHSApp.

‘At Livi we welcome this new guidance from NHS England. Accessibility is not about sticking assistive technology onto the website. It is about building the website from the ground up to work with third-party assistive technology (e.g. screen readers). It is also about ensuring the website content is written in a way that is clear and understandable by the majority of users. By using the NHS Digital Service design system, Livi websites are NHS branded, optimising functionality and providing confidence for patients to engage with online GP services (as well as other locally commissioned services and third-party tools). We believe practices should have generic accessible content and definitions of local service providers to help patients manage their own care. This approach has allowed us to build a practice website platform that gives practices back more time to spend on patient care by:

nudging more patients to digital services and appropriate alternative NHS services,

reducing the time needed to manage and maintain the website

Dillon Sykes, NHS Partnerships Manager

To the commissioners – let’s do this together….

Most useful in the website guide is valuable information for NHS commissioning teams to help procure GP websites ‘at scale’ and to know what to ask of suppliers in terms of user testing. Perhaps now is the time to rethink the stance that ‘it’s a GMS requirement to have an online presence’. This must be the way forward to support local population communications and connecting the services at a local level for patients. It will support primary care network development and reduce the burden on individual practices to know and learn about website technicalities, so they can just focus on the message and how it is presented or accessed. As more services are delivered together, why would we expect each separate practice to upload its own content and service description? Surely this is done once by the local service provider? Let’s take a current example. Practices will all be delivering Flu and Covid boosters soon. They need one single page for who’s eligible, then the ability to edit and add what’s happening locally, so that people know how to book and where to go. Currently each website supplier may duplicate this, and some are good enough to offer a ‘Flu’ content page. NHS England have issued the criteria in a Specification. Public Health (UK Health Security Agency) have some promotional material, and poor practice managers will be trying to make sense of it all to tell their patients what is happening, whilst awaiting the final dates from vaccine suppliers and working out which members of the team can deliver. One forward thinking area has thankfully collated all of this information together for its member practices and wait for it…… shared it as a google drive document to 200+ practices via email!!! That’s my Friday job folks – to upload and create this years Flu page.

google drive document containing all of the information required for 2022/23 Flu campaign

Hopefully, you can see where I’m going with this. Do we really need 6500 individual digital front doors? I think not, but always open to be persuaded if you think the status quo is better.

Access to your Medical records online – It’s hard work for practices, even to do the right thing….

It’s hard enough dealing with illness, worry and the pressure that results from this, without having a system which seems to be hindering rather than helping. I’ve been touched by an event where someone who cares for their son (he has a life changing, long term illness) is despairing because of the struggle to get access to his medical records to make sure he is cared for safely and receives the right medical treatment for his conditions.

I thought I would try and explain why some practices have not prioritised this area of work. That’s not to excuse them but more to give context to the problems. I hope this provides a broader understanding of the challenges so that if you too are struggling to get access to your records and need to have a conversation either with your practice or local CCG, this is easier because you know some of the background details.

I work as a Practice manager in West Cumbria and I’m also working across Lancashire and South Cumbria to spread digital working so Online Records Access is a bit of a passion of mine – largely inspired by the work of Ingrid Brindle and Dr Amir Hannan.

Haughton Thornley Medical Centre had a specific reason to start the records sharing – they had to rebuild trust after Shipman.

Dr Hannan describes this as a Partnership of Trust and often a critical event like this triggers a huge swing in the opposite direction, hence their policy for openness and transparency. He is driven by this almost like a crusade and has been doing this for 13 years.

Unfortunately, the majority of GPs do not have either his reason or understanding of the benefits of providing full records access.

This post isn’t to debate the pros and cons, more to explain why it’s not as easy as presented. Most practices have only started in the last 2 years which have been an increasingly pressured time in General practice due to dwindling resources and increased demand. Our practice started to provide detailed online records access in 2015 following an evening training session with our patient group, staff and with Dr Hannan and yet according to the lastest NHS statistics, we still only have 33% of records access. I have been unable to spread this work across the practices in my area of Cumbria largely due to the chicken and egg situation; ‘patients don’t ask, so we don’t have to provide’ vs ‘patients don’t know what to ask for, or when they do ask, its too hard to do’ for the practice. I also support our local group of PPGs and help to raise awareness about the benefits of records access and I’m often frowned at by my PM colleagues, who are finding it hard enough to do the day job with multiple complex priorities and change.

We are dealing with a society where increased litigation is creating more fear in clinicians than ever before, ramped up by risk aversion and caution in the medical indemnity and professional bodies such as RCGP

The guidelines we have to follow and assurances we have to give to regulators (CQC) are confusing and completely at odds with patient experience and NHS policy directive ie our GMS contract See Section 3.

Pulse, like many other organisations provide both detailed and summary guidelines to address the new GDPR regulations but interpretation is varied across practices, some provide the absolute contract minimum records access, others have increased their provision rather than deal with Subject Access Requests.i

I know there are really good General Practices, with Outstanding recommendations from CQC, who still only have 0.27% for their Detailed Care Record Access.

As a member of a patient group, I have asked my practice to enable some of this functionality, but have stopped asking as I’m aware that I could be perceived as a nuisance and that this may affect our relationship. So I appreciate the experience from both sides of the divide.

If you are interested to see how your local practice compare, here is the latest data so you can find your CCG and practice and see where they benchmark.

Many of you will know that General practice income is reducing year on year and expenditure increasing. The Independent contractor business model means that any additional unfunded work comes directly from the bottom line of GP Partners income. If Partners have a choice to pay locums to keep the service going, rather than spend this on clinical and admin time to carry out the data checking required to ensure the records are accurate, readable, viewable and cleansed (I mean redacting any 3rd party information which is required by law), then they will spend their money on the locum every time so that patients get seen. It’s a continual balancing act between providing access and shifting to new ways of working.

GDPR has increased this anxiety and whilst from a patient perspective, the regulation is a good thing i.e we should know what’s in our records, this has created a huge amount of work in practice. Software to help carry out this process is available such as iGPR but at a cost to the Practice or the CCG and is only recently developed. Initial feedback is good, 6A916A36-EFBE-408F-96A7-C73BF15A2D2B but their earlier versions of their insurance reports were clunky so many practices were put off by this.

Think back to the days when your GP wrote in Lloyd George paper notes, probably in medical shorthand to describe what your symptoms were. Many of these old records are illegible, some contain inappropriate comments as societal norms and subsequent language has changed. These were always the ‘GPs notes’, not the patient’s – but now thats changed, even if the content in the notes is the same.

Each time a patient moves from one practice to another, your new GP then becomes the data controller for someone else’s data entries. Would you be happy with this responsibility and be willing to share without checking the historical records? Until recently, none of this was taught in Medical School and I suspect its still skipped over. Our practice teach medical students – this topic is always on our training schedule – even if the Student tells me they want to be a surgeon.

Roll forward to today when people are requesting 10-30 years of this history to be viewable and I think you can appreciate the workload to share this in a presentable way.

Another feature of GDPR (in addition to the increased workload and anxiety) is the removal of the ability to charge for the work. Hence, some practices suggesting to all patients that online access is the answer and then realising the workload to tidy the records is no less onerous than printing them. Yet Practices still have to put in place mechanisms to ensure that records are continually checked for external 3rd party content and protect this information from disclosure.

I’m not aware that NHSE have provided any direct resource linked to the volume of this work to practices since 2012, when they funded a Direct Enhanced service for online services for a short period. This work is now incorporated as a GMS contract requirement for online services, with a ‘stretch target’ for further adoption. The current figures mainly reflect use of transactional services (online appointments and medication requesting) to present the story of ‘14million users’, so this satisfies the DH & Secretary of State’s headlines of success, but provide little support in terms of detailed care records access. NHSE Patient Online team have reorganised as the ‘Empower the Patient team’ and whilst offer presentations and promotional materials to support practices, they do not have any budget for deployment or direct training at a practice level.

CCGs are responsible for the Infrastructure to support General Practice in terms of IT and local Training capability and capacity varies from area to area, so unless the Practice team has some understanding of what the patient can see through the various record viewers, then they wont understand the consequences of scanning correspondence, without details being attached to the images. Correspondence may have scanned historically before this became a priority, hence many online records have no valid descriptions on the attachments. Practice priority is to get the correspondence into the records asap so that if a patient comes into the surgery, the clinician can view the letters or act on the information contained therein. Bulk adding of correspondence is a common task, followed by summarising of ‘read coded’ information and if a patient has a large record, then often the GP2GP (thats the electronic system for transferring the electronic record) fails. So someone has to painstakingly read every piece of correspondence to glean the pertinent details and manually code this information. There are add on software products that can help, but stable infrastructure is required or else this adds further risk if documents cant be accessed by the clinician in the consulting room.

In our practice we have 3 years worth of scanned images from 2006-09 that are unable to be converted into a viewable format. That was due to the scanning system configuration at the time and long before records access was even considered. Our CCG paid for the remainder of our historical scanned images to be converted to a readable format. Many practices have to fund this cost themselves.

As Ingrid Brindle regularly points out, complex patients or their carers often have the best knowledge of their history – she says ‘it’s their life’s work’ and patients can be a great support to help practices correct any inaccuracies. Patients can help by highlighting all of the pertinent information and checking with their practice that this is:
A. Read coded
B. In a format that is shareable across the health organisations in their area
C. Visible through whatever records viewer a patient chooses to use.

The introduction of Snomed might make it easier for hospital coding to be automatically transferred into GP records but this has been in the pipeline for many years, although expected later this year.

Sorry this was a long post, but as you can hopefully see, this isn’t an easy or quick fix and it shouldn’t be left to individual practices to resolve. NHS Digital seem to be focussing on front end entry to the NHS through apps and also single identity authentication to remove the need for multiple passwords and sign ins. They are currently working with existing market providers like Evergreen Life and Patient Access for the records viewing element but its not clear yet how this will impact on records access at a practice level.

Alongside this, CCGs and clinical system/Electronic health record providers are focussing on large scale inter-organisation data sharing, but not direct sharing with the patients. It will be interesting to see if the launch of the NHS app for accessing all services increases the requests from patients for records access online and how this will be resourced.

#SpreadinNWC

Hi there

This is for Claire @haighclaire and Glenys @cumpstonarchive

I’m sort of messing about a bit, trying something new and then seeking a bit of feedback (I hate that bit already), maybe just a bit of a reaction to see what this blog might generate.

Glenys has said a couple of times – ‘why don’t you write a book’? This is usually when I’m sharing a story of an event because sometimes, there is a back story to a headline which would make your toes curl. But that’s maybe for another blog.

I suppose the quick answer is, I rarely sit down long enough to think through what I want to share. Although, I am a sharer by nature and like connecting people who have shared interests to help them make their things happen.

So this week during a coaching session, Claire encouraged me, in a very gentle way, to start blogging. Its raining outside (finally), so I’ve registered with WordPress and I hope to use it to share further experiences through ‘What Lisa did next….’

Earlier this year, I blagged a place on the Innovation Agency’s Coaching Academy for Spread and Adoption programme. They are recruiting again and I’d recommend it to anyone with an idea or innovation that they want to share. I say blagged because I’m actually in the North East AHSN patch but I couldn’t see this course in my area, so felt it was worth an application. I was about to take a sabbatical and test if I could start working in other areas, both geographically and in other sectors, as I was ready to change in career direction.

I hoped the programme would help with one of my regular challenges at work; trying to spread a message about using digital tools, techniques and services to a large majority of people who don’t quite get what I’m talking about. I know that sounds vague but all I’m trying to achieve is to bring the everyday technology and experience of our life outside of work into General Practice, where I’ve worked as a Practice Manager for 8 years. I’m talking about the sorts of things we take for granted; we bank and book train tickets, holidays and events online, we chat and network using Social Media, we use ‘phones, tablets, gadgets and devices, software and apps to carry out these activities, yet in the parts of the NHS if you talk about using this type of ‘Digital’ stuff to deliver services or make workload efficient, many people glaze over and then often get confused with IT, Tech, hardware and infrastruture and geekiness – or at least it seems that way in General Practice and in many areas of the NHS in Cumbria. That’s perhaps understandable given the pressures in General practice where its hard to innovate when practices are struggling to keep going. I said to a CCIO recently, ‘sometimes, I feel like an alien amongst my Practice Manager colleagues’, they replied, ‘that’s because you are like one, to them’. Yet, I know this isn’t the case everywhere and I’ve been fortunate enough to work with the Healthier Lancashire and South Cumbria Digital Workstream on the Primary Care Digital Exemplar Programme. This has provided me with the space to try to develop my message and also to realise that if the context and environment is ready for this message, its heard and spread with enthusiasm. I am meeting like minded General Practice colleagues who are ready to adopt these new ways of working.

By the way, I’m none of the above – neither alien, technically gifted or geeky and I most definitely suffer with imposter syndrome when working alongside truly talented individuals who know about User Experience & Digital Design, Technical architecture and infrastructure and System configuration.

But I do know a fair bit about introducing new ways of working, going at the pace that people can cope with when introducing change, about the need to explain what we hope to achieve and why, also about how to help people learn to use something they feel a bit unsure of. And I mean both NHS employees and people who use our services.

So that last paragraph helps me a little to understand myself a little better. I think that I’m able to look for the stuff thats out there, see the opportunity for its use in improvement, maybe interpret the strategy and then link it to delivery, whilst understanding the pressures and level of competence in general practice. I’ve no idea what job title you would give to that role. Any suggestions? Feedback and reaction most welcome.