Recommendations for board members to adopt an organisational approach to health literacy

1.1.a NHSE have developed a business case template for organisations seeking to embed a focus on health literacy.

1.2.a Identifying an organisational lead outlines ownership of the work, states leadership commitment and board level commitment to becoming a health literate organisation.

1.2.b As the organisation’s work on health literacy expands, it might be necessary to appoint operational leads for health literacy in below-board roles or establish health literacy teams.

1.3.a Developing a policy provides strategic vision and direction. It also creates a common way of working across the organisation in relation to health literacy and provides staff at all levels with an opportunity to identify how their role contributes to the overall shared goal.

1.3.b The organisational policy could be accompanied by an action plan, with more specific goals and timelines, which could be reported and updated on at the board at regular intervals to monitor implementation progress.

1.3.c The organisation might also develop guidance for staff, outlining what health literacy is and what actions they will be expected to enact in their role. This could involve providing a toolkit or checklist for specific departments within the organisation.

1.3.d The organisational strategy, and any accompanying documents, should be easily accessible to all staff.

2.1.a Review population and demographic data to understand the existing health literacy rates within your local patient population and wider communities.

2.1.b Use NHSE and University of Southampton’s health literacy geodata tool to identify current health literacy rates within your local area. The tool provides a percentage estimate of low health literacy among local authority areas.

2.1.c This could also involve reviewing information gathered from existing patient feedback routes, such as patient experience forms, Friends and Family Test (FFT) information, or patient complaints. This might involve working closely with the Patient Advice and Liaison Service (PALS).

2.1.d Local Healthwatch services, or other local Voluntary, Community and Social Enterprise (VCSE) organisations, might have relevant information on local community needs – particularly in relation to any access barriers communities have faced related to written or verbal communication.

2.1.e Local authority public health teams may also have access to data on literacy rates, or other factors, that could inform your demographic review.

2.1.f Ensure there are accurate records of patient communication needs in order to provide a range of communication methods to meet them. Manage this information securely and confidentially, while ensuring that patient’s communication needs are accessible to relevant staff members.

2.1.g Compile a written report for the board outlining the existing rates of health literacy and use this as a comparator for assessing the levels of accessibility of your existing written and verbal communications.

3.1.a This will range from written communications shared with patients (letters, leaflets, online information) to written information in the physical space (signage, posters).

3.1.b Use readability tools to audit and assess the average reading age of your current written content.

3.1.c Involve patients and communities in assessing the quality of your existing written communications. This could involve feedback forms or in-depth engagement sessions.

3.1.d Compile a written report for the board outlining the volume of written content within the organisation and the average reading age of existing documents.

3.2.a This will involve engaging with staff in a range of patient facing roles, from healthcare staff to receptionists.

3.2.b Involve patients and communities in gathering their views and experiences of the quality of existing verbal communication skills. This could involve feedback forms or in-depth engagement sessions.

3.2.c Compile a written report for the board outlining the quality and effectiveness of existing verbal communication skills across the organisation.

3.3.a Work with staff, patients and communities to update existing written content within the organisation to align with the appropriate health literacy rates – aiming for a reading age of 9-11 years and written in ‘plain English’.

3.3.b Use NHSE design principles and advice for writing for digital services when creating content. The Patient Information Forum have also developed a health literacy checklist to follow when making resources more health literacy friendly (Patient Information Forum, 2023a). Where available, take inspiration and information from templates or resources that other trusts have developed on similar topics. Test and refine new materials by using resources such as readability tools.

3.3.c NIHR have summarised several common pitfalls in miscommunication, based on analysis of academic research on health literacy (NIHR, 2022):

• Technical and medical language is too complex.
• Gaps in information can be misleading.
• Resources did not provide a balance between benefits and risks of treatment or medication options.
• Lack of clarity on the action patients should take from the resource.
• Lack of awareness and understanding of cultural differences within communications.

3.3.d Advice includes using simple language that avoids acronyms and jargon. Considering design and visual elements in easy read formats (such as colours, font, sizing) and images or videos. Resources should help the reader identify what their action is. Posters, signage and the layout of organisations should support people to find and access services in a timely manner.

3.3.e Involve patients and communities in the development and review of new resources, to ensure patient feedback is considered throughout the process.

3.3.f Organisations could consider establishing an agreed process for reviewing and updating materials, with attention to how relevant board members will be involved in overseeing the process. This could involve setting up an internal review group or committee that meets regularly and involves a group of internal staff experts and patient representatives.

3.3.g Timelines should be established for how often resources and materials will require updating in future. Updating resources should be considered an iterative process that will need to be repeated over time. For example, there could be opportunity for staff, patients and communities to feedback on resources once they are live.

3.4.a Specific attention should be given to updating and refreshing online information. Information should be easy to access, use and navigate.

3.4.b Similar processes should be followed for updating online information as per all other written information.

3.4.c Offline options should be available for individuals that are unable to access digital devices, as these individuals are more likely to experience health inequalities.

3.5.a There are specific tools for staff to use to refresh and improve communication skills. These include ‘teach back’ and ‘chunk and check’ techniques for delivering information and ensuring that patients have understood.

3.5.b NHSE have developed an easy read for shared decision making, to support staff to empower patients as active participants in their healthcare.

3.5.c Central London Community Healthcare NHS Trust have produced a healthcare communication resource, which has been designed to be used with adults with communication difficulties while attending healthcare services.

3.5.d Where possible, healthcare staff should embed the Making Every Contact Count (MECC) approach to interactions with patients, to encourage positive behaviour change within communities.

3.6.a Each individual will have unique needs, requiring communication to be delivered in a person-centred approach. Effective communication will rely on using a mix of written and verbal communication skills. This approach will align with organisations’ overall aim to provide the right care, in the right place, at the right time.

4.1.a NHSE have developed an eLearning for health module on health literacy. The course provides tools, resources, and enables individuals to create a personalised action plan. This course could be completed by individuals at all levels of the organisation, including the board.

4.1.b There are a number of approaches to health literacy training, ranging from broad awareness raising (for both staff and patients), to ‘train the trainer’ models which enable staff to become individual advocates for health literacy, and embedding health literacy content within existing training modules and resources. For example, organisations might consider running training on health literacy and AIS concurrently. A combination of approaches could be considered.

4.1.c Training could also be tailored for specific roles or specialties within the organisation. The board might consider whole board development or learning sessions on health literacy.

4.1.d Patients and communities could be involved in the review and/or delivery of training.

4.1.e Training should be regularly reviewed to ensure it is providing the most relevant information in relation to health literacy.

4.2.a Healthwatch has called on all health and care services to have an accessibility champion (Healthwatch England, 2023). Some trusts have taken this further by encouraging staff members to volunteer as health literacy champions within their organisations.

4.2.b Champion positions can be held by anyone with an interest in health literacy, at a range of roles and covering different speciality and operational departments.

4.2.c Having health literacy champions provides a visible point of contact for the wider workforce, promotes awareness of the work, helps to cascade training and learning, and encourages leadership for the work to filter down across the organisation.

For example, Dorset County Hospital NHS Foundation Trust have 15 health literacy champions, with plans for a champion in each department of the organisation (Naughton et al, 2021).

4.3.a Library and knowledge services play a key role in embedding health literacy practices across trusts, through their role in finding, appraising and summarising information (Naughton et al, 2021). They are typically involved in the development of written resources and leaflets.

4.3.b NHSE has developed a national community of practice for knowledge and library staff in England, specifically related to health literacy.

4.4.a Staff should be able to easily access information on health literacy through internal resource pages (e.g. the intranet) and sharing of resources between organisational departments.

4.4.b Good practice should be celebrated and highlighted by leadership.

4.5.a All resources and leaflets should be promoted via appropriate channels of communication, to ensure they reach patients.

4.5.b Trusts are encouraged to share and disseminate their resources, templates and materials with other organisations. While trusts will want to keep in mind local need within their communities, many of the plain language messages will be transferrable nationally.

4.5.c National, regional or local communities of practice on health literacy can provide peer support and opportunities for sharing information.

4.5.d Communication directors and teams could consider actively engaging in Health Literacy Month, Health Information Week, or other campaign opportunities, to continue to raise awareness among staff.

5.1.a The majority of the suggested actions refer to the ways in which organisations can improve access to their services by being reflective of the existing health literacy rates within their local communities. Alongside this, trusts can also consider their role as anchor institutions to directly engage with communities in efforts to improve health literacy rates. This could involve working with partners in communities, schools, colleges, local authorities, VCSE groups, to deliver education initiatives with communities. This approach would align with the organisations’ broader commitments to prevention and early intervention.

5.1.b There are a range of practical resources that staff could share with patients, including NHSE Your Health Collection – a selection of books and digital resources from the national NHS library and knowledge services team to support individuals to understand and manage their health.

5.1.c Trusts could work with Core20PLUS5 ambassadors or connectors, or other local community champions to share learning and information to improve health literacy. Communities could be encouraged to establish their own peer support networks to share and distribute health information.

For example, the library service at Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust has developed fiction and self-management materials to encourage patients to read more and support their own literacy and self-care (Naughton et al, 2021).

5.2.a Underpinning each of the suggested actions is a commitment to co-production and engagement with patients and communities as a key enabler to an effective health literacy approach in trusts (NHS Providers, 2024b).

5.2.b Particular attention should be given to engaging with patients and communities locally that are known to have low health literacy levels. Working closely with those most likely to be impacted will result in the most significant improvements.

5.2.c Co-production and engagement with communities on health literacy interventions can also be expected to have broader benefits to individuals and organisations, such as increasing trust levels between NHS staff and communities, and encouraging individuals to improve their own health literacy rates.

6.1.a Review and evaluation should be incorporated into the organisational health literacy approach, to monitor the impact of interventions and encourage a continuous improvement approach. Interventions should be reconsidered and redesigned based on evaluation feedback.

6.1.b Reflection should involve staff and patient feedback.

6.1.c Within evaluations, consider any metrics to assess the impact in line with financial savings or improvement to productivity.

6.1.d Progress within health literacy interventions should be regularly reported to the board through existing reporting processes.