NHS services are for everyone, whatever their physical or mental health, social, cultural or learning needs. It’s important that we make digital services as inclusive as we can. People who can’t access our services, who don't understand that a service is for them, or who don’t feel respected and included are less likely to get the health information, care and treatment they need.
There’s lots of guidance already to help build inclusive services
For example, there’s accessibility guidance in the NHS digital service manual to help teams meet the new regulations. In the UK, almost 1 in 5 people have a disability of some kind. Many more have a temporary impairment like an illness or injury.
There’s also a section on designing content for users with low health literacy. More than 4 in 10 adults struggle with health content for the public and more than 6 in 10 adults struggle with health content that includes numbers and statistics. The guidance in the service manual helps teams make sure that they are writing content at a level most users can understand.
Our new forms guidance will help too
We recently published some guidance on how to write good questions for forms.
Our research showed us that digital teams working in health need guidance on asking sensitive questions. Sensitive questions often relate to the "protected characteristics" in the Equality Act 2010 and these are questions people may be reluctant to answer: for example, questions about their sex or gender, their age or mental health. Often forms ask unnecessary questions. That’s why the guidance is designed to help teams ask only the questions they really need to ask and explain why they need to ask.
The guidance also helps teams think beyond binary choices. Forms often ask “Yes” or “No” questions but people may want to give you another answer, like "I don't know" or “I’m not sure”. We recommend that teams always try out a 3rd option in their user research, for example with a box to type in something other than "Yes" or "No".
"Other" can be a good alternative to “Yes” or “No” but you need to be wary of using it when you're collecting personal data or with sensitive topics, like ethnicity. It can make people feel that you do not care enough about their personal circumstances to be specific.
But some things are difficult to get right
The language around sex, gender and sexuality, in particular, changes all the time and it's an area that people hold strong and differing opinions about. We try to make sure that we are in touch with the communities we are writing for and we update our guidance regularly.
We published an updated inclusive language page in August and got lots of comments on it - positive and negative. We looked at all the feedback, consulted further and have addressed the issues that people raised.
In particular, some people didn’t like us talking about sex or gender being “assigned at birth”. They said, for example, that sex is described, observed or noted at birth or in a scan. But we know that many trans people prefer the word “assigned”, and the midwives we’ve talked to use it too.
Our research showed us that digital teams working in health need guidance on asking sensitive questions.
We’ve looked at user research, including the work of colleagues at the Office for National Statistics. We decided to use the phrase “sex assigned at birth” when we’re talking about trans health and gender dysphoria, as this is the language our audience uses.
In other cases, we use “the sex someone was registered with at birth” because user research shows that most people understand this better as it refers to an actual event.
We also had a lot of feedback about the terms “intersex” and “differences of sex development” (DSD). Some people prefer one term, some the other. We’ve made this clear in our guidance and we recommend, as always, that teams test their language with the people who’ll be using their content or service.
We’ve just published another update to our page on inclusive language. The guidance there should help you get started but, when you do your user research, you may find that something else works better. There is no one right answer. Please let us know what you find.
And there’s more work to do
We’ve identified, for example, that we need to get better at describing rashes, birthmarks and skin symptoms on different skin colours on the NHS website. In the past, we’ve tended to focus on how things look on white skin but we want to make sure that our health information is just as useful to people from black and minority ethnic communities. We’re working on this at the moment.
We also know from our forms guidance research that we need to do more work on how best to ask questions about sex, gender and ethnicity.
Talking openly about our work and encouraging people to share their user research and insight will help us improve our guidance and that will help make digital services more inclusive for everyone.
If you’ve done any user research in these areas, please get in touch with us. You can email us at service-manual@nhs.net, join our public Slack workspace or contribute via GitHub (where we manage our backlog and code in the open).
