Making it Easier:
A Health Literacy Action Plan for Scotland for 2017-2021

FOREWORD

Health literacy is important to us all, whether as an individual, a carer, family member, teacher, employer, or health and care worker. It is an area that is often overlooked, and one where we can all play a role in improving people's understanding, knowledge, confidence and skills.

When the Scottish Government first looked at the evidence on the impact of health literacy, in 2009, it was clear that it was time for action. It was less clear what needed to be done, but we knew that health information had to speak more clearly to you and your life.

We published our first plan of action, Making it Easy in 2014. It did not focus on just improving people’s health knowledge or understanding but challenged the health and care system to remove the barriers that get in the way when we try to improve the wellbeing of ourselves and others. It raised awareness of the hidden problem of health literacy with the workforce and helped them respond better. It built a go-to web place for health literacy news and tools. It tested ideas for how services can be better designed and a health organisation can become responsive to health literacy needs.

This was done by the many health literacy champions who are making a real change across our communities and working hard to help achieve our ambition for Scotland as a health literate nation.

Our second action plan, Making it Easier, builds on what we’ve learned so far. It moves us closer to removing existing barriers and preventing them being put there in the first place as we design how we deliver services for the future. It is a cornerstone of Realising Realistic Medicine’s drive to better support people’s needs through shared decision-making. Scotland has the chance to lead the way, in thought and deed, on this vital topic that sits at the heart of our person-centred aims. And here’s how we plan to do it.

Our ambition remains
“We want Scotland to be a health literate society which enables all of us to have the confidence, knowledge, understanding and skills to live well and die, on our own terms, and with any health condition we may have”

INTRODUCTION

The case for action on health literacy is clearly set out in Making it Easy – A Health Literacy Action Plan for Scotland, published in 2014.

Its actions explored:

·  how the hidden problem of low health literacy impacts on our ability to access, understand and engage with our health and social care;

·  how low health literacy leads to poor health outcomes;

·  how all of us involved in health and social care should see health literacy as a priority in our efforts to reduce health inequalities;

·  that our ambition should be for all of us in Scotland to have the confidence, knowledge, understanding and skills we need to live and die well on our own terms, with the health conditions we have; and

·  how with joint action the Scottish Government and partners can help all of us in health and social care realise this ambition.

We have set out what has been achieved under Making it Easy in a report (to be) published in July 2017. It is from this learning that our new set of actions have been built to get us closer to our aim for Scotland to be a health literate nation.

To explore the detail that led to the development of Making it Easy and Making it Easier, please visit The Health Literacy Place at www.healthliteracyplace.org.uk

HOW HAS THE CONTEXT CHANGED SINCE MAKING IT EASY?

Healthcare systems must improve to better meet our needs. We should support people to live and die well, on their own terms, with the health conditions they have. Shared action built on shared values is needed to make this happen. To allow people to be more active in decisions about their own care we need to improve how we respond to people’s levels of health literacy.

At a worldwide level, health literacy is a World Health Organization (WHO) global health promotion priority.

HEALTH LITERACY AND THE WORLD HEALTH ORGANIZATION (WHO) SUSTAINABLE DEVELOPMENT GOALS
http://www.who.int/healthpromotion/conferences/9gchp/health-literacy-sdgs/en/

At a Scotland-wide level, this focus on the relationship between people and their practitioners is clearly expressed in the Chief Medical Officer’s annual reports, Realistic Medicine and Realising Realistic Medicine. Both reports highlight improved health literacy as a vital area for progress.

The Scottish Public Services Ombudsman (SPSO) in a report on consent set out the role for health literacy in building a better understanding for both health and care workers and people using services. There is a key link to be made with work to support people at times when they struggle to communicate their views, for whatever reason.

Across Scotland, we can build upon what we’ve learned from the work of Making it Easy, in particular from the Demonstrator Programme in NHS Tayside. The work to date has given us two main types of output: real changes to improve services and how to spread these; and how to create fertile conditions for new ideas to flourish.

The context for action to improve health literacy locally, nationally and globally has never been better.

SCOTTISH PUBLIC SERVICE OMBUDSMAN’S (SPSO) THEMATIC REPORT ON CONSENT
The process for ensuring people’s understanding ahead of health procedures has been a theme of several SPSO cases in recent times.
In recognition of this, the SPSO published a report on the subject.
It set out the work that is underway to strengthen consent processes and increase people’s involvement in their health decisions. It drew upon real-life experiences to show how they should inform changes to policy and practice.
It offered a checklist to help health and care workers evaluate whether a consent process is clear enough. Following the report’s release, it has become clear there is a need to make an equivalent checklist to guide patients too, and help them ask the right questions.
For such a checklist to be useful it must be responsive to people’s health literacy needs. We will progress that as part of this action plan and draw upon our experiences in preparing people for conversations about their health and what matters to them. It will also consider whether the checklist should become a core part of appointment letters.

ACHIEVING OUR AMBITION

In Scotland our challenge remains for us all to make things easier, by removing barriers where we find them, making our service easier to navigate, and making our information more engaging. To achieve this we need to engage better with people who are using the health and care system, no matter what skills they currently have.

For any of us to be a lead partner in our care, we do not want to be held back by a system or words that are confusing or unclear. Everyone across the health and care workforce can help with this.

Some of the changes needed may be small but make a big impact; others need a longer-term shift in approach and mind-set. The outcomes from this plan serve this by strengthening culture and practice based on a human rights approach founded on:

·  equal access

·  shared decision making; and

·  people supported to live and die well on their own terms with the health conditions they have.

This means making it easier to access and use health and care, which in turn supports us to be in the driving seat of our care.

This challenge will be met through three types of action:

·  Spreading the learning from Making it Easy

·  Supporting new work

·  Shifting the culture

ACTION AREA 1

SPREADING THE LEARNING FROM MAKING IT EASY

Based on the work of Making it Easy, our key learning areas for scaling up are:

·  Health literacy tools and techniques, such as Teach-Back;

·  The scope and coverage of The Health Literacy Place as the online resource to support this work;

·  Clearer information shared with people before they attend and leave hospital;

·  Improved appointment letters, making them more considerate of people’s communication needs;

·  Better information to improve safety and support for people to self manage their healthcare, particularly for drugs such as warfarin.

The quick guide to ‘Making It Easy’ remains really useful to promote key tools
·  Use the ‘Teach-back’ technique: check that you have explained things in ways people understand, by asking them to explain in their own words the information you have given.
·  Chunk and check: break what you need to discuss into small chunks, and check understanding using teach-back.
·  Use pictures: draw or show a picture to help convey a concept or body part.
·  Use simple language: avoid jargon. Use language that is easy for people to understand, both when you speak to them and in any written information you provide.
·  Routinely ask people what help they would like in filling out forms.

We will develop a plan for the scale-up of each of these strands. The plan will be owned by the current governance group for the health literacy work, the Scottish Health Literacy Action Plan Implementation Group.

When considering things for scale-up, we will develop a set of common features that makes these tools more easy to recognise and use. This will include a brief “elevator pitch” description, a set of key images, links to further reading, and examples of social media content to promote their use.

A key part of scale-up will be to increase the public awareness of health literacy issues through the Health Literacy Place website and social media.

Wider engagement strands such as the ‘What Matters to You?’ movement and Our Voice framework could have a useful role in both enabling members of the public to speak out and raise issues around health literacy with staff, and provide new ideas to improve the current design and re-design of services.

OUR VOICE CITIZENS’ JURY APPROACH
A citizens' jury is a group of between 12 and 20 people that represent the communities from which they come. They will be asked to look at health and social care issues in the same way as a jury looks at a case in a courtroom.
The jury will spend a day or more considering the chosen subject. They will be given facts and figures and will hear evidence from a range of experts, including practitioners as well as people and families with lived experience.
Jurors then discuss the issues among themselves before reaching a conclusion and putting forward a number of recommendations.
The first Our Voice Citizens’ Jury will explore the issue of shared decision making as set out in the Chief Medical Officer report Realising Realistic Medicine. Findings and actions from that Jury will be incorporated into this action plan.

Expand on Demonstrator Site successes and deepen the work in Tayside

In addition to spreading current ideas to more sites, the trailblazing work in Tayside will continue. Whilst no longer under the formal banner of a demonstrator programme, their learning will be broadened to new areas that place barriers for people in regards to health literacy.

This will support sites across Scotland to:

·  learn from Tayside’s journey;

·  learn from Tayside’s plans for ‘what to do next’; and

·  see an illustration of what the ‘next phase’ looks like.

BUILDING UPON OUR NETWORK OF HEALTH LITERACY “CHAMPIONS”
As part of Making it Easy, we trained more than 90 trainers across Health Boards to promote skills to support better health literacy practice.
We have a network of people across Boards who are “champions” of the health literacy cause. We need to sustain these positive attitudes and behaviours across all types of healthcare worker.
To do this, we will charge this network with clear tasks to promote scale-up and spread.
HOSPITAL WALKTHROUGHS IN NHS TAYSIDE
A group of people – adult learners, students, health workers – walked through Ninewells Hospital in Dundee to see what the journey was like from the front door to their clinic location.
They found the information of the appointment letter and on signs was different. For example it read “Children’s Outpatient Department” on the letter, and “Tayside Children’s Hospital” on the signs. The signs on the way to the clinic also used different terms for the same place
Volunteers at the hospital were helpful but the directions they offered were too complex.
There were few details on how to travel to the hospital. It would be helpful to know that parking at the hospital may be some distance away from the front door. The appointment letter could also include some indication of the time it takes to reach the clinic from the car park or the front door.
This is a core action for other parts of the health and care system to consider to inform their drive to better health literacy responsiveness.
HEADLINE ACTIONS FROM THIS SECTION
·  The Scottish Health Literacy Action Plan Implementation Group (SHLAPIG) will take ownership of the Scaling-Up Plan for Health Literacy in Scotland. The group will assure its delivery.
·  Through our network of health literacy champions, we will support scale-up locally.

ACTION AREA 2

SUPPORTING NEW WORK AND COLLABORATIONS

Through the work of Making it Easy we have made many useful links across the health and care system. Many of these have benefitted from being quick, simple and responsive, but there’s an opportunity to better target effort on key areas.