Category: Digital inclusion
What follows is a transcription of the audio recording. Due to differences between spoken and written English, the transcript may contain quirks of grammar and syntax.
MD - Michelle Drumm
JC - Janet Crozier
MD Near Me in Social Services is a project Iriss has been leading in partnership with the NHS Near Me team and the Scottish Government Technology Enabled Care (TEC) Programme over Autumn/Winter 2020/21. The project is producing new evidence around the priorities, enablers and challenges of using video consulting in social services.
Iriss has supported five services to participate in a rapid Quality Improvement cycle to start using Near Me; provided light touch improvement support to organisations that are setting up Near Me independently within their work, and has developed a Learning Network.
The Learning Network aims to build on and continue the support to these organisations using Near Me, while increasing the scope of support to others. Each Learning Network meeting includes speakers on related topics. In this episode, Janet Crozier, Knowledge Manager from the Knowledge Hub shares how having a range of tools and techniques such as teach back, chunk and check, and pictures can improve people’s Near Me experiences of social services.
JC Thank you very much for the invitation to join your session this afternoon. As Louise has said, my name’s Janet Crozier and I’m a Knowledge Manager at NHS Education for Scotland and I work within the digital team. And yes, we do have responsibility for the knowledge network digital library but also for social services.
We have the SSKS, Social Service Knowledge Scotland digital library which I hope some of you may be familiar with and certainly for anyone that’s working within social services, you’re able to get access to all the wonderful digital resources that we have in the library but I’m not here to talk about the library today, I’m here to talk about tools and techniques to support remote consultations and when I say remote consultations what I’m really referring to this afternoon is either video consultation such as Near Me or also telephone conversations.
But before I go on and talk about the tools and techniques I think it’s really important to put these into context and to give a bit of background around the tools and to explain why they’re promoted in health care settings and I hope you’ll forgive me for the term health literacy this afternoon, I hope that you’ll be able to see by the end of this presentation that, you know, it’s not just a health term that it can be applicable to social service setting as well and instead of health literacy you can use other terms such as information literacy, please don’t be put off by the term health literacy and apologies if I use that more than the other terms.
So, what is health literacy? Health literacy is all about people having enough knowledge, understanding, skills and confidence to use health information to be active partners in their care and to navigate health and social care systems and that’s from the health literacy action plan that was produced by the Scottish government in 2014.
Why do we need a health literacy action plan? Well, it’s quite striking that research has shown that in a gp consultation half of what a person is told is forgotten and half of what they remember is misunderstood and I think you’ll agree with me that that’s quite striking, really. And I think the other thing to bear in mind as well is that that was through face-to-face appointments, that research was done. So, I think it’s not too much of a stretch of the imagination to think about how those figures could be worse than that when we think about having remote consultations or remote communication. And I think the other striking thing to remember is that in a gp consultation, for example, people will just sit and say yes, I understand, and I think that that’s quite transferable to other settings as well instead of wanting to admit that we don’t understand and we’re not sure it’s much easier just to nod our heads and say, yes, we understand. And in fact, there’s also been other reports of people that will come out of a doctor’s consultation and go to speak to the receptionist and say, well can you just explain to me what’s been said.So, I think that’s quite striking.
I’m going to tell you a wee story about Doctor Graham Kramer, some of you may have heard of Graham Kramer, he is a gp and he’s also a health literacy champion and he said for him that the penny dropped when he had some problems with his IT and he had to get Ray, the IT technician to have a look at his laptop for him. So, what he did was he, obviously, left him to it in his surgery and then returned a little while later and Ray the technician was sitting his chair so, Doctor Graham Kramer took the other seat, which would have been the patient’s seat, so what he did was he just said to Ray, he said go on then, tell me what’s the worst … you know, what’s the diagnosis here? And the IT technician proceeded to explain in very technical language, well it’s something to do with your hard drive and it’s your software and it’s this bit and here, and Graham of course didn’t understand any of it but found himself sitting there nodding. He then realised that that’s probably what it’s like for my patients when they come to see me because I’m using jargon and acronyms and technical terms and they’re probably just really very polite and sit and nod.
So, I think as well it’s important to remember that it’s not just when we have conversations, it’s also in written information as well that we need to be careful and this was a tweet by Jason Leitch, quite a few years ago now, before Jason Leitch is as famous as he is today and he’s just explaining that these are the sort of written instructions that you’ll get within a steroid inhaler, and I’m sure there’s lots of examples of those in health but it didn’t take me long to actually find something within a social service setting and this I found very quickly, just on a council website when it was talking about eligibility for social care support, I think it’s really interesting, there’s further research that has shown that the average reading age in the UK is between 9 and 11 years of age so I think that you can agree that some of this wording could do with attention.
So, what’s the impact of poor health literacy? Well poor health literacy can lead to health inequalities and that’s shown with poor understanding of how to use medicines information and again there’s research that shows that 43% of the English working age, adult population will struggle to calculate a childhood paracetamol dose.
Poor health literacy also leads to higher emergency admissions, it means that some people find it difficult to navigate both health care and social care systems and to get the support that they need and it can also impact not only on our own health but also the health of those that we care for such as children or older adults for example.
I’ve already mentioned the health literacy action plan and the Scottish government introduced this in 2014, it’s called Making it Easy and that was really to try and tackle some of these issues. We’re now on the second of these action plans, it’s called Making it Easier and that takes us through to 2025. You can find these on the health literacy place website.
Health literacy is also imbedded in the realising realistic medicine strategy document by the chief medical officer so it’s really so that increasing health literacy levels can mean that people can have more of an involvement in shared decision making and manage risk better, have more of a say when it comes to personalised approaches to care.
I think the other thing as well to bear in mind is that on top of all of this, we then have the idea that everyone is going to be able to access health and social care information online. We’re assuming that people know how to evaluate information, how to avoid scams and recognise fake information.
We often assume that people can book appointments online, that they can use video consultation tools such as Near Me, that they’re familiar with the use of apps and that they could use wearable technologies to help self-manage conditions, for example, and they could also have the skills to be able to access online support forums. So, we may come across some people that have good health literacy levels but limited digital skills and even though we don’t want to make assumptions, typically could reflect more older people in society as well some people we come into contact with could have good digital skills but poor health literacy and that could relate to possibly younger people in society who’ve got good digital skills but we mustn’t make these assumptions, it’s really important to take a universal approach and realise that everyone can be at risk of poor health literacy and it’s important not to assume but to try and imbed the tools and techniques that I’ll show you shortly into practice.
The other thing to bear in mind as well is that somebody normally may have really good health literacy levels but if they’ve just been faced with some distressing news, for example, then their health literacy level might just plummet so while we’re saying that yes it’s a really good idea to adopt a universal approach to health literacy there will be some of the groups that you come into contact with that may be at more risk of poor health literacy such as people with learning disabilities or autism and as we’ve already mentioned maybe older adults. And in fact, there’s some research that has shown that for older adults, 71% may have difficulty using print materials, 80% may have difficulty using documents with forms or charts, 68% may have difficulty interpreting numbers and performing calculations for example.
Okay, so what I’m going to do just very briefly now is introduce the (… unclear) and techniques that are recommended in the health literacy action plan. And there are 5 of them, Teach Back, Chunk and Check, Use of Pictures, Use Simple Language and to Routinely Offer Help with Paperwork. So, the first one is called Teach Back and this is where you would just explain what you need the person to do and then you would ask them to explain back to you in their own words or teach back to you in their own words. It’s really important though that the person doesn’t feel that you’re putting them under pressure or that you’re testing them. And so, one way that you could do that without them feeling that they’re being tested is just to say, just to put the onus back on to yourself, so to say, just so that I know that I’ve explained things to you properly, could you tell me what it is that we’ve discussed or you could say, can you tell me how you’re going to explain things to your family, when you see them later.
What you don’t want to do is, you don’t want to say to them, have you understood because as we’ve just said, they will sit there and they will nod when perhaps they haven’t understood. And I think that this technique is even more important when we think about remote communication as well because say if you’re on a telephone call for example and you can’t even see the person, so it’s going to be even more difficult to check for understanding so, Teach Back is a really useful tool.
Another tool is called Chunk and Check and this is where you break the information down into small pieces or chunks and you check for understanding after each piece and you can actually use Teach Back at the same time as this one to check understanding as you go, as you break the information down. Now usually in a health situation I would use the example of say somebody that’s just had a hip replacement and they’re just coming out of hospital and so they’re being given lots of different instructions about when to change their bandages, when to take their medication, when to see their gp, etc or health visitor so, I was trying to think of a situation where it could be used in a social service setting and one of the things I came up was say, if you’re giving information to a carer about support that they’re eligible for so, you’d maybe cover things like carer’s entitlements, carer’s allowance, perhaps some support groups, respite care, etc. so there’s quite a bit of information that you’re trying to get across so, what you would do is you just break that down and then you’d just check for understanding as you go and it’s also a good opportunity by breaking it down it means that if somebody does have a question, they can ask you then rather than waiting right till the end and they might have forgotten what they wanted to ask.
Okay, we’ve already covered this, this is the use of simple language and we’ve talked already about jargon that we use and acronyms and how that can be very challenging for people to understand so, always try and take a step back and think about how you can use more plain and simple language.
Pictures can be another useful tool, some concepts can be really difficult to explain and again here I was thinking perhaps something like self-directed support and the 4 options that are available and you can maybe try and get a bit creative and come up with some graphics and pictures that can help or again, you know, if you’re wanting to talk about how to use wearable technology, pictures could be very useful there as well. This one is important because it’s again, it’s about not making any assumptions and this refers to helping with paperwork, for example, I think as well you could also link this to remote consultations so, don’t assume that somebody knows how to use video technology and has got the skills to do that. It’s important to offer support and again not to make assumptions.
I have spoke to a dietician who works with people with learning disabilities and what they’ve done is they’ve changed their appointment letters and they now use pictures in the appointment letter because they were having a lot of people that were missing appointments so instead now in their appointment letters, they have a clock face with the time on as well and they also have a picture of whether it’s a hospital or whether the appointments at home, etc and they’ve really noticed a difference in the number of people now being able to attend appointments.
So, what I’m going to just briefly finish off then is just with some tips for how to build relationships when we’re doing remote calls either through Near Me or telephone conversations. It’s worth bearing in mind that short calls might be better than one long session so that you can build up trust and familiarity. It’s important to try and find new ways to build rapport, traditionally if you’re actually visiting somebody face to face then you’ve got the talk about the weather, the would you like a cup of tea, etc. but that’s not possible when you’re straight into a video call or telephone call and so an ice break may be trying to find out how the experience has been for that particular person meeting on line but it’s just trying to find new ways of doing that building rapport.
Obviously subtle social cues and nonverbal cues can be easily missed, you may not be able to see facial expressions, obviously if you’re using a telephone but if you’re using a small screen. You can’t rely on your physical senses to build a bigger picture of what’s going on or who else may be present for example especially if that’s telephone or indeed Near Me, some people perhaps who are in situations where they’re experiencing domestic abuse or perhaps some people who are in shared accommodation, you just don’t know who else is present. It’s important to plan ahead for difficult conversations, what are you going to do if people become upset or end the call abruptly.
Also, to think about what support is available for the person after the call and then again to think about some practical issues such as how to end the call, do you give a five-minute warning, perhaps you could wrap up with Teach Back to check for understanding or you know, just ask if there’s anything that they wanted to cover. Again, in a face-to-face situation there’s more social cues to rely on which you don’t have if you’re doing a remote consultation. It’s important to think about how you’re going to schedule the calls so try not to do back-to-back calls, they can be quite intense so, instead it’s important to try and schedule in some time for reflection as you would have done with say, travel time. Now we’ve already touched on this, if you’re going to be sending out information before hand, then remember that use plain English, the average reading age of UK population is between 9 and 11 years so, again and we’re touching on this need to avoid jargon and if you do have to use acronyms then define them and also to be aware of any IT terms that you’re using such as, even terms such as copy and paste could be confusing for some people. If you have to use complex terms then explain them and use short sentences and I’m suggesting here that you use a readability checker and again there’s a link to a couple of these in the resources sheet and what you can do with these is you can just copy and paste in your text and it will automatically give you a reading age for that.
Also think about how to make your information if you’re sending that out in advance, how to make that translated, if you’re making information about how to make test calls, it’s easy to understand. And that the information if interpreters or family members are going to be involved, that again, that’s clearly explained and again you could maybe be creative and use pictures for some of these.
Okay, just a few more practical issues. It’s good to give some guidance about how the appointment will work, what they can expect, how long it will take, that there are clear joining instructions and also what to do if something goes wrong. It can be useful in order to reduce anxiety and break down barriers and again to build that relationship and the trust and rapport, to try and schedule a telephone call beforehand just to go through things or you could also maybe send a text reminder the day before hand with some telephone support details for example.
I hope this has encouraged you to maybe want to find out a little bit more about health literacy. We’d love you to get involved, have a look at the health literacy place website, that’s a Scottish government website, it would be great if you could contribute a blog or a case study of how you’ve used these, you already use these techniques or how you plan to use the techniques in practice. And you can also follow us on Twitter @healthlitplace
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