Designed for accessibility to all users

When you look at a Sites4Doctors practice site, you might think it looks rather basic compared with modern commercial sites. On this page, the designer and developer of the package explains the vitally important issue of accessibility and the discipline it imposes on site design. But your site has to look like all the other Sites4Doctors ones: it can be given a different look-and-feel at no extra cost - all you have to do is ask!

When I started developing and managing websites for the NHS in 2001, I was told that the over-riding requirement for all sites was accessibility - so important that it was written into my job-description. Everything I developed had to be run through specified accessibility checkers before going public.

This was a new area for me, and I needed to understand it very quickly.

I was required to ensure that all the sites I built for NHS organisations and initiatives, including PCTs and other NHS trusts, would be accessible to the whole patient population - not just to those with 20/20 vision, five good GCSE’s and state-of-the-art home computers. The NHS provides services for sighted, partially-sighted and blind people; for graduates, people with learning disabilities and everything in between; and for people at all income levels.

Another section of my job description stipulated that I was to develop a group of local information sites under the banner Information for Patients and the Public (IPP). This project was steered by a large and diverse committee of people from public services and the voluntary sector, as well as patient representatives. Information on a huge range of locally-available services would be collected by information officers in the five PCTs covered by the project, who would be responsible for accuracy and data-protection issues. This would be my first experience of developing a website that drew its content dynamically from a large database - and so the first rung on the ladder to Sites4Doctors. Not only is IPP alive and well - I recently learned from a former colleague that it was considered important enough after nearly ten years to merit a facelift: http://www.ipp.derbycitypct.nhs.uk/. I’m proud to say that, though re-styled, the underlying site is still what I developed in 2001.

A crucial part of the IPP project was a series of Patient Involvement Workshops to evaluate all aspects of the sites - but particularly their accessibility. These were attended by a wide cross-section of the patient population, including both partially-sighted and blind people, who brought along their own computers and specialised access devices. At different stages in their development, the sites were tested and critically evaluated by all these people.

The lessons learned from this process were rigorously applied to every NHS site I and my team built - and, of course, to Sites4Doctors.

What were the main criteria?

First, the organisation and presentation of the information. Could users navigate quickly and easily to the information they needed - even those with learning disabilities or specific literacy problems? Was the information logically structured and expressed in clear, concise, simple language? And was the information on the the pages structured in a way that allowed blind people using talking screen-readers to find the information they needed quickly?

Could the pages be viewed easily at different screen resolutions. This was important both for users with small monitors and low-powered computers and for those with visual impairments, allowing them to read the text without having to scroll from left to right to read every line. And were they easily read using various magifying utilities?

Did the sites allow users to choose the fonts and sizes that best met their needs - particularly important for the partially-sighted?

Did the style of the sites take into account guidance about the default fonts that were most legible to people with literacy problems and visual difficulties, and the text and background colours which would suit people with colour-blindness and other visual problems?

Applying the findings

IPP was my first major web development project for the NHS, but in parallel with it I was also developing sites for the Health Authority (as it was then), the five local PCTs, the county mental-health trust and various local NHS initiatives.

All text would be in colours and on backgrounds that provided maximum legibility. While preferred fonts would be specified to conform to NHS Identity Guidelines, nothing would be done to prevent users substituting their own choices of font. Text sizes would be specified relatively rather than absolutely, allowing them to adjust to different screen resolutions and users to choose sizes to suit their vision. The width of the central portion of each page, containing the main text, would also be specified relatively, and text would be allowed to wrap automatically so that nothing disappeared off the edge of the screen at low resolutions.

Crucially, all essential information would be presented as text - not in images. And where images were used, clear text labels would appear when the mouse-pointer passed over them.

IPP had special layout requirements because of the large number of first- and second-level options that had to be offered. For all other sites, a standard layout was agreed.

Main buttons in a line across the top of the screen were rapidly ruled out because of the need to accommodate a wide range of screen resolutions and text sizes. The main menus would be down the left-hand side as standard. Links to important external sites would be down the right-hand side. Both side columns would be kept narrow to leave as much space as possible for the main text of each page. And any images used as links would have simple text ’repeater’ links at the bottom of every page.

All text would be coloured and on backgrounds chosen to provide maximum contrast, with the main page text always black on white.

The general web ethos

Websites providing information on important services to people with pressing needs are not vehicles for the vanity of either clients or designers. Whether or not a site ’looks nice’ may be important - this does, after all, reflect on the client organisation - but the effective communication of information must come first. Given the wide range of patient needs, we must not impose rigid designs on our sites. Once a page has been downloaded to a user’s computer, what is displayed belongs to the user, who should be able to display it in whatever way suits his or her needs. The result might outrage the client, but all that really matters is that it works for the user.

Accessibility in Sites4Doctors sites

The principles stated here have been applied to all Sites4Doctors sites, because I believe that GP practices have the same duty to patients as other NHS organisations.

In addition, our sites offer a fast and easy way to ensure that all the most important information about a practice and its services can be published automatically in a clear, logically organised way. Another item in my NHS job description was the responsibility for maintaining accurate, up-to-date information on local GP, dental, pharmacy and optician services on the NHS’s central website, www.nhs.uk. This was done by editing a database online. The structure of this database had been developed and tested, at great expense, by what was then The NHS Information Authority, and it seemed sensible to follow this in Sites4Doctors. This led to a major feature of the Site Management System, which allows all basic practice information to be entered on simple forms. It is then published automatically on standard pages.

This is an additional level of accessibility, ensuring that patients can find all the most important information quickly and easily.

It also means that even a large practice can set its own site up from scratch, with all essential information, very quickly.

However, Sites4Doctors also allows practices to switch any or all of this system off if they prefer to present the information in different ways on web pages they develop themselves.

Simple tests

Here are three easy ways to check whether the designer of a site has taken accessibility into account. The instructions are for Microsoft Internet Explorer. Anyone using a different browser should know how to achieve the same results.

• Click View and then, in the Text Size dropdown, change the selection. Do the sizes of all the different styles of text change as you would expect? If so, does the line-spacing adjust as well - on many sites, increasing the text size causes the lines to overlap? And does the flow of the text from line to line also adjust?
• If you couldn’t change the text size setting, click Tools and then Internet Options. Click the Accessibility button and check the box for Ignore font sizes specified on web pages. Now try the font size again. You can try ignoring font styles as well. Both properties should now be under your full control, with the line-spacing and text flow adjusting with the font size.
• Drag the right-hand edge of your browser window to the left, simulating what would happen if a visually-impaired patient used a lower screen resolution to increase the size of the text. As the text space narrows, does the text flow automatically adjust so that it can all be seen? Or are the ends of the lines chopped off so that you have to scroll to the right to read everything?
• If you are confident to do this, change your screen resolution to the lowest level temporarily. Is the text much bigger, and does it wrap properly so that you don’t have to scroll from side to side to read it?

If the site you are looking at fails any of these tests, the provider is not making allowances for patients with special needs.