DOCUMENT CONTROL

Version: 6.1

Ratified By: Covid-19 Gold Command

Date Ratified: 7 April 2020

Name of Originator / Author: Head Patient Engagement and Experience

Name of Responsible Committee/Individual:

Executive Director of Nursing and Allied Health Professionals

Unique Reference Number: 317

Date Issued: 24 April 2020

Review Date: January 2021

Target Audience All staff

Description of Changes: Due to the Covid-19 Pandemic Gold Command agreed a review extension from July 2020 to January 2021

Patient Information Policy

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CONTENTS

SECTION PAGE NO.

1. INTRODUCTION 4

2. PURPOSE 5

3. SCOPE 6

4. RESPONSIBILITIES, ACCOUNTABILITIES AND DUTIES 6

4.1 The Board of Directors 6

4.2 Care Group Directors, Associate Nurse Directors Service Managers and Modern Matrons

6

4.3 Care Co-ordinators & Lead Professionals 7

4.4 All Staff 7

4.5 Head of Patient Engagement and Experience 8

4.6 Communications Team 8

5. PROCEDURE/IMPLEMENTATION 8

5.1 Principles for producing patient and carer information 8

5.2 Minimum requirements for patient and carer information 9

5.3 How information is provided to patients to support their decision making, including risks, benefits and alternatives

9

5.3.1 Assessment 9

5.3.2 How the discussion and provision of information to patients is recorded

9

5.3.3 Archiving arrangements for any information given to patients to support their decision making

10

5.3.4 Procedure for developing information leaflets 10

5.3.5 Funding the development of information 10

5.3.6 Distributing the information 11

5.3.7 Review of the information 11

5.3.8 Version control 11

5.3.9 Trust arrangements for the archiving of leaflets/posters 11

6. TRAINING IMPLICATIONS 12

7. MONITORING ARRANGEMENTS 12

8. EQUALITY IMPACT ASSESSMENT SCREENING 13

8.1 Privacy, dignity and respect 13

8.2 Mental Capacity Act 13

9. LINKS TO ANY ASSOCIATED DOCUMENTS 13

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10. REFERENCES 14

11. APPENDICES 14

Appendix A - How do I get my leaflet produced? 15

Appendix B - Submission Form 16

Appendix C Service User and Carer Information Questionnaire 18

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1. INTRODUCTION

The clinical care provided within the NHS environment should be of the highest quality supported by robust policies and procedures. The availability of high quality and accessible information underpins effective communication between staff and patients.

The purpose of providing relevant, up to date, accurate and high quality information to patients and carers is to:

Support people to make informed choices about their care and treatment.

Improve understanding about the services available.

Support the process of gaining informed consent (Written information can support but not replace a dialogue with a patient about their individual care).

Provide all people who need to use the Trust’s services with equal access to information.

Provide information regarding lifestyle changes/choices.

The information needs of patients and their preferred methods of communication must always be considered by Trust staff when preparing information. In June 2015, SCCI1605 Accessible Information – the ‘Accessible Information Standard’ was launched. This directs and defines a specific, consistent approach to identifying, recording, flagging, sharing and meeting the information and communication support needs of patients, service users, carers and parents, where those needs relate to a disability, impairment or sensory loss. The Standard is a legal requirement and applies to service providers across the NHS and adult social care system. Effective implementation will require organisations to make changes to policy, procedure, human behaviour and, where applicable, electronic systems. Organisations must follow the Standard in full by 31st July 2016 and complete five distinct stages or steps leading to the achievement of five clear outcomes: 1. Identification of needs 2. Recording of needs 3. Flagging of needs 4. Sharing of needs 5. Meeting of needs

Patient information includes:

Information between medical, non medical and other professional staff to patients around suggested treatment options, the benefits of these and any alternatives available. This may be written, verbal, in British Sign Language (BSL) on internal and external web-sites or DVD etc.

Information provided before the start of any treatment/service on

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conditions and the effects on the individual, the proposed treatment/service and any ‘side effects’, plus alternative treatments/services – given face to face and/or in writing or BSL.

Information to patients and carers on other places of help and advice provided by the Trust and external organisations.

Information on the services provided, for example: contact details, opening times, visiting times and roles of staff involved in an individual’s care.

How to raise concerns and/or how to complain and information on their rights.

Examples of patient and carer information:

Notice board displays in clinical, waiting and public areas

Written and pictorial signs

Posters

Fact sheets

Leaflets on specific conditions (produced externally or internally)

Leaflets on assessments/treatments/procedures (produced externally or internally)

Leaflets on services (produced externally or internally)

Leaflets on rights (produced externally or internally)

Trust website

Self-help information (produced externally or internally)

Signage

2. PURPOSE

The purpose of this policy is to set out the arrangements for managing the risks associated with patient information and standards for the development of written information for patients to allow patients to make an informed choice in relation to their care.

It sets out the steps staff should take when identifying or developing information for patients and provides guidance on best practice.

The policy:

Provides a documented process for the identification and development of written patient information.

Supports a consistent approach to the development of that information.

Aims to raise the standard of both written and signed information, where appropriate, (BSL) available to the patient.

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Supports equal access to information.

Supports compliance with Care Quality Commission (CQC) Fundamental Standards and the Equality Act 2010.

3. SCOPE

The contents of this policy apply to all Trust staff and any contracted staff working within services.

The policy covers:

The development and provision of written information and the monitoring of written patient information. This includes how information is used to support decision making, including risks, benefits and alternatives.

Information for people where English is not their first language or they have difficulty reading (this may mean providing interpreters and / or audio tapes and visual information).

Where a person’s disability means they need to use different forms of communication, such as the use of symbols.

This policy does not cover:

Information about patients. See Information Governance Policy for guidance on information about patients.

The statutory duty imposed by the Mental Health Act 1983 (amended 2007) to provide information to patients about detention, Community Treatment Orders, consent to treatment, rights of appeal and other legal matters. See Trust Procedure for Informing Detained Service Users of their Legal Rights under Section 132 of the Mental Health Act 1983.

4. RESPONSIBILITIES, ACCOUNTABILITIES AND DUTIES

4.1 The Board of Directors

The Board of Directors has responsibility for the implementation of this policy and the monitoring of compliance.

The Director of Nursing and Quality has lead responsibility for information for patients and will provide periodic updates to the Board of Directors in relation to the information provided by the Trust.

4.2 Care Group Directors, Associate Nurse Specialists Service Managers and Modern Matrons

Care Group Directors Associate Nurse Specialists, Service Managers and Modern Matrons are responsible for the dissemination and implementation of this policy within their departments.

Service Managers and Modern Matrons are responsible for:

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Identifying the core set of information applicable to their service area. This should be done in collaboration with patients through e.g. Care Group Governance Groups, focus groups, other meetings, questionnaires etc.

Agreeing preferred formats for accessing information e.g. printed/ web based, and how information will be distributed.

Identifying if the required information is available through established external sources.

Compliance for all Trust produced patient information with Trust Corporate Identity and ‘Get It Write’ guidance. (Appendix a,b,c)

Keeping information up to date and accurate and presented to standards in accordance with this policy.

Ensuring material displayed in their area of responsibility complies with this policy.

Ensuring staff record verbal ,written or signed (BSL) information which is given to patients in the patients’ notes. If a challenge is made to the consent process or treatment at a later date, the information documented as having been provided to the patient at the time needs to be determined.

Ensuring information is presented in a non-discriminating and inclusive way and the correct documentation is used, please see hyperlinks below.

Service User and Carer Information Questionnaire. Please click here Get it Write to access

Get it Write – Submission Form. Please click here Get it Write to access

How do I get my leaflet produced? Please click here Get it Write to access

4.3 Care Co-ordinators and Lead Professionals

It is the responsibility of Care Co-ordinators and Lead Professionals to:

Ensure that patient and carer’s communication needs have been documented and that information is presented in an accessible manner

Make information available to support patients to make choices about their care and treatment.

Use information in support of dialogue to obtain informed consent, as set out in the Trust’s Care Programme Approach Policy.

Ensure patients and carers know how to complain and have information on their rights.

4.4 All Staff

All staff should be aware that high quality and accessible information underpins effective communication between staff and patients and supports the delivery of high quality care and services.

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4.5 Head of Patient Engagement and Experience

Head of Patient Engagement and Experience is responsible for: Supporting the Care Groups to facilitate patient carer and public consultation events as required. A central data base to hold the consultation evidence will be managed within the PPEE Team

4.6 Communications Team Department

The Communications Team is responsible for the production, of information leaflets which are to be used within the Trust. They upload new leaflets to the website and remove earlier versions

5. PROCEDURE/IMPLEMENTATION

5.1 Principles for producing patient and carer information

Information should be in a language, style and format which makes it easily accessible to the intended audience. A glossary should be included where clinical terms are used.

The audience may include (but not be exclusively made up of) people with specific needs, for example people who do not speak English as a first language, people who use British Sign Language, people with literacy problems and people with disabilities. Information should be produced in the appropriate medium for the intended audience e.g. younger people may request text messaging whereas older people may request larger print. Visually impaired people may prefer black print on a yellow background.

Processes should be in place to allow for materials to be made available in different formats (such as electronic, large print, audio tape, CD or in other languages) and the Head of Patient Engagement and Experience will support the delivery of this requirement. These alternative methods should be actionable on request, and the ability to request alternatives widely publicised.

Information should be sensitive to the religious or cultural needs of all people, avoiding stereotypes.

Information should be easily available. Managers should identify how any information will be made available to the intended audience before the information is produced.

Information should be made available or produced in the most cost effective way possible.

New information should not be produced if it already exists in the preferred format from NHS approved external sources. For example, the Royal College of Psychiatrists, MIND, RETHINK and others produce information leaflets about specific conditions which can be downloaded or are available to purchase. Information may also be available via the Department of Health, NHS Direct or NHS.UK. Information is available

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from these and other sources in many languages commonly used across the areas where the Trust provides a service.

5.2 Minimum requirements for patient and carer information

Clinical services should, as a minimum, have information available about their services and on all common conditions, the treatments available and sources of self-help advice and support. Non-clinical services should have relevant information available to patients which relates to the services they offer.

It is essential that information associated with care, treatments, medication, therapies and procedures should include risks, benefits, side effects and alternatives, where appropriate. This will help people to make choices (see Section 5.3).

Information on rights, confidentiality, and/or how to complain should be included where appropriate.

Information produced by the Trust should:

Comply with the Trust’s Corporate Identity and ‘Get It Write’ guidelines.

Give an accurate reflection of services and help people understand what to expect when they are in contact with different elements of the service.

Contain accurate contact details (addresses and telephone numbers) for services and a directional map, including public transport routes, if appropriate.

Sign post people to other sources of information if relevant.

Sign post people to someone they can talk to for more information or about any questions. Job titles should be used here, not staff names.

5.3 How information is provided to patients to support their decision making, including risks, benefits and alternatives

5.3.1 Assessment

As part of the initial assessment of all patients, the need for information in the best format, style, medium and language to meet their needs should be identified and recorded. Also refer to the Policy for the Provision of, Access to and Use of Interpreters for Service Users and Carers.

5.3.2 How the discussion and provision of information to patients is recorded

A record of verbal, written or visual language information which is given to patients should be made in the patient’s health record. If a challenge is made to the consent process or treatment at a later date, the information documented as having been provided to the patient at the time needs to be determined. Compliance with this will be monitored by the annual records audit.

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5.3.3 Archiving arrangements for any information given to patients to support their decision making

Any information given to patients to support their decision making should be archived with the patient’s health record.

5.3.4 Procedure for developing information leaflets

The first course of action is to identify whether or not the information is actually needed, and staff should consider the following:

Review the leaflets on the RDaSH website to see if the information is already available and in a suitable format?

If not, do any other organisations have a leaflet which can be adapted for use within the Trust? If using another organisation’s leaflet, copyright permission must be obtained. If the leaflet is to be redesigned in the RDaSH style it will still need to go through ‘Get it Write’ checking procedures.

Have alternatives been explored, such as printing off information from the internet?

Has approval been given by the Service Manager for the leaflet to be produced?

Is there funding available for the production of the information?

Does the information need to be produced in hard copy format, or can it be held electronically and printed as required?

Consideration should be given to readability of any information. The Flesch Reading Ease Readability Score can be checked on Word documents.

If there is not the appropriate information available either within the service, or from the RDaSH website or from a reliable external source there may be a need to develop an information leaflet.

If this is the case the ‘Get It Write’ process set out in Appendices a,b, and c must be followed.

5.3.5 Funding the development of information

There is no central budget within the Trust for the development of patient information leaflets, so each Care Group will need to identify funding from their allocated budget. This will need to be authorised by the relevant budget holder.

The Trust does not allow commercial sponsorship of leaflets, for use within the Trust, as it could compromise the integrity of the information which is being provided. Where services are delivered in partnership with other non-commercial organisations information leaflets may be deemed acceptable providing they meet the Trust’s ‘Get it Write’ criteria.

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5.3.6 Distributing the information

When developing patient information, staff need to be clear how the information will be distributed and consideration given to the following points:

Will staff be responsible for distributing the leaflet, and if so when is the leaflet to be given out?

Are copies of the leaflet to be made available in a leaflet rack?

Is the leaflet to be sent out with appointment letters?

5.3.7 Review of the information

Any patient information which is produced by the Trust should be reviewed every two years following publication, unless there is a change to legislation, practice or contact details which prompts an earlier review. To assist in the review, all leaflets or posters will contain details of the date it was first produced, and a review date. Responsibility for keeping track of review dates lies with the author of the information and monitored by the Communications Team .

When undertaking a review/update the reviewer should consider whether or not the information is:

Being used and meeting the needs of its target audience.

Still accurate and appropriate.

Up to date in relation to any new research or practice guidance.

In the event that any information leaflets are beyond their review date they should be taken out of circulation until reviewed and reissued.

5.3.8 Version control

Each leaflet/poster will be allocated a DP number by the Print Department which will be used for the purposes of document control. Each leaflet/poster will also have a job number which is unique and a month and year which they were worked on. Hence, a particular leaflet will have the same DP number on each version but will have a different job number, month and date they were worked on to enable it to be later identified. These numbers will also be recorded on the electronic database. Some documents will have WZT numbers which identify them as items held in stock by the Print Distribution Department.

5.3.9 Trust arrangements for the archiving of leaflets/posters

All approved information leaflets/posters within the Trust have been produced by the Communications Team and an electronic copy retained by them for archiving purposes. Only the latest copy of the leaflet is kept by the communications team. All other versions of the leaflet should be archived

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within the originating service area

Any information given to patients to support their decision making should be archived with the patient’s health record (see Section 5.3.3).

6. TRAINING IMPLICATIONS There are no specific training needs in relation to this policy, but all staff who have direct contact with patients and their carers and any other individual or group with a responsibility for implementing the contents of this policy will need to be familiar with its contents. Staff can be made aware through a variety of means such as:

Local induction

Team Talk

Team meetings

7. MONITORING ARRANGEMENTS

Area for Monitoring

How

Who by

Reported to

Frequency

How information is provided to patients to support their decision making, including risk, benefits and alternatives

Clinical Records Audit

Clinical Audit Department

Clinical Quality Group

Annual

How the discussion and provision of information to patients is recorded

Clinical Records Audit

Cl Clinical Audit Department

D

Clinical Quality Group

Annual

Archiving arrangements for any information given to patients to support their decision making

Quality/ availability of information provided to patients

Thematic analysis of complaints and claims in QSIR

Complaints Manager Claims Manager

Quality and Safety Sub Committee

Quarterly and annual

Informal feedback & information requests from patients

PALS Coordinator

As above Ongoing

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8. EQUALITY IMPACT ASSESSMENT SCREENING

8.1 Privacy, dignity and respect

The NHS Constitution states that all service users should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi’s review of the NHS, identifies the need to organise care around the individual, ‘not just clinically but in terms of dignity and respect’.

As a consequence the Trust is required to articulate its intent to deliver care with privacy and dignity that treats all patients with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity and respect, (when appropriate this should also include how same sex accommodation is provided).

Indicate how this will be met

No additional requirements have been identified in relation to this policy.

Privacy, dignity and respect underpin the implementation of this and the associated policies, which set out a person centred approach to care, working in partnership with the patient and carers as appropriate

8.2

Mental Capacity Act

Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individual’s capacity to participate in the decision making process. Consequently, no intervention should be carried out without either the individual’s informed consent, or the powers included in a legal framework, or by order of the Court.

Therefore, the Trust is required to make sure that all staff working with individuals who use our services are familiar with the provisions within the Mental Capacity Act. For this reason all procedural documents will be considered, if relevant to reflect the provisions of the Mental Capacity Act 2005 to ensure that the interests of an individual whose capacity is in question can continue to make as many decisions for themselves as possible.

Indicate how this will be achieved

All individuals involved in the implementation of this policy should do so in accordance with the Guiding Principles of the Mental Capacity Act 2005. (Section 1)

9.

LINKS TO ANY ASSOCIATED DOCUMENTS

Handling of Formal Complaints Policy (including unreasonably persistent complainants) - General Policies

Consent to Examination or Treatment Policy – Clinical Policies

Procedure for Requesting a Second Opinion – Clinical Policies

Patient Advice and Liaison Service (PALS) Policy - General Policies

Information Governance Policy – Information Governance Policies

Care Programme Approach Policy – Clinical Policies

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Procedure for Informing Detained Service Users of their Legal Rights under Section 132 of the Mental Health Act 1983 – Clinical Policies

The Provision of, Access to and Use of Interpreters for Service Users and Carers Policy – Clinical Policies

Policy for the Management of Local and Corporate Induction – Employment Policies

The Big Word - How to get information in in alternative formats – ukgov@thebigword.com

10. REFERENCES

Mental Health Act 1983 (amended by the Mental Health Act 2007)

Mental Capacity Act 2005

Health and Social Care Act 2008

Equality Act 2010

Care Quality Commission Fundamental Standards

NHS Direct http://www.nhsdirect.nhs.uk/

MIND http://www.mind.org.uk/

Royal College of Psychiatrists: Mental Health Information http://www.rcpsych.ac.uk/mentalhealthinfo.aspx

RETHINK http://www.rethink.org/

NHS.UK http://www.nhs.uk/Pages/homepage.aspx

11. APPENDICES

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Appendix A

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Appendix B

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Appendix C