Document type

Making patient letters accessible

Appointment letters, results letters, discharge summaries and leaflets: why patient PDFs fail screen readers, what the NHS standard asks, and how to fix them.

Many patient letters are not written one at a time. Appointment and results letters are merged from a patient record into a letter template, discharge summaries are exported from a clinical system, and leaflets are laid out in design software for print and then saved as PDF for the website or an email. Whatever accessibility the template or the export lacks, every letter produced from it lacks too. In England, the Accessible Information Standard (DAPB1605) is issued under section 250 of the Health and Social Care Act 2012, and all providers and commissioners of NHS and publicly funded adult social care must have regard to it. It asks them to identify, record, flag, share, meet and review the information and communication needs of patients, service users and carers with a disability, impairment or sensory loss. Where a system generates correspondence for someone with a recorded need, it must either produce an alternative format automatically, which the standard prefers, or let staff produce one, and organisations must ensure a standard print letter is not sent to someone for whom it is not accessible. The standard points to section 20(6) of the Equality Act 2010, under which the reasonable steps can include making sure information is provided in an accessible format. It names braille, large print, email and audio as alternative formats, and communication support such as a British Sign Language or deafblind interpreter. An accessible PDF can meet some of those needs, for example for a patient who reads with a screen reader or enlarges text on screen; it cannot meet a need for braille, audio or communication support, and it is not by itself a way of meeting the standard. Normfluss checks each PDF against PDF/UA-1 and the WCAG AA success criteria that apply to PDF, remediates it, and issues a signed evidence record stating which checks ran and what they found, with documents processed in the EU. The record documents conformance within a stated scope; it is not an assessment against the Accessible Information Standard, and whether an organisation meets its duties is for the organisation and its advisors to decide.

Where patient letters typically fail accessibility

• The letter is merged and then printed to PDF through a print driver, which keeps the look of the page and discards any structure, so the file has no tags and a screen reader gets either nothing or an unordered stream of text.
• The appointment details a patient actually needs (date, time, clinic, address, what to bring) sit in a positioned text box or a letterhead area, so the reading order starts with the trust address and reference numbers and reaches the appointment last, or not at all.
• Medication lists and results in discharge summaries and results letters are laid out as grids of positioned text rather than tagged tables, so a drug is announced without its dose, route or frequency, and a value is separated from its reference range.
• Leaflets designed for print use two or three columns, pull quotes and sidebars; without a set reading order, text from separate columns is read as if it were one line.
• Scanned letters and clinic forms uploaded to a patient portal are images of paper with no text layer, so there is nothing for assistive technology to read until the page is run through OCR.
• Logos, diagrams of the body, maps to a clinic and QR codes carry no text alternative, and the diagram that explains a procedure in a leaflet is silent.
• Translated leaflets and letters with a passage in another language have no language set, or the wrong one, so a screen reader pronounces the whole text with English rules.

Remediation checklist

• Fix the letter template and the export route first, so tags survive from the clinical or administration system into the PDF instead of being lost at a print driver.
• Set a logical reading order that puts the purpose of the letter and the appointment or result details ahead of reference numbers, footers and return addresses.
• Tag medication lists and results as real tables with header cells, so every dose, frequency and reference range is announced with its label.
• Give each informative image, diagram and map a text alternative written for its purpose in that document, and mark decorative logos and rules as artefacts.
• Set the document title and the primary language, and mark any passage in another language (WCAG 3.1.1 and 3.1.2).
• Run image only pages through OCR, then check the recognised text against the original before tagging, since a misread date or dose is worse than no text.
• Label every field in reply slips and consent or questionnaire forms, so a patient using assistive technology can complete them (WCAG 3.3.2 and 4.1.2).
• Check the result against PDF/UA-1 and the WCAG AA success criteria that apply to PDF, and keep the signed record with the template it came from, so a later template change can be compared against it.