When patients, carers and the secretary of state all plead for plain English why does the NHS insist on incomprehensible

documents? Bernadette Friend investigates

In just 400 words, consultant dermatologist Nicholas Telfer managed to explain a technique used in skin cancer treatment. His leaflet on Mohs' micrographic surgery tells patients why a visit to the hospital is necessary and what happens on the day of surgery, including what they should do before they arrive and what they should bring with them.

It is easy to read, informative and concise, and has won Salford Royal Hospitals trust an award for clear public information from the Plain English Campaign. Dr Telfer says the aim was to give patients the nuts and bolts rather than chapter and verse.

Salford was the only trust to receive an award last December, but other award winners in the health field included Help the Aged, the World Cancer Research Fund and the Anthony Nolan Bone Marrow Trust.

The government says it wants to stamp out jargon in the health service and, last autumn, health secretary Frank Dobson urged the NHS to 'call a bed a bed'. Speaking to the Health and Medical Public Relations Association in October last year, he said the NHS could improve how it speaks to patients by using language they understand. 'Vulnerable people want a simple explanation of their care,' he said. 'They want to hear more patient-speak and less management-speak.'

Chrissie Maher, founder of the Plain English Campaign, describes his rallying cry for clarity as music to her ears. But the road to crisp and concise writing in the NHS may be as long and winding as some of the paragraphs that end up on the pages of health service documents (see box). 'Management- speak and gobbledygook,' she insists, 'are still rife in NHS documents. Poor communications still baffle patients and waste huge amounts of taxpayers' money.'

John Wild, the campaign's information technology manager, says there are still people in the health service, and other organisations, who take the view that if people don't understand what has been written, it's their fault.

But he says health service information must be clear. People may be reading it when they are at a very low ebb, newly diagnosed with a condition they may not understand, and fearful about their treatment and prognosis.

In his view, the biggest pitfall is failing to address the target audience. 'People forget that they are not talking to their fellow professionals.' But he stresses that it is not about 'dumbing down'. 'Plain it is,' he says, 'simple it isn't.' His advice is 'to know your audience', and in training he often suggests that people put themselves on the other side of the desk.

Plain English also runs a Crystal Mark scheme, and lists around 40 hospitals and trusts which have a document bearing the campaign's crystal logo (see box). Other organisations include health boards, the General Medical Council, the Royal Pharmaceutical Society and the Family Planning Association.

Individuals or organisations can submit a draft or completed document and pay the campaign to change it. Free guidance is available on why a document fails to meet its Crystal Mark standard.

Last year Dundee Healthcare trust set about preparing its patient charter. Discussions included some drawn-out arguments about using particular words. The trust sent the document to the campaign and it came back with a number of amendments.

Quality manager Jim Duffy said: 'We then looked at their adjustments. We had to make sure we were happy that the document still reflected the sense of what we were trying to say. We prepared a pre-printed draft of the document and sent it to the campaign, saying that this was how it was going to appear. They confirmed that it conformed to their standard of clear English and we got a Crystal Mark.'

At the end of the process, the document was much easier to understand. Without the changes, he says: 'I suspect that people may not have read it with the same ease of interpretation, and therefore they may not have been entirely clear about some of the promises we were making.'

Eight members of staff, including the trust's clinical directors, discussed the document and the group tried to cut down on jargon. Some of the changes suggested by Plain English were to use simpler sentences. Complex paragraphs were broken up into bullet points. When telephone numbers were included, the abbreviation 'tel' was changed to 'phone'. The text was printed in green ink and the campaign suggested removing the background colour tints to make it easier to read.

The trust had written: 'We welcome your views on our services. If you have any concerns you should raise the matter with the staff. Most problems can be dealt with at this level. If you are not able to settle the matter in this way you can write to...' The Plain English Campaign changed it to: 'We welcome your views on our services. If you have any concerns please tell us about them. We can sort out most problems in this way. If you are still not happy you can write to...'

But Mr Duffy warns that putting a document through the Crystal Mark system is not cheap - although he could not recall the actual cost. The campaign says it cannot quote prices because it depends on the size of the document and how much work is required to pull it into shape. Mr Duffy thinks a more feasible way forward may be for the trust to train its own editorial team.

Clifford Burden, communications manager at Western General Hospitals trust, Edinburgh, was not with the trust when its patient information booklet was put through its Crystal Mark paces. But as a former journalist, he knows how important it is to write clearly.

'It is vital that you get your communication right, and right first time,' he says. He believes that as more trusts employ professional public relations staff, the standard of writing in the NHS is improving.

But not everyone believes that outside assistance is necessary. New literature at the Central Manchester Healthcare trust - which has previously had a Crystal Mark - is tested out on patient information groups. Communications director Richard Emmott says: 'There's no substitute for asking the patients themselves.'

Central Middlesex Hospital trust is also listed as having a Crystal Mark, although the trust says the document never reached the printers. The trust uses local agencies when it needs additional help with written material. Everything written in the trust is seen by the quality department. Patient focus groups are sometimes used, but general manager, Philip Sutcliffe is not convinced about using 'Joe Public'. He suggests that, just because someone says a thing is rubbish, it doesn't mean it is rubbish.

The Plain English Campaign's work includes government, legal, insurance and banking documents. The campaign has worked on part of the South African constitution covering human rights, and a UK police force 'bible' which was whittled down from 750,000 words to just 60,000.

The organisation has an interesting history. Founder Chrissie Maher OBE was illiterate until her mid-teens. During the 1960s she was involved in community work and launched Britain's first community newspaper. She later went on to launch the country's first newspaper for semi-literate adults.

The campaign grew out of her work to help people fill out forms. While assisting two women trying to claim fuel allowance, one of them died of hypothermia. During the 1980s, the campaign was involved in the Rayner review of public forms in government, which led to 36,000 of them being scrapped and 57,000 redesigned. Plain English estimates that rewriting and redesigning government documents has led to savings of pounds250m.

'How many hundreds of extra kidney dialysis units could be bought for our hospitals,' Chrissie Maher wonders, 'if bureaucrats could learn to communicate clearly with each other and with the public?'