Report: Given the opportunity for greater online engagement, how accessible are GP websites?
Ahead of Global Accessibility Awareness Day we investigated the digital accessibility of GP websites in the UK to highlight the most common issues faced by users with access needs, and some opportunities to make things more inclusive.
We investigated the digital accessibility of GP practice websites in the UK to highlight the most common issues faced by users with access needs.
There are some positives to be taken from the fact the sites we assessed outperformed some sectors. However, some findings are still concerning and show that website platforms supplied to practices by vendors and suppliers do not comply with current WCAG guidelines, potentially leaving millions of people at risk of being unable to access the healthcare support they need. Given the pressure on primary care and the benefits of remote access to healthcare services and online engagement, we are calling for the digital industry and vendor community to do more to help.
“All too often GP practices are given digital platforms and products lacking in core accessibility. These platforms are also provided without sufficient ongoing support to maintain their content and how it is displayed once uploaded, not just to the naked eye but through accessibility tools.
“Suppliers also have a duty to educate GPs and practice staff that will be contributing to the website on the nuances of accessibility. The content of a website is distinct from the platform itself, and most people in a GP practice won’t appreciate that or have an awareness on how to accommodate for access needs. This leads to unwitting GP surgeries providing websites that aren’t accessible to a sizeable proportion of their potential users.
“The onus isn’t on the primary care providers but those commissioning the digital products from platform vendors. Are they demanding enough? The vendors themselves should also be creating products with accessibility at their core. Our audit and industry feedback would suggest that is not the case. There’s also a lack of investment in digital skills training and roles within the sector – this must change.
“If there is a greater expectation for people to engage with health provision and care online, a rethink on how those platforms are funded and commissioned is urgent.”
Introduction
For the fifth consecutive year, WebAIM has conducted and published its Million Report, a comprehensive review of the web accessibility of the top million home pages on the internet. But what happens if we take a more detailed look at the healthcare sector, and specifically GP practice websites. Do they perform better than the average website? What barriers to access are most common? How can we make navigating these websites easier for people with disabilities and access needs? From our work with clients including Health Innovation Manchester and NeuroResponse in recent years, we have seen the value virtual wards, remote care and online engagement can offer to patients, clinicians and families but it all relies heavily on user-centred, accessible technology and inclusive service design.
The Web Content Accessibility Guidelines (WCAG) were originally published in 1999, becoming a World Wide Web Consortium (W3C) recommendation in May 1999. As technology and website usage have evolved so too have the requirements for accessibility. WCAG 2.0 was released in 2008, and WCAG 2.1 was published in 2018, with the latest version, WCAG 2.2, slated for release in Q3 2023.
The current recommendations still set out the requirements of a website that “is accessible to people with a diverse range of hearing, movement, sight, and cognitive abilities”. But WCAG’s new criteria also expands its advice for a broader range of user groups that were not recognised in the earlier versions, with expansive user research showing that updates are needed to address keyboard, mouse, and mouse emulator users and additional cognition criteria.
However, despite the progression of WCAG and our understanding of accessibility we, the digital design industry, have had almost 25 years – a quarter of a century – to make sure digital products and services are created with accessibility at their heart. So why are digital products and services still being so poorly designed, and why are disabled and often more vulnerable people being excluded from using vital services?
Methodology
We reviewed 50 UK-based GP website homepages, selected randomly, from the GP Patient Survey 2022 list across a set of common WCAG criteria using WebAIM’s WAVE suite of evaluation tools, and other recurrent accessibility errors. We looked at examples of low contrast text, missing alternative text for images, empty links, empty buttons and use of H1 titles, as well as desktop research to determine the use of overlays and plugins.
In addition, we also reviewed the social media presence of the chosen GP surgeries to see if they had a profile, if it was updated and if they followed content best practice.
The majority of websites have detectable errors
We found that two-thirds (66%) of GP surgeries websites had detectable errors and WCAG failures. The majority of websites returned at least one fault. The good news is this is significantly better than the average website, with WebAIM’s research finding 96.3% of all home pages have at least one error. The public and health sectors are typically further ahead than many private sector organisations, who will have a challenge to meet the expectations of the coming European Accessibility Act.
The average GP website has 3 errors on its homepage, a stark contrast to the average homepage which has 50.0 errors per page. However, fewer errors being present is little consolation to someone desperately trying to access information or services from their primary care provider. This type of automated testing only accounts for a relatively small number of WCAG/ accessibility failures too, as products and services need to be designed and tested with (and ideally by) people with access needs and ranging digital skills. We have broken down the recurring themes in an attempt to guide people on how to make things more inclusive.
Poor colour contrast
The most common error among the websites we reviewed was poorly colour contrasting text. Almost two thirds (62%) had low contrast text, compared to 83.6% of the top 1 million websites. There was an average of 6.4 contrast errors on homepages alone.
Inadequate contrast between the text color and the background results in users with vision-based disabilities being unable to read text and understand information. Often aesthetic design choices result in poor colour contrast and thin script-style fonts which cannot be picked out by people with low vision. Instead, developers should ensure their colour patterns pass WCAG contrast ratios or choose large text that is 18pt and larger, or 14pt and bold.
Abundance of empty links and buttons
A quarter (24%) of GP surgeries’ sites reviewed had empty links. A hyperlink which doesn’t contain text or describe its destination if clicked can cause confusion. A website user is less likely to click it if they can’t see it properly or are not sure exactly where they’re being taken. Half of all websites (50.1%) contain an empty link, according to WebAIM. What’s more, they’re remarkably easy to fix. This may occur if:
Anchor text has been edited but the original link tag has not been removed.
A web font or icon font has been added incorrectly
A link contains an image or scalable vector graphic without an aria-label or screen reader text
Empty buttons are much the same. Any link that is stylised with a html button tag qualifies. They are used to direct people to visit a particular section of a website, submit a form, or download a file. Our audit found one in 20 (6%) GP surgeries websites have empty buttons – more than three times less than the average website (27.5%). These can create dead-ends for key user interactions.
Alt text shouldn’t say a thousand words
One in 10 (8%) GP surgeries websites have missing image alternative text. In comparison, almost six in 10 (58.2%) of the top one million websites are missing alt text for images. Without alt text, screen readers and people with low vision cannot understand what the website’s image is portraying and if it has any significance to what they’re trying to achieve. GP website imagery is also often poor quality, dated and/ or uses stock imagery. Using images of the surgery and doctors a patient is going to visit can go some way to reducing anxiety around a visit.
The average GP surgery website is missing alt text on at least three images on their home page. Again, fixing this is simple and can improve the user experience drastically and it’s important to understand the use of images that are purely decorative and not intended to convey meaning
Hectic headings
Hierarchical headings are used to communicate the content of a page and its constituent sections. Within a webpage they are ranked from H1 – H6. H1 tags are often page titles and the first thing a user sees on a web page. But one in six (14%) GP surgeries’ websites fall short and do not include this type of page title.
Poor use of heading tags leads to assistive technology struggling to navigate a website. Screen readers typically switch from heading to heading as H tags signify a new section of text or information. When they’re not used navigation becomes difficult. WebAIM’s Screen Reader User Survey found that 85.7% of people find heading levels ‘very’ or ‘somewhat useful’.
While many websites do not use H1 tags or heading navigation at all, some may use them in the wrong order or the same tags multiple times, which also leads to poor user experience. Headings must be nested – this means H1 tags first, followed by H2 tags then H3 tags, and so on.
A heading tag should be descriptive and easy to understand, unique, succinct, and scannable. Do not use all capital letters, this can be troublesome for neurodiverse users to read. Using headings tags for whole paragraphs of text also creates an unpleasant experience for website users.
PDFs must also follow the same rules
As well as websites, PDF documents and resources which are linked to and from a website must meet accessibility guidelines. More than a quarter (28%) of GP practices websites link directly to at least one PDF. Things like patient application forms, information on common illnesses, and after care advice are commonly shared in this way. The average GP site links to at least two (2.7) PDFs from its homepage, meaning that people with access needs can be excluded from large amounts of important information.
But the providers of GP surgeries’ websites must make sure that guidance on sharing content is passed on to those that will be managing the content too. Unless they are specifically created for use online it’s likely that as PDF will not be accessible and assistive technology will struggle to read the document. Digital versions of leaflets and forms available at the physical surgery should be checked against accessibility criteria before being uploaded. They should be formatted correctly and designed in a way which text-to-speech technology can assist, e.g. alt text for PDF images.
Fix the Six
As a result of these findings, we’re encouraging website vendors and suppliers, and their designers and developers to focus on the six most common design flaws identified in our audit and WebAIM’s annual research. Eradicating these regular occurrences on a GP surgery’s website would go a long way to making it more inclusive and drastically improving the experience of people with visual or hearing impairments, and cognitive disabilities.
Colour and contrast
Missing alt text
Empty links
Missing form input labels
Empty buttons
Missing document language
“Improving inclusivity is a journey, and as a website’s content grows and changes regular checks must be made. But we cannot expect the primary care providers to lead on this without proper training and investment in digital skills. Collectively as an industry we must do more, share best practice and make accessibility a priority. To do this we must move away from accessibility as a compliance measure and embrace universal design.”
Danny Lancaster, Accessibility Lead, Nexer Digital
Accessibility statements
Since 2018 regulations have required public sector organisations to host and regularly update an accessibility statement on their website. Our audit found one in six (16%) GP websites didn’t have a discoverable accessibility statement.
Of the 84% of doctors’ surgery websites that were compliant and contained an accessibility statement, the vast majority – 90% – were not up to date, often dated with expired timings of when they were last reviewed for WCAG requirements, and with a date in the past listed for a new check and update to be published.
In a small number of cases the accessibility statement had simply been copied and pasted from a template and developers had not removed or updated the blanks. This can be directly traced back to the supplier of the website, with their details and organisation name being listed as the party responsible for conducting the next check. This shows poor attention to detail but also a lack of understanding of what the statement is proof of, and a lack of commitment to maintaining the standards of the website on behalf of the practice. When used in the right way, accessibility statements can give a clear indication on what the experience for specific users might be, as well as show a commitment to a roadmap of improvements still planned.
Overthrowing overlays
Overlays are a common solution used to improve website accessibility. The audit found more than one in four (26%) of GP and doctor’s surgeries’ websites use them as an off-the-shelf accessibility solution.
While overlays might provide additional features and functionality to help users with access needs, they are typically third-party tools or plugins that can be added to a website to improve the user experience for people with disabilities, such as those with visual impairments, hearing impairments, or cognitive disabilities. They offer features such as text-to-speech conversion and keyboard navigation.
However, overlays are not the best solution for improving accessibility and are often implemented as a quick fix or box ticking exercise by suppliers instead of addressing the root cause of the accessibility issues experience on a website. They can create additional barriers to accessibility, such as adding more clutter and complexity to the user interface, causing compatibility issues with assistive technologies, and potentially interfering with the user's assistive technology settings. There is also potential for errors and inaccuracies in their translations or misinterpretations of the content on the website.
Overlays can be a useful tool to improve website accessibility, but they should not be relied upon as the sole solution to accessibility issues by vendors. Instead, web designers and developers should prioritise creating accessible websites from the ground up, using best practices and WCAG guidelines to ensure that all users can access and use the website regardless of their abilities.
Social media standards
We have looked into activity levels as well as accessibility best practices of the same surgeries on social media. Social media channels and content aren’t covered under the current WCAG compliance standards, however that doesn’t mean we shouldn’t extend best practice and accessibility across all channels and communications.
Almost two-thirds (60%) of doctors’ surgeries and GP practices have a Facebook page, however one in three (33%) of those GP practices’ Facebook pages are not regularly updated.
There are vast differences between GP practices and their approaches to social media. Some have accounts across three channels and are regularly updated with content, making the best use of accessibility tools. Others include a variety of content sourced and repurposed from different places, shared with well-meaning but a lack of thought for their audience. This re-emphasises the need for thorough training to skill those that will be creating content and using the channels once they are set up.
We can see that lots of social media channels were most active during the pandemic when proactive primary care workers wanted to communicate with their patients quickly. However, in many cases inclusion was overlooked. Many of these channels are now dormant after the pandemic was downgraded by the World Health Organisation. This could lead to some patients reaching a dead-end when trying to find information.
Molly Watt, Accessibility and Usability Consultant, Nexer Digital
A third (32%) of social media channels reviewed shared video content of some sort, although just a quarter (26%) of that video content had captions.
Almost all (99%) of video content with captions was shared from central NHS trust social channels, showing that good content practices can cascade down from a central source to individual surgery channels.
Conclusion
On the whole, GP surgeries websites perform better than the average website against the majority of WCAG criteria, which is encouraging. But they are not perfect and can still be improved. This duty, in the first instance, falls on the suppliers and vendors to the surgeries who must present them with platforms that have accessibility at their core. Surgeries also need ongoing support as their content evolves.
Every accessibility failure presents an instance where users may not be able to access the healthcare information or support, they urgently need, and discourage them from seeking support in the future. To overcome this, digital product designers can involve a diverse selection of people in the process means that many different experiences and perspectives can be drawn upon.
To make instant and impactful change there are six common failures which most websites present which can be addressed today by IT teams. But beyond that, and to make meaningful change, we need to move away from compliance as a measure of accessibility. This removes the potential for creating a website that is technically compliant but that isn’t accessible or user friendly, and therefore not easily accessible to everyone that may need to use it.
While we have used WCAG criteria as a top line indicator of inclusivity, a deeper look at an individual site’s structure and content is needed before making improvements. WCAG is also not definitive or the holy grail of accessibility.
We should approach design and development through a proper user and human-centered approach. This means involving a diverse range of people at all stages of research, build and testing, rather than at the end. The whole population needs to access a GP surgery website at some point in their life so involving users with a broad range of access needs is necessary.
As an industry we need to focus on outcomes and creating accessible products and services, not a technical standard that is masked as inclusion.
What we’re doing with the NHS and healthcare sector
Jo Dunning, Account Director, Nexer Digital
This year has seen Nexer Digital and the NHS work more strategically together across a number of accessibility and usability projects to ensure NHS Services and products are inclusive to all.
This includes working with one trust on a usability testing pilot that ensures GP websites are adhering to NHS guidelines around accessibility and usability, and that any changes are being made consistently and in line with NHS guidance across the country.
We are currently on the second round of testing, exploring if users’ experiences have improved as a result of GP surgeries increasing awareness around creating accessible content, and suppliers making their templates more accessible.
Nexer is also working with another trust on a large scale accessibility audit of GP practice websites. This project is innovative in its scale. We’ve written the audit reports in plain English, ensuring that people who work in healthcare but aren’t accessibility experts know where to start to make their websites more accessible. This will include content changes and having discussions with website suppliers to bring existing site templates in line with WCAG 2.1 accessibility standards. We are keen to do more audit, training and testing work across the NHS and vendor community to help people develop their awareness and skills.
Lisa Drake, Director - Quality, Service and Improvement, Redmoor Health
Whilst the vendors are being asked to take responsibility for accessible design website templates for GP Surgeries, Nexer Digital supported Redmoor Health with its ‘Digital Journey Planner’; a practice based, learning and improvement system.
Redmoor Health support General Practice teams to optimise delivery of online services, where websites and social media form an essential role in good patient communications and access to healthcare.
Raising awareness of the issues faced by users helps practice teams to prioritise frequent content checking, rather than just relying on an annual check and accessibility statement from the vendor. Seeking user feedback to improve the information supplied will be part of the new plans to improve access to services and patient experience.
Redmoor also now offer a social media managed service to practices, to reduce the incidences of posting inaccessible content and produce guides and helpful resources to support practice teams who manage their own social media profiles.
Working with the team at Nexer Digital helped our creative communications team to rethink their content, and helped our delivery team who support practices, to understand and explain why this is so important for patients and users.
