Background

Thirty years ago, my cervical smear result came back positive. Shaken, nervous, confused, I did what anyone of that era would do – traipsed off to the nearest library for help. When none was forthcoming, I repaired to the nearest bookshop. And the next bookshop. And the next. I never did track down either the information that my conscious mind was seeking nor the advice, reassurance and support that I subconsciously longed for. (In the end, I gave up on finding a book that addressed my concerns and wrote my own.)

Thirty years later, I wouldn't need to wear out my shoe leather. Nowadays, thankfully, I would be able to type in the words ‘positive smear’ and ‘cervical cancer’ on my laptop and get everything I needed in terms of information and consolation within a few seconds and in the comfort of my own home.

It was the realisation of just how dramatically things have changed in this respect that has led me, in this Consumer Correspondent article, to profile the second biggest health website in the world, NHS Choices. Hundreds of thousands of pages, 50 different service directories, 20 000 articles, 10 million users each month – concrete proof of the seismic shift in global health resources that has occurred in my own lifetime.

The beginning

NHS Choices' starting point was in 2007, with the realisation by those involved in British health care that even after decades of activity on the web, of well-meaning projects, of brave attempts at in-depth coverage, there was still no single, comprehensive health website that gave the searching patient information, advice, guidance and a chance to choose the best services and influence the development of those services.

The website arguably couldn't have been initiated previously. Not only was the technology not sufficiently advanced, not only were website developers not sufficiently experienced in such complex projects, but patients were not yet sufficiently proactive and empowered to actively engage with such a site.

Plus, the political will hadn't been there. It took the then British Secretary of State, Patricia Hodge, to task the then mandarins at the Department of Health (DH) to develop a health site that was the “front door of the NHS”. She also asked them to do so in just 6 months. In the words of Bob Gann, Head of Strategy for NHS Choices and the conduit for my exploration of the website: “We used what we had … we pulled in from our existing site … we put together a team … we did what we had to do”.

The development

“Doing what they had to” might have been a little fraught at times, but the results were spectacular. In their first year up and running, NHS Choices site-user visits totalled 2 million a month. By this time, the DH start-up team had expanded their staffing, clarified their approach and house style, and were not so much up-and-running as sprinting a marathon. Now, the site has 10 million users a month.

Who uses the site? Unsurprisingly, given the propensity well known to Journal readers for the female of the species to be more proactive in health matters than the male, NHS Choices users number more than twice as many women as men. Equally predictably, given younger generations' comfort with all things technological, almost two-thirds of users are ≤45 years of age. Black or ethnic minority groups are slightly more fully represented than in the general population of Internet users, while a third of users have children aged under 18 years; a third have a long-term health condition; and a quarter are carers for a family member, friend or neighbour.

On the other side of the equation, who delivers the site? There is a London-based editorial team who write the copy, get it checked by a clinical advisory board, peer review it and then publish. The London team is backed by a Leeds-based team working on the technical side, and by researchers gaining market feedback, by trainers helping NHS and local government staff use the site, and by public relations support to spread the word.

The content

What's in there? The site covers the full range of medical issues, but for Journal readers the section of choice is clearly going to be that dealing with sexual health. For further detail I spoke to Susanna Wood, web editor responsible for the aforementioned section, who outlined for me their coverage of male sexual health, female sexual health, sexual problems and sexual communication. A user can find these topics from the search facility home page itself, and via the clinical A–Z for any relevant topic, and through the more lifestyle-oriented ‘Live Well’ section (Box 1).

How full is the coverage? A thorough exploration by your intrepid columnist revealed solidly comprehensive content. There are special sections on vaginal and penile health, sexually transmitted infections and safer sex. Pregnancy and fertility are fully covered, with accompanying blogs and forums. Lesbian sexual health, gay sexual health and transgender issues are represented. There are several sections on how to talk about sex, including talking to children, talking to teenagers, talking to a partner – this last one with skill-teaching video coverage of sexual problems, and advice on how to find and use sex therapy. Plus, some welcome features on topics often not addressed by health professionals, such as sex advice for people with chronic pain, and sex for the over-60s.

All this is done through a variety of tools over and above plain text: video walls, slideshows, widgets and apps, health assessments, quizzes, real stories, lifestyle checks, online clinics, and so on. In addition, the site regularly offers features that pull together and highlight the foundation content, often in list form, such as ‘Five safer sex tips for the party season’. Plus following the general strategy of the site, NHS Choices also links with and supports one-off health initiatives; my interview with the team followed shortly after a men's health campaign looking at penile health.

I found only one gap, and this arguably a justifiable one: NHS Choices does not address sexual pleasure issues. No how-to's. No positional diagrams. As an advice columnist in my other life I wonder if this is an omission, for there is a huge need for support of healthy and mature sexual pleasure. But as a wider social commentator who sees the negative impact of the sexualisation of society, I can see why the strategy is to focus on health alone. As Susanna explained: “It's a very thin dividing line between sexual well-being and sexual technique, and NHS Choices needs to tread very carefully”. Point taken.

The mission

There is a huge commitment to quality here and not just in theory. All the NHS Choices content is quality controlled and peer reviewed, and the site is a certified member of The Information Standard scheme, an independent scheme supported by the DH that has been set up to help the public identify reliable sources of health and social care information (www.theinformationstandard.org).

This commitment to quality however, though essential, was not what seemed to raise most passion in the spokespeople I talked to. That was the commitment – Bob Gann did use the word ‘mission’ – to get from users as well as to give out to them, to make NHS Choices interactive, to encourage citizens to become discerning consumers. In an age where technology is allowing more and more participation and involvement, NHS Choices believes that this involvement needs to extend to the health services.

Bob Gann spoke at length about the fact that via the feedback mechanisms on the site, individual practices, clinics and hospitals were finding out what their users really think, and were responding to that feedback. Complaints were being dealt with and concerns were being addressed. Above all, in a general sense, site users were learning that they could have an impact on the health services being delivered to them. In this author's opinion this must surely, long-term, lead not only to a better service for consumers but also to better job satisfaction for health professionals themselves.

The brickbats

So far, so wonderful. But are there no closet skeletons in this story? I am, truly, not writing an NHS Choices advertorial. But when I did a quick straw poll of both users and health professionals, the verdict was almost universally positive. “Good information” … “very accessible” … “I like the feedback on health facilities”. The team themselves, however, were disarmingly willing to admit to criticisms from various quarters.

The first accusation levelled, apparently, is that in these days of financial constraints and when treatment waiting lists are not at their shortest, it may be a poor use of public money to fund a website. Certainly when the recession hit, Government spending cuts were laid on NHS Choices as on other DH projects – apparently the dreams of advertisements on the sides of buses had to be shelved along with plans for a steep and speedy development of the site. The counterargument for keeping the site alive, however, is indisputable: it actively saves money. Common sense alone suggests that the huge user figures will translate into lifestyle improvement with consequently less need of health services, while independent research at Imperial College London suggests that 37% of people who had logged on to NHS Choices said that they had then not needed an appointment with their general practitioner.

A second accusation strand has been about the more controversial campaigns. Particularly relevant to journal readers here was the push to encourage condom use, with a videoed story line that tracked a sexual encounter through a streetwise plot and style, signalling several choice points with regard to safe sex. There were complaints that it was little short of pornography; but again, given that the video garnered 2 million hits on YouTube then – if journal readers will pardon the pun – market penetration must have a positive impact.

Third in the accusation list, NHS Choices reports having met with some resistance from the health profession over the feedback facility. As Bob Gann commented: “We do need to educate the clinician market as to the value of user comments which pinpoint what is good and bad about services and offer health professionals the opportunity to put right what is going wrong”. I echo his sentiments, but it's worth noting that the professionals I spoke to for my straw poll admitted to no such reservations and, to the contrary, even demanded more accurate and specific feedback on individual practices or hospitals.

The future

What next? As mentioned previously, NHS Choices' expansion dreams of the late ‘noughties’ are on hold in the face of global financial wobbles and in the context of a new and currently coalitional government: “2012 finds us in a very different world, financially, politically and technologically”.

The current focus is on informed cost effectiveness and increased user involvement: consolidating existing available materials; developing awareness through social networking sites such as Facebook and Twitter; involving existing user networks such as mumsnet.com. When I met with the team, they were in the midst of a huge consultation exercise with nearly 700 patient organisations, finding out what those organisations and their patients wanted on the site; as to the results of that consultation, by the time you read this article all should be revealed.

And what, I asked Bob Gann, does he want to say to Journal readers? His answer was clear: “Ask them to be aware of us and to raise awareness of us … to use the site if they don't already … to get their patients using the site if they don't already … in particular to use our interactive facilities, the forums, the feedback forms. Ask them to join us in making user voices heard”. Consider it done, Bob. Consider it done.