The NHS style guide promotes simple language like ‘pee’ instead of urine and ‘poo’ instead of faeces. It infuriates some but there’s a logic behind it.
Back in 2019 the NHS updated its style guide, more formally known as the NHS service manual, with advice on simple alternatives to clinical terms.
Sara Wilcox, then a content designer with NHS.UK’s standards and service manual team, was sent out to explain the guidance to the public via the media. (Sara, who many of us here at Sparck have worked with at various points is, to put it plainly, awesome.)
As she put it on Word of Mouth with Michael Rosen on BBC Radio 4:
“We started using pee and poo a few years ago because we thought it was simple language. But we also started getting a lot of complaints... So one of the things that I did was to actually look at a whole lot of website responses, something like 10,000 feedback survey responses, looking for the people who were complaining and the people who were positive. And although there were a lot of people complaining about words like pee and poo there were 10 positive responses for every negative one. Most people... much prefer us being direct, and simple, and clear.”
However reasonable and measured Sara’s explanations, that didn’t stop the press and other critics getting wound-up about it.
For example, tabloid newspaper The Sun gave an otherwise quite positive story the headline “Dumbing Gown” – a pun which itself requires a footnote or two to understand. It’s a reference to the phrase ‘dumbing down’ which implies a general decline in the intellectual quality of public discourse.
And one surprisingly angry linguist wrote:
“The assumption that patients are all stupid and the NHS, doctors in particular, need to go down to our level is extremely annoying. I do wish this idea would penetrate the NHS language supremo’s skull on its way to their brain.”
I’ll admit this language even made me bristle when I first noticed it on posters in a doctor’s surgery in Marazion, Cornwall, while I waited for a check-up, back in about 2016. “I’m not a toddler!” I thought, grumpily.
But since working on the NHS website from 2021 to 2023 I’ve gained a new understanding of the drivers behind these choices, and have become a big fan of this approach.
What the NHS service manual says
Here’s the entry for ‘poo’ from the NHS service manual:
poo
We mostly use "poo", rather than "stool". We know that everyone can understand "poo", including people who find reading difficult.
We do not use "opening your bowels" or "bowel movements".
We sometimes use the words "stool" or "bowel" when people will hear their GP use them. But we will explain the term or phrase. For example:
- “a sample of poo (stool sample)"
- “Bowel incontinence can affect people in different ways. You may have a problem if you have sudden urges to poo that you can't control."
There are similar entries for terms like ‘fart’ and ‘bottom’, with examples of how to use them in practice.
What’s important here is the reasoning: ‘poo’, whether you like the word or not, is universally understood. And content designers always strive to find language that most people will understand.
It’s a little more complicated than that, of course. The guidance acknowledges that people might hear more technical terms especially if they spend a lot of time talking to doctors.
As ever in content design, it’s not about simple rules, but understanding the context in which specific groups of users are discovering your content.
The research behind these decisions
The NHS has a well-established content design function with gold standard practices around user research and testing.
It doesn’t take decisions around language lightly because, unlike in many organisations, clarity can literally be a matter of life or death.
In this case, the NHS content team used tools such as pop-up testing, speaking directly to members of the public on the high street, or in GP surgeries.
They also invite users into a research lab where they can be observed using the NHS website, or draft versions of pages. Personally, I find this especially valuable, because there’s a lot of non-verbal cues around confusion and frustration that it’s easier to pick up through observation. And also, occasionally, evidence of real delight, when you get it right.
As Sara mentioned in the quote above, and in this post on the NHS website, they also scoured 10,000 website feedback responses:
“Most people are positive about the language we use. They like the way we write… Overall, we get more than 10 positive comments for every negative one. This reflects what we see when we test our content face-to-face. Most people appreciate simple, everyday English.”
Sara’s team also tested this simpler language with people who are dyslexic or have learning disabilities and found that they were “slightly more likely to use words like poo”.
You might not think that “slightly” warrants a total overhaul of the way an organisation writes, especially when it annoys some people. But in the context of the NHS a slight improvement might mean that many lives are saved or improved.
Working in the open
One thing that’s particularly impressive about the NHS content design practice is its willingness to truly work in the open.
This is made possible partly by the fact that civil servants and public sector employees learn to write everything on the assumption that it will one day be published in The Daily Mail or at an inquiry. I speak from experience, having spent most of a decade working in Westminster.
That means that even behind the scenes discussions can be shared publicly without too much risk.
In the case, the place those conversations happen is on GitHub, where the service manual team maintains an open discussion board, or backlog.
There you can see some of the discussion that led to the current guidance. You can also see that this is an ongoing conversation with potential for the guidance to evolve.
For example, a post from 2023 highlights that complaints are still being received about the use of “juvenile terminology” and that NHSInform Scotland takes a different approach. On that website the word ‘flatulence’ is used by default with ‘farting’ employed a couple of times to explain what it means in plainer language.
Lessons to be learned
Beyond the NHS, and even beyond healthcare, there are a couple of lesson to be learned here.
First, be brave. Focus on the needs of the diverse majority of users rather than a handful of vocal ones. Nobody ever died of being irritated. And if you have evidence to back your decision, stand your ground.
Secondly, get that evidence. Making controversial or counterintuitive choices is much easier when you can point to stats and facts. In my experience, stakeholder objections often melt away when they can see proof that the content works for users. My colleague Antonio has written about how powerful video can be in this context.
Thirdly, think about the unintended benefits. A recent NHS campaign with the tagline ‘Your next poo could save your life’ generated extra publicity because people found it funny. Their inner 5-year-olds couldn’t help but share the link and spread the word.
Learn more
Check out Sparck's offer around human-centred design for healthcare services and read more blog posts about health services on our topic hub.
