‘No Decision About Me,Without Me’: A place for social marketing within the new Public Health architecture?

Abstract

July 2011 marked the 40th anniversary of social marketing. However, while the previous Labour administration dedicated sustained resources and support to developing the field of social marketing, this was followed by a time of uncertainty during the Coalition Government’s ascent to power. This paper explores the potential future position of social marketing within David Cameron’s evolving public health landscape, outlining areas of synergy between social marketing’s key features, and the coalition’s emergent public health architecture. The paper concludes with an exploration of the development opportunities nascent within social marketing, suggesting that support for the new commissioners (GP and local authority), and an enhanced emphasis on evaluation of financial and social outcomes, will be required if the evidence base for strong practice is to continue to grow and evolve.

Keywords

big society coalition government public health social marketing

Introduction

July 2011 marked the 40th anniversary of social marketing as a discipline first defined by Kotler and Zaltman in 1971:

‘Social marketing is the design, implementation, and control of programmes calculated to influence the acceptability of social ideas and involving considerations of product, planning, pricing, communication, distribution and marketing research’.¹

More recently, the National Social Marketing Centre (NSMC) in England has defined social marketing as ‘the systematic application of marketing, along with other concepts and techniques, to achieve specific behavioural goals for a social good’.² In addition, the NSMC has defined the key features (known as the ‘benchmark criteria’), which distinguish social marketing from more generic public advertising or health promotion campaigns. These include Fundamental principles such as ‘Consumer Orientation’, ‘Exchange’, ‘Market Segmentation’, ‘Methods Mix’, ‘Competition Analysis’, and clear ‘Behavioural Goals’.³ In essence, then, the aim of social marketing, is voluntary behaviour change for the benefit of society, and the discipline has a wide range of applications within the public health arena.

The evidence base for the impact of social marketing is strong, both internationally and in England. In June 2006, the NSMC published ‘It’s Our Health!’,⁴ a review of the social marketing evidence base, which demonstrated the impact of the discipline when positioned as part of a more wide-ranging strategic approach to public health, and recommended the development of a national social marketing strategy to ‘improve the impact of our efforts to improve people’s health’.⁵

As suggested by the ‘It’s Our Health!’ report, one of the unique features of the previous Labour administration was its sustained endorsement of social marketing, both as an academic discipline, and as a potentially effective behaviour change methodology. Under Tony Blair and Gordon Brown, a public commitment to social marketing was sustained, through the 2004 ‘Choosing Health’ White Paper,⁶ the 2006 ‘It’s Our Health’ report,⁷ and the 2008 ‘Ambitions for Health’ Strategic Framework.⁸ Leading the way amongst the international social marketing community, the Labour Government launched and funded the National Social Marketing Centre⁹ as a centre of excellence for the discipline, as well as funding large-scale, national social marketing programmes, including Change4Life,¹⁰ Think!,¹¹ and national strategies for alcohol¹² and tobacco.¹³ Each of these case studies is published on the NSMC’s evidence resource, ShowCase¹⁴ (along with around 50 other successful programmes), and evaluations, where robustly conducted, show a tangible impact on health behaviours (although it is acknowledged that the practice of evaluation still needs to be strengthened within the field).¹⁵ However, the ascent of the Lib-Con Coalition Government in May 2010 marked the end of this era of guaranteed centralised support, and a period of uncertainty for the social marketing community, during which budgets were frozen or reviewed, and guidance on future policy direction tenuously anticipated.

With Health Secretary Andrew Lansley’s first speech on public health, it became clear that his vision for a new Public Health Service, which would support society to work together to get healthy and live longer, had social marketing very much at its heart:

“Effective social marketing is the essential tool to better understand your local population and empower your community to manage their own health and meet the government’s vision”.¹⁶

The Public Health White Paper, published on 30 November 2010, confirmed this commitment:

“Central government will sequence social marketing for public health through the life course, so that, at each stage in a person’s life, there is a meaningful and trusted voice…We will trial new ways of changing behaviours, using emerging ideas from behavioural science, such as the use of social norms, changing defaults, and providing incentives. We will publish a social marketing strategy, setting out our plans in more detail, in Spring 2011.”¹⁷

Behaviour change tools such as applied social norms theory, or incentivisation (‘exchange’), have underpinned good social marketing practice for decades, and there is little new in Lansley’s statement of intent. The Department of Health’s new social marketing strategy, ‘Changing Behaviour, Improving Outcomes: A New Social Marketing Strategy for Public Health’ (April 2011), makes it increasingly clear that opportunities are emerging from the evolving public health landscape, which offer the potential for alignment between enhanced social marketing practice and the centralised precepts of the Coalition Government.

A landscape of opportunity

“My vision is for a new Public Health Service which…draws together a national strategy and leadership, alongside local leadership and delivery and, above-all, a new sense of community and social responsibility”

(Andrew Lansley, Health Secretary).¹⁸

The new public health agenda creates significant opportunities for embedding key social marketing principles within local and national work streams. Three significant developments are noted below:

1) Creating a ‘Big Society’: co-owned interventions

Cameron’s vision of the Big Society marks a political aspiration for a redistribution of power to “the man and woman on the street”,¹⁹ but has been heavily criticised as being “all about saving money”,²⁰ by creating a volunteer-led “cut-price alternative”²¹ to decent public services. With the withdrawal of Liverpool City Council from big society plans, the initiative received a high profile public vote of ‘no confidence’ from one of the proposed pilot cities.²²

However, this strain of scepticism is underpinned by a feeling amongst local authorities and communities that ‘we have been doing this for years’, as community groups and volunteers have increasingly been given more control over the design and delivery of local services. Social marketing evidence suggests that the big society ambition has its foundations in a proven model, whereby engaging volunteers and local communities in creating their own solutions heralds a significant opportunity for sustainability and impact.

At the heart of social marketing is the individual as ‘customer’, and successful programmes ensure that, not only are this customer’s needs and aspirations understood, but they are fully engaged in the process of co-creating solutions that enable long term behaviour change. Despite Liverpool’s withdrawal from the big society, in both Liverpool and Knowsley, ‘Roy Castle’s Fag Ends’ represents an example of exactly this move towards community and individual empowerment, and the results are impressive. Unlike traditional NHS smoking cessation services, which are often run in clinical settings by clinical staff, and follow a more conventional ‘command and control’ approach, ‘Fag Ends’ is a service that has been designed by its users, and which is run ‘by people like us, for people like us’.²³

Staff are trained community members, sessions are held in well-liked community venues that have been selected by users, and promotion is carried out locally by word-of-mouth. The service helps thousands of local people to quit each year, and according to 2007-2008 national league tables, more people have quit smoking in Knowsley than anywhere else in England. More importantly, because the service has become embedded locally, in the communities that most need it, it is now co-owned and jointly delivered in such a way as to ensure sustainability.²⁴

It is this type of delivery that will be essential if Cameron’s vision for the Big Society is to be achieved. Instead of a top-down dictation of centralised commands, big society ideals promote a redistribution of the power of decision-making to the people who are best placed to advise on their own individual requirements. What Cameron needs to ensure is that a distinct separation is made between big society aspirations for community empowerment; and public spending cuts.

2) Shifting from ‘illness’ to ‘wellness’: a focus on social determinants

Amid the Government’s move to re-embed public health within local authorities,²⁵ a strain of anxiety is emerging. At a recent debate, jointly hosted by Finnamore²⁶ and the think tank, Reform,²⁷ top public health professionals and politicians discussed the implications of this move, voicing concern that ring-fencing public health budgets and transferring pre-formed teams directly into local authorities would in fact reinforce the delineation and separation of public health that this move is intended to counter. Whilst this risk should not be overlooked, the move heralds a Government commitment to addressing “the root causes of ill health”,²⁸ and a significant opportunity for health issues to be re-instated within the environmental, social and demographic contexts that drive them. Sir Michael Marmot’s strategic review of Health Inequalities underscores the cumulative impact of social factors such as education, occupation, and social cohesion, reminding us that health is not an isolated issue, but that “action on health inequalities requires action across all the social determinants of health”.²⁹

By seeing the individual as part of a complex web of influences, social marketing has already moved health programmes back towards their social determinants, paving the way for this more holistic, upstream approach. In Liverpool, for instance, poor housing conditions cause up to 500 deaths and 5,000 illnesses requiring medical attention each year,³⁰ with rates of excess winter deaths as high as 242 per year,³¹ and accidents in the home accounting for half of all accidents (estimated 77 deaths per year) in Liverpool.³² In response, the innovative ‘Healthy Homes Programme’ has been established as a partnership between Liverpool PCT and City Council. The programme has identified and targeted over 15,000 high risk properties, with a specialist work force visiting each property to assess the health needs of each occupant, and prioritise 2,750 premises for HHSRS³³ inspection.

At each visit, referrals are made into health and well-being related services across the partnership (e.g. GP, dentist, smoking cessation, benefit maximisation, employment, age concern), and Home Safety promotion is undertaken (particularly for under 11s and over 65s). Through the removal of hazard exposure, the programme is designed to reduce premature deaths by up to 100 when fully implemented and reduce GP consultations and hospital admissions by over 1000 cases.

Between April 2009 and December 2010, 13,006 properties were visited, with 13,022 referrals being made to support partners (37% of service users were receiving benefits), and 2,511 HHSRS inspections being carried out. In support, 51 health promotion events have been hosted through the programme, giving a strong public visibility to the social marketing programme.³⁴ By combining health support with tangible housing improvements, the programme is making considerable progress against Marmot’s first and fourth policy objectives: “give every child the best start in life”, and “ensure a healthy standard of living for all”.³⁵

3) Strengthening the role of GPs: public health as everybody’s business

Whilst detailed plans are still under consultation, the Government has committed to strengthening the public health role of GPs, by improving equitability of access to GP public health services and outcomes; increasing public transparency about how effectively GP practices provide public health advice; and developing a workforce strategy to ensure appropriate GP training around public health.³⁶

Most significantly, incentives and drivers for GP-led public health activity will also be designed, with proposals for a sum that is 15% of the current value of the QOF³⁷ being devoted to evidence-based public health and primary prevention indicators from 2013.³⁸ There are some concerns about the prominence of GPs within the new public health landscape, but social marketing again demonstrates the value that can be gained from engaging GPs in the health improvement agenda.

‘Early Detection of Lung Cancer’ is a social marketing programme, run in Doncaster to raise awareness of early symptoms of lung cancer and increase the number of people with potential symptoms presenting to 11 prioritised GP surgeries.³⁹ The customer ‘push’ side of the programme is pitched around a specific call to action: ‘if you have a persistent cough that lasts for over 3 weeks, ask your GP about a chest x-ray’.

For this to be effective, however, a strong service ‘pull’ element has also been developed, to ensure GP preparedness and support for an uplift in service demand. This has involved not only capacity planning and tailored training within targeted GP surgeries (including brief intervention training and reminders about NICE guidance on referral with suspected cancers), but also work with radiology departments to ensure sufficient capacity for increased chest x-rays, and understanding of this capacity amongst GPs to reduce their concerns about overloading radiologists with new referrals.

Prior to the programme, 64% of people said they would ask for an X-Ray when visiting the GP with a ‘bad’ cough; this increased to 76% following the intervention. Chest X-Ray referrals were also reviewed, and a comparison with the same 6 weeks of the previous year showed an increase of 40% across Doncaster (31% increase in non-targeted practices; 80% increase in targeted practices).

Comparing the 6 weeks pre- and during- the intervention also showed an increase of 13% in chest x-ray referrals (9% increase in non-targeted practices; 27% increase in targeted practices).⁴⁰ Such strong outcomes suggest that, if positioned in such a way as to align service delivery and demand, a strengthened role for GPs within public health harbours significant opportunities for balancing push and pull interventions as standard practice.

Key Challenges: Making The Vision Real

The new public health landscape remains fraught with uncertainties and debate, and emerging propositions remain contested by opponents and advocates alike. However, there are three key areas where ramifications will be felt within the evolving discipline of social marketing:

1) Support for the new purchasers

Health-related social marketing has traditionally been commissioned by Primary Care Trusts in England. As the new purchasers, GPs and local authorities will need to become familiar both with the business case for, and principles of, effective social marketing. This will require rapid skills development, with appropriate support to ensure quick adoption and spread of social marketing tools, evidence and theory. It will also require dedicated engagement work with GPs who, as a cohort, can traditionally be difficult to engage due to time and resource pressures.

2) Application of low cost approaches

Despite ring-fenced public health funding, widespread cuts across the public sector, and the move towards a volunteer-led ‘Big Society’ (i.e. finance-free) horizon, will require a new commitment to delivering social marketing on a shoestring. The discipline is already well positioned in its approach to engaging non-financial resources to achieve change (e.g. using people’s time and skills, or mobilising community leaders and networks). However, a renewed pressure on budgets will demand an even more innovative approach to identifying and mobilising existing individual and social assets, in order to embed behaviour change locally, and at minimal cost.

3) Development of evaluation competence

The social marketing community has responded well to increased pressure for robust evaluation, and its evidence base is steadily growing. However, this pressure is set to increase further with the introduction of the Public Health Outcomes Framework, and proposed health premiums.⁴¹ Not only will programmes need to demonstrate measureable impact going forwards, they will also be required to show return on investment and value for money, demanding a stronger focus on economic evaluation than has previously been the case, and a tighter prioritisation of resource against both outcome and need.

Evaluation criteria will be further complicated through the focus on social determinants, requiring a revised focus not just on the health outcomes of specific programmes (e.g. teenage pregnancy indicators), but also on the social determinant outcomes that the programme has been designed to influence (e.g. education, employment, income status). Again, this will put demands on social marketing commissioners to ensure appropriate evaluation and outcome frameworks are developed.

Conclusion

Social marketing is a stand-alone, internationally-evolved discipline, with a robust evidence-base to support its continued growth and development across the globe. It is not an appendage of this or the last UK Government, and its continued existence is testimony to strong behavioural outcomes, rather than to any specific era of political endorsement.

However, as with all disciplines that are promoted to address a current time’s pressing issues, social marketing does run the risk in England of ‘going out of fashion’, or being discarded by practitioners and policy-setters alike as ‘the last administration’s fad’.

It is encouraging, therefore, to observe that, in spite of a year of unprecedented upheaval within England’s health sector, many of the core concepts of the new public health narrative suggest an important alignment with social marketing’s key tenets. In seeking to change individual and communal behaviours for the collective good, social marketing commits to seeing the person in the round, not seeking to fix an isolated condition, but integrating care, support and encouragement around a person’s holistic needs and aspirations.

Today’s evolving public health landscape claims to have a similar commitment at its heart, so that, whilst there may be a need for social marketing to ‘flex’ to new market conditions, this will be underpinned by the core underpinning precepts of customer insight, community mobilisation, and a social determinants approach to change.

Rather than leaving social marketing behind, then, as an outmoded Labour trend, the new administration gives political momentum to the discipline, heralding new horizons and a move to integration of its principles throughout the public health landscape. The coalition’s push for big change across society places social marketing at the heart of an exciting opportunity for change, which sees the individual regaining power and the state realigning services around his or her personal needs. As noted by Patrick Ladbury of the National Social Marketing Centre:

“The coalition’s emphasis on the big society, and the importance of behaviour change (marked by the establishment of the new ‘Behavioural Insights’ team) show just how important social marketing still is to the work of central and local government”.

On this 40th anniversary year, the future ahead seems long for social marketing, both at the operational level of individual behavioural change, and at the strategic level of the emerging Government’s public health policy.

References

Kotler

Zaltman

(1971). Social marketing: A planned approach to social change. Journal of Marketing 1971; July(35): 3–12. Available at: http://bit.ly/jBzK88

National Social Marketing Centre, 2006, http://www.nsmcentre.org.uk/

National Social Marketing Centre, ‘Social Marketing: The Basics’, 2010, http://www.nsmcentre.org.uk/content/starter-10

National Social Marketing Centre, ‘It’s Our Health!’, June 2006, http://www.nsmcentre.org.uk/sites/default/files/itsourhealth.pdf

‘Choosing Health’ White Paper, Department of Health, 2004. http://www.dhcarenetworks.org.uk/_library/Resources/ICN/Choosing%20Health%20White%20Paper.pdf

‘It’s Our Health’, July 2006, was an independent report commissioned jointly by the National Consumer Council (NCC) and the Department of Health (DH) as one of the commitments set out in the public health White Paper Choosing Health. http://www.teespublichealth.nhs.uk/document.aspx?id=4130&siteID=1012

‘Ambitions for Health’, Department of Health, 10 July 2008, http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_090348 . ‘Ambitions for Health’ was a strategic framework for maximising the potential of social marketing and health-related behaviour, by providing a framework for action on social marketing and public health.

Established by Government in 2006, The National Social Marketing Centre is a centre of excellence for social marketing and behaviour change in the UK. http://thensmc.com/about-us.html

10.

Change4Life is a national programme to promote increased exercise and improved diet amongst children and parents, in order to address the rising obesity trend. http://www.nhs.uk/change4life/Pages/change-for-life.aspx

11.

Think! Is a national programme to increase road safety. http://www.dft.gov.uk/think/

12.

The previous Government’s national alcohol strategy was firmly grounded in social marketing principles. http://thensmc.com/resources/showcase/a-z-of-titles.html?task=view&id=98

13.

http://thensmc.com/resources/showcase/search-case-studies.html?task=view&id=103 .

14.

ShowCase, National Social Marketing Centre, http://www.nsmcentre.org.uk/resources/showcase

15.

Christopoulos

See A

Reynolds

, Evaluating social marketing: Lessons from ShowCase. Perspectives in Public Health 2009; 129(6).

16.

Andrew Lansley speech, 7 July 2010, published by Breathe on 15 July 2010. http://www.breathe-media.co.uk/news/home/health-secretary-encourages-social-marketing/

17.

‘Healthy lives, healthy people’ White Paper, 30 November 2010. http://www.dh.gov.uk/en/Publichealth/Healthyliveshealthypeople/index.htm

18.

Lansley

Andrew

, Health Secretary, sets out future of public health, 7 July 2010, http://www.dh.gov.uk/en/MediaCentre/Pressreleases/DH_117228

19.

Cameron

David

, 19 July 2010, http://www.bbc.co.uk/news/uk-10680062

20.

Prentis

Dave

, general secretary of Unison, 19 July 2010, http://www.bbc.co.uk/news/uk-10680062

21.

Prentis

Dave

, general secretary of Unison, 19 July 2010, http://www.bbc.co.uk/news/uk-10680062

22.

‘Liverpool withdraws from government ‘big society’ pilot’, BBC News, 3 February 2011, http://www.bbc.co.uk/news/uk-england-merseyside-12357450

23.

A full case study is available on the National Social Marketing Centre’s ‘ShowCase’ resource, at: http://thensmc.com/component/nsmccasestudy/?view=single&section=benchmark&id=79

24.

25.

Healthy Lives, Healthy People: our strategy for Public Health in England, November 2010, http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_122347.pdf , p.9.

26.

Finnamore is the UK’s largest independent health consultancy, and won the Health Investor’s Award for ‘Best Consultancy 2010’. Finnamore manages 15 national Healthy Places, Healthy Lives sites, as well as overseeing the Core Cities Health Improvement Collaborative, to build public health best practice between England’s 8 largest cities. http://www.finnamore.co.uk/

27.

Reform is an independent, charitable, non-party think tank whose mission is to set out a better way to deliver public services and economic prosperity. http://www.reform.co.uk/About/Reform/tabid/62/Default.aspx

28.

29.

Marmot

Fair Society, Healthy Lives: The Marmot Review, February 2010, http://www.marmotreview.org/ , p.15. Healthy Lives, Healthy People: our strategy for Public Health in England, November 2010, http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_122347.pdf , p.4: the White Paper ‘responds to Professor Sir Michael Marmot’s Fair Society, Healthy Lives report and adopts its life course framework for tackling the wider social determinants of health’.

30.

BRE estimates. Liverpool’s 5,500 rented properties contain in the region of 7,500 category 1 hazards (2006 stock condition survey); Liverpool has the worst overall rate of fuel poverty in the country at 7.5% - some wards approach 50% (CSE 2003); For each winter death, there are 8 emergency admissions (DoH); 27% of households in Liverpool lack central heating (2006 stock condition survey). www.liverpool.gov.uk/healthyhomes .

31.

2009 NHS profile. www.liverpool.gov.uk/healthyhomes .

32.

2008 PCT estimate. www.liverpool.gov.uk/healthyhomes .

33.

The Housing Health and Safety Rating System (HHSRS) is a risk based evaluation tool to help local authorities identify and protect against potential risks and hazards to health and safety from any deficiencies identified in dwellings. It was introduced under the Housing Act 2004 and came into effect on 6 April 2006. It applies to residential properties in England. http://www.communities.gov.uk/publications/housing/hhsrsoperatingguidance

34.

For more information, contact Stewart Petrie, Stewart.Petrie@Liverpool.gov.uk, www.liverpool.gov.uk/healthyhomes.

35.

Marmot

Fair Society, Healthy Lives: The Marmot Review, February 2010, http://www.marmotreview.org/ , p.15.

36.

See: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_122347.pdf, p.62.

37.

The Quality and Outcomes Framework (QOF) is a voluntary annual reward and incentive programme for all GP surgeries in England, detailing practice achievement results. It is not about performance management but resourcing and then rewarding good practice. http://www.qof.ic.nhs.uk/ .

38.

The funding for this element of QOF will be within the Public Health England budget. http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_122347.pdf , p.62.

39.

A full case study is available on the NSMC’s ShowCase resource, at: http://thensmc.com/component/nsmccasestudy/?task=view&id=85

40.

41.

Proposed Public Health changes will “be supported by a proposed public health outcomes framework and a ‘health premium’, which will incentivise local government and communities to improve health and reduce inequalities, while leaving them free to decide how best to do this, in line with local needs. Data will be published to make it easier for local communities to compare themselves with others across the country and to incentivise improvements”, http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_122347.pdf , p.26.