Public services in the UK have been slow to develop social marketing. Can the NHS reclaim the term so it is no longer thought of simply as spin? Caroline White reports

If the health service is to become truly patient led, it must first be market led, argued the Chartered Institute of Marketing in its recent paper on the use of marketing in healthcare. But it also suggested that the concept of marketing is widely misunderstood in the NHS, and is often perceived as just "spin or advertising".

Social marketing, which aims to change behaviour for "social good" rather than for commercial gain, fares little better. The government is keen to use it for public health initiatives and to narrow health inequalities. Every strategic health authority is to have its own social marketing adviser to help it understand and deploy the techniques properly.

Borrowing from commercial marketing techniques, social marketing has been around for 30-odd years but came to prominence in the UK health sector with the public health white paper Choosing Health in 2004.

It aims to be customer focused and user friendly. Campaigns are shaped by a deep understanding of the knowledge, attitudes and beliefs of those in the target groups - smokers, for example - and by recognising the differences within those groups.

The technique uses a range of approaches to achieve a specific behavioural change, acknowledging that people have many pressures and demands in their lives.

Although it can be tailored to different contexts and timeframes, it comprises several stages, all of which have to be systematically applied, topped off with careful monitoring and evaluation against benchmark criteria.

Although social marketing has been widely used in the US and Australia, National Social Marketing Centre director Jeff French thinks the UK has been slow on the uptake.

"Generally in public services, marketing and communications is a lower-order priority than it should be," he says. "But now there's a shift towards the business model, which focuses on the customer as the main driver for better products and services."

Language of change

However, Professor French acknowledges that there is a degree of suspicion about the concept. "The language can get in the way," he says. "People have a negative view of words like 'customer' and 'marketing', with their overtones of privatisation in the NHS," he says. "But the outcome is not about profit but about behavioural change."

Lisa Cohen, who used to work in Scotland on health improvement and promotion before becoming director of private consultancy firm XL Communications, became interested in the potential of social marketing over a decade ago.

She now helps primary care trusts set up social marketing projects, and worked on the West of Scotland cancer awareness project. This aimed to boost the earlier detection of mouth cancer among those most at risk: primarily men over 50 who are heavy drinkers and smokers.

The project made use of a wide range of media, including TV, as well as training for healthcare professionals, service redesign and a review of patient pathways.

"There's still a lot of misunderstanding about what it's all about," says Ms Cohen. "Raising awareness of an issue is not social marketing nor needs assessment."

Nor is jumping straight into an intervention without doing solid groundwork first. The project spent a year gathering its research, finding out what would enable people to go for a check-up and working extensively with healthcare professionals, who are central to supporting change.

Key funding

The project was given£1.3m from the Big Lottery fund. Ms Cohen agrees it is a hefty sum, which trusts might baulk at. Campaigns can be run on much smaller budgets; social marketing requires an initial outlay, and that may not come cheap.

Professor French of the Social Marketing Centre agrees "front-end investment" is essential. He suggests that as the technique becomes more widely used, trusts will be able to benefit from others' findings and sharpen them for local use.

"But PCTs are right to be anxious and demand evidence that social marketing works and that they are going to get a good return on their investment," he says, suggesting that accountability at senior level is essential.

Healthcare professionals' reactions to the mouth cancer campaign also revealed the divide in thinking about prevention and the limitations of finger pointing.

"At the beginning, the professionals said 'you have to tell people about prevention, and to cut down on the booze and stop smoking'. But our research told us that if we went in with those messages, we would just put them off," says Ms Cohen.

When the numbers of patients presenting to secondary care were tracked, 62 per cent said the campaign had prompted them to act. Half the cases of pre-cancerous changes and one in three of those with cancer owed the detection of their condition to the campaign.

See to believe

Diana Forrest is director of public health in Knowsley PCT, an area of high deprivation in the North West. Social marketing was applied to smoking cessation in her borough. Clinicians and PCT staff who were initially reluctant were "sold on the idea" once they could see what a difference it made, she says.

"In the past, we tended to carry out a consultation after we had decided what we were going to do. Social marketing completely changed the way we approached smoking cessation."

This included the type of support provided - changing to a social enterprise which employed people who had quit smoking themselves and upping the number of venues from eight to 56. Knowsley went from having one of the worst quit rates in the country to consistently being among the top three performers.

"You also need to do it systematically. If you cut corners, you don't get the results," she says of the£1m programme's success. "That's particularly important the first few times you use it. Once you have the information, you can transfer it to other projects."

Manchester PCT director of corporate affairs Zoe Cohen agrees. "We need to grow our capacity in order both to commission it properly and to understand its opportunities," she says.

She adds that it offers many organisational development opportunities and helps to focus on priorities for strategic plans: "It has very clearly contributed to our understanding of what we need to do to be a world class commissioner."

It can be an important tool for narrowing race inequalities, she says, by providing "a great opportunity to understand different cultures in different cities", ensuring their voice is really heard, adding that it need not be confined to understanding patient behaviour, but could also be used to find out why general practice staff are so reluctant to record ethnicity, for example. While its potential is considerable, she nevertheless thinks trusts should be realistic.

"It is just one of the tools we have. It's not a panacea and it's not a quick fix solution. And in some specialist areas it just won't be applicable. But it is a way of helping PCTs understand what their job is about."