Health promotion suffers from a 'conspiracy of passive failure'. Could work in the North West turn it around, asks Stuart Shepherd

No matter how important the issue, how catchy the slogan and how bright the image, it has become increasingly difficult for messages selling health to be heard and seen, competing as they do in an ever busier multimedia marketplace.

Obesity on an epidemic scale, the rise of alcohol misuse and high incidences of depression and anxiety are just some of the indicators of these shortcomings. A lack of in-depth knowledge about how to influence behaviour change, short term policies and planning, and the need to do "something rather than nothing" have all contributed.

"Health promotion specialists have been feeling disempowered in their approach to the challenge," says Marilyn Simpson, social marketing lead director at Ashton, Leigh and Wigan primary care trust. "The National Social Marketing Centre described the situation as a 'conspiracy of passive failure' at an international conference [in 2007]."

The 2006 launch of the centre, a collaboration between the Department of Health and the National Consumer Council, underlined the part to be played by social marketing in delivering national health strategy.

Marilyn Simpson's appointment as Ashton, Leigh and Wigan's first director-level social marketer confirmed the PCT's desire to respond to policy by implementing a structured approach to influencing behaviour change and health.

Ms Simpson says: "Social marketing is about systematically applying some of the principles and techniques used in commercial settings, with its aim set on behaviour changes relevant to the public good. Done well and done right it can work.

"What we are trying to do in effect is market against some of the excess of choice people are currently being given.

"In terms of our local population, we face some real challenges," Ms Simpson notes. "Nearly 90 per cent of the electoral wards in the borough are in the most deprived 20 per cent in the country. Life expectancy is 75 years for men and 79 years for women, both below the national averages."

Hard to reach services

The PCT wants to make substantial changes in a number of areas, including reducing cancer and cardiovascular mortality, cutting the number of alcohol related hospital admissions and lowering the prevalence of obesity. In Ms Simpson's opinion, the biggest driver for this is world class commissioning.

"This is about how we structure plans for the next five years to address those challenges," she says. "A social marketing programme can have a place in the greater scheme of things, but the only way it can be implemented is if it is based on what we offer as a service. That means having product development through commissioned services that are responsive to the needs of the population, clear messages about what's on offer and a call to action."

"Taking a patient centred approach might sound glib, but it is central to what we are doing," Ms Simpson continues. "We talk about hard to reach groups, but often what we offer are hard to reach services. Behaviour change is as much an issue for the practitioner as it is for the population we serve."

The total planning process, which combines scoping, development, implementation, evaluation and follow-up, shaped Ms Simpson's earlier work on tackling late presentation for cancer when she was cancer project management lead for Greater Manchester. Some of the most important learning from it - always start with consumer insight, understand what motivates the key audience, make sure they understand your health improvement message, take it to where they can find it and do it on an industrial scale - is now informing a three-year borough-wide social marketing programme with a budget of£1.4m a year.

"We took the 'don't be a cancer chancer' message and other straplines from an earlier campaign and ran with it over four weeks," says Ms Simpson. "Blanket coverage included all the traditional media outlets as well as 1.5 million bus tickets, through health trainers, in shops and at chemists. To reinforce the message, we will run the whole campaign again next year."

The same basic format is now being used to tackle obesity in the borough.

For Jane Thomas at Liverpool PCT, the concepts of insight and motivation, and what they bring to public health, are very familiar. She is, after all, the organisation's head of insight and social marketing and a former commercial marketer. "As a commissioning organisation," she says, "we have behavioural change objectives that we want to meet.

"Equally, though, we must understand our population so we can commission not just public health interventions but also services based on real rather than perceived need."

Don't ignore data

She believes some of that understanding could be developed from information collected from patients at the various points in their lives when they come into contact with providers.

"We are the only service that interacts with people from birth until death," says Ms Thomas.

"We ask them lots of questions but never seem to pull all the data together. In an anonymised format it could help us commission the services that properly benefit our population."

An example from the strategy to tackle health and social problems caused by excessive alcohol consumption in Liverpool demonstrates how good information helps target messages to key audiences. Through a newly developed public health brand, consumer research has delivered responses to address, in this instance, some of the concerns of younger women.

"When I came into post in 2005, the agencies were effectively putting out competing moderation messages about drink-driving, alcohol related violence, health risks," says Ms Thomas. "Establishing a joint marketing group allowed us to bring our resources together under the "Pssst!" logo, through which all our safe drinking messages and social marketing campaigns can go out."

"We now understand that messages about liver cirrhosis wouldn't motivate a young woman to moderate her drinking in the short term," she says. "But if you put the message in the context of the things that might matter to her, such as weight, and help her realise that the number of alcopops she has in one night is like eating two Big Macs, you find you have more chance of success."