DoH guidelines have opened the door for hospitals to use commercial advertising techniques. Is this necessary for healthy competition or a green light for unseemly publicity battles? Kaye McIntosh hears some early pledges of fair play

'Tomorrow's medicine today.'

'Every life deserves world-class care.'

'The most accomplished minds in medicine, working for you.'

All real advertising slogans used by prestigious academic hospitals in the US. Now that the Department of Health has given its blessing to the prospect of UK hospitals advertising their wares, could similar pitches become familiar here?

There is nothing in the guidelines to rule it out, although claims such as: 'We do Botox!' and '25 per cent of all adults are habitual snorers - fortunately, we have a solution' may be a long way off: the proposed code of practice for promoting NHS services rules out anything that encourages patients to undergo unnecessary treatment.

The idea is that healthcare providers (NHS and independent sector) can use adverts or 'promotional activity' to galvanise patient choice. Health secretary Patricia Hewitt says, in the draft code, that this is about making 'more information available to patients and referring clinicians'.

The code, now out for consultation, warns against 'disproportionate' spending on ads or marketing, without setting any limits, although 'the cost of TV or cinema promotion is very unlikely to be justifiable'. Advertising must not be 'misleading, inaccurate, unfair or offensive'.

But ministers have made it clear that trusts could use celebrities to endorse their services, as long as the stars were genuine patients and were not paid. And they can also claim their services are better than those on offer from other providers, as long as comparisons are 'accurate, balanced and fair' - and capable of independent verification.

Alyson Morley, policy officer at the Democratic Health Network think tank, says permission for trust A to compare itself favourably with trust B is a step too far. 'The idea that a local NHS body can say: ì-¥ have a better success rate than another hospitalî ·ill not do much to promote better patient care. This information is not going to improve the quality of care in a local health economy.'

Many people would think NHS resources would be better spent on healthcare, she adds. 'Most people feel uncomfortable at the prospect of the NHS being advertised in the same way as a chocolate bar.'

The unions feel even more strongly. Unison head of health Karen Jennings believes spending taxpayers' money on advertising is 'ridiculous'. And the British Medical Association warns that government policies will force trusts to spend public money on advertising in order to compete against private providers with big marketing budgets.

NHS Alliance chief executive Mike Sobanja believes primary care trusts will look carefully at the impact of acute trust advertising to attract patients on their budgets. 'It is legitimate to bring to the attention of commissioners and practice-based commissioners good things about provider units. I'm not sure it is a good thing to be selling to patients and driving them into particular hospitals. The biggest worry is that money might be diverted from patient care. The thought of doing McDonald's style 칯u're loving itî ¡ds leaves me cold, and would be a misuse of taxpayers' funds.'

Dr Gill Morgan, who helped to draw up the code as chief executive of the NHS Confederation, says aggressive advertising would not be appropriate for the health service. 'What we are not expecting is lots of ads saying: ì???µy's and Tommy's will kill you, come to University College London Hospitals foundation trust

Association of Healthcare Communicators chair Nick Samuels thinks the code could have done more to encourage creativity and innovation. Instead it is 'a long list of don'ts followed by an invoice'.

Enforcing the code

Indeed, the bulk of the document is 'thou shalt nots' but these are often setting limits rather than completely ruling out ideas such as using testimonials from satisfied patients - as long as they are genuine patients and have not been paid, it is OK.

The invoice comes because providers will pay fees to a secretariat set up to enforce the code. Every trust will have to appoint someone to ensure compliance with the code. And providers that are found to have breached the code, or those that make unsuccessful complaints about other providers, will be charged.

UCLH director of service development and marketing Sarah Johnston sees the new code as a way 'to give confidence to ministers that this won't get out of control with everyone spending hugely on advertising'.

In fact, she argues, marketing is a response to patient choice. 'Ultimately patients will benefit from us being more responsive to the needs of patients using our services.'

She is keen to point out that marketing is much more than just ads.

'The people we need to have informed are our GPs and they react very badly to glossy advertising.'

Ms Johnston says UCLH is unlikely to increase her current marketing budget, just 0.05 per cent of turnover, covering the hospital's internet, intranet, annual report and internal magazine.

Mr Samuels expects marketing to account for less than 0.5 per cent of turnover in most trusts. But he agrees with Dr Morgan, who said at the launch of the code that it would be impossible to place an official cap on spending because it is difficult to draw a distinction between marketing and information - do you include patient newsletters or leaflets, for instance? In any event, chief executives thinking of investing large sums in lavish advertising campaigns should take note of the code's warning that the figures must be spelt out in the annual report and on the agenda of the annual board meeting.

Private sector providers are keen to talk down the prospects of big-budget advertising. Capio, which runs a chain of independent sector treatment centres, placed ads in professional journals including HSJ in October and November. Gill Barnes, director of NHS Partnerships, says this was merely making commissioners aware of its services. It worked - hits on Capio's website went up by 15 per cent after the campaign. But she is not planning any boom in marketing activity. 'We are likely to use it very sparingly, when we have committed to investing in a new service or a piece of equipment, when we are keen to show people what is available.'

She expects to spend less than 0.5 per cent of Capio's NHS revenue on marketing. 'Everyone working on the NHS tariff is working on very tight budgets.'

Marketing versus reality

Mr Samuels says the way the health service goes about marketing will have to change: 'NHS communications have been about managing reputation and communicating with staff, not about growing and developing areas of the business.'

But advertising will have to be part of an overall business strategy - a good ad cannot rescue a bad product or 'sustain an inaccurate image'.

Large trusts such as his own, London's Hammersmith Hospitals, see hundreds of thousands of people walk through their doors every year - if marketing doesn't reflect the reality, 'we will be rumbled', he warns.

Instead, hospitals need to identify 'which bits of the business they want to grow' and how much profit they will make from marketing those areas. It's about understanding what you do and what competition you are facing. 'The first question is, how good are we at the day job?' Relationships with the GPs who refer patients and, increasingly, commission services at practice level, will be key.

He is confident that NHS PR and marketing staff can do it in-house, with no need to spend vast sums on flashy external consultants. 'I think people have the skills to manage this and to commission marketing.'

Dr Morgan agrees the new freedom to extend the reach of marketing can be done internally, but warns that 'there is a whole new skill-set we need to develop so we can communicate in new ways, more effectively than the written word'.

One area where marketing could be very useful, she suggests, is where there are not enough patients to maintain local specialties such as eye surgery. Specialist eye trust Moorfields has already announced plans to create 'boutique services' in hospitals across London.

At a time when waiting lists are low, UK patients will want factual information about issues such as MRSA rates or car parking charges, not glossy advertising, she believes.

Dr Morgan believes relatively few trusts will take up the opportunity to advertise to patients. 'If you are sitting where 60 per cent of the population sit and there is only one local hospital around, you won't see aggressive marketing. It doesn't suit our culture and patients would
be offended.'

Download the code of practice for promotion of NHS services at

What marketing will mean
As director of communications at London's Hammersmith Hospitals trust, Nick Samuels says his organisation will make it clear what it does and what it stands for.

'We believe we have a range of services that will distinguish us from other providers. We believe that patients who come to us experience a quality of care they won't get in other places. As a teaching hospital we are at the cutting edge of clinical practice.

'That offers us a unique range of selling points in our health economy that we would be keen to promote.'

Hammersmith's marketing will be 'led by clinicians' - the trust will be asking staff, as its 'ambassadors', how it should be promoting its services. 'We will not invent our marketing strategy in a small room full of people in dark glasses.'

Marketing to GPs will be crucial, he adds, with a responsive GP-handling service, perhaps along the lines of PALS - providing good-quality information, reacting swiftly to resolve any concerns or confusion.

University College London Hospitals foundation trust is also targeting GPs rather than patients. A survey of family doctors in 2006 showed they didn't know about some of the services available. So the trust is updating its clinical services directory, but is also running a series of seminars on topics such as services for young people, showcasing what the hospital can do.

The feedback was that GPs had not realised this was an area the trust specialised in, but they would now consider referring patients.

Director of service development and marketing Sarah Johnston says that in the future, as patients become better informed and more aware about the choices available, there may be a move towards marketing to the public. But for now, 'we will be making sure our GPs know where our expertise is, such as our specific services for adolescents'.