Selling health to the public

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We are all used to advertisements urging us to try the latest in jeans, mobile phones, television programmes, and beer. But should the NHS use its resources to entice us to seek its services, such as flu vaccination or screening for cervical or breast cancer?

The problem with advertising is also its strength—namely, that it quickly delivers a short memorable message, such as “Don’t let the flu turn on you,” which is NHS Scotland’s plea for you to roll up your sleeves for a seasonal vaccination. The campaign leaflet depicts a sketch of a man connected to an oxygen mask and a drip. Inside we are told, “Anyone who suffers from heart or lung problems, has certain other medical conditions, or is 65 or older, should get the flu vaccine.” Stephen Fry provided the voiceover for an official national advertisement for the NHS in 2008, stating, “If you knew about the flu, you’d get the jab”; but the NHS now seems to produce different but similar advertisements in different regions, with the message that everyone in groups at risk should make an appointment at their general practice.

When it comes to cervical screening, NHS Scotland has produced pink themed posters featuring smiling young women and asking viewers to “put it on your list” of things to do. Similarly, breast screening also occupies the same lurid end of the colour range, with NHS South Essex having launched a campaign that features topless women covered with calendars and stating, “The earlier the diagnosis, the better the outcome, so 30 minutes every 3 years is a date we never miss.” One woman is quoted as saying, “It’s a no brainer finding the time for screening.”

Posters from the NHS breast screening programme implore the reader, “It’s time to look after yourself.” At the bottom of the poster, shot with a woman with her grown-up children in the background, it says, “You’ve looked after them all their lives. Now, how about you? The NHS Breast Screening Programme saves 1400 lives every year. All women aged 50 or over are entitled to regular breast screening. Some things are worth making time for.” Bowel cancer screening is the subject of several NHS posters, one of which is luminous yellow and says, “You can’t always see the signs. 60+. Take the test. Bowel cancer is the third most common cancer in the UK. The earlier it’s found, the more effectively it can be treated.” Another poster, this time in bright orange, comes with the message, “Eat well. Keep fit. Use the test kit.”

But the short messages beloved of advertising campaigns don’t make it easy to convey unbiased information to readers. Although it’s easy to set out catchy emotional clichés, it’s far harder to inform people of the availability of such services while treating them as competent adults, capable of deciding on the merits of healthcare interventions for themselves. Flu vaccination campaigns, for example, do not explain that Cochrane reviews have found a lack of evidence of usefulness in vaccinating people older than 65 years1 and uncertainty about whether vaccinating people with asthma reduces flare-ups,2 but they have found some evidence for reducing the frequency of exacerbations in chronic obstructive pulmonary disease.3

When it comes to breast screening it is apparent that the rather more complex messages of systematic reviews focusing on the ratio of potential benefits and harms are somewhat obscured; the most recent evidence indicates that, for 2000 women invited for screening throughout 10 years, one will have her life prolonged; 10 healthy women, who would not have been given a diagnosis if they had not been screened, will have a diagnosis of breast cancer and will be treated unnecessarily; and 200 more will have a false positive result.4 Cervical cancer screening, similarly, is not a process quite as simple as adding to a health shopping list but an intervention with potential hazards. For example, a modelling study published in the BMJ in 2003 indicated that about 40% of women were likely to have an abnormality detected in screening that would require further testing and follow-up.5 About 1000 women have to be screened for 35 years to prevent one death, and screening will reduce, not stop, deaths from cervical cancer. It is also known that some screening related interventions are capable of doing harm—for example, cone biopsy can lead to premature labour.6 Is it fair to use the snappy lure of advertisements to draw customers in?

The question of whether advertising works has been in part answered by a recent review in the Lancet concluding that some public health campaigns have had a measurable effect on uptake of services or in changing behaviour.7 Crucially, however, the measurable outcomes have not included how well the evidence is imparted and explained or how people are enabled to make the best use of it.

It could be argued that posters like these merely do a duty of informing a public that services are available and provide a push for people to get further information about benefits and harms of that intervention. However, we have no evidence that they do. Rather, NHS advertising has the potential to overshoot the evidence, and none of the current NHS advertising highlights the fact that flu vaccinations and screening interventions are choices with nuances rather than stipulations. True, advertising would find it hard to do anything but. Yet the NHS is meant to be more than spin. Do we really need any of this advertising anyway?