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Tuesday 27 September 2016
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Social considerations

Caroline Kerby 

Managing Partner
Brentfield Medical Centre, Northwest London

Joint Lead
NHS Alliance Practice Managers' Network

Caroline has worked in primary care for more than 20 years. She is the director of management for Harness Care Cooperative, a not-for-profit GP provider company. Caroline is a commissioning lead and sits on the council of the Brent Federation of Practice-Based Commissioners. Her passion is tackling health inequalities and the development of the primary care workforce with the clinician manager partnership at the heart of care delivery

Practice managers are renowned for their ability as influencers in behavioural change in both patients and colleagues. As primary care navigates its way through the current reforms, these abilities will need to be honed and developed as practice teams enter the new world of collaboration and competition.

An understanding of social marketing techniques can be an invaluable weapon both in understanding our patient populations and effectively communicating key messages in a manner that is understood and motivates the desired change. The use of 'social media', such as Facebook or Twitter, may be powerful communication tools and might form part of a social marketing plan but they should not be confused with 'doing' social marketing, which developed as a method to achieve a social good rather than the purely financial aim of a commercial advertising campaign.

General practice faces an unprecedented challenge over the next few years, with increasing clinical need, restricted resources and an increasing workload – in a recent British Medical Association (BMA) survey responded to by 40% of all GPs in the UK, almost nine in 10 said the intensity of their workload has increased in the last five years.(1)

Practices are already contributing towards Quality, Innovation, Productivity and Prevention (QIPP) savings and Quality and Outcomes Framework (QOF) targets by reviewing clinical historic data and changing clinical practice through peer review.

However, to achieve the level of transformation required to maintain financial balance and improve clinical service delivery, substantial behaviour change is required not only from clinicians but also from patients and communities – and from management.

Know your audience
Key to effective social marketing is a detailed understanding of who the target audience is and the most productive methods of communicating with them to achieve a desired change.

Information alone will always be insufficient to achieve long-term behavioural change. We can all think of numerous occasions when we, or someone we know, has attempted to give up smoking, lose weight or drink less, and success has only occurred once their "head was in the right place".

Social marketing interventions help translate the information into accessible messages that the recipient can relate to and absorb, helping them to appreciate the benefit of change.

An example of this is work being undertaken by NHS Brent with the local Somalian population, where uptake of the MMR vaccination is low. A discussion with a local Somalian women's group revealed that the community does not take much notice of written literature, but word-of-mouth is an extremely potent and effective communication tool. This information has been used to continue to work with the community and has prevented waste of costly translation and printing in favour of promoting work with local women to redress concerns about the vaccine.

While learning from professionals is always helpful, social marketing does not have to be a high-cost venture. Practice managers and their teams will be able to identify many areas of primary care where they can think creatively about how to engage with patients, such as:

  • Use of long-acting reversible contraception.
  • Uptake of cancer screening.
  • Improvements in lifestyle – diet, exercise and alcohol usage.
  • Uptake of childhood vaccination.
  • Encouraging early maternity booking.
  • Reducing A&E attendances.

A Christmas message
A colleague recently explained that effective social marketing is as simple as remembering being a child and really wanting something for Christmas – ie, how you went about persuading 'Father Christmas' to make sure the desired item was under the tree on Christmas morning with your name on it. This example fits exactly into four key steps in running an effective social marketing campaign.

  • What is the behaviour you wish to change and what will it cost now and in the future?
    You just knew that Father Christmas believed you would really benefit from another book or a warm jumper.
  • Why do people currently exhibit these behaviours and what will motivate them to change?

    Father Christmas' belief was based on what was sensible and good for you as a responsible adult. Your challenge was to change this belief into one that would be really good for you (a pair of shiny roller skates or that robot with flashing lights).
  • How will you deliver the message?
    
This one was easy and usually involved vastly improved behaviour, washing up, bedroom tidying, dog walking and even possibly getting on with your siblings to set the scene. It then involved going in for the kill with some serious hint-dropping and conversations about how absolutely everyone else had the desired object bought for them by the world's most caring and understanding parents – emotional blackmail was always sure to deliver.
  • How will you measure the success of your intervention and return on investment?
    
Again, nice and easy and clearly observable by the large box in robin-covered paper taking pride of place at the end of your bed, worth every angelic smile and grovel. Happy days!

So, what is it that four-year-olds know that we have forgotten?

Demographic reminders
The answer is, firstly, a very good ability to understand and interpret three key aspects of their parents' perceptions, motivations and values. Secondly, the ability to focus on what is most important to them and the determination to achieve it at all costs. The third is an innate ability to reinvent themselves into whatever paragon of virtue the key decision-makers most desire.

This is true of our patients and the populations for whom clinical commissioning groups (CCGs) will be responsible. We will have to work differently if we are to begin to appreciate the less tangible information we require alongside the harder social demographic data or public health profiles we currently work with.    

Harness Commissioning Group in Northwest London worked with communications experts Eleven Social to pilot the combined use of social marketing and clinical auditing to reduce non-elective admissions for paediatric asthma. This work involved analysing non-patient identifiable registration data to profile patients using 'MOSAIC' data to understand their socio-demographic profile, background, lifestyle and communication preferences.

A doctor simultaneously carried out a clinical audit of non-elective admission of patients aged 0-14 years during the preceding year for asthma. A pharmacist reviewed prescribing patterns in the audit practices and shared the outcomes with the clinical audit data. A social map was created showing disease prevalence and geographic hotspots within the group's catchment area.

The resulting analysis was used to draft a social marketing plan focused on changing patient, parent, teacher and clinician behaviours in improved management and reduced admission for childhood asthma.

Summary
The patient participation direct enhanced service (DES) challenges practices to understand the complex make-up of their patient population and to use this information to make sure their patient representative group does, in fact, attempt to represent the diversity of patients.

As human beings we all have our own perceptions and assumptions about how the world is and our role in it. The stark reality is that we all understand that radical transformation is needed if our NHS is to be financially able to stay true to its founding values.

The essence of clinical commissioning is for the transformation to be led and informed by frontline clinicians who understand local need. To achieve the full potential of frontline knowledge and insight, the use of high-level data combined with a focused approach to understanding how truly to relate and influence the preferences and assumptions of our patients and their communities can be a powerful force for change. An unexpected but interesting side effect is often that we will change our own view of the world at the same time.

Reference
1. British Medical Association Health Policy & Economic Research Unit. National survey of GP opinion 2011. London: BMA; 2011. Available from: http://www.bma.org.uk/images/gpnationalsurveyresults2011_v2_tcm41-210046...