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Summary
Heart attacks kill 94,000 people a year in the UK. Many of those deaths are caused by 'patient delay' - where people having a heart attack fail to call 999 immediately.
The problem is that people donít know the full range of symptoms, and so don't realise they're having a heart attack.
Historically, campaigns - particularly communications campaigns - have been unsuccessful in changing behaviour.
But the British Heart Foundation refused to accept that behavioural change is impossible.
It believed communications could reduce patient delay by raising awareness of the range of heart attack symptoms.
This paper is about how planning challenged its own conventions and assumptions to meet that difficult brief.
Firstly, it challenged the convention of the single-minded proposition.
Secondly, it challenged the assumption that all communications are unwanted; and that to work, communications must therefore impose themselves repeatedly upon peopleís lives
The resulting campaign raised awareness among millions of people of the range of symptoms and has saved an estimated 70 lives so far.
By breaking conventions the film was not just effective; it was useful.
So much so that the "ad" has been repurposed by other organisations and is still being watched long after its paid-for appearances have ended.
Deadly delay
In the UK, someone has a heart attack every six minutes. Sadly, one in three dies before they even get to the hospital.
The problem is that people donít call 999 quickly enough. The NHS has done a terrific job in improving treatment; the ambulance service is quick and skilled. The problem isn't about systems or treatment. Itís about people.
According to research conducted in Glasgow, someone having a heart attack will wait an hour before calling the emergency services.
This is called "patient delay", and it kills people.
Delaying treatment of heart attack reduces the chances of survival.
Amongst those who survive it reduces life expectancy and quality of life.
Why do people delay? Everyone knows heart attacks are dangerous. People delay the 999 call because they don't realise theyíre having a heart attack.
The same Glaswegian research found that ìin all cases where delay was more than one hour the main reasons for the delay were thinking that symptoms would go away or that they were not serious.
Why does that happen?
The Hollywood Heart Attack
Picture a heart attack.
Chances are youíre imagining someone clutching their chest and collapsing with sudden, massive pain.
That's the picture we get from films and soaps.
Some heart attacks do look, and feel, like that.
Many do not.
A huge range of symptoms could indicate a heart attack.
Awareness varies for each.
For example, 82% know about chest pains, 87% know about pain in the arms or legs.
By contrast, only 21% realise that feeling faint or dizzy can indicate heart attack.
Only 23% know to worry about pain in the face or jaw.
Yet any of these symptoms could mean heart attack ñ just as the familiar chest pain could mean heart attack.
The "Hollywood Heart Attack" is a powerful myth. Itís also a deadly one. People think they know heart attacks, but they donít. This is what causes patient delay.
A complicated brief
The British Heart Foundation's previous "Doubt Kills" campaign had focused on ìthe most common symptom: chest pain.
To some extent this approach had succeeded.
Half the audience said theyíd seen it, and 52% said chest pain worries them "a little or a lot" compared with 40% during pre-wave research.
It had done a good job for a single symptom. But what about patients whose heart attacks started with other symptoms? What would stop them delaying their call?
By 2008, the BHF believed that awareness of the full range of symptoms was still ìextremely low.
A new approach was needed. The brief this time was necessarily more complicated.
The objective was still to reduce patient delay, saving lives and reducing damage to the hearts of survivors.
To do that, we needed to ìincrease awareness, knowledge and understanding of the range of heart attack symptoms.
The problem with this will be obvious to anyone trained in the convention of the single-minded proposition.
A "range of symptoms" sounds a lot like a list. Lists are anathema to the brutal simplicity of planning.
This was the first of five factors that made planningís job particularly difficult.
1. No singularity
To move things on from the first Chest Pains campaign, we couldnít just simplify by choosing a single symptom.
This would mean leaving out other symptoms.
We would simply be replacing the movie myth of the Hollywood Heart Attack with a medical myth.
This would, in effect, be picking a large number of future heart attack victims and deciding not to talk to them about their heart attack simply because their heart attack didnít fit with our ideas about how advertising should work.`
We had to communicate as many symptoms on that list as we could.
2. No generalising
Nor could we synthesis multiple symptoms into one generalised story. Five product points could not be bundled into an aggregated benefit.
If we were to raise awareness of specific symptoms, takeout would have to be literal and specific. We had to communicate the uncompressed list.
3. No targeting
We couldnít select a discreet target audience either. 2.4 million people in the UK have heart disease. Any one of them could be the next victim of heart attack. So could any number of apparently healthy 40-something squash players.
4. A need for shared viewing
Even just targeting those likely to suffer a heart attack (assuming that were possible) wouldnít necessarily work.
It's often the partner, not the sufferer, who makes the 999 call. In fact, partners are often the ones who prod, cajole and nag those at risk into taking an interest in their heart health.
So the mainstream audience had to see our list of symptoms together.
5. A need for impact
Those most at risk are often in denial about their condition; or else (for similar reasons) highly apathetic. They ignore information that might help them.
These barriers mean a simple door-drop or website outlining heart attack symptoms won't cut through.
The list had to have visceral impact whilst delivering the detail.
A different kind of problem
So the technical challenge for planning was immensely complicated. Using only mainstream media (i.e. not online multimedia), we had to deliver a message that was simultaneously detailed and impactful.
That detailed message had to reach millions, watching together.
While doing so it had to combine an intense emotional wallop with enough literal attention to detail that people would learn the symptoms of a heart attack, and recognise one if it happened to them.
A different kind of solution
We decided that the only way forward was to look outside familiar genres of advertising. Dramatising one symptom would oversimplify.
A straightforward delivery of information would lack the "teeth" needed to break through barriers. So what else could we do with mainstream media to ensure success?
As it turns out, there is one type of communication thatís expressly designed to do pretty much all we needed to do: simulation.
Simulation is used to teach pilots to fly because flying is complex. Itís also used because the reality of flying is emotionally charged. Simulations work by creating complex models of reality. They provide detail, and then make that detail come alive so participants respond emotionally.
As such, simulation was the perfect vehicle for our message. But it required a different approach to TV advertising.
After all, pearls of TV advertising usually grow from the grit of simplicity. Simulations, on the other hand, rely on viscerally involving detail.
We'd seen a suggestion of how simulation could help us in a focus group.
A respondent whoíd had a heart attack described what it felt like. He could clearly remember the experience viscerally as he spoke about the symptoms he felt.
His story was a world away from a dry list of symptoms.
We (and the other respondents) couldnít help but listen. Despite everything we knew about our list of symptoms, for the first time, we could imagine what it must have been like.
Which made us think: "If only we could give the whole nation a dry run at a heart attack. Then they'd know what it was like."
The dry-run heart attack
Immediately we knew this approach was right even if it would be difficult.
With a limited budget we had to deliver an accurate approximation of what a heart attack felt like to millions of people.
As a simulation, it had to be multi-sensory, detailed, impactful and long. And we needed ours to be experienced by partners as well as those at risk.
This was something only mainstream TV could deliver. But we simply couldn't fit all we needed into a conventional 30î spot.
An effective simulation demanded a longer time-length. On the other hand, we couldn't buy many longer spots on mainstream TV for our £1.35 million media budget.
This meant we had to make a tough decision.
Forgetting ourselves
We would make a filmed simulation of a heart attack. It would be two minutes long.
Anyone who saw it would get a visceral but informative dry-run, covering a range of symptoms, so that when they had a heart attack they would be able to spot it, and call 999.
Then we'd take that film, and weíd run it once on ITV1 - burning a significant part of our media spend in two minutes.
We wouldn't use repetition as a battering ram and force our message into people's minds.
We would create an experience they couldnít ignore and would only need to go through once.
This meant we had to forget we were in advertising.
We had to forget that we spent most of our time creating ephemera that people didnít want to watch.
We had to act like content creators, and make something people would actively seek out.
Simulation made this possible because it meant we could treat our ad like content, investing in creating an audience, rather than solely in delivering a message.
We advertised the filmís exact time slot with TV and radio trailers.
We used celebrities, from David Cameron to Chris Tarrant, to tell the public that theyíd be watching too. People could set online reminders to watch.
And then we'd make the film available online.
Unconventional Success
This unconventional strategy was not an end in itself. It had to deliver conventional results ñ to raise awareness, educate and influence behaviour. Every rule we broke had to be broken to save a life.
It worked.
First, people really did make an appointment to view.
Hall and Partners' tracking showed that a full third of those who remembered seeing it had tuned in specifically.
10,000 people requested email reminders from 2minutes.org.uk, the website set up to support the film.
How many saw it?
BARB data records there were just over 6m people watching when our ad aired: 9.17-9.19pm on the 10th August, 2008.
That means about 13% of the adult population had the opportunity to see and remember the ad.
According to tracking data, 17% of the adult population remembered seeing it.
This suggests that everyone who was in the room at the time it aired remembered it. A remarkably efficient result for a single TV ad.
Crucially, the choice of TV paid off. When interviewed afterwards by Hall and Partners, four out of five of those who remembered the film felt that there was more to heart attacks than chest pains.
Awareness of the five key symptoms featured in the film went up ñ and stayed up in the most recent results.
Inevitably this greater understanding has saved lives.
During the campaign period, there was a two-and-a-half minute drop in the average time between first symptoms and 999 calls.
People called faster.
Based on the value that medical research has placed upon each minute wasted before treatment, we estimate that 70 people who saw our film survived because they called more quickly.
But perhaps the most interesting direct effect of our unconventional approach was something we didnít plan for.
We set out to make a piece of must-see content to solve a communications problem. But in doing so, we accidentally created something others wanted to use.
At the time of writing, the film has been adopted by 5,000 Heartstart UK first aid groups; 20 first aid trainers; and even the London Ambulance Service.
Advertising, whether grand or humble in its manner, is usually simple and ephemeral at heart.
Even when it breaks conventions and lives on in case studies, the advertising itself runs its useful life within a short space of time.
This film was different.
In opting for simulation, and then making useful content, planning engineered a future life for this piece of communication.
So as you read this paper our film is giving more people a dry-run of their first heart attack - and possibly saving their life as a result.
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