One of the constant challenges for charities trying to raise awareness about sensitive issues is how to grab attention, but without being irresponsibly shocking or gratuitously distressing. 

This was the challenge faced by adam&eveDDB when they created a cinema commercial titled ‘Sicker than the patients’ for Frontline19, a charity that supports NHS workers suffering from mental health problems. You can watch the ad by clinking on the link here.  (We should add that adam&eve worked pro bono for Frontline19, and we were pleased to work with adam&eve on the same basis on the defence of this ad.)  

Background 

There had been considerable strain on NHS staff in in recent years, particularly during the Covid pandemic. An article by The British Psychological Society published in 2024 outlined results from an NHS staff survey with 42% of staff saying that they had felt unwell because of work-related stress in the last year, and 30% saying that they often or always felt burnt out because of their work.

Frontline19 is a free, independent, confidential service which aims to help frontline NHS workers seek the psychological support they may need through a network of highly experienced and qualified practitioners. In addition, Frontline19 amplifies the voices of those in need and seeks positive change via advocacy and education.  

So how did adam&eve and Frontline19 strike the right balance between effectively addressing mental health issues without irresponsible shock tactics or causing undue distress amongst the audience? 

Nuanced creative decisions.

Rule 4.2 of the CAP Code says that ads must not “cause fear or distress without justifiable reason; if it can be justified, the fear or distress should not be excessive”. 

The cinema ad portrays a range of situations faced by NHS workers daily, such as a paramedic walking past an empty ambulance; a nurse crying after singing happy birthday to a patient; a staff member in blue scrubs with her hands above her head; a paramedic washing blood from their gloves; a police officer attending the scene of a reported suicide and finding a nurse’s lanyard; and a man sitting next to an incubator. These scenes are followed by on-screen text stating: “With over half suffering from poor mental health many NHS workers are sicker than the patients. Not that they’d ever let you see it”. The ad then returns to the same staff members composing themselves before returning to assist patients and ends with a request for donations, plus a QR code to enable audiences to do so quickly and easily: “Donate now so we can provide the therapy they urgently need. Frontline19. Emotional support for the frontline.” 

Several creative decisions ensured that the ad was realistic by without causing undue distress. The clips are played in quick succession, with the audience unable to dwell on any one moment for too long. The image of the bloodied gloves, which is arguably the most ‘graphic’, is on screen for less than two seconds. Some particularly distressing images were avoided, such as sick children, grieving families, or physical injuries. 

Any reference to suicide is potentially unsettling, but Frontline19 and adam&eve were careful to ensure that the scene was not unduly graphic. The brief scene includes a voice over stating “suspected suicide” before a policewoman says “looks like she works at the hospital” as she hands over a nurse’s lanyard. It is an important element of the ad and its inclusion is justified by the fact that more than 220 nurses attempted suicide during the first year of the pandemic. 

Careful media selection

The creative decisions were backed up by careful media selection to ensure social responsibility and avoid excessive distress.  The ad was given a 12A rating by the British Board of Film Classification and the Cinema Advertising Association Copy Panel approved it for cinema exhibition with 15 and 18 rated films.  In addition, although the ad was exhibited over 24,000 times between 19 April 2024 and 25 April 2024, this was during school term time to avoid school age audiences. The content of ad is also considerably less graphic and distressing than many of the films around which it was shown. As only 5 complaints were made to the ASA, this suggests that any fear and distress was not widespread.

Consistency with previous ASA decisions

As mentioned above, the balance between impact and shock in charity ads is a problem that has been considered by the ASA several times over the years.

As recently as 5^th June 2024, the ASA rejected 235 complaints that an Alzheimer Society’s advertisement was excessively distressing, offensive and irresponsible on the basis: “Whilst we acknowledged the subject matter could be difficult for members of the wider public to watch and hear, we considered the context of the overall message, as raising awareness and promoting support, was likely to be understood in the context of an important cause”. You can read that decision here and our blog post about it here. Geraint's blog also includes a link to the ad itself.

In 2022, the ASA ruled that a TV ad by Campaign Against Living Miserably (CALM) did not breach the BCAP Code.  The TV ad centred on the topic of suicide, sharing personal video clips of men and women smiling before revealing “these are the last videos of people who took their own lives. Suicidal doesn’t always look suicidal”.  The ASA Council concluded that the reference to suicide was not “irresponsible and distressing” despite featuring real people who died by suicide, rather than actors depicting a realistic situation. 

On the other hand, some ads have crossed the line. In 2016, an internet ad for FanBet, a betting company, showed a silhouette of a man hanging. The ASA banned the ad, citing concern that it presented suicide in a “light hearted way” and that it was likely to cause serious offence. FanBet did not provide resources or details to prevent suicide or provide support for those with suicidal thoughts. The in 2019, the ASA also upheld complaints in a Dead Happy ad for life insurance. The paid-for Facebook post, which featured an image of a laughing skull and a man leaning his head against a wall alongside the text “Life insurance to die for”, was found to trivialise suicide. 

Final diagnosis

It is great news that the ASA has rejected the five complaints against Frontline19, showing the extent to which causing distress may be justifiable in the right circumstances. The efficacy of the ad is demonstrated by the fact that it won Silver and Bronze awards at this year's Cannes, but more importantly, it has raised awareness about the important issue of mental health among NHS workers. For more information, visit Frontline19.