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Arts on Prescription: A review of practice in the UK Hilary Bungay and Stephen Clift Perspectives in Public Health 2010 130: 277 DOI: 10.1177/1757913910384050 The online version of this article can be found at: http://rsh.sagepub.com/content/130/6/277

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Paper Arts on Prescription: A review of practice in the UK

Arts on Prescription: A review of practice in the UK Authors Hilary Bungay SRR, HDCR, MA, PhD, PGCLT, Senior Research Fellow, Sidney de Haan Research Centre for Arts & Health, Canterbury Christ Church University, University Centre Folkestone, Mill Bay, Folkestone, CT20 1JG, UK Tel: 01303 220870 Email: [email protected] Stephen Clift BA (Hons) PhD, FRSPH, Professor of Health Education, Director of Research, Sidney de Haan Research Centre for Arts & Health, Canterbury Christ Church University, Folkestone, UK Corresponding author: Hilary Bungay, as above

Key words

social prescribing; arts on prescription; mental health; evaluation

Abstract The current levels of psychosocial distress in society are significant, as evidenced by the number of prescribed antidepressants and the numbers of working days lost as a result of stress and anxiety. There is a growing body of evidence that active involvement in creative activities provides a wide range of benefits, including the promotion of well-being, quality of life, health and social capital. In the UK there are currently a number of projects operating that offer Arts on Prescription for people experiencing mental health problems and social isolation. The purpose of such schemes is not to replace conventional therapies but rather to act as an adjunct, helping people in their recovery through creativity and increasing social engagement. Although the schemes are varied in their approaches and settings, the common theme is that there is a referral process and creative activities take place in the community facilitated by artists rather than therapists. This paper explores whether such schemes can be part of the solution to the current challenge of mental ill-health, and looks at the evidence supporting the value of such schemes which may influence government, funders and healthcare professionals to implement Arts on Prescription more widely.

Introduction Arts on Prescription (AoP) is a type of social prescribing and operates in a similar manner to that as Exercise on Prescription and Books on Prescription. Essentially, in social prescribing there is a referral process whereby health or social care practitioners refer people to a service or a source of support. Over the past decade the number of AoP programmes has increased throughout the UK. A distinctive feature of AoP is that rather than a trained art therapist working with individuals or small groups in an acute setting, AoP programmes are facilitated by artists or musicians and engage groups of people living in the community. The first programme, AoP Stockport, came into being in 1994 and offers a range of creative activities to people with mild to moderate depression with the aim of increasing their level of mental well-being. Since then other schemes have emerged throughout the UK (Box 1). Not all programmes formally call themselves ‘Arts on Prescription’ and there are a variety of approaches, settings, and ‘Arts’ offered by the different schemes, but generally the overarching aim is to provide access to the arts, in the belief that active participation in a creative activity can promote health and well-being. This paper discusses the development of AoP initiatives in the context of the current challenges posed by

Copyright © Royal Society for Public Health 2010 SAGE Publications ISSN 1757-9139 DOI: 10.1177/1757913910384050

Box 1 Arts on Prescription projects Arts on Prescription Stockport Good Times Prescription for Art Creative Alternatives Arts on Prescription Nottingham Arts on Prescription Devon Arts on Prescription Pendle Arts and Health Blackpool Arts and Minds Creative Health Lab Start in Salford Art for Well-Being All these projects have websites and a simple Google search will find them.

mental ill-health in the UK and the more generic notion of ‘social prescribing’. It goes on to review current initiatives and considers the challenge of providing evidence for their effectiveness in the light of proposed changes in the structure of the NHS and future arrangements for the commissioning of health services.

Challenge of mental distress in the UK Interest in the potential role of the arts in healthcare and health promotion in the UK is

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particularly focused on addressing the considerable challenge of poor mental health and well-being. Current levels of psychosocial distress are significant as evidenced by the number of prescribed antidepressants and the numbers of working days lost as a result of stress and anxiety. It is reported that spending on antidepressants in 2006 was more that £291 million.1 The need to reduce dependence on antidepressants has been highlighted by the Mental Health Foundation,2 with prescriptions for antidepressants having increased by 95% since 1998 (18.4 million to 35.9 million in 2008). Furthermore, it is estimated that approximately 13.8 million working days were lost in 2006/07 due to work-related stress, depression and anxiety, and that each case of work-related stress leads to an average of 30.2 working days lost.3 Consequently, poor mental health has major implications for policy not only due to its economic costs but also the costs associated with increasing pressure on GPs and primary care practitioners, and the social costs to individuals, their families and their communities. It was estimated in 2004 that mental health problems cost the country £77 billion a year through costs of care, economic losses and premature death.4

Prescribing social activities When an activity is ‘prescribed’ the inference derived from medicine is that it has the potential to benefit the health and well-being of recipients. ‘Social prescribing’ has been described as a means of helping people experience support from the community, through promoting the use of community and voluntary sector resources in primary care.5 There are several other definitions of social prescribing, each of which suggests a different model of referral and provision, for example, Friedli et al.6 define social prescribing as: ‘… a mechanism for linking patients in primary care with non-medical sources of support within the community. These might include opportunities for arts and creativity, physical activity, learning, volunteering, mutual aid, befriending, and self-help, as well

as support with, for example, benefits, debts, legal advice and parenting problems.’ (p. 11; emphasis in the original) In this example, patients are linked to sources of support through the provision of information about what is available in their local community. A form of such social prescribing was featured in Our Health, Our Care, Our Say,7 where proposals were set out for introducing ‘well-being prescriptions’ for those with long-term conditions, to provide specific information on how to help manage a health problem and to enable people to access a wider provision of services. These information prescriptions were piloted in 2007/08 and are currently being implemented throughout the NHS.8 The prescriptions may include information on a condition and its treatment, care services, benefits, support groups, information for carers, employment and training, and leisure. A more precise model of social prescribing has been put forward by Brandling and House9 who define it as: ‘… a formal means of enabling primary care services to refer patients with social, emotional or practical needs to a range of local non-clinical services and provides a framework for developing alternative responses to meet need.’ (p. 3) From this it is understood that people are referred to community services in the same way that they may be referred to any healthcare service or person, with a letter or prescription form. Use of the word ‘prescribing’ in this context has been criticized because of its obvious medical connotations and the link with the biomedical model; in response, the phrase ‘community referral’ has been suggested as an alternative.6 However, using ‘community referrals’ in this context may not be appropriate because the phrase is already used in relation to referral to healthcare services based in the community. The significant difference between the two models of social prescribing outlined above is the procedure through which people are given access to services.

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Nevertheless, whichever model is adopted, social prescribing is considered to have three key benefits: improving mental health outcomes for patients; improving community well-being; and reducing social exclusion.10 Such benefits are a result of additional support, whether through practical advice or through activities, which is believed to be beneficial to health and well-being.

Policy context for social prescribing It has long been recognized that health is influenced by a broad range of social, economic and cultural factors, and indeed the current political emphasis appears to be on the wider community and the sociocultural factors that may impact on health and well-being. This is a more holistic approach to care which takes account of wider social factors impacting on the individual and their specific illness or condition. Mental health problems, for example, are more common in areas of deprivation, and poor mental health is consistently associated with unemployment, less education, low income or material standard of living.11 In the National Service Framework Health Improvement and Prevention: A Practical Aid to Implementation in Primary Care, it was recognized that to promote health and well-being it is necessary to strengthen social support and to bring resources into deprived communities and improve the community infrastructure.12 The Healthy Communities Programme13 was set up with the purpose of putting local government at the forefront of improving health and tackling inequalities in partnership with the NHS, and was followed by Our Vision for Primary Care which set out a strategy based on four keys areas, one of which is to promote healthier lives. As part of this, it suggests services need to evolve to reflect changes in healthcare and society and that patients require access to a greater range of services in the local community.14 This echoed the Local Government Association approach outlined in The Future of Mental Health: A Vision for 2015, which acknowledged that mentally healthy communities require


initiatives that build confidence and self-esteem, such as affordable access to sport and leisure, cultural, artistic and other activities.15, 16 More recently, New Horizons: A Shared Vision for Mental Health aims to improve the mental health and well-being of the population, and to improve quality and accessibility of services for people with poor mental health.17 Suggested interventions include such activities as community arts projects, reading initiatives, inner-city sports projects and older people’s lunch clubs, which fit within the Five Ways to Well-Being Framework18 – therefore, mental wellbeing is improved by connecting with others, being active, taking notice of one’s surroundings, continued learning and giving to others. With the well-known difficulties facing the UK and world economies, and the recent change in the British government, interventions such as those suggested in Our Vision for Primary Care and New Horizons: A Shared Vision for Mental Health, may receive a new impetus, as the emphasis shifts to community and voluntary engagement in social care, and there is an ideological shift from the ‘Big State’ to the ‘Big Society’. As yet it is too early to be certain what will happen with respect to mental health policy, but there is a drive to transfer power away from central government to local communities in decision-making for public services including healthcare. The white paper, Equity and Excellence: Liberating the NHS,19 proposes that the views of local people will be taken into account in local commissioning by local consortia of general medical practitioners of health and social care services. There is also a focus on outcome measures and quality standards, which will inform the commissioning of all NHS care. Both changes could have implications for the development of social prescribing schemes, including AoP, as will be discussed below.

Arts on Prescription: evidence and practice There is a body of evidence that supports the notion that active involvement in creative activities can

provide a wide range of benefits, including the promotion of well-being, quality of life and health,20–24 increased levels of empowerment, positive impacts on mental health and social inclusion for people with mental health difficulties.25 As such, arts and creativity contribute to the ‘health’ not only of the individual but also of the wider community. While there is a body of available work about the benefit and value of ‘arts in health’ and ‘arts for health’, extensive searches of databases such as Medline and Cinahl found little published empirical research that focuses specifically on AoP. However, examples of programmes were found through contacts with key people, existing networks and web searches. Much of the available information found is ‘grey’ literature and consists of reports on individual projects and discussion of issues around implementation.26 A number of AoP schemes have websites, and some include reports that are free to download (for example, Start in Salford: http://www.startinsalford.org.uk; and AoP Devon: http://www.petroc.ac.uk/ information/14/artsopresp/aop_home. htm). Communications with AoP project managers of schemes including those listed in Box 1 found that outcome measures such as HADS and the Warwick-Edinburgh Mental Well-Being Scale (WEMWBS) are being used to assess the impact of interventions on participants and qualitative accounts from clients and facilitators are being collated. These often provide striking testimony of the power of creative activities on well-being. The lack of published peer-reviewed evaluations may be due to the small sample sizes, as a result of the necessarily small cohorts of participants – typically 12 people per group. If schemes continue, however, they will eventually accrue a more substantive body of data. Furthermore, many of the schemes start as small-scale pilots to test feasibility and do not have the resources to conduct independent rigorous evaluations; others are required to provide outputs imposed by funding bodies which do not adequately capture all the project outcomes.27

Where empirical work does exist (mostly using qualitative methods), the findings are positive and researchers are enthusiastic about the role of AoP and its impact on health and well-being. For example, the evaluation of AoP Stockport found that participation in creative activities raised self-esteem, provided a sense of purpose, helped people engage in social relationships and friendships and enhanced social skills and community integration.28 This scheme also contributed to a major national project on arts, mental health and social inclusion undertaken by Secker et al.29 on behalf of the Department for Culture, Media and Sport and the Department of Health. The study undertook a survey of arts and mental health projects in England to ascertain the extent of participatory art work and to explore the approaches to evaluation. It also provides a retrospective analysis of outcomes from two ongoing projects (AoP Stockport and Time Being on the Isle of Wight) and presents a series of qualitative case studies. Overall, the project found that arts participation positively benefits people with mental health problems, increasing levels of empowerment and social inclusion.25 An evaluation of two arts for mental health projects in Scotland utilized in-depth interviews with artists to explore whether people with enduring mental health problems experience a sense of belonging through participation in the arts, and the perceived contribution of art work to building social capital.30 A total of 40 interviews were conducted, 35 with project artists who discussed how participation in the arts provided stability in their lives, enhanced their well-being and contributed to their ability to relate to and work with others. Within one of the projects there was a strong sense of collective artistic endeavour which facilitated the building of social bonds and friendships and thus social capital. On the Isle of Wight, Time Being was established as AoP by Healing Arts in 2002 until 2005. Time Being provided a series of self-contained, 12-week programmes of two-hour sessions in different art forms (visual arts, music and singing, creative writing, and dance and



movement). An extensive evaluation of the project in the form of interviews, focus groups and questionnaires demonstrated the impact that creativity had had in terms of improvement to individual health and his/her appreciation and understanding of their own health.31 However, although the findings from the evaluation were very positive, the authors reported that it was evident that the primary care trust (PCT) required quantified health gains, and detailed cost benefit analysis on the role of arts in healthcare before it would consider it as part of mainstream health services. This suggests that although qualitative methodologies have become more acceptable as a research paradigm in healthcare, as evidenced by the increasing number of papers using qualitative methodologies published in the British Medical Journal over the past decade,32 for some commissioners there remains an issue surrounding the nature of the evidence provided by such methodologies. Yet qualitative methodologies are most appropriate to capture the experiences of participants, but it will take effort to convince funders in the current economic and political climate that the current research evidence is valid and reliable.

Challenges facing arts on prescription schemes As with all innovations, implementing AoP programmes is challenging. The lack of a scientific evidence base can mean that it is difficult to secure

There is evidence to indicate that AoP may contribute to recent government policy objectives through building social capital and community engagement, and enhancing health and well-being. AoP as a form of social prescribing could be used as an adjunct to conventional therapies in the treatment of mental ill health and to promote social engagement in the isolated. Participating in the arts (where ‘arts’ encapsulates a broad range of creative activities) operates at two levels. First, at an individual level people may experience improved health and well-being; second, at the community level participating

within a group promotes social engagement and therefore inclusion. There may be some critics who say that any group activity, such as playing bingo or watching a competitive event as part of a crowd, could have the same impact. There may be others who argue that in the current economic climate, AoP will incur costs to the NHS that are unacceptable when new treatments for those with terminal and/or debilitating illnesses are not available or are restricted because of funding cuts. All new drug therapy is reviewed by National Institute for Clinical Excellence, which recommends whether or not it should be made available. These recommendations are based on a detailed review of the research evidence, and as yet there is not a sufficient body of evidence about AoP to conduct such a review or support its wide-scale implementation. However, the evidence does indicate that participation in creative activities with others promotes well-being and social inclusion. The mechanisms involved are as yet uncertain but it is clear that creating something tangible, whether it is music, a painting, a dance or a community garden, engenders a sense of achievement and an opportunity to share with others. AoP is not just about supporting recovery for people with mental health problems; it is also about prevention, helping socially isolated people with mild to moderate anxiety and depression, and the lonely, to prevent them succumbing to more serious illness with all its attendant social and economic costs to the individuals and our wider society.

Deputy Prime Minister, 2004. Available at Last accessed 23/08/10 5 South J, Higgins TJ, Woodall J, White SM. Can social prescribing provide the missing link? Primary Health Care Research and Development 2008; 9: 310–318 6 Friedli L, Vincent A, Woodhouse A. Development Social Prescribing and Community Referrals for Mental Health in Scotland. Edinburgh: Scottish Development Centre for Mental Health, 2007 7 Department of Health. Our Health, Our Care, Our Say. London: Department of Health, 2006

8 Department of Health. Information Prescriptions. London: Department of Health, 2009. Available at Last accessed 23/08/10 9 Brandling J, House W. Investigation into the Feasibility of a Social Prescribing Service in Primary Care: A Pilot Study. Bath: University of Bath, 2008 10 Friedli L, Watson S. Social Prescribing for Mental Health. Durham: Northern Centre for Mental Health, 2004 11 Friedli L, Jackson C, Abernethy H, Stansfield J. Social Prescribing for Mental Health: A Guide to Commissioning and Delivery. Stockport: Care

resources and overcome institutional barriers and professional isolation.33 This is corroborated in reports from ongoing programmes. Stickley and Duncan,34 for example, reported that the successful implementation of AoP initiatives depends on the enthusiasm and interest of the individual GP practice manager. An evaluation of the Community Health Advice Team in Bradford South and West PCT concluded that the success of social prescribing relies on the presence of a link worker with a good knowledge of the voluntary sector and of community development principles and practice, and a flourishing local voluntary and community sector.5 It is also necessary to increase the awareness of both patients and health and social care practitioners working in primary care of the potential of non-medical resources and support.6

Conclusion

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