Setting the Stage: The Arts in Health

Last Friday, the AIF team attended AESOP ’s extraordinarily compelling Arts in Health Conference and Showcase at the Southbank Centre – the first conference of its kind to bring together practitioners and commissioners from the health and arts worlds to explore how they could work together more closely. As social investors in arts and culture that have health & wellbeing as one of our target outcomes areas, we were hoping to learn about what is currently being delivered and how it is paid for; the interventions that work, and how we know; projects and ideas in development and the challenges faced by the sector. The event was a sell-out, with a show of hands at the opening plenary demonstrating an impressive balance of representatives from arts and medicine.

Healthy ends, artistic means

It was off to a powerful start: eight-year old Ben’s mother Sharon gathered herself after her son’s dazzling and assured magical performance in front of a huge audience, including Peter Bazalgette and Jeremy Hunt, to tell us about the incredible difference in impact that ten days of intensive training at Breathe Arts Health Research’s Magic Camp made to her son’s dexterity relative to his prior “sporadic and sparse” therapeutic  interventions. Karen Hamilton, of Dance to Health, explained how it has choreographed a routine that “smuggled in” movements from the Otago and FaME falls prevention exercises –  which have been proved in randomised control trials (“RCTs”) to reduce falls by up to 55% – but which health professionals report difficulty in getting patients to practise because they are boring and painful. Encouraging participants to immerse themselves in a regular activity is not only of obvious social and emotional benefits, it also helps to deliver physical therapy in an integrated and sustainable way.

The Breathe Camps are delivered by Magic Circle magicians, and Arts Council England Chair Peter Bazalgette made the point that the quality of the art involved can be critical to its therapeutic value. This was emphatically reinforced by Caroll Forth, who participates in the English National Ballet’s programme for people with Parkinson’s Disease . It was touching to hear that her involvement had helped mitigate the effect of her “dehumanising disease” not only to “help her body do something pretty again” but also to make her “feel like a real ballerina”, dancing ENB-choreographed moves to live music from professional musicians. It was a point revisited many times during the day, that the quality of the output and skills of the practitioners make a huge difference to engagement and resultant self-esteem of participants – even the relatively untechnical puppet-making workshops which encourage children in Dudley to talk to their adults about the perils of passive smoking was given conceptual kudos by artist-practitioners in the room for its creative use of empowerment through puppetry, enabling children to deliver messages they might find it intimidating to deliver directly.

Capturing impact

The social and emotional benefits of many of the programmes were clear; most are capturing these in pre- and post-questionnaires, and levels of engagement with these (notoriously troublesome data sources) were impressive. Time and time again participants also took great pains to stress the social benefits that we (as audience members in general, and in particular commissioners) ought not to miss – the feeling of belonging, of meeting people in the same boat; of being treated like people rather than conditions and therefore transcending labels; of being present, and not overlooked.

The subject of performance came up – practitioners and participants alike testified to the importance of performance; of something to work towards, and an opportunity to showcase hard work. One participant in Turtle Key Arts’ composing singing programme for people with dementia and their companions and carers said the validation of the performance was a key element in the programme helping him to “lose his labels” and maintain his sense of self, then added quickly “believe me, commissioners don’t want me to live up to or down to his labels: it will cost them a bloody fortune”. We heard a range of persuasive testimonials, and the social benefits of singing were powerfully illustrated looking round the room after the assembled delegates had written and performed their own song, with expert facilitation, in just twenty minutes. 

The challenge of income

Another theme that came up from every angle was funding. Many presenters were asked by interested audience members (usually arts organisations) how their pilot projects were funded, and in most cases this was by philanthropic funders, though often with close CCG involvement. Presentations visited the question of how target health outcomes should be determined – the audience suggested that acute admissions and exacerbations of stays (or delays in discharge) would be the most attractive outcomes to a commissioner in terms of cashable savings, but some interventions simply aren’t designed to achieve these, and would be setting themselves up not only to fail, but also to undermine any other important outcomes they may achieve if they were to tip their hat in the wrong direction at the outset. Refusing to let the tail wag the dog in this way is critical to maintaining the integrity of any intervention’s original vision; though at the same time, of course, if the arts organisation is to participate in the value of the intervention, they will have to convince someone to pay for it.

This is a key question for us – in order for the Arts Impact Fund to invest in scaling up an organisation, we’d have to have a reasonable expectation of forthcoming revenues associated with the investment, and therefore would not be able to shoulder the bulk of the commissioning risk – where revenues as well as social impact depend on efficacy, like in a payment-by-results programme, the threshold standard for an intervention would be higher than in the case of, say, a cross-subsidised outreach programme.

Where do the risk and the value sit?

Arts organisations rarely have the resources to fund development projects at their own risk, and the philanthropic funders are stretched (though Guys and St Thomas Charity certainly got a lot of mentions throughout the day, as did Paul Hamlyn Foundation and Esmee Fairbairn). Whilst volunteering in general can be of huge value to beneficiaries and volunteers alike, sustainable models cannot be predicated on artists providing their time and expertise for free, when many are already being squeezed by falling incomes and rising cost of living. Commissioners are looking for a burden of proof commensurate with medical proof of efficacy, though with the broader adoption of social prescribing and individual budgets the threshold may prove lower, which enables commissioners themselves to put money behind discovering what works – as we heard one GP had said: “I have more proof that singing works [as an anti-depressant] than Prozac”.

We need to make sure that commissioners are empowered to exercise judgement and not leave philanthropic funders and artistic organisations out in the cold when developing these interventions. A clever answer, like Dance to Health, is to connect up the dots – integrate an intervention with proven results into an arts programme, but this isn’t always available or practicable. In some cases, causation is so firmly established (such as loneliness and social isolation with negative health outcomes – as the arresting Jane Davis of the Reader Organisation told us, whilst singing the praises of literature as our “simple human technology to address” the problem, the WHO says depression will outstrip cancer, heart disease and war as the leading global cause of death within 30 years), that commissioners can be prepared to pay out for a reduction in loneliness. This is to be applauded, as AESoP’s founder and Chief Executive Tim Joss recognised in his opening appeal to the Secretary of State to give commissioners “permission” to commission non-medical interventions; as Public Health England pointed out, it is vital that CCGs and GPs are given the necessary infrastructure to make informed decisions. AESOP’s evaluation and development framework, launched on the day, is a new tool aimed at precisely this area.

Sounding the right cadence

There is a huge opportunity here –Dr Azhaar Saleem, who is a GP and his local CCG’s lead for respiratory disease provided some incredible facts about chronic obstructive pulmonary disease (“COPD”) during the presentation on Sidney De Haan Research Centre for Arts and Health’s Singing for Better Breathing programme: 1 in 5 people die from COPD; the total cost to the UK public purse exceeds £6.5bn including direct healthcare costs and indirect costs of lost productivity – it is also indicative of social inequality, with half of sufferers coming from low/middle income families with smoking a key factor. Dr Saleem encouraged the clinicians assembled to broaden their definition of therapy – and added, astonishingly, that the top 5 costliest medications in the UK are all inhaled therapies. The singers were convinced, to a person, that the singing had reaped greater benefits for the breathing alone than any other therapy, and that was before taking into account the dramatic social and mental health benefits.

Of course commissioners need to be satisfied that something works when, as the Secretary of State pointed out, there is always an alternative therapy on which to spend constrained budgets, but sustainability of this endeavour demands that the innovation risk is spread throughout all the stakeholders. Friday’s event was a magnificent demonstration of the people and organisations out there making sure that the arts and health sectors work together for a healthier, happier, more creative population.