All-Party Parliamentary Group on
Arts, Health and Wellbeing
Inquiry ReportCreative
Health:The Arts for
Health andWellbeing
July 2017

“This report lays out a compelling“The mind is the gateway through“At Paul Hamlyn Foundation, wecase for our healthcare systems
which the social determinants
have always believed that the arts
to better utilise the creative arts in
impact upon health, and this report
are a force for change, enrichingsupporting health and wellbeing
is about the life of the mind. It
people’s lives and transforming
outcomes, building on a growing
provides a substantial body ofcommunities, so we were pleased tobody of evidence in mental health,evidence showing how the arts,
support this important work, toenriching the mind through creative shine a light on the links between
end-of-life care and in supportingand cultural activity, can mitigate
arts and wellbeing and to uncoverthose living with long-term
the negative effects of social
the excellent practice and evidence
conditions.”
Lord Darzi, Professor of Surgery,
disadvantage. Creative Healthto underpin our assertions. The
Imperial College London
should be studied by all thosefindings emphasise the positivecommissioning services.”
impact that arts access andProfessor Sir Michael Marmot,
participation have on helping
Director, Institute of Healthpeople to overcome disadvantage
Equity, University College
and enjoy healthier lives, and theLondoncase studies clearly demonstrate thepower that partnerships between
health agencies and arts
practitioners can have.”
Moira Sinclair, Chief Executive,
Paul Hamlyn Foundation“At least one third of GP
appointments are, in part, due
to isolation. Through socialprescribing and community
resilience programmes, creativearts can have a significant impact
on reducing isolation and enabling
wellbeing in communities.”
Dr Jane Povey GP, Director,
Creative Inspiration
Shropshire Community
Interest Company“This report sets out the significant“There is growing evidence that
contribution that arts and culture
engagement in activities like dance,music, drama, painting and reading can make to keeping ourhelp ease our minds and heal ourcommunities healthy and happy.
It is a call for action and a powerfulbodies. This timely report sets out
argument for continuing to expand
a clear policy framework for thethe artistic and cultural offer that
cultural sector to continue its
complements and enhances ourimpressive work in improving
health offer.”
people’s health and wellbeing.”
Izzi Seccombe, Leader of
Sir Nicholas Serota, Chair,
Warwickshire County
Arts Council EnglandCouncil; Chair, LGA
Community Wellbeing Board“The therapeutic value of art is anasset we must use. A partnership
between arts organisations andhealth organisations has the power
to improve access to the arts and tohealth services for people neglectedby both. Through our Creative
Minds programmes in Yorkshire, Ialso know these partnerships canboth save lives and make lives.”
Robert Webster, Chief Executive
South West Yorkshire
Partnership NHS Foundation
Trust; Lead Chief Executive,
West Yorkshire and Harrogate
Sustainability andTransformation Partnership“The Sackler Foundations support“Art helps us access and express
creative people who are known to be parts of ourselves that are often
passionate about connecting theunavailable to other forms ofarts to ordinary people’s lives andhuman interaction. It flies below the
who are expert at what they do. We
radar, delivering nourishment forhave always supported both artsour soul and returning with stories
and health-related activity andfrom the unconscious. A worldcontinue to commit to quality
without art is an inhuman world.
programmes, often where other
Making and consuming art lifts ourpartners – public, private andspirits and keeps us sane. Art, likephilanthropic – will join us. We
science and religion, helps us makewould welcome strategic andmeaning from our lives, and to makesustained collaboration tomeaning is to make us feel better.”support the arts to promote
Grayson Perry, Artist
health and wellbeing.”
Dame Theresa Sackler“Artistic self expression gives
participants an identity beyond
illness. I have seen the arts build
confidence and communityand provide hope in the midstof suffering.”
Eva Okwonga, Peer Support
Advisory Board Member for
Mind and Music Workshop
Leader at Music In Mind

“This is an impressive collection ofevidence and practice for culture
and health, which reflects thepassion and breadth of engagementof the APPG and its partners overthe last two years.”
Duncan Selbie, Chief Executive,
Public Health England“In every age, the arts haveinspired people and given them
comfort. This major report gives
striking evidence of the contributionof the arts to wellbeing in today’s
world and makes compelling
proposals for how this contribution
can be enhanced.”
Lord Layard

All-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Report

All-Party Parliamentary Group on
Arts, Health and Wellbeing
Inquiry ReportCreative Health:
The Arts for
Health and Wellbeing
July 2017

Singing in Care Homes
Live Music Now and Creative Inspiration Shropshire
Community Interest Company
41All-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Report

Contents
Foreword

4

Summary

10

1 The Arts for Health and Wellbeing
1.1 Defining Health
1.2 Defining Wellbeing
1.3 Defining the Arts
1.4 	Interactions Between the Arts,
Health and Wellbeing

14
16
17
19

2 	The Arts and the Social Determinantsof Health and Wellbeing
2.1 The Social Determinants and
Health Policy
2.2 Environmental Adversity
2.3 Health Inequalities and the Arts
2.4	Arts Participation Across theSocial Gradient
3 Considering the Evidence
3.1 Quantitative Methods
3.2 Measuring Wellbeing
3.3 Qualitative Methods
3.4 Economic Analysis
3.5 Deploying the Evidence Base
3.6 Inquiry Meeting on Evidence
4 	The Policy, Commissioning andFunding Landscape
4.1 An Emphasis on Prevention
4.2 Management of Long-Term Conditions
4.3 Commissioning in Health andSocial Care
4.4 Integration of Health and Social Care
4.5	Parity of Esteem Between Physicaland Mental Health
4.6 Policy for Arts, Health and Wellbeing
4.7 The Funding Landscape
4.7.1 Health and Social Care Funding
4.7.2 Arts and Heritage Funding
4.7.3 Charitable Funding
4.7.4 Private-Sector Funding

20
24
27
28
29
30
32
34
35
36
37
39
39
44
46
47
50
50
51
52
55
55
58
59
60

5 Place, Environment, Community
62
5.1 The Natural and Built Environments
64
5.2 Healthcare Environments
66
5.3 Devolution
69
5.4 Place-Based Commissioning70
5.5 Arts on Prescription
72
5.6 Museums, Libraries and Health76
5.7 Age-Friendly Cities and Communities
77
5.8 Dementia-Friendly Communities
77
5.9 The Arts and Marginalised Communities 79

Culture Shots 2015, partnership between Central
Manchester University Hospital NHS Foundation Trust,
The Whitworth and Manchester Museum,
University of Manchester
Photographer: Andy Ford

6 	Childhood, Adolescence andYoung Adulthood
82
6.1 Gestation and Birth84
6.2 Perinatal Mental Health85
6.3 Early Childhood Development
86
6.4 Education
90
6.5	Recovery from Illness and Managementof Long-Term Conditions
93
6.6 Improving Mental Health and Wellbeing 94
6.7 Children’s Healthcare Environments
98

7 Working-Age Adulthood
7.1 Workplace Health
7.2 Improving Mental Healthand Wellbeing
7.3	Recovery from Illness andManagement of Long-Term Conditions
7.4 Adult Healthcare Environments
7.5 The Criminal Justice System
7.6 Post-Traumatic Stress
7.7 The Arts in Health Education
7.7.1	Undergraduate andPostgraduate Education
7.7.2	Improving Staff and Patient
Wellbeing
7.8	Health and Care as Routes for Arts
Professionals
7.9 Public Engagement Platforms

100
102

8 Older Adulthood
8.1 Healthy Ageing
8.2 Dance and Falls Prevention
8.3 Combating Social Isolation
8.4 Museums on Prescription
8.5 Residential Care
8.6 The Arts and Dementia
8.6.1 Delaying Onset
8.6.2 Cognitive Functioning
8.6.3 Personhood and Quality of Life
8.6.4 Music
8.6.5 Singing
8.6.6 Dance
8.6.7 Visual Arts8.6.8 Digital Arts
8.6.9 Performing Arts
8.6.10 Written and Spoken Word
8.6.11 Community Festivals
8.6.12 Dementia-Friendly Design

120
122
125
126
128
128
130
131
131
132
133
134
134
135
135
136
136
136
137

9 End of Life
9.1 Dying Well: The Hospice Movement
9.2 Beyond the Hospice Movement
9.3 Environment Design
9.4 Finding Meaning in the Story of Life
9.5 Legacy
9.6 Finding Voice
9.7 Bereavement
9.8 Children and Adolescents
9.9 A Public Conversation About Death
9.10 Training and Professional
Development

140
142
143
145
146
147
147
148
149
149

10 Recommendations and Next Steps

152

Acknowledgements

158

Inquiry Partners And Funders

166

Abbreviations

168

References

170

103
105
109
109
112
113
114
115
116
117

150

3

All-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Report

ForewordIt is time to recognise the powerfulcontribution the arts can make to health andwellbeing. There are now many examples
and much evidence of the beneficial impact
they can have. We have three key messages inthis report:•	The arts can help keep
us well, aid our recovery
and support longer lives
better lived.
•	The arts can help meet major
challenges facing health andsocial care: ageing, longterm conditions, lonelinessand mental health.
•	The arts can help save moneyin the health service andsocial care.
The All-Party Parliamentary Group on Arts,
Health and Wellbeing (APPGAHW) was formed in
2014. Our aim is to improve awareness of thebenefits that the arts can bring to health andwellbeing, and to stimulate progress towards
making these benefits a reality all acrossthe country. We decided to carry out an Inquiry
into existing engagement of the arts inhealth and social care, with a view to making
recommendations to improve policy and practice.
We have held a series of 16 round tablediscussions at which some 300 people – serviceusers, people working in the arts, health and social
care, including the prison service and end-of-life
care, commissioners, funders and academics –have come together to share their thoughts onchallenges they face, tell us what they are alreadydoing and what they aspire to do and debate how
progress may best be achieved. We have been
struck by the passion and eloquence of ourwitnesses, both providers and beneficiaries of thearts in health and social care (some of what they
told us can be read and heard on our website:www.artshealthandwellbeing.org.uk).
We have been able to share thinking at meetings
with ministers in the Departments of Health andCulture, Media and Sport, with the Chief Medical
Officer and with NHS England, Public Health
England, the Care Quality Commission, the4Cabinet Office, the What Works Centre for
Wellbeing, Arts Council England and the Local
Government Association. We have also beenadvised by service users, carers, clinicians, artists,
academics, commissioners and philanthropic
funders. We have held further meetings at whichpeople with much experience – officials andother professionals in the field as well as
parliamentarians – have provided a reality checkon our provisional findings. The exchange of ideas
stimulated by the Inquir y has, we havebeen told, y ielded new insights a mongpractitioners as well as greater understanding
among parliamentarians.
In parallel with all this activity, our researcher,
Dr Rebecca Gordon-Nesbitt, from King’s College
London, has conducted a major piece of research,
examining the interactions between the arts,
health and wellbeing throughout the life course. A
large amount of evidence has been examined:
academic research, project evaluations, thetestimonies we heard at the round tables andsubmissions elicited from a call we issued forexamples of practice. This report brings together
all the strands of the Inquiry and, we believe,
provides the most comprehensive overview of the
field to date.
Chapter two provides a theoretical basis for ourcase. It discusses thinking about ‘social
determinants’ which underpins current healthpolicy and questions why the arts, as anenrichment of human experience, have, until now,largely been neglected in this orthodoxy. We havediscussed our ideas with Professor Sir Michael
Marmot, who has done much to advance thinking
about the social determinants of health in the UK
and beyond and has welcomed our extension ofthis thinking. Chapter three discusses the present
state of evidence concerning the impacts of thearts on health and wellbeing, and makes
recommendations for the development of researchand evaluation. Chapter four sketches the policy,
commissioning and funding landscape as it is now,and offers some new vistas. Chapter five locatesser vices within physical and community
environments, argues for improved design andenvironmental quality in the interests of healthand wellbeing and calls for the arts to be included
in health-creating strategies being developed at
local and city-region level.
Chapters six to nine review significant researchand exemplary practice through successive
phases of the life course from birth to death. These
chapters report substantial achievement in many
parts of the country, and we hope they will provide
a valuable reference point. We believe this material
compellingly demonstrates the opportunities thatexist but have yet to be seized widely. As it is, theUnited Kingdom is still very far from realisingmore than a small modicum of the potential
contribution of the arts to health and wellbeing.

We lag in significant respects behind othercountries, such as Australia, Cuba and theNordic countries.
While not wishing to overclaim, we firmly
believe that the arts can be enlisted to assist in
addressing a number of difficult and pressing
policy challenges: strengthening preventative
strategies to maintain health for all; helping frail
and older people stay healthy and independent;
enabling patients to take a more active role in theirown health and care; improving recovery from
illness; enhancing mental healthcare; improvingsocial care; mitigating social isolation andloneliness, strengthening local services andpromoting more cohesive communities; enabling
more cost-effective use of resources within the
NHS; relieving pressure on GP services; increasing
wellbeing among staff in health and social care;encouraging voluntary work; creating a morehumane and positive existence for prisoners;
enhancing the quality of the built environment;
and ensuring more equitable distribution of arts
resources and better access to the arts for people
who are socially or economically disadvantaged.

The initia l for mation and continuing
professional development of members of the
medical professions is almost exclusively sciencebased. Medical humanities are available in the
curriculum in some medical schools, but the arts
are not part of the syllabus for public healthtraining. Medical research criteria – in whichlarge-scale randomised controlled trials are thegold standard and qualitative assessments areoften viewed sceptically – are unsuited toevaluation of the arts in health. Modern medicine
achieves extraordinary things, but the culture ofhealthcare can tend too much towards thetechnical-industrial and bureaucratic. Medical
professionals, of course, seek to imbue theculture with humanity and genuine caring. Where
they fail to do so, at the extreme, we havethe catastrophe of Mid-Staffordshire. Received
wisdom has yet to recognise consistently that thearts can help to humanise the system, not just as anice add-on but in complementing and enhancing
the effectiveness of conventional medicine
Proponents of the arts in health have too often
not made their case as well as they should. Toomany evaluations of ar ts
projects have been less thanrigorous, and the return on
investment in the arts has been
unclear. Nor, as Professor Dame
Sally Davies put it to us, has
wellbeing been rigorously
conceptualised. Whereas many
cultural organisations havebeen superbly capable andcommitted, they have noteverywhere put themselves forward sufficiently
confidently, insistently and convincingly. Whilemost cultural organisations have now embraced
education with conviction as a part of their
mission, far fewer are seriously interested in thecontribution they can make to improving health orin extending their audiences through such work. It
is also fair to say that discontinuities of funding,and, in some parts of the country, large-scale
withdrawal of funding, have genuinely prevented
arts organisations from remaining available tosupport health and social services.
Local authorities, even before they were under
the present draconian pressure to reduce
expenditure, have not given high priority tospending on the arts. Other discretionary items –well-maintained public spaces, cleaner streets,
leisure opportunities – appear to be more popularand also enhance quality of life. There is relatively
little protest if the arts are casualties of economy.
We make the case here that the arts are a vital partof the public health landscape and therefore an
essential responsibility of local authorities.
With ferocious pressure on funding, little
capacity within the NHS and social care has been
available to support more than the maintenance ofWe firmly believe that the arts can beenlisted to assist in addressing a numberof difficult and pressing policy challenges.
The arts, where they are intelligently engaged topromote health and wellbeing, can help to realise
the Prime Minister’s vision of a shared society.
Some defenders of the arts may object that thisis one more example of the instrumentalism
through which politicians blight our culture. We
have no desire to ignite another flare-up in thechronic and sterile altercation between the
proponents of art for art’s sake and those whojustify public intervention at least in part on thebasis that the arts confer benefits on society. We
believe that it is the validity of art itself that canlead to better health and wellbeing. As SamuelJohnson said, ‘the only end of writing’ – and it is astrue of the other arts as of literature – ‘is to enable
the reader better to enjoy life, or better toendure it’.
The conundrum that we have found ourselves
pondering is why, if there is so much evidence ofthe efficacy of the arts in health and social care, it
is so little appreciated and acted upon. In our
discussions, we have identified a number ofbarriers to recognition and embrace of thepotential contribution of the arts. These barriers
are attitudinal rather than legislative or inherent
in formal policy.

5All-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Report

Foreword

existing services. The NHS has, in any case, been
intently focused on acute medicine and too little on
prevention or the management of chronic
conditions. Commissioning methodologies havepursued volume rather than outcomes, squeezingout innovation. Unremitting pressures have madeit difficult for people to reflect and try different
approaches. Perhaps they should be reminded ofLord Rutherford’s observation to colleagues at theCavendish Laboratory: ‘Now that we’ve run out ofmoney we’ll have to start thinking.’
While it has been welcome that David Cameron
established the Government’s programme of
Measuring National Wellbeing, in the era ofneoliberal economics it has not been expected thatpolicy would be addressed directly to thepromotion of wellbeing. Nor has there been astrong public voice demanding more arts in healthor social care. Indeed, some in the media havebeen disparaging of what there has been. Whether
or not for these reasons, political leadership has
been hesitant and inconsistent.
Although four Secretaries of State for Health in
the last 25 years have also held office as Secretaryof State for Culture, there has been little
recognition in government of the potentiallybeneficial symbiosis between the arts and health.
At junior ministerial level, from time to time, there
has been engagement between those two
departments, but, with vagaries of politicalcircumstance, efforts at collaboration have
petered out. There have been moments ofparticular promise, such as the collaboration
between the Department of Health and Arts

government. However, it became clear to us thatthe challenges we describe would not satisfactorily
be met by ordinances from on high or throughbureaucratic processes. We consider that the
Health and Social Care Act 2012 – particularly theprovision in that legislation for public healthstructures – provides an adequate framework
within which progress can be made. And whilemore money, and in particular greater continuityof funding, would obviously be helpful, existing
public funding systems, especially if further
enhanced by philanthropic contributions, arecapable of supporting significant extensions of thework we would like to see. We do not ask thatfunding for the arts in health should be privileged.
Where public funding is concerned, we ask onlythat properly informed, realistic and unbiased
assessments should be made, throughout thesystem, of the potential value for money in funding
the arts to support existing agendas in health andsocial care.
In deference to the proprieties of devolution, therecommendations we make as an all-party groupat Westminster are addressed to people making
decisions in England, but we hope they may haveuseful applicability in the other nations of the UK.
We have drawn upon examples of excellent
practice in the devolved countries, and we verymuch appreciate collaboration with colleagues inNorthern Ireland, Scotland and Wales.
Our specific policy recommendations aremodest and limited; if the purpose is accepted, we
see no reason why they should not quickly be
consulted upon, agreed and implemented. We are
not calling for new legislation or
regulation, nor for changed
structures. The essential need
we identify is culture change:c h a n ge i n c on ve nt ion a lthinking leading to change inconventional practice. The
key to prog res s w i l l be
decentralised leadership andcollaboration diffused acrossthe complex systems of healthand social care and the arts.
These systems are neither
com ma nd str uctures nor
markets; they have elements of both, but theirperformance depends upon judgement andleadership by a host of decision-makers. People
in positions of responsibi l ity, whether
commissioners or clinicians or arts professionals,
are free to mobilise the arts in health and social
care if they judge it appropriate to do so.
The Prime Minister has signif ied hercommitment to more effective interventions by theGoverment in support of people who need help. If
the Secretary of State for Health were simply toreaffirm the endorsement of the value of the arts inhealth made by his predecessor in 2008, it would

The conundrum that we have foundourselves pondering is why, if there is somuch evidence of the efficacy of the artsin health and social care, it is so little
appreciated and acted upon.
Council England to produce the Prospectus forArts and Health in 2007 and Alan Johnson’s finespeech at the Wallace Collection in 2008, but thesehave not been followed through.
Ed Vaizey’s Culture White Paper of 2016
represents the latest moment of promise, with its
explicit commitment by the Government to
respond to this report. We very much hope that
this will be the prelude to a settled and coherent
commitment by all relevant government
departments and to cross-party consensus.
As parliamentarians, we expected at the outsetthat our recommendations would principally be to
6give new heart and impetus. Better still, if theSecretary of State for Health, the Secretary of State
for Culture and ministers in other departments
were, after suitable analysis and consultation,
jointly to endorse, in a cross-governmental
document, the propositions in this report, it would
do much to encourage wider and more confident
innovation and advance. We appeal for thatpolitical leadership.
Culture change is already afoot. The New NHS
Alliance says that ‘What has been missing is awillingness to empower both frontline staff andcommunities to work differently’ and to balancetechnical innovation with social innovation.1 The

clinical decisions. Together they can unlock
change, but, at the moment, they may not believethat the arts can be an effective means to help
them in their purposes.
In the months following the publication of thisreport, we will campaign to make our case andconvince people to take up our recommendations.
We will actively seek to develop the debate, notonly in Parliament but also among the professions
and across the country.
We hope to inspire and energise individuals andencourage better communication between
different disciplines and institutions. Among thevirtues of the arts is that they challenge habitual
thinking. We aim to provoke
dissonant conversations andcreate pressure for change. We
challenge people to emerge
fromtheir silos, discover shared
territory and join forces.
We are extremely grateful toeverybody who has so far joined
us in this work. We have been
particularly guided by theknowledge, experience andgood judgement of a number of our members,
including Baroness Andrews, Lord Bichard, Lord
Crisp, Rt Hon. Baroness Morris of Yardley, Rt Hon.
Ed Vaizey MP, who I am delighted has recently
become Co-Chair of the APPGAHW, and Baroness
Young of Hornsey.
We have benef ited continuously fromexchanging ideas with our partners in the Inquiry,
the National Alliance for Arts, Health andWellbeing, King’s College London, the Royal Society
for Public Health and Guy’s and StThomas’ Charity.
We are deeply grateful to our principal funders,Paul Hamlyn Foundation and Wellcome. They
have not only funded the Inquiry generously but
have taken a close and perceptive interest in it. We
are also most appreciative of King’s College
London and the Arts and Humanities ResearchCouncil who have been imaginative and practicalsupporters of the research side of our work.
On behalf of my parliamentary colleagues I
want to pay a particular tribute to Alex Coulter,
project manager for the Inquiry, and to Rebecca
Gordon-Nesbitt, who carried out the research anddrafted this report. Both of them have worked withtotal commitment and remarkable ability. We
have been extraordinarily fortunate to besupported by them in this project.

The essential need we identify is culturechange: change in conventional thinking
leading to change in conventional practice.
Social Prescribing Network notes that up to a fifthof patients see a GP for a problem that requires asocial solution, and some clinical commissioning
groups are already supporting arts on prescription.
NHS England is calling for much greater staff,
patient and community involvement in the designand delivery of services while also working
collaboratively with the voluntary sector andprimary care to design a systematic and equitableapproach to self-care and social prescribing.
The APPGAHW is part of a growing movement.
As Lord Crisp and colleagues have put it, in their
manifesto for a healthy and health-creating
society, we must aim for ‘the transformation of thehealth and care system from a hospital-centred
and illness-based system to a person-centred andhealth-based system’.2 Such a sea-change needs tobe supported across conventional boundaries. The
Royal Society for Public Health urges us all to see
ourselves as members of the public healthworkforce. Artists and arts organisations, byfostering imagination and creativity, are crucial inthis movement.
In this report we are addressing a range ofaudiences: fellow parliamentarians, government,
healthcare providers, social care providers,artists, arts therapists and arts organisations,educators, academics, funders, service users, thepublic. We hope the report will be read by people
working in health and social care, who may
benefit from understanding the arts better, andby people working in the arts, who may be helped
to understand better how they can engage withthe health and social care systems. We
are particularly addressing people who have to
make policy decisions, funding decisions andRt Hon. Lord Howarth of Newport
Co-Chair, All-Party Parliamentary Group on Arts,
Health and Wellbeing.
7Arts in Health andCare Environments
This includes hospitals,
GP surgeries, hospices
and care homes.
A mental health recovery centre
co-designed by service users in
Wales is estimated to save the NHS£300k
per year.

Visual and performing artsin healthcare environments
help to reduce sickness,anxiety and stress.

The heart rate of new-born babies iscalmed by the playing of lullabies.
The use of live music in neonatal
intensive care leads to considerably
reduced hospital stays.

Participatory Arts
ProgrammesThis refers to individual and group arts activities
intended to improve and maintain health andwellbeing in health and social care settings andcommunity locations.

79%
77% 82%After engaging with the artsof people in deprived
communities in London
ate more healthily

engaged in more
physical activity

enjoyed greater
wellbeing.

£1 spent on early care and education has
been calculated to save up to £13 in future
costs. Participatory arts activities withchildren improve their cognitive, linguistic,social and emotional development andenhance school readiness.

8

Music therapy reduces
agitation and need for
medication in

Arts Therapies
This refers to drama,
music and visual arts
activities offered toindividuals, usually inclinical settings, by anyof 3,600 practitioners
accredited by the
Health and Care
Professions Council.

Arts onPrescription
Part of social prescribing, this involves people
experiencing psychological or physical distressbeing referred (or referring themselves) toengage with the arts in the community(including galleries, museums
and libraries).

£216

An arts-on-prescription project has shown a 37%
drop in GP consultation rates and a 27% reduction
in hospital admissions. This represents a saving ofper patient.

A social return on investmentof between £4 and £11 has been
calculated for every £1 invested
in arts on prescription.

Over the past two centuries,
life expectancy has increased by
two years every decade, meaningthat half of people being born in
the West can expect to reach 100.
Arts participation is a vital part ofhealthy ageing.

Participatory arts
activities help toalleviate anxiety,depression andstress bothwithin andoutside of work.

67%

Attendance at Cultural Venues
and Events
This refers to attendance at concert halls, galleries,
heritage sites, libraries, museums and theatres.

of people with dementia.

Arts therapies
help people
to recover frombrain injury
and diminish
the physicaland emotional sufferingof cancer patients andthe side effects of theirtreatment.

Arts therapies have beenfound to alleviate anxiety,depression and stresswhile increasing
resilience and wellbeing.

Attendance tends tobe determined byeducational level,prosperity and ethnicity.

Cultural engagement
reduces work-related
stress and leads tolonger, happier lives.

2,500
Of

Medical Training
and Medical
Humanities

museums and galleries in
the UK, some

600

This refers to inclusion of the arts
in the formation and professional
development of health and social
care professionals.

have programmes targeting
health and wellbeing.

Within the NHS, some 10 million
working days are lost to sick leave
every year, costing£2.4bnThe Built
and Natural
Environments

85%

Arts engagement helps health and carestaff to improve their own health andwellbeing and that of their patients.

EverydayCreativity
This might bedrawing, painting,pottery, sculpture,music- or filmmaking, singing
or handicrafts.

Poor-quality built
environments have adamaging effect uponhealth and wellbeing.
of people in England agree
that the quality of the built
environment influences
the way they feel.

34£
9.4 million

Every £1 spent on maintainingparks has been seen to generate

There are more than

49,000amateur arts groups
in England

involving

17%

peoplein community benefits.

that isof the population.

9

All-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Report

Summary
1

The Arts for Healthand Wellbeing
The creative impulse is fundamental to theexperience of being human. We might express
this through art, craft, creative writing, dance,
design (including architecture), drama, film- ormusic-making or singing, by ourselves or withothers; increasingly, we might make creative useof digital media. We might access outcomes ofcreative processes by walking around our cities
or heritage sites, visiting concert halls, galleries,
museums, theatres or libraries. The act of
creation, and our appreciation of it, provides anindividual experience that can have positiveeffects on our physical and mental health andwellbeing. How, where and why this works is the
subject of this report.

2

The Arts and the Social
Determinants of Healthand Wellbeing
The World Health Organization defines the social
determinants of health as the ‘conditions in whichpeople are born, grow, work, live, and age, and thewider set of forces and systems shaping theconditions of daily life’. Many would agree that
unequal distribution of power, income, goods andservices within and between countries createslarge differentials in health and wellbeing. To takejust one example, children born into families at thelower end of the social gradient are more vulnerable
to heart disease, mental health problems, obesity,
respiratory disease and stroke than their more
affluent contemporaries. Recognition of the social
determinants of health is now consistent across UK
health policy documents.
The devolved administrations in the UK andcombined authorities in England are increasingly
using arts-based strategies to address the social
determinants of health. In attempting to show how
the arts can help to meet some of the major healthand social care challenges, chapters six to eight ofthis report look at how we are born, grow, work, live
and age and how arts engagement can lessen theimpact of health inequalities at each of these life
stages at the same time as steps are taken to reducethem. To this list, we have added consideration of
how we die, with chapter nine dedicated to creative
encounters at the end of life.
10

Central to these life-course chapters is the ideathat arts engagement helps to mitigate the effects
of an adverse environment by: inf luencing
maternal nutrition, perinatal mental health andchildhood development; shaping educationaland employment opportunities and tacklingchronic distress; enabling self-expression andempowerment and overcoming social isolation. At
the same time, we find that an embrace of the arts
via health and wellbeing routes helps to overcome
well-publicised inequalities in access to the
publicly funded arts. This suggests that asignificant component of investment in the arts
should be made in a graduated way, according
to need.
Of course, not everything fits into neat
generational categories. Throughout the life
course, environmental quality, sense of place andcommunity are crucial to our health and wellbeing
and form the basis of a separate fifth chapter.

3

Evidence
The evidence base linking arts engagement tohealth and wellbeing comprises both research andevaluation, and it spans a range of methodologies
and practices. This report introduces us to thevarious types of evidence that are typicallyencountered in the field, including evidence
derived from quantitative and qualitative
methods, economic analysis and the measurementof wellbeing. In the process, we foregroundresearch which considers the social value of arts
interventions, and we explore what works, forwhom and in what circumstances. This reportargues that evidence not only needs to be
meticulously gathered but also proactively
deployed, in processes such as the formulation ofclinical guidance by the National Institute for
Health and Care Excellence.
Evidence is unevenly distributed across thefield, is of variable quality and is sometimes
inaccessible. Looking to the future, greater focus
needs to be placed on good-quality evaluation
which allows for comparative analysis. Equally,
there is a pressing need for appropriate
longitudinal research into the relationshipbetween arts engagement, health and wellbeing.

4

Policy, Commissioning
and Funding
The current crisis in health and social caredemands a search for innovative solutions.
Funding aside, the greatest challenges to thehealth and social care systems come from anageing population and a prevalence of long-term
conditions for which there is no obvious cure.
In addressing these challenges, the Five Year
Forward View, published in 2014 by NHS England
as a new vision for health policy, emphasised aneed for rapid improvements in prevention andpublic health.
Millions of people in the UK engage with the arts
as part of their everyday lives. As we demonstratein this report, arts engagement has a beneficial
effect upon health and wellbeing and therefore has
a vital part to play in the public health arena. At thesame time, this report shows that the arts have asignificant role in preventing illness and infirmity
from developing in the first place and worsening in
the longer term. Added to which, engagement in
the arts is consistently seen to enhance wellbeing
and quality of life in people of all ages. In short, thearts can help to address many of the challenges thehealth and social care system is facing and improve
the humanity, value for money and overall
effectiveness of this complex system.

5

Place, Environment,
Community
The natural and built environments have a
profound impact upon our health and wellbeing.
Within healthcare, access to daylight, fresh airand natural materials aids healing, restoring the
integrity between mind, body and soul. Patientsand staff alike appreciate health and social careenvironments which are well designed andanimated by the arts.
The ongoing shift from an acute and costly
hospital-centred, illness-based system to apersonalised, health-based system relies uponi nd iv idua l a nd com mu n ity a sset s. The
contribution of the arts to person-centred, placebased care urgently needs to be recognised.
Social prescribing sees people finding solutions
to psychosocial problems in the community.
A wide range of schemes and referral pathways
is in operation. Hosted by com mun ity
organisations and cultural venues, arts-onprescription activities reduce anxiety, depression
and stress and aid in the management of longterm conditions.
Operating at the intersection between
health and social care, the arts form an integral
part of age-friendly cities and dementia-friendly
communities. The participatory arts provide aprime site for co-production – equal involvement
by people using services and people responsible
for them, not only in design and delivery but also in
evaluation and refinement.

6Childhood, Adolescence,
Young Adulthood
Even before we are born, exposure to adverse
environments can increase our susceptibility tochronic health conditions and lead to diminishedwellbeing. Life chances, however, are not set instone, and an improved environment, such as that
produced by engagement with the arts, can help toredress the balance.
The early years are crucial to fostering the
cognitive and socio-emotional skills that servechildren well later in life, and the arts can have acentral role in aiding these developmental
processes. Reading aloud to children spurs
linguistic advances, narrowing the attainment gap
that persists across the social gradient. Learning
to play music changes the morphology of the brain,
leading to improved literacy and spatial reasoning.
Distressing and costly behavioural problems inchildren can be addressed through both theparticipatory arts and arts therapies.
The 2016 Culture White Paper pledged to put
measures in place to increase arts participation.
Schools are a prime potential site for this, via thenational curriculum, extracurricular activities
and counselling services. At the same time, arts
activities in the community can provide awelcoming non-school environment, which isparticularly important for children and young
people excluded from school. This suggests a needfor joint working by the Department for Culture,
Media and Sport, the Department for Educationand the Department for Communities andLocal Government.
At all ages, the arts can have a beneficial part toplay in recovery from illness and the managementof long-term conditions. In children and young
people, improvised dance can diminish acutepain, accelerate rehabilitation from brain injury
and aid in the regulation of chronic conditions.
Arts participation can increase the time children
spend being active, contributing to a reduction inchildhood obesity. In children’s hospitals, art,
craft, music and theatre provide a welcome
distraction from the tedium of long stays and theanxiety and pain of invasive processes.
Several studies point to a decline in the
wellbeing of young people, and an estimated850,000 children and young people in Britain havemental health problems and related physicalhealth problems. One of the factors influencing themental health of children and young people is themental health of their parents (particularly theirmothers); another is academic pressure. Arts
participation helps to overcome anxiety,depression and stress in parents and theirchildren, encouraging bonding and emotional
expression. NHS England has made mental health11

a priority, and the Government has committed to
improving access to prevention and earlyintervention. Supported by compelling evidence,
we advocate that the arts are taken seriously inhelpi ng to overcome t he i mped i ment s
to pr e vent ion a nd ea rly i nter vent ion ,perhaps especially in black, Asian and minority
ethnic communities.

7

Working-Age Adulthood
Poor-quality work combines high demand andeffort with low control and reward. The main causeof sickness absence from work is anxiety, depression
and stress, and mental health problems in theunder 65s account for almost half of NHS diagnoses.
Arts engagement at work and in leisure time helps
to overcome anxiety, depression and stress.
In relation to recovery from illness in adults,
there is good evidence that listening to music after astroke helps to hasten recovery and lift mood. Whenit comes to the management of long-term
conditions, dancing and group singing enhancecognition, communication and physical functioningin people with Parkinson’s while enhancing
wellbeing. Singing alleviates chronic respiratory
conditions and cystic fibrosis. Arts engagement also
has a part to play in diminishing the physical andemotional effects of heart disease and cancer.
In the criminal justice system, the arts provide
an excellent tool for the healthy expression of
suppressed emotions and the processing ofexperiences, while art therapy provides an effective
non-verbal means of accessing painful memories
for people experiencing post-traumatic stress.
Despite many proven benefits, the arts are not a
habitual part of the training and professional
development of hea lth a nd socia l ca reprofessionals. There is, however, increasing
recognition of the contribution of the arts to thecommitted, compassionate care advocated by theFrancis Inquiry and envisaged in the 2014 Care
Act. We identify a need for the arts andhumanities to become more integrated into healthand social care training and for health andwellbeing to be included in the professional
development of artists.

8

Older AdulthoodWithin the growing population of adults beyond
working age, health inequalities affect vitality,
mobility, mental acuity and life expectancy. The
arts have a part to play in fostering healthy ageing
and staving off frailty.
12

As in previous life stages, arts engagement candiminish anxiety, depression and stress while also
increasing self-esteem, confidence and purpose.
Music training can improve differentiation ofsounds, such as voices in busy environments.
Dance is particularly effective in the prevention of
falls in older people, and dance programmes up
and down the country have better retention rates
than alternative NHS initiatives.
Social participation by older people can have aprotective effect on health comparable to giving
up smoking. Arts-based groups offer a popularsocial activity in rural areas, while many museums
and galleries in urban areas are reaching out totheir local populations, particularly isolated
older adults.
An estimated 850,000 older people in the UK
have a dementia diagnosis, predicted to increase
to one million by 2021 and two million by 2051. The
annual cost of dementia to the UK is £26.3bn,
which is more than the combined cost of treating
cancer, heart disease and stroke and is expected to
exceed £50bn over the next three decades. The
arts can provide significant help in meeting thismajor health challenge. Arts engagement canboost brain function and improve the recall of
personal memories; it can also enhance the qualityof life of people with dementia and their carers. In
dementia care, colour, reflection and shadow canhave an impact on mood and lead to better
nutrition, hydration and engagement.

9

End of Life
Around 500,000 people die in England every year,
usually after a phase of chronic illness. The
participatory arts and arts therapies can offer
physical, psychological, spiritual and social support
to people facing death. They can assuage the pain
and anxiety of terminal illness and assist people incoming to terms with dying. They can help people tofind meaning in the story of their lives and develop
hopeful narratives. They can provide access todeep, nuanced feelings, communicated throughmetaphor and imagery. They can form part of alegacy, through the creation of artworks to beshared with loved ones. They can give voice to those
who no longer feel able to speak and restore a senseof control to those who feel powerless.
In end-of-life care, homely environments for the
dying, grieving areas for the bereaved, religious
and cultural places and quiet spaces for visitorsand staff are in high demand. The arts cantransform the capacity to cope with bereavement
and open up a healthier public conversation
about death.
Russell, Artlift, Gloucestershire
Photographer: James Garrod

Creative Families at theSouth London Gallery
Photographer: Lawrence Bradby

The Arts for
Health andWellbeing
14

15

All-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Report

1 The Arts for Health and Wellbeing“Health is an exquisitely sensitive indicatorof our societal structures, economic
conditions and political priorities. Healthis also an elegant gauge of the physical andsocial fabric of our communities and of
our individual journeys through life – fromthe nurturing received and opportunities
available during the early years of life,
through to the experiences and challenges
encountered in adulthood and in later
life. The health of the nation is a definitive
and unifying societal measure, reflecting
these individual, collective and cumulative
influences, experiences, challenges
and journeys.”
Chris Harkins, Glasgow Centre for Population Health, 2014T

his report seeks to explore the value tohealth and wellbeing of engagementwith the arts. This immediately poseschallenges in relation both to definitionof the slippery keywords of ‘health’,‘wellbeing’ and ‘arts’ and to the values we hold as
we use these three words. A brief attempt will bemade here to unravel this troika.

1.1

Defining Health
Drawing up its constitution in 1948, the World
Health Organization (WHO) defined health as a‘state of complete physical, mental and social wellbeing and not merely the absence of disease or
infirmity’.3 This embraces a positive and holistic
understanding of what it means to be healthy in
16

body, mind and community. However, modern
biomedicine is much better at dealing with disease
and infirmity, and the UK healthcare system islargely geared up to addressing acute situations inwhich health is compromised. This prompts
distinctions between health and medicine, between
illness and disease, between health and healthcare
provision and between health and social care.
Funding aside, 4 the greatest challenges to thehealth and social care systems are posed by anageing population and a prevalence of chronic
conditions, such as cancer, cardiovascular disease,respiratory diseases, dementia and diabetes.5 Thisis compounded by the presence of comorbidities(two or more simultaneous medical conditions),
which exist in 30 percent of the over-75s andincrease treatment costs six-fold.6 These factors
compromise life expectancy and healthy life
expectancy, the implications of which will be
explored in this report.

In Scotland, a prevalence of ‘social diseases’ hasbeen noted, leading to deaths caused by drugs,
alcohol, violence, suicide and mental healthproblems. Known risk factors include deprivation,
employment, housing, incapacity benefit, limiting
long-term illness, violence, substance misuse,
physical health and marginalisation.7 Added tothis, almost half of the UK adult population isestimated to be affected by chronic physicalpain, often unrelated to a specific disease andpredicted by age, gender, housing tenure andemployment status.8
Expanding its definition as part of the Health2020 strategy, WHO noted that ‘Good health forcommunities is a resource and capacity that cancontribute to achieving strong, dynamic andcreative societies. Health and wellbeing include
physical, cognitive, emotional and social
dimensions. They are influenced by a range of
biomedical, psychological, social, economic andenvironmental factors that interconnect acrosspeople in differing ways and at different times
across the life-course’.9 As we see in chapter four,
definitions of health for policy purposes have beenbroadened to include not only a focus on acuteillness and disease but also on consideration of
long-term health conditions, with not only
biomedical but also psychosocial models of careand not only curative but also preventative
strategies.10 This report considers the arts as anchallenges faced by the NHS in present
circumstances. Among the four main areas
around which the manifesto suggests action
should be coordinated, the recommendations ofmost relevance to this report are that ‘The
transformation of the health and care system froma hospital-centred and illness-based system to aperson-centred and health-based system needs tobe accelerated and funded’ and ‘The UK needs todevelop and implement a plan for building ahealth-creating society supported by all sectors of
the economy and the wider population’.12 Thisapproach is consistent with our emphasis on thecontribution of the arts to person-centred,
salutogenic approaches, seen in the context of thebroader community as it influences health.

1.2

Defining Wellbeing
The WHO definition of health includes wellbeing
as an essential component, but these two factors
can be pulled apart. In an introduction to theanthology Cultures of Wellbeing, Professor ofInternational Development and Wellbeing at the
University of Bath, Sarah C. White, noted that ‘The
ubiquity of references to wellbeing and the
diffusion of meanings they bear means any
attempt to summarise the fieldmust inspire some trepidation’.13
In 2008, the Foresight Mental
Capital and Wellbeing Project
defined mental wellbeing asa ‘dynamic state, in which
the indiv idua l is able todevelop their potential, work
productively and creatively,
build strong and positive
relationships with others, andcontribute to their community.
It is enhanced when an individual is able to fulfil
their personal and social goals and achieve a senseof purpose in society’.14 The ability to fulfil one’s
individual and social potential, as a defining
feature of wellbeing, is taken as axiomatic inthis report.
Evidence reviewed within the Foresightproject showed wellbeing to be self-perpetuating
and inextricably linked to health, to the extent
that ‘a high level of wellbeing is associated withpositive functioning, which includes creative
thinking, productivity, good interpersonal
relationships and resilience in the face ofadversity, as well as good physical health and life
expectancy’.15 At the same time, the project noted
the damaging effects of the uneven distributionof wellbeing:

Funding aside, the greatest challenges
to the health and social care systems
are posed by an ageing population anda prevalence of chronic conditions.
element of psychosocial care with a part to play inthe creation of a healthy society.
The notion of a healthy society has a relationshipwith the concept of ‘salutogenesis’ – a phrase
coined by Aaron Antonowsky, a medicalsociologist, to denote the creation of healththrough a process of healing and recovery. 11
The term salutogenesis offers a counterpoint
to pathogenesis (the development of disease),and represents a focus on assets rather thandeficits. Assets-based health approaches are
increasingly found within health discourse, andwe make the case that the arts are a key individualand community asset in achiev ing andmaintaining wellness.
A manifesto for a healthy and health-creating
society – drafted by Lord Crisp in a group including
Lord Adebowale, Lord Bird, Baroness Campbell
and others in the field of health – addresses the17Chapter 1

The Arts for Health and Wellbeing[ …] people with a low level of wellbeing, even if
they do not have a mental disorder, function far
less well and have poorer health and life
expectancy. This latter group is unlikely to cometo the attention of specialist mental healthservices, but constitutes a large part of the
population who are neither flourishing nor
disordered, yet could benefit greatly from having
access to interventions to improve theirwellbeing. They are frequently seen in GP
surgeries, primary care settings, social work
departments and many other front-line
public services.16
Confining its focus to mental wellbeing (rather
than the physical and social components includedin the WHO definition), this explanation usefully
distinguished wellbeing from mental health andintroduced us to the concepts of resilience andflourishing, which recur several times in thisreport. The Foresight definition also drewattention to the substantial proportion of people
w ith compromised wellbeing who need
opportunities to improve their condition. We
argue that the arts have a significant part to play inimproving wellbeing, thereby relieving pressure
on front-line public services.
As part of the Foresight project, the New
Economics Foundation (NEF) was commissioned
to develop a set of evidence-based actions aimed at
improv ing wel lbeing, a na logous to therecommendation to eat five portions of fruit andveg a day. NEF took wellbeing to mean feeling goodand functioning well, and devised ‘five ways to
wellbeing’, recommending that we: connect; beactive; take notice; keep learning; give.17 Several of
the practice examples given in this report adopt
these five ways to wellbeing; Out of the Blue –commissioned by health services in Kirklees,
Yorkshire, to provide creative interactions forpeople with mental health needs – proposes the
addition of a sixth way to wellbeing: be creative.18
Professor White noted that ‘What perhaps unites
contemporary work on wellbeing is the conviction,
expressed in many ways, that it is possible to bringwellbeing about intentionally, through a
combination of will and technique. Its positive
charge offers a corrective to tired old problem-

All-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Reportidea that it is possible to enhance wellbeing, it does
so in full cognisance of the broader societal factors
upon which wellbeing depends.
In the same year as the Foresight project
reported, the President of France, Nicolas Sarkozy,
established a Commission to explore the limits of
GDP as an indicator of economic performance andsocial progress and identify metrics more relevant
to capturing phenomena with a long-term impact
upon wellbeing. The Commission def ined
wellbeing as a multidimensional complex,
comprising largely objective factors:i. 		Material living standards(income, consumption and wealth);ii. 		 Health;iii. Education;iv. 		 Personal activities including work;v. 		 Political voice and governance;vi. Social connections and relationships;
vii. 	Environment (present and future conditions);
viii. 	Insecurity, of an economic as well as aphysical nature.20
Several of these factors are revisited in the next
chapter and beyond, while environment is given
special consideration in chapter five.
There is a variety of perspectives on wellbeing
within public policy. In her 2013 report, the Chief
Medical Officer, Professor Dame Sally Davies,
examined the evidence for wellbeing as it related
to public mental health, to observe that wellbeing‘means different things to different people. Eachapproach has inherent strengths and weaknesses,
but one thing is obvious: there is no clear
consensus on the best way to define and measurewell-being within mental health’.21 The What
Works Centre for Wellbeing – part of theGovernment’s What Works Network – examines
the factors underlying wellbeing and seeks costeffective ways in which to enhance it.22 Through aDelphi consensus development process involving
a range of stakeholders, three dimensions of
wellbeing have been identified. The personal
dimension includes confidence and self-esteem,
meaning and purpose, reduced anxiety andincreased optimism; the cultural dimension
includes coping and resilience, capability
and achievement, personal
identity, creative skills andexpression and life skills suchas employability; the social
dimension includes belonging
a nd ident it y, s o c i abi l it yand new connections,bonding and social capital,
reducing social inequalities
and reciprocity.23
In chapter three, consideration will be given
to ways in which the elusive construct ofwellbeing might be measured in relation to arts

People with a low level of wellbeing
function far less well and have poorer
health and life expectancy.
focused policy-making, encouraging people toexpress their aspirations rather than rehearse theirdeprivations’.19 While this report subscribes to the18interventions. For now, a distinction from two
related concepts may be useful.
In The Happiness Industry, William Davies
argued that the ‘future of successful capitalism
depends on our ability to combat stress, miseryand illness, and put relaxation, happiness andwellness in their place’.24 Davies observed a‘growing unease with the way in which notions ofhappiness and well-being have been adopted bypolicy-makers and managers. The risk is that thisscience ends up blaming – and medicating –individuals for their own misery, and ignores thecontext that has contributed to it’.25 In seeking to
improve wellbeing through the arts, this reportremains mindful of the pitfalls of individualism to
advocate community-based and societa lapproaches. In the process, it maintains a
scepticism towards attempts to use the arts as acure-all for an unhealthy society.26
Another domain from which wellbeing may
usefully be distinguished is that of quality of life.
When considering care and services for older
people, WHO defined quality of life as ‘The productof the interplay between social, health, economicand environmental conditions which affecthuman and social development. It is a broad
ranging concept, incorporating a person’s physicalhealth, psychological state, level of independence,social relationships, personal beliefs andrelationsh ip to sa l ient features in theenvironment’.27 Unlike wellbeing, quality of life
can be assessed by relatively well-establishedmeasures. Further into this report, we see that
quality of life increases in significance across thelife course and encounter evidence of ways inwhich this might be enhanced throughengagement with the arts.

1.3

Defining the Arts
The process of the Inquiry has required us to adopt
a working definition of what we mean by the arts.
When we talk about the arts, we include the visualand performing arts, crafts, dance, film, literature,music and singing. To this list, we add gardening –which is considered as a form of creativity inchapter five – and the equally absorbing culinaryarts, which, aside from their contribution to
wellbeing, have a practical connection to diabetes28
and renal dialysis29 and to loss of taste duringchemotherapy.30
Raymond Williams described culture as a whole
way of life within which the arts are a process of
discovery and creative effort. 31 This reportconsiders individual discovery and creative effort
in its immediate and societal context. We adopt
and broaden Pierre Bourdieu’s designation of the‘cultural field’ as the territory in which the arts

engagement takes place. We understand this toembrace concert halls, galleries, heritage sites,
libraries, museums and theatres. We emphasise
the importance to health and wellbeing ofa rchitecture, design, planning and theenvironment, which we understand to haveprofoundly important impacts on health andwellbeing, both in their own right and via their rolein enhancing healthcare.32
We seek to expand consideration of the arts
beyond publicly funded activities and acknowledge
the benefits of activities that take place within thehome and community, such as crafts and digitalcreativity. Written evidence submitted by
Voluntary Arts England to the Culture, Media andSport Select Committee in September 2010 said
that ‘There are more than 49,000 amateur arts
groups in England with an estimated 5.9 million
members, in addition 3.5 million people volunteer
as extras or helpers making a total of 9.4 million
people’.33 A scoping study conducted at the Third
Sector Research Centre – involving researchers
from the universities of Birmingham, Exeter andGlamorgan, in partnership with Voluntary Arts
and with funding from the Arts and Humanities
Research Council (AHRC) – identified a range ofimpacts of grassroots arts activities upon civilsociety, including improvements in healthand wellbeing, educational attainment andworkplace functioning, all of which are relevant to
the Inquiry.34
In this report, then, ‘the arts’ is used as
shorthand for everyday human creativity, rather
than referring to a lofty activity which requires
some sort of superior cultural intelligence toaccess. As will be seen, the field is full of stories ofpeople engaging deeply with creativity for the firsttime through health and wellbeing routes, having
been told earlier in their lives that they had no
aptitude in this area.
It is also worth distinguishing the non-profit arts
sector from the creative industries, defined by the
Department for Culture, Media and Sport (DCMS)
as ‘those industries which have their origin in
individual creativity, skill and talent and which havea potential for wealth and job creation through thegeneration and exploitation of intellectual
property’.35 Figures published in January 2015
suggest that the creative industries are worth£76.9bn annually to the UK economy.36 This
category of activity is taken by the Scottish
Government to include architecture, advertising,arts and cultural industries, design (including
fashion, design and crafts), film, interactive leisuresoftware (computer games, consumer packaged
software), music, new media, publishing, radio andtelevision.37 While there are overlaps between thecreative industries and territory covered in thisreport, our consideration of individual and social
value, in terms of health and wellbeing, has little to
do with the commercial exploitation of intellectual
19Chapter 1

The Arts for Health and Wellbeing

property. Some participants in our meetings did,
however, identify the creative industries as
a possible source of funding for the activities
we describe.

1.4

Interactions Between theArts, Health and Wellbeing
The creative impulse is fundamental to theexperience of being human. 38 Professor of
Psychology and Public Health at Canterbury
Christ Church University, Paul Camic, has notedthat creative activity has ‘existed in various forms
using different materials for perhaps 800,000
years but certainly for the last 200,000 years
during the time of Homo erectus and well before
modern Homo sapiens appeared. In every
prehistoric, ancient and contemporary culture
there is evidence of what we have come to call “theAll-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Report

judgement; yield opportunities for guided
conversations; 42 increase control over life
circumstances; inspire change and growth;engender a sense of belonging; prompt collective
working; and promote healing. Creativity was also
seen as a means of empowerment that can help us
to face our problems or be distracted from them.
Consistent with all this, it was acknowledged thatthe arts are not anodyne; they allow us to access arange of emotions, including anguish, crisis andpain, which can serve as a preferable alternative tobeing sedated.
At the end of 2012, the AHRC initiated the
Cultural Value Project, under the direction ofProfessor Geoffrey Crossick, which led to a
programme of seminars and the provision of
grants to 72 separate research initiatives. This
project aimed to stimulate exploration of theindividual and social value of engagement with thearts and culture, across professional and amateur
sectors, and a chapter of the ensuing report wasdedicated to health, ageing and wellbeing. Oneof the findings of the Cultural Value Project
was that the arts at once
prov ide enga gement a nd
aesthetic detachment, enabling
individuals to become more
ref lective. The concept oft he ref lect ive i nd iv idua lencompasses an ‘improved
understanding of oneself, anability to reflect on different
aspects of one’s own life, anenhanced sense of empathy […] and a sense of thediversity of human experience’.43 At one of three
Advisory Group meetings held as part of theInquiry, Professor Crossick noted that ‘One of themost important things about health is selfreflection and empowerment and a sense that you
can actually control what is damaging your health’.
This sense of mastery over one’s environment
leads to enhancements in health and wellbeing
through a process of health creation.44
Individual experiences of the arts can lead torecovery from illness, injury or addiction or to theprevention of disease or infirmity. Equally, arts
engagement contributes to the attainment andmaintenance of wellbeing in healthy people orthose experiencing ill health and their carers. This
report explores the implications of these twostatements for our society by interrogating theimpact of the arts upon health and wellbeing. In
doing so, it often refers to a particular art form
having a specific impact. This is solely because theevidence is arranged in such a way and not because
we wish to uphold the compartmentalisation ofart forms.
The National Alliance for Arts, Health andWellbeing (NAAHW) – which provides the
Secretariat to the APPGAHW – isolates five mainsites at which the arts and health typically intersect:Engaging with the arts has a significant
part to play in improving physical andmental health and wellbeing.
arts”’.39 A Working Group on Arts, Health andWellbeing at the Royal Society for Public Health(RSPH) – research partner to the Inquiry –observed that, ‘For early civilizations, aesthetic
beauty in objects or surroundings and the soothing
rhythms of words, movement and music
contributed to the balance and harmony between
bodily systems and environment which was
believed to maintain good health’.40 A 2017 book
explored this history in some depth to argue thatthe ‘birth of art was also the birth of artsin health’.41
The central premise of this report is thatengaging with the arts has a significant part to playin improving physical and mental health andwellbeing. Engagement with the arts – throughattendance at cultural events and, morecommonly, through participation in creative
activity – begins with an individual experiencethat can have positive effects.
During the course of the Inquiry, a great rangeof first-hand benefits was attributed to the arts.
This included recognition that creativity can:stimulate imagination and reflection; encourage
dialogue with the deeper self and enable
expression; change perspectives; contribute to theconstruction of identity; provoke cathartic release;provide a place of safety and freedom from20•	A rts in health and care environments – mostcommonly arts in hospitals, which is consideredat some length in later chapters together witharts in social care settings.45•	Participatory arts programmes – individual andgroup arts activities aimed at attaining andmaintaining health and wellbeing, in health andsocial care settings and community locations,discussed as this report progresses.46•	A rts on prescription – the referral of people totake part in creative activities, often but not
exclusively in response to mental healthproblems;47 examples from Gloucestershire andCambridgeshire illustrate chapters four and five,and the role of such initiatives within thecommunity beyond the clinical environment
is outlined.
•	A rts therapies – drama, music and visual arts
activities targeted at individuals, usually inclinical settings, by any of 3,600 practitioners
accredited by the Health and Care Professions
Council (HCPC), examples of which will be
provided throughout.48•	Medical training and medical humanities –inclusion of the arts in the formation andprofessional development of health and social
care professionals, in ways that will be consideredin chapter seven.49
Disciplinary demarcations are breaking down,
partly as a result of work by special interest groupsof the RSPH and the Faculty of Public Health (FPH).
Yet, while many of the mechanisms are similar, adistinction remains between therapy and theMissing from the arts and health canon isattendance at arts events, which, as we shall see,has a contribution to make to longer lives better
lived. Also absent from this list is everyday
creativity,52 which might be undertaken alone or incompany and has an immense contribution to
make to happy, healthy lives without necessarily
having a connection to health or social care. As theformer Secretary of State for Health, Alan Johnson,
put it, ‘Access and participation in the arts are an
essential part of our everyday wellbeing andquality of life’.53
Parenthetically, certain branches of arts andhealth activity might be thought of as arts andstealth, inasmuch as arts participation often
increases the appeal of activities that mightotherwise be offputtingly arduous, such as
occupational therapy (e.g. Breathe Magic forchildren with hemiplegia)54 or exercise (e.g. dancefor older people).55
In 2016, Chair of NHS England, Professor
Malcolm Grant, expressed the view that, where
health was concerned, any arts activity was better
than none.56 On the one hand, it would be adisservice to participants to offer substandard
arts activities under the banner of health andwellbeing, and the examples given in this reportshow high-quality work being undertaken in an
avowedly inclusive way. On the other hand, inparticipatory arts activities with people who havenot previously been encouraged to express theircreativity, it is the quality of the activity, rather
than the quality of output, that matters.57 Similarly,
in art therapy, ‘As patients strive to express andexplore their inner emotionallandscape through their art
there is no expectation thatwork should be aesthetically“good” in a conventiona lsense, or viewed outside thetherapy space’.58
Those delivering arts andhealth work are primarily
charities, community interestc ompa n ie s (CIC s), s m a l lenterprises and individual
practitioners working on af reelance basis. The vast
majority are arts organisations
reaching into the world ofhealth and social care, rather than the other way
round. For an overview of the arts and health field,
readers are referred to the 2013 RSPH report Arts,
Health and Wellbeing beyond the Millennium: How
far have we come and where do we want to go?59
In the recent history of the arts interacting withhealth and wellbeing, Greater Manchester isarguably the wellspring. In 1973, Neil Kessell,Professor of Psychiatry at the University ofManchester, invited artist Peter Senior to exhibit
his work in the outpatients’ department of

While the many excellent examples of thearts improving health and wellbeing
suggest a resoundingly positive picture, itis essential to stress that good-quality arts
activity within health and social care is far
from universal.
therapeutic by virtue of intention and modeof action. The former generally refers to aservice being offered to patients with a particularclinical goal in mind; the latter tends to be centredon the stimulation of creative activity withan indirect ef fect on health, 50 whereby‘emphasis is on the intrinsic value and quality of
the creative process and what it produces’.51
The transition from therapy to the therapeutic,
from patient to person, forms part of thehealing process.

21

Chapter 1

The Arts for Health and Wellbeing

Withington Psychiatric Hospital. This led to
Senior’s appointment, funded by the Calouste
Gulbenkian Foundation, as artist-in-residence at
St Mary’s Hospital, Manchester. In 1977, Senior
established a team of artists under the Manpower
Services Commission’s job creation programme.60
This experiment was consolidated as Manchester
Hospitals Arts Project, which undertook to
produce site-specific works within hospitalbuildings and beyond. In the 1990s, under the
directorship of Brian Chapman and in recognitionof the fact that success had rendered ‘hospital arts’a generic term, the project was renamed Lime.
This early experiment gave rise to a wealth ofprojects and activities across Greater Manchester,
spanning the categories outlined above. On 14
June 2016, the archives of several prominent
Greater Manchester arts and health organisations
were accepted into the Wellcome library.
In 1987, Peter Senior established Arts for
Health at Manchester Metropolitan University(MMU), which has continued to inf luence
research and development in a rapidly evolving
global field. In 2011 and 2012, Arts for Healthpublished a defiant two-part manifesto which
declared: ‘I am part of this movement. I might bein the North of England. I might be anywhere in
the world. We are the same. We are unique. We
believe the arts shape and challenge thinking. We
believe the arts are a vehicle for health, wellbeing
and social change’.61 In chapter five, we hear more
about how the devolution of powers to Greater
Manchester could enable synergies between thearts, health and wellbeing to flourish.
In relation to wellbeing, a study of 1,500 Italian
adults found a positive correlation between arts
engagement and wellbeing.62 The Cultural Value
Project report suggested that increased politicalinterest could presage acknowledgement of thecontribution of the arts to human flourishing
while regretting that this opportunity had largely
been missed within recent wellbeing indicators.
Yet, evidence is building of the contribution ofarts engagement to wellbeing.
In 2007, Arts Council England (ACE) joined
the larger Big Lottery-funded Well London
programme – led by the Greater London
Authority and London Health Commission –which had been set up to explore new ways of
improving the health and wellbeing of someof the most deprived communities in the capital.
ACE coordinated a series of large-sca leparticipatory arts projects, collectively known as
Be Creative Be Well, which aimed to enhance thewel lbeing of 3 , 30 0 residents. Th is wa s
independently evaluated along the lines
envisaged by NEF and resulted in a substantial
repor t, detailing not only how a dozen
selected projects enhanced wellbeing but also
how learning from them could be built upon in
the future.63
22

All-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Report

In September 2014, the APPG on Wellbeing
Economics published a report identifying thearts and culture as one of four key policy areas for
wellbeing. The report championed the intrinsic,
non-economic human benefits of the arts andacknowledged their impact upon health as acentral driver of wellbeing.64 The APPGAHW helda round table jointly with the APPG on Wellbeing
Economics to discuss the implications of theCare Act, which took wellbeing as an organisingprinciple for social care. Chair of the APPG on
Wellbeing Economics, David Lammy MP,
described it as axiomatic that the arts and culture
have a relationship with wellbeing.
Health and wellbeing are increasingly discussed
when the individual and social value of the artsand culture are under consideration.65 The
relationship between the arts, health andwellbeing is periodically celebrated during
Creativity and Wellbeing Week in London andduring the week-long Culture Shots in
Manchester, which ‘injects a shot of culture in
the arm of the NHS’ by taking over hospitals andenabling staff to gain a fresh appreciation of the
wellbeing benefits of the arts.
Examples are provided in this report of ways
in which the arts play a positive part inproducing health and wellbeing, from theearliest development of children to meaningfulencounters at the end of life. In areas where a
project has proven particularly influential, it isworked up into a brief case study. Examples andcase studies seek to be representative without
being exhaustive. While our consideration islargely confined to England, we recognise thepresence of distinct NHS models in all four
nations of the UK and note positive examples in
each. We also draw upon international insights.
Whereas the many excellent examples of thearts improving health and wellbeing suggest aresoundingly positive picture, it is essential tostress that good-quality arts activity within
health and social care is far from universal in
England or the UK. The examples and casestudies woven into this report are thinly spreadand patchy, often short-term and usuallydependent upon persuasive individuals andenlightened commissioners. There has,regrettably, been a general refusal to take thearts seriously in the context of health andwellbeing, and long-running, exemplary
projects – such as START in Manchester, whichgrew out of the Manchester Hospital Arts
Project in 1986 – have been decommissioned.66
In light of the foregoing, the two main aimsof this report are to secure greater recognitionof the beneficial impact of arts engagement
upon health and wellbeing and to ensure thatthe assistance offered by the arts to some of themost pressing challenges in health and social
care is embraced. We are not proposing that thearts should somehow substitute for a fully
functioning health service, nor that the arts
should take funding away from the NHS, butrather that the arts should be used more
extensively in preventative and restorative
strategies and fully integrated into health andsocial services in ways that would alleviate
some of the pressures on them.
In aligning the arts with health andwellbeing, this report is not an attempt to insist
that the language around the arts become
medicalised, nor does it seek to make arts
funding dependent upon health or wellbeing
outcomes. Neither will it offer a standardised
approach to commissioning. Rather, thisreport advocates national recognition of thehealth and wellbeing aspects of the arts andargues for much more widespread, locallyspecific provision.

23

Connecting Barnfield by New
Global Image as part of Be
Creative Be Well, Barnfield
Estate, Woolwich Common,
Greenwich
Photographer: Bethany Clarke

The Arts andthe Social
Determinantsof Health andWellbeing
24

25

All-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Report

2 The Arts and the Social Determinants of Health and Wellbeing“The development of a society, rich orpoor, can be judged by the quality of its
population’s health, how fairly health isdistributed across the social spectrum,and the degree of protection provided
from disadvantage as a result of ill-health.”
World Health Organization Commission on Social Determinants of Health, 2008In the early twenty-first century, the nonmedical causes of non-communicablediseases – and their unequal distribution
within and between societies – have been
acknowledged and addressed. What may
come to be seen as a turning point was theestablishment, in 2005, of a Commission on Social
Determinants of Health by WHO. Its report,
published three years later, suggested that: he poor health of the poor, the social gradient inThealth within countries, and the marked healthinequities between countries are caused by theunequal distribution of power, income, goods,
and services, globally and nationally, theconsequent unfairness in the immediate, visible
circumstances of people’s lives – their access tohealthcare, schools, and education, theirconditions of work and leisure, their homes,
communities, towns, or cities – and their chancesof leading a flourishing life.67

To take just one example of the social gradient inhealth within countries, the Commission foundthat a man living in a deprived part of Glasgow had
a life expectancy of 54 years, while his counterpart
in a wealthy suburb of the same city could expect
to reach the age of 82.68
In considering the uneven distribution of healthacross the social gradient, the Commission
counselled reduction in inequities across the life
course,69 beginning with the prenatal phase andthe early physical, social, emotional and cognitive
development of children. It was envisaged that thiswould require urgent action at a local, national andglobal level, including: the provision of goodquality universal healthcare as a vital public
service; the improvement of employment security
and conditions; and the implementation ofredistributive welfare systems. Rather than justtargeting the worst off, Chair of the Commission,
Professor Sir Michael Marmot, advocated the
distribution of resources on a sliding scale acrossthe social gradient.70 The Chief Medical Officer has
explicitly endorsed this approach, which Marmot
calls ‘proportionate universalism’.71
In considering the unequal distribution of
power, income, goods and services, a brief
distinction must be made between absolute andrelative poverty. Marmot notes that people in Cuba
– with its low levels of relative poverty, near-total
primary school attendance and well-developeds ystems for education, hea lt hca re a ndsocial protection – enjoy health and life
expectancy that are remarkable for a country witha small GDP.72 Arts engagement has for many years
been a cornerstone of policy in Cuba,73 as
has recognition of the relationship between thearts and psychotherapy.74
In a 2008 editorial for Arts & Health journal,
three board members of the RSPH Special Interest
Group on Arts, Health and Wellbeing welcomed
the work of the Commission while noting that thearts were conspicuous by their absence from its

Health is influenced by the conditions in which people areborn, grow, work, live, and age, and the wider set of forces
and systems shaping the conditions of daily life.
26

The arts can intervene at key developmental stages, before birthand during childhood, adolescence and young adulthood.
published guidance.75 This omission was reiterated
in a 2016 Oxford University Press textbook on arts,
health and wellbeing, edited by two of the authorsof the earlier statement, which also accepted thelimitations of the arts in addressing global
health inequities.76
The present report aims to bridge the gap
between an embrace of strategies tackling thesocia l deter m i na nt s of hea lt h a nd a n
acknowledgement of the role the arts can play. It
considers the conditions of our lives – our access tohealth, education and employment, our work andleisure, our homes, communities, towns and cities.
In all these areas, we show that the arts have a partto play in encouraging human flourishing.
Chapter four of this report attempts to identify
the most promising areas within the current
policy landscape in which conjunctions between
the arts and health might be encouraged. At thisstage, we look at specific examples of UK healthpolicy in which the social determinants of healthhave made themselves felt.

2.1

The Social Determinantsand Health Policy
In 2008, Marmot was invited by the Secretary ofState for Health to chair an independent review of
evidence-based strategies for reducing healthinequalities. This became known as the Strategic
Review of Health Inequalities in England post2010 and was published as Fair Society, Fair Lives:
The Marmot Review. The review reinforced thefinding that health inequalities resulted fromsocial inequalities,77 pointing to an average
difference in English life expectancy of sevenyears and disability-free life expectancy of 17
years between rich and poor. It predicted that ‘If
no action is taken, the cost of treating the various
illnesses that result from inequalities in the levelof obesity alone will rise from £2 billion per year
to nearly £5 billion per year in 2025’.78
This analysis points to a salutogenic approach,which aims to generate health by reducing social
inequalities across public policy.79 Such a joined-up
approach is sometimes referred to as Health in All
Policies (HiAP), and it is championed by aneponymous APPG at Westminster. Public Health
England (PHE) has partnered with the Local
Government Association (LGA) to implement
HiAP at a local level.80

The overarching recommendation made in the
Marmot Review was that strategies for tackling
hea lt h i ne qua l it ie s shou ld be appl ie dproportionally across the social gradient. Six
specific policy objectives were proposed forachieving this:•		 Give every child the best start in life•		Enable all children, young people and adults tomaximise their capabilities and have control
over their lives•		 Create fair employment and good work for all•		 Ensure a healthy standard of living for all•		Create and develop healthy and sustainable
places and communities•		Strengthen the role and impact of ill healthprevention81
In later chapters of this report, we detail thecontribution the arts have to make to each of theseobjectives.
In 2010, the Secretary of State for Healthpresented a White Paper to Parliament, entitled
Healthy Lives, Healthy People: Our Strategy for
Public Health in England. The White Paper
explicitly referenced the Marmot Review andadopted its life-course framework for tackling thesocial determinants of health. It also recognisedthat health inequalities were unsustainable andpresaged devolution of responsibility from central
to local government and to citizens andcommunities.82
In 2012, announcing a new Public Health
Outcomes Framework for England 2013–6, theDepartment of Health (DH) stated that ‘services
will be planned and delivered in the context of thebroader social determinants of health, likepoverty, education, housing, employment, crimeand pollution’. 83 In this endeavour, it was
anticipated that ‘The whole system will be
refocused around achieving positive healthoutcomes for the population and reducing
inequalities in health’.84 This implied increasing
healthy life expectancy throughout the population
and reducing differences in life expectancy andhealthy life expectancy between communities byaddressing the wider determinants of health.
Following on from the Outcomes Framework,
the Health and Social Care Act 2012 established aduty for the Secretary of State for Health and the
NHS Commissioning Board to address healthinequalities through the provision of services.85
The Act also legislated for ‘public involvement inhealth and social care matters, scrutiny of healthmatters by local authorities and co-operation
27

Chapter 2

The Arts and the Social Determinants of Health and Wellbeing

between local authorities and commissioners ofhealthcare services’, 86 which the Outcomes
Framework had identified as a way to iron out
health inequalities.87
Local authorities are now under a legislative
duty to ameliorate the conditions that make people
ill, which compels recognition of the social
determinants of health. 88 There has been
widespread uptake of the Marmot principles inlocal authorities, with assets-based approaches
often benefiting from political support and being
integrated into the local plan. 89 The social
determinants of health are increasingly
recognised throughout the NHS and careservices.90 However, in April 2017, the House ofLords Select Committee on the Long-term
Sustainability of the NHS concluded that ‘The
reductions in health inequalities called for by the
Marmot Review have yet to be realised’.91
Work on the social determinants of health has
been carried out in the devolved administrations.
In Scotland – where health inequalities account fora difference in life expectancy between affluent
and deprived areas in men and women of 11 and 12
years respectively92 – the Government has, since2007, been allocating resources according to five
strategic objectives, of which improved health isone.93 In 2008, a Ministerial Task Force on HealthInequalities published a report entitled Equally
Well.94 This framed reduction of the country’s
abiding health inequalities as both a matter ofsocial justice and a means of achieving sustainableeconomic growth. The crosscutting strategy
drawn up by the taskforce prioritised early childdevelopment, heart disease, mental health,smoking and drug and alcohol misuse. Equally
Well contained useful guidance on areas of policythat are likely to be effective in reducing healthinequalities, acknowledging cultural conditions asa factor. The Scottish Executive had earlier
acknowledged that ‘Participation in culture adds
enjoyment to life, increases self-belief, equips
people with important life skills and improves
well-being and health’.95 The National Performance
Framework for Scotland, published in March 2016,
included the objective of increasing cultural
engagement.96
In Northern Ireland, a strategic framework for
public health was published in 2014, spanning thedecade from 2013 to 2023. Explicitly referencing
the Marmot Review, this insisted upon the
reduction of health inequalities through action
across the life course.97 The draft Programme forGovernment 2016–21 included the reduction ofhealth inequalities, the improvement of healthy
life expectancy and increased participation in
culture in its list of desired national indicators.98
In Wales, 24 percent of the population live inpoverty. In 2009, the Welsh Government launcheda strategic framework, entitled Our Healthy
Future, which prioritised the reduction of health28

All-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Reportinequalities. The internal market for the NHS isbeing abolished in Wales, leading to a collaborative,
rather than competitive, model. In 2013, NHS
Wales was framed as a listening organisation at
the heart of person-centred care.99 Health boards
cover all aspects of care and operate according to aset of principles which include the attainment ofhealth and wellbeing through co-production anduniversal proportionalism. Action has, until
recently, been centred upon 52 Communities Firstclusters, each made up of 10–15,000 people andaccounting for the quarter of the population in
greatest need of support. The 2015 Well-Being of
Future Generations Act compels all public bodies
to consider the impact of their decisions upon thesocial, economic, environment and cultural
wellbeing of the people.100 It is less apparent that
HM Treasury is encouraging such crossdepartmental strategic approaches.

2.2

Environmental Adversity
The conditions in which we experience life have a
profound effect upon our physical and mental
health and wellbeing.101 In order to understandhow this works, we need to differentiate between
positive stress (eustress), which is necessary to
perform well, and negative stress (distress),102
which debilitates and hampers human flourishing.
At a molecular level, socio-economic disadvantage– and the chronic distress it causes for bothchildren and adults – has negative effects on
biological pathways and cellular functions.103
Distress causes alterations to the non-coding
part of DNA. Such epigenetic changes may be
incurred before birth and accumulate throughout
the life course,104 exacerbated by environment andcompounded by factors like obesity (which also
follows the social gradient) to increase
susceptibility to such conditions as coronary heartdisease, chronic obstructive pulmonary disease(COPD) and stroke.105 Data on more than 60,000
people demonstrate a direct link between
psychological distress and cardiovasculardisease.106 Adverse childhood experience, such as
trauma and abuse, increases the likelihood ofchronic illness and shortens life expectancy.107
Children from disadvantaged backgrounds are
two to three times more likely to develop mental
health problems,108 including depression.109
It is important to note, however, that the social
determinants of health are mutable, and ‘poverty
is not destiny’.110 Environmental enrichment has
been found to improve cognitive functions, such aslearning and memory,111 and increase willingness
to explore.112 As people’s circumstances alter, so
too do their responses to health-affecting factors.113
Levels of distress can diminish, and epigenetic

changes can be reversed through exposure to
conducive environments. Rather than being an
optional extra, this implies that better-quality
environments are fundamental to improving
health and wellbeing.
A leading Swedish epidemiologist, Professor
Lars Olov Bygren, posits arts engagement as a formof environmental enrichment that may contributeto better health.114 As part of this consideration ofhealth and wellbeing, instances are given of thearts contributing to improved environments andhelping to overcome distress. Arts engagement
may be envisaged as a factor that can mitigate theeffects of health inequalities while policies are
implemented to eradicate their causes.
Since the 1940s, the connection between the
hypothalamus and pituitary and adrenal glands(the HPA axis) has been looked to as a possible
mediator in psychosomatic mechanisms. The HPA
axis is implicated in major depressive disorder,
bipolar disorder and attention deficit hyperactivity
disorder (ADHD).115 Studies of brain function
repeatedly implicate excess production of
glucocorticoids (cortisol in humans – produced
when the body is distressed) in brain deterioration.116
We present evidence that arts engagement reduceslevels of the stress hormone cortisol.
Distinguished Professor of Psychology andManagement at Claremont Graduate University,
Mihaly Csikszentmihalyi, has suggested that our

2.3

Health Inequalities andthe Arts
We have seen that the WHO Commission on Social
Determinants of Health prescribed reduction in
health inequalities across the life course and that
this principle has been adopted within policy in
the UK. We have opted to structure four chaptersof this report according to the different life stages
at which the arts can have an impact on health andwellbeing from birth to death. Where healthconditions persist across the life course, they are
introduced within the chapter at which their onset
is most common. This is not to preclude
intergenerational factors, such as the relationshipbetween parents and children, between
grandparents or grandchildren, between thecared-for and their carers and between community
residents of all ages. A separate chapter
contemplates the intergenerational relevance of
place, environment and community.
The Commission’s call for action began with theprenatal phase and the early physical, social,emotional and cognitive development of children,and the Marmot Review recommended policies
which ‘Give every child the best start in life’ and‘Enable all children, young people and adults tomaximise their capabilities andhave control over their lives’. In
chapter six, we consider ways inwhich the arts can intervene at
key developmental stages,
before bi r t h a nd du r ing
childhood, adolescence andyoung adulthood, potentiallyof fsetting some of theconsequences of differential
educational outcomes and employment prospects.
While research in this area is at an early stage, it ispossible that the arts can indeed contribute toovercoming disparities in health outcomes and life
expectancies.
In its consideration of action across the life
course, the Marmot Review called for ‘fair
employment and good work for all’. Elsewhere,
Marmot has elaborated that it is not only
differences in income which determine health;occupations which place high demands on
workers, while depriving them of control, have a
detrimental impact upon health.119 In chapter
seven, the positive effects of arts engagement on
working-age adults are considered. We see a role
for the arts in reducing anxiety, depression andstress and having a positive impact on healthconditions exacerbated by inequalities. Thissuggests that arts engagement needs to be
encouraged both in and out of work at the sametime as fair and equitable work is pursued as a

Arts engagement needs to be encouraged
both in and out of work at the same time asfair and equitable work is pursued as a goal.
nervous system is only capable of processing about
100 bits of information per second; when deeply
immersed in creative activity, much of thiscapacity is occupied and we are unable to monitor
physical or psychological pain. During decades ofinterviews by Csikszentmihalyi, the word thatrecurred most often to describe this state ofcreative absorption was ‘f low’. This implies
focused concentration, a sense of being outside
reality, combined with great inner clarity andknowledge that a creative objective can beachieved, which carries its own reward. 117
Embracing an abiding passion for painting while
recover ing f rom a stroke, the politica lcommentator Andrew Marr speculated that ‘The
mind is completely engaged in something that isboth difficult and absorbing – “pure” problems of
tone, harmony, line and so forth. The body is
working, the mind is at full stretch, time
disappears and out of it all comes – well –something or other’.118

29

Chapter 2

The Arts and the Social Determinants of Health and Wellbeing

All-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Report

The arts provide a route to better health and wellbeing while healthprovides a route to the arts that can help to overcome persistentinequalities of access.
goal. We welcome the Prime Minister’scommitment to greater equity in the conditions of
employment, and we believe that engagement withthe arts in childhood and adulthood will support
this agenda.
The Commission on Social Determinants ofHealth highlighted the importance to people’s
health of home and community, and the Marmot
Review advocated a ‘healthy standard of living forall’ and ‘healthy and sustainable places andcommunities’. In chapter five, the significance of
healthy and sustainable places and communities
is elaborated; the role of the arts, includingarchitecture and design, is foregrounded as part ofa wider person-centred, place-based strategy for
improving health and wellbeing. Among thebeneficiaries of such an approach will be older
adults, particularly those at risk of frailty or social
isolation, which is considered at length inchapter eight.
At the round table on the Arts and Public Health,Professor Richard Parish told us that ‘the arts canimprove reach; they can enable access both to andby a range of communities to health-relatedresources that can impact on inequalities, and thearts can equip people with the skills necessary forlife’. Proposing that such health-creating activities
could provide lifelong immunisation, Professor
Parish positioned the arts as one of the ‘essential
vaccines within that immunisation package’.

2.4

Arts Participation Acrossthe Social GradientSince 2005, DCMS, in partnership with ACE,
English Heritage and Sport England, has carriedout a survey of cultural and sporting engagement
known as Taking Part.120 Analysis of data generated
by the survey has shown that people who visit
museums and galleries are disproportionately
prosperous, well-educated professionals in the 55
to 74 age range, who also visited museums andgalleries when they were young. When it comes toparticipating in creative activities, the picture is
the same in terms of education and occupation,with the older generation joined by those aged
between 16 and 19 years and both age groups
having been encouraged by their parents to becreative. In both attendance and participation,
ethnicity is a factor, with museum and gallery
30

visitors unlikely to be black or Asian and arts
participants most likely to be white. Both attendees
and participants enjoy good health.121
In much the same way, the Scottish Household
Survey has captured engagement in culture andsport since 2007. This shows that ‘cultural
engagement levels are highest in the highest
household income groups in Scotland and decline
to be lowest in the lowest household income
groups. Similarly, adult participation in culturaland sporting activities varies by area deprivation,with participation increasing as area deprivation
decreases’. 122 Throughout the UK, the overrepresentation of certain groups, and the underrepresentation of others, at publicly funded arts
events is acknowledged to be a problem. At theround table on Museums and Health, we discussed
widening the accessibility of museums, which it
was thought might involve taking arts experiences
to the people rather than expecting people to cometo them.
In direct contrast to the normal demographics
of publicly funded arts, people accessing arts
activities through health routes tend to beexperiencing poor health. Disadvantaged andmarginalised groups are disproportionately
affected by ill health and, as a result, are well
represented within arts and health activities.
In a reciprocal relationship, the arts provide aroute to better health and wellbeing while healthprovides a route to the arts that can help toovercome persistent inequalities of access. Thismeans that arts and health activities often
inadver tently confor m to the model ofproportionate universalism.
On the understanding that the most vulnerable
groups are 20 percent less likely to participate increative or cultural activity in the UK than the leastdeprived and that such activity increases subjective
wellbeing, the Calouste Gulbenkian Foundation is
working towards mainstreaming the participatory
arts.123 The APPG on Wellbeing Economics has
suggested that public subsidy to the participatory
arts be distributed proportionally across the social
gradient with a view to ironing out inequalities inwellbeing.124 We endorse this proposition andadvocate that it is extended to include health.
In his first speech as Chair of ACE in March 2017,
Sir Nicholas Serota said that ‘we must never forgetthat the arts are first about the magic of that
individual encounter, the special experience thatchanges our view of the world or our understandingof ourselves. The chance to have this kind of
encounter should not be limited by social,educational, or economic privilege’.125 We call upon
ACE to recognise explicitly the ability of the artsfor health and wellbeing to cross ‘all social barriers,
not only the protected characteristics, but alsoclass and geography’.126 We hope that research willcontinue to demonstrate the ways in which thisis achieved.
While the distribution of arts and healthactivities across the social gradient is encouraging,helping to even out some of the disparities inaccess to the arts, this diversity is not reflected
within the workforce.127 A Culture White Paper,launched by the Min ister for Cu lture,
Communications and Creative Industries, Ed
Vaizey, in March 2016, rightly asserted that ‘Weneed a more diverse leadership and workforce inthe cultural sectors’.128 More will need to be done toencourage people finding their way to the arts via
health and wellbeing to take up leadership roles.
The Commission on Social Determinants ofHealth recognised that material, psychosocial andpolitical empowerment – gained throughparticipation in society – underpins equitable
health and wellbeing. Accordingly, this reportconsiders ‘participatory practice involving peopleroutinely marginalised from decision-making
processes by having the least access to the policymaking machinery’.129 Addressing the findings of
the Commission on Social Determinants of Health,Vicente Navarro – Professor of Health and Public
Policy at Johns Hopkins University in the USA andProfessor of Politica l a nd Socia lSciences at Pompeu Fabra University in Spain –argued that: he major causes of mortality – cancer andT
cardiovascular diseases – will not be solved
through medical interventions. Medical
institutions take care of individuals with these
conditions and improve their quality of life, butthey do not resolve these (or most other) chronic
problems. Disease prevention and healthpromotion programs primarily based on
behavioural and lifestyle interventions are also
insufficient. We have plenty of evidence that
programs aimed at changing individual
behaviour have limited effectiveness. And
understandably so. Instead, we need to broaden
health strategies to include political, economic,
social and cultural interventions that touch on
the social (as distinct from the individual)
determinants of health. These interventions
should have the empowerment of people as theirfirst objective. Thus, a national health policy
should focus on the structural determinants ofhealth and should have as its primary
components political, economic, social andcultural health policy interventions.130

lack a national framework for cultural healthpolicy interventions in the artistic sense.131 This
report is envisaged as a first step towards
achieving such a framework.
Policies addressing health inequalities acrossthe life course are now being considered ingovernment throughout the UK. This reportmakes the case that the arts have a vital part toplay in mitigating the effects of the social
determinants of health, by influencing earlychildhood development, and hence educationaland employment opportunities, and by forming
part of an enriched environment, reducing
distress and having a potentially profoundeffect upon physical and mental health. Our
recommendations seek a more even distributionof healthy life expectancy across the population,with the arts playing an indispensable part.
The late Mike White, Senior Research Fellow
at Durham University, whose contribution tounderstanding arts and health was epochal,said ‘A commitment to addressing the social
determinants of health requires a process ofengagement that goes beyond the healthservices themselves and builds alliances forsocial change’.132 The Commission on Social
Determinants of Health noted that ‘The role ofgovernments through public sector action isfundamental to health equity. But the role is notgovernment’s alone. Rather, it is through the
democratic processes of civ il society
participation and public policymaking,supported at the regional and global levels,
backed by the research on what works for healthequity, and with the collaboration of private
actors, that real action for health equity ispossible’.133 This report seeks to advance anappr oach i nvolv i n g he a lt h s er v ic e s ,governments and members of civil society
working towards health equity.

While Navarro refers to cultural interventions in
the anthropological sense, in the UK we currently
31

The Art Room, Oxfordshire
Photographer: C. Silver Lewis

Considering
the Evidence
32

33

All-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Report

3 Considering the Evidence“Wonder is the beginning of wisdom”
SocratesThere is an expanding body of evidence
to support the contention that the arts
have an important contribution to
make to health and wellbeing. The
evidence is being developed in scholarly
work and disseminated through dedicatedjournals and other platforms.134 There is growinginterest in the field from professional bodies,including government agencies, and new strategic
partnerships are being developed.
Evidence includes both research and evaluation.
Research usually involves a project or intervention
being designed to test a hypothesis or answer aquestion, whereas evaluation involves a particular

3.1

Quantitative Methods
Within clinical research, randomised controlled
trials (RCTs) are considered the ‘gold standard’,placing them at the top of the so-called hierarchyof evidence. An RCT takes place within a sizeable,
randomly selected group but not within anothersimilar group, the latter of which serves as a‘control’ or basis for comparison.
Drawing upon evidence derived from RCTs,
Cochrane Reviews systematically analyse thefindings of a range of studies of a particular
i nt er vent ion . To en s u r e
objectivity, more than one
person generally conducts asystematic review. Studies are
selected for inclusion on thebasis of having used establishedprotocols, which means that‘grey’ literature, arising fromproject evaluations, is not
generally taken into account. A
search of the Cochrane libraryfound that reviews relating the arts to health drew
upon more than 1,000 RCTs.137
Arts therapies have amassed evidence of the
impacts of precise interventions, but this is lessthe case for the participatory arts, with the
National Institute for Health Research (NIHR)
rarely supporting work in this area. As comparedto the scientif ic culture of medicine, theparticipatory arts foreground experience andprocess. Much research into community-basedarts and health activity has considered small
sample sizes without a control group.138 Such
research has sometimes been hampered by poor
cooperation from health professionals whenrecruiting participants. In this report, study sizes
are reported where relevant, to aid readers inassessing their respective merits.
The Cultural Value Project report observed thatthe quantitative aspect of research design might
be strengthened in some areas, but ‘to insist on it
exclusively may not do justice to the character ofarts interventions used in relation to health, nor totheir outcomes’. 139 The chapter of the report
dedicated to health, ageing and wellbeing
identified a ‘need to step back from the establishedhierarchy of evidence that places randomised

The relationship between arts engagement
and health is important and needs to beunderstood.
project being assessed, concurrently and/or
retrospectively, according to a range of criteria. At
a round table held by the Inquiry, Professor Camic
noted that evidence is sometimes confused with
proof, when a more nuanced question might be ‘Isthere sufficient evidence that an assertion,
proposition or hypothesis can be supported?’ An
obstacle to the com m issioning of a r ts
organisations in the health sector seems to bethat the ‘burden of proof’ forces them to justify
the impact of creative approaches as compared tobiomedical alternatives.135
The evidence base spans a wide range of
methodologies and practices. It is unevenly
distributed across the field, concentrated in suchareas of scholarly interest as arts and dementia
and patchier in relation to, say, prevention andthe management of long-term conditions.
Different forms of evidence are persuasive todifferent audiences; commissioners needdifferent evidence from clinicians, practitioners
or service users.136 A brief overview is provided
here of the types of evidence that will be
encountered in this report, and a hint is given
about the ways in which these might be developedin the future.
34

Arts therapies have amassed evidence of the impacts of precise
interventions, but this is less the case for the participatory arts.
controlled trials and experimental approaches at
the top, not least in contexts such as mental health,where outcomes have to be subjectively validated
by the participants, and where intended outcomesmay not translate straightfor wardly intomeasurable health improvements on clinicalscales’.140 A recent shift away from RCTs has been
noted, in favour of good observation data. Thisimplies the documentation of outcomes, such as
reductions in depression or medication.
Increasingly, a combination of methods
is advocated.141

3.2

Measuring Wellbeing
When it comes to wellbeing, a range ofpsychological scales has been designed to facilitate
quantitative analysis. The Chief Medical Officer
found that, when the lack of a precise definitionof wellbeing was:[…] combined with contested boundaries(particularly within public mental health) andthe widespread use by researchers andpolicymakers of an array of validated,unvalidated , subjective and objective
measurement approaches and ‘proxy scales’ ofvarying lengths and sophistication, it can become
difficult to scientifically examine any single wellbeing perspective in a robust and consistent way
for public health policy in general, and public
mental health policy in particular. Contrasting
two perspectives appears harder still, and yet isof theoretical and practical importance.142
In 2010, the Prime Minister, David Cameron,endorsed a commitment to explore wellbeing,
made by the Office for National Statistics (ONS) in
2007, inviting the National Statistician to take thedefined wellbeing by reference to 10 dimensions –including health and personal wellbeing –subdivided into 41 indicators. Since the ONS study
began, the health dimension has shown moderateincreases both in healthy life expectancy and in
illness, disability, depression and anxiety (which
imply reduction in healthy life expectancy). The
dimension documenting personal wellbeing,
which takes account of happiness and life
satisfaction, shows that only a third of the
population feel very happy or satisfied.145
The Cultural Value Project report noted that the
ONS ‘responded to criticism over its having
omitted cultural engagement by subsequently
introducing it as one of 41 measures on its Wellbeing Wheel, but the programme has made no
significant attempt to understand the relationshipbetween cultural engagement and its other“contributors” to wellbeing’.146
The What Works Centre for Wellbeing is
working with four universities to conduct
systematic reviews of areas of the arts andwellbeing evidence base in which research isconcentrated, including grey literature derived
from project evaluations. These reviews areavailable on an open-access basis, the first of whichhave been published, exploring the impact ofmusic and singing upon wellbeing in healthy
adults and adults with health conditions
and dementia.147
In 2011, a team involving Lord Layard
contemplated the measurement of subjective
wellbeing by the ONS. The report arising from thiswork stated that, in order to inform policymaking,accounts of wellbeing needed to be theoreticallyrigorous, policy relevant and empirically robust.148
In this endeavour, three main measures ofsubjective wellbeing were isolated – evaluation(based on life satisfaction), experience (based on
the extent to which people felt happy or worried)and eudaemonic (the extent to which life felt
worthwhile) – and it was argued that each of thesecomponent s shou ld bem e a s u r e d s e p a r a t e l y. 1 4 9
Of these, Lord Layard later
argued in a discussion paper for
the What Works Centre for
Wellbeing that ‘life-satisfaction
comes nearer to satisfying
these characteristics than any
other measure (single
or composite)’. 1 50 In the meantime, theOrganisation for Economic Co-operation andDevelopment (OECD) produced guidelines formeasuring subjective wellbeing as a component

Wellbeing is difficult to measure, but life
satisfaction comes closest to capturing it.
lead on measuring wellbeing.143 This gave rise to
the Measuring National Well-being project, 144
aimed at developing subjective measurements ofwellbeing. Favouring quantitative approaches, this35

Chapter 3

Considering the Evidenceof quality of life taking account of jobs, healthand housing.151
In 2008, a scale was launched to enable themeasurement of wellbeing at a population level:‘The Warwick-Edinburgh Mental Well-being Scale[WEMWBS] was f unded by the Scottish
Government’s National Programme for Improving
Mental Health and Wellbeing, commissioned by
NHS Health Scotland, developed by the Universityof Warwick and the University of Edinburgh’.152 It
is based upon the understanding that subjective
wellbeing can be used to measure a particular
programme’s effectiveness.
Originally a fourteen-item questionnaire, aseven-item shortened version of the scale(sWEMWBS) is increasingly used. This asks users
to rate their responses to the following questions
on a five-item Likert scale ranging from ‘noneof the time’ to ‘all of the time’:•		 I’ve been feeling optimistic about the future•		 I’ve been feeling useful•		 I’ve been feeling relaxed•		 I’ve been dealing with problems well•		 I’ve been thinking clearly•		 I’ve been feeling close to other people•		I’ve been able to make up my own mind
about things
Shortly after it was launched, WEMWBS began tobe taken up within arts and health organisations.
WEMWBS has been included in the Health Survey
for England and the Scottish Health Survey. It wasalso inserted into the British Cohort Study 1970
(BCS70) at age 42 alongside questions about arts
engagement,153 yielding a dataset of around 17,000
entries, which enables cross-sectional associations
between subjective wellbeing and arts engagement
to be studied at scale.
Telephone interviews with more than 700
Western Australians, conducted using WEMWBS,
found that respondents with high levels of arts
engagement enjoyed significantly better mental
wellbeing than their low-attending counterparts.154
The threshold appeared to be 100 hours per year
(two or more hours a week), leading Western
Australia’s health-promotion organisation
Healthway to commit sizeable sponsorship to
cultural venues.155
The Cultural Value Project report noted that
explorations of the relationship between the arts
and wellbeing had largely been centred on selfreported subjective assessments and criticised fortheir focus on transient gratification, or hedonic
wellbeing, as opposed to a more sustained sense of
meaning in life (eudaemonic wellbeing). Critics of
WEMWBS point to its relentlessly upbeat natureand its failure to capture other factors impacting
upon wellbeing, including socio-economic
inequalities, the vagaries of daily life and theimminent end of enjoyable arts activities.
36

All-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Report

Other psychological scales relevant to thisreport include the University College London(UCL) Museum Wellbeing Measure,156 the EQ-5D
Health-Related Quality of Life Questionnaire157
and Dementia Care Mapping.158 The Canterbury
Wellbeing Scales, developed by researchers andclinicians at Canterbury Christ Church University,
provide a simple snapshot of the subjective
wellbeing of people with dementia and people
caring for, or working with, them. Corresponding
to the experience category isolated by Lord Layard
et al, this asks respondents to evaluate themselvesin the moment, from happy to sad, well to unwell,interested to bored, confident to unconfident andoptimistic to pessimistic.159
Beyond individual measurements, the Mental
Wellbeing Impact Assessment – developed by the
Head of Mental Health Promotion at South London
and Maudsley Hospital (SLaM) – enables themental wellbeing impact of policies, programmes,
services and projects to be assessed.160 A checklist
enables consideration of wider structural
determinants including creativity and culture.
This then moves to a detailed assessment of
whether particular initiatives include the threefactors shown to protect mental wellbeing, namely
control, resilience and inclusion. This method also
encourages consideration of population
characteristics – gender, race and ethnicity, socioeconomic position, physical health, disability andsexuality. It has been deployed to great effect inevaluating the work of the Dragon Café, discussed
in chapter five.

3.3

Qualitative Methods
Individuals within a group respond differently tothe same experience, which is a challenge toevaluation. Rather than attempting to isolatemechanistic relationships between a r ts
engagement and health or wellbeing, qualitative
methods enable descriptive exploration ofindiv idua l and sha red exper iences andrelationships. In this way, a nuanced picture ofcommonality and difference emerges.
The evaluation of arts and health projects has
historically centred on anecdote, which is rarely
persuasive to com missioners. A usef uldevelopment in evaluation would be towards more
rigorous sampling in the collection of individual
testimonies. Testimonies might be obtained using
such methods as semi-structured interviews or
focus groups, enhanced through the use ofparticipant observation and reflexive diaries (withthe latter as both a tool of documentation and an
ongoing mode of self-analysis).
An adjunct to participant testimony andanalysis is the compilation of case studies,selected without bias according to defined
criteria and carried out either by organisations
coordinating projects or by independent
researchers.161 This report includes a number ofbrief case studies that are relevant to our
discussion. These draw upon information
provided by the host organisations, such as costto participants and project funding sources,
including those beyond the health field. There is
ample scope for qualitative case studies to beworked up in many more areas of practice, toprovide a clear picture of the breadth anddistribution of activities across the UK.
Professor the Baroness Finlay of Llandaff has
observed that ‘It is the humanities that truly
express the humane’.162 In recent years, creative
activity has increasingly been framed as a researchmethod in itself – a way of understanding the world
and our place within it.163 Given that the subject
under scrutiny is the impact of the arts, there is
scope for a creative form of analysis to be
developed. Working on the basis that creative andarts-based methods are ‘effective for uncovering
hidden perspectives, adding empathic power andstrengthening participants’ voices’164 – researchersat the University of Sheffield have gathered
responses to live classical music using a WriteDraw method which solicits textual and visual
thoughts and feelings.165 Creative evaluation is also
used in the f ilmmaking that sometimes
accompanies projects, documenting the distancetravelled by participants, examples of which areprovided in this report.
In chapter seven, we consider the contributionof the medical humanities to humanising
healthcare. In recent years, a strand of criticalconsideration of the specific skills and attributesof artists which make such projects effective.
The Academy of Medical Sciences has been
looking at ways in which health challenges andopportunities might be addressed through thegathering and translation of appropriate evidence.
A 2016 report explored ways in which the health ofthe public could be improved within a generation.
Acknowledging the limits of biomedical research,
the report advocated research which ‘works acrosstraditional discipline boundaries, integrating
aspects of natural, social and health sciences, aswell as the arts and humanities, which directly or
indirectly influence the health of the public’.167
This is a welcome acknowledgement of the partthat arts-based methodologies can play in the
future of public health research.168

3.4

Economic Analysis
HM Treasury periodically publishes The Green
Book: Appraisal and Evaluation in Central
Government, offering guidance to public sector
bodies on how projects should be appraised toqualify for funding. The attribution of monetary
values to proposed projects is advised wherever
possible, enabling a judgement to be made about
the impact of public funding. In later chapters of
this report, evidence is provided of the costbenefits of various arts and health activities.
In 2014, DCMS commissioned researchers fromthe London School of Economics and Political
Science (LSE) to consider how the wellbeing
impacts of its portfolio might bemeasured and monetary values
attributed to them.169 The APPG
on Wellbeing Economics has
identified that conventional
cost benef it analysis ‘hasserious shortcomings as asource of evidence, but it also
embodies a particular set ofva lues which ma kes it aparticularly inappropriate
yardstick for valuing activities
like arts and culture: material
over non-material goods, andmarket over non-market outcomes’. 170 The
APPGAHW follows the APPG on Wellbeing
Economics in noting that:

Qualitative research and evaluation
would benefit from more rigorous
sampling, detailed compilation of casestudies and greater use of arts-basedand co-produced approaches.
medical humanities has emerged which argues forbroadening conceptions of the medical beyond theclinical encounter to take account of the context
and constitution of health and wellbeing.166 This
attempts to understand how humans experience
ill health and how movement through healthpathways can influence outcomes and informclinical science. Critical medical humanities
suggest that the arts and humanities have a part toplay in bringing essential new perspectives andshaping research. The literature currently lacks

 ne of the strengths of a wellbeing approach is itsOability to better value nonmarket goods, andgoods which we value for reasons that have little
to do with the market. In a climate where the arts
community feels under increasing pressure tojustify its activities in terms of their instrumental
benefits, we set out to explore whether a wellbeing
37

Chapter 3

Considering the Evidence

approach can better capture the true value tosociety of arts and culture subsidies to human
lives – thus helping both to make the case for artsand culture spending and to identify priorities
for that spending.171
In a similar vein, under the rubric of Where We
Live Now, the British Academy recommends that‘policies that foster well-being and well-being
measures throughout our lives should be pursued,rather than adopting solely economic measuresof progress’.172
Where it is not possible to monetise the benefitsof projects, HM Treasury says cost effectivenessmay be considered. Our report details the costeffectiveness of the arts in health and social care,through savings and avoided costs. Analysis
reveals a strong relationship between socio-

All-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Report

the round table on Commissioning, this caution
was echoed on the basis that commissioners might
only be interested in savings in their particularbudgets while projects might only be able todemonstrate savings elsewhere. If we are to movetowards a healthy and health-creating society,policy-makers and budget-holders need to take asynoptic view.
When considering the value of the arts in healthand wellbeing, it should be borne in mind that‘successful participatory arts projects are of muchgreater value to the individuals that take part thanthe economic benefits they may represent for
health or other agencies’.177 In other words, thedifference that arts participation makes to people’s
lives often transcends economic value.
The Green Book requires that account is takenof the ‘impact on health of poverty, deprivation andunemployment, as well as poor
housing or workplace
conditions’ when the social
va lue of publicly f unded
activities is estimated.178 The
Public Services (Social Value)
Act (hereafter the Social ValueAct), which came into force on 31
J a nu a r y 2 0 1 3 , r e q u i r e s
com m issioners of publ ic
services to think about how
they can secure not only
economic but also social andenvironmental benefits. This
could be a power f ul tool in achiev ing
acceptance of socially motivated approaches, but
commissioners have so far proven somewhat
resistant to considerations of social andenvironmental value.179
At the parliamentary launch of the Social
Prescribing Network in March 2016,180 Dr Marie
Polley, co-chair of the network, reported that, forever y £1 invested in socia l prescribing
programmes (discussed in detail later in thisreport), there was a social return on investment(SROI) of between £1.20 and £3.10 within the firstyear. In 2011, South West Yorkshire Partnership
NHS Foundation Trust – which is exemplary inintegrating social prescribing into every aspect ofhealth – set up Creative Minds to promote
engagement in creative activities to improvehealth and wellbeing.181 At the second of two roundtables discussing the Care Act, the Chief Executiveof the trust estimated an SROI of £4 for every £1
invested in the arts. In St Helens, an arts-onprescription service has shown an SROI of £11.55
for every £1 invested.182 Development of research inthis area would better enable SROI to be captured
more broadly.

The Public Services (Social Value) Act
requires commissioners of public services
to think about how they can secure not
only economic but also social andenvironmental benefits.
economic deprivation and costly emergency
hospital admissions.173 Core Arts, which promotes
mental health through the arts in Hackney,particularly among black, Asian and minority
ethnic (BAME) males, estimates savings throughavoided hospital admissions of up to £2.58 forevery £1 invested.174 We emphasise that investmentin the short term often pays dividends in the longer
term. Indeed, ‘Evidence across a range of service
areas shows that investment in “upstream”
interventions that prevent conditions worsening
can help to reduce demand for more acute services
and thereby avoid increasing pressure and costs’.175
Reminiscence Arts & Dementia: Impact on Qualityof Life (RADIQL), a project by Age Exchange which
is taken as a case study in chapter eight, uses
quality adjusted life years as a measure ofcost effectiveness.
A PHE review of return on investment
calculations by government departments otherthan DH uncovered a tool to measure the impact ofsport but not culture.176 At the round table on Place,
Environment, Community, it was argued that wemight be setting ourselves up to fail by trying tocompete with things that can more readily bemeasured. At a meeting of the Inquiry Advisory
Group, a note of caution was sounded in relation to
return on investment, on the grounds that savings
might actually be quite small and self-defeating. At
38

3.5

Deploying the
Evidence BaseOnce gathered, evidence needs to be brought tothe attention of commissioners. One way in whicharts approaches may be established in healthprotocols is through the guidance issued toclinicians by the National Institute for Health andCare Excellence (NICE). At present, of almost 300
pieces of guidance published by NICE, mention of
the arts only just enters into double figures. At ameeting held by the Inquiry, the Director of theCentre for Guidelines at NICE noted that, in thesecases, the arts had been picked up in a general
trawl of the research rather than in a specificfocus. He also observed that the arts wereconspicuous by their absence in guidelines onmental health and indicated that this might berectified. A similar consideration applied topain management.
There is an established protocol for bringing
topics forward for review.183 Following an initialscoping phase, NICE makes recommendations tovarious collaborating centres which conduct
reviews of the available evidence. This process
typically takes 12 to 18 months and is sometimes
accompanied by a call for evidence or an invitationfor expert testimony. Topics are reviewed forsubscribe to a hierarchy of evidence and willconsider observational and qualitative research.
We urge arts and health researchers to registeras stakeholders. We were told that, during a recent
update of the guideline on depression, the‘clamour’ from 600–700 stakeholders on the roleof the arts was not loud enough; regrettably, thearts have been excluded as a result. At the time of
publication of this report, the guideline will be out
for review, making it too late to intervene in thisparticular process, but we are delighted that NICE
has offered to commission a surveillance review
with a specific focus on the arts and psychosocial
treatments for mild to moderate depression.

3.6

Inquiry Meeting on
Evidence
On 13 September 2016, the APPGAHW held ameeting at Wellcome, at which practitioners andacademics discussed evidence relevant to the field.
There was widespread recognition of the existenceof a substantial evidence base, albeit disparate andat times inaccessible.
As a way of consolidating the evidence base, asystematic review of the entire field was mooted.185
In the College of Health and Social Care at the
University of Derby, doctoralcandidates are beginning tocompile a systematic review of
research evidence for the arts inhealth, forming a Cochrane
Review group to aid them intheir work. Such an exercise iscomplicated by the fact thatdifferent studies ask different
questions. The case was madefor practice descriptors thatwould aid research and allow
for future comparative analysis.
Systematic reviews are generally conducted ofparticular aspects of the field, rather than whole
fields. So, for example, a doctoral candidate at the
University of Nottingham is compiling aninternational taxonomy of the arts in dementia.186
With a few notable exceptions,187 arts and healthactivity tends to be centred on a particular art
form, and this is also reflected in systematic
reviews. In chapter seven, for example, we
encounter a Cochrane Review of the relationshipbetween music therapy and the physical andpsychological effects of cancer, drawing uponevidence from 52 previous clinical trials.
At the Inquiry’s evidence meeting, the focus ofsystematic reviews on whether or not somethingworked was identified as a limitation, and adeparture from biomedical, positivist philosophy

We urge arts and health researchers
to register as stakeholders with the
National Institute for Health and Care
Excellence (NICE).
updates every two, three or five years, a list ofwhich is available online.184 While reviews are
generally focused on diagnosis, there is a movetowards more holistic approaches. Evidence
pertaining to the arts might usefully be orientatedtowa r d s publ ic hea lt h (wh ich focu s e s
on prevention and individual engagement) orsocial care.
Interested parties can register as stakeholders
via a ‘get involved’ link on the NICE website.
Stakeholders can intervene in the review process
at several stages. At the scoping phase, attention
can be drawn to new areas of research. Once
guidance has been drafted, it is sent out tostakeholders for review. In the post-consultation
phase, queries may be raised and new evidence
identified. When a topic is reviewed for an update,it goes back out to stakeholders. NICE does not

39Chapter 3

Considering the Evidence

was advised. As an antidote, a realist approach was
advocated. This involves asking what works forwhom and in what circumstances. Realist
research challenges the basic premise of RCTs –that a particular intervention is the only difference
between the experimental group and control
group – by considering neither intervention norgroup a stable construct, especially where social
interventions are concerned. Rejecting outcomedriven, quasi-experimental approaches imported
from clinical trials, a realist approach seeks toadapt methodologies to the complexity of the topic
under scrutiny.188 A realist approach can be applied
not only to health but also to wellbeing, by looking
at what matters to people and why and allowing
descriptions of human flourishing to emerge.
It was suggested that an audit of ongoingprogrammes might be conducted with arealist focus, including consideration ofqualitative findings.
An example of a realist approach being used toevaluate participatory arts activity in relation to
health and wellbeing is provided by the Be Creative
Be Well project introduced in the previous chapter.
This project was orchestrated and evaluated on
the basis of a theory of change – ‘namely, that acreative or arts-based intervention in a particularcommunity will enable it, and the individuals
within it, to achieve higher levels of wellbeing,
better mental health and wider participation in
the arts’.189
To the extent that this report reviews evidence
and practice in the field, it has adopted a realist
approach by looking at what works, for whom andin which circumstances. In a realist approach,evaluation can be used to aid reflective practiceand inform the development of future activities –what Professor Stephen Clift, in the Sidney De
Haan Research Centre for Arts and Health at
Canterbury Christ Church University, has called
evidence-based practice.190
To make the evidence more accessible, an openaccess platform was advised, along withtranslation of research into language more
intelligible to practitioners.191 The University of
Florida has compiled a sizeable database of
research connecting the arts, health andwellbeing.192 The RSPH Special Interest Group on
Arts, Health and Wellbeing is developing an online
Repository for Arts and Health Resources.193 This
houses a range of searchable resources not easilyfound on the main websites dedicated to coveringarts for health practice as it has grown anddiversified in the UK over the past twenty years.
The site will be a valuable resource for academics
and researchers; policy-makers in central andlocal government; health and social care managers;
creative arts professionals engaged directly
in using their artistic skills in healthcare
and community settings to support healthand wellbeing.
40

All-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Report

At the Inquiry’s evidence meeting, thecomplexity and diversity of arts and healthpractice was acknowledged. The complexity of the
field was taken to serve as a counterpoint to thebinarism of the health service. As an example ofdiversity, much of the literature on music points to
its non-verbal or post-verbal properties as thesource of its impact,194 while the work of the Reader– until recently known as the Reader Organisation,
which involves group reading of literary works bypeople experiencing physical and psychological
pain – seems to be effective precisely because of its
verbal nature. In this sense, diversity might serveas shorthand for disciplinary specificity. At theevidence meeting, it was thought desirable todevelop understanding of what the arts and theirdifferent modes of engagement have in common
with each other, as distinct from non-arts
activities, and how generically they impact upon
our bodies and minds.
Also at the evidence meeting, reference wasmade to research into mindfulness, which has
been described as a ‘relaxation technique formedout of a combination of positive psychology,
Buddhism, cognitive behavioural therapy andneuroscience’. 195 Research has shown such
benefits of mindfulness as healing trauma andreducing depression, and £6.4m has been
allocated by Wellcome to a seven-year study
looking at the impact of mindfulness upon themental health of teenagers. 196 There aresimilarities between mindfulness and the ‘flow’that is typical of arts engagement – both requirepresence in the moment and a sense of absorption.
By contrast to the relatively clear-cut nature ofmindfulness, the complexity and diversity of artsand health work has served as a disincentive toresearch funders.
As this report shows, multifarious physical andpsychological benefits have been observed to arise
from arts engagement in ways that evade simple
description, and a theoretical framework
appropriate to all activity in the field has been
elusive. It should be recognised by research
funders that arts and health interventions are, insome ways, more complicated and timecon su m i ng to a s ses s t ha n biome d ic a linterventions.
In the process of considering the evidence basefor arts, health and wellbeing, three main reasonsfor gathering evidence in the UK cultural field
were outlined:
1. To increase knowledge
2. To provide accountability for funding
3. To aid reflective practice
To date, the second of these imperatives has driven
most evaluation, leading to a focus on specificshort-term projects. Evaluation tailored to fit thepriorities of funders assorts ill with objective

consideration of public health and the long-term,
preventative impact of arts engagement, for which
it is much harder to evidence cost benefits. Goingforward, evaluation needs to be taken more
seriously and better resourced, opening up routes
for the development of early career researchersand future academic leaders.
A project called Creative and Credible, fundedby the Economic and Social Research Council(ESRC), looked at ways in which arts-based
perspectives and methods might be used to inform
evaluation.197 Aesop has also developed resources
for arts and health evaluation.198 Drawing uponlearning from both of these strands, PHE
commissioned the Arts and Health Evaluation
Framework.199 This Framework was used as thebasis of a call for practice examples made by theInquiry, which elicited almost 200 responses.200
Professor Norma Daykin, lead researcher for
Creative and Credible and author of the
Framework, describes how it:[ …] offers a common reporting framework so that
we can start to understand how projects areconstituted, what resources they need, what
their artistic content is and how they areevaluated […]. It is designed to enablecommissioners, practitioners and policymakers
to better understand how projects compare, how
they fit together and what their particularstrengths are. Beyond this, evaluation
and research methodologies cannot be
imposed: these need to be tailored to specificevaluation questions.201
Further training and advice for practitioners on
how to use such frameworks was identified as
useful. At the University of Winchester,
professional development programmes are offeredin Evaluation for Arts, Health and Wellbeing.
In considering the breadth and depth of theevidence base, two major omissions were noted.
The first of these was the lack of studies examining
the results of arts and health activities at scale,confined as they tend to be to single projects orlimited geographical areas. The argument wasmade that studies covering whole systems would beof value, which might involve an examination of the
impact of arts activities not only on individuals but
also on their families, carers and wider networks.
The second omission identified was that of study
length. Funded studies tend to be limited to five
years, which precludes exploration of long-term
conditions and continuities of effect. Researchundertaken as part of the Cultural Value Project
explored the longitudinal impact of arts
engagement upon health. This found 15 relevant
studies, largely centred on the Nordic countries,
where continuing population-scale datasets
enable health and cultural preferences to be crossreferenced.202 Several of the studies in the evidencebase pay attention to the association between arts
engagement and mortality; others take conditions
such as cancer, heart disease and dementia as
their main outcome measure; yet others examine
obesity. Engagement in the arts is taken to include
attendance at high-quality cultural activities – inmuseums, galleries, theatres, concert halls,
cinemas and publishers – and participation in
drawing, painting, photography, singing andmusic-making. The first-order cultural value ofsuch encounters is acknowledged, and socioeconomic status is taken into account. By
controlling for socio-economic factors, thesestudies show that the health benefits of arts
engagement are not necessarily confined to more
affluent audiences.
Longitudinal analysis seems to suggest that arts
engagement paves the way to longer lives better
lived. Partly because it is not possible completely
to rule out other health-influencing factors, themajority of studies in the Nordic evidence basereport an association or correlation, rather than acausal relationship, between arts engagement andhealth, with the effect presumed to be morepreventative than remedial. Yet, however
tentatively the findings of individual studies
within the evidence base are reported, a collective
sense emerges that the relationship between arts
engagement and health is important and needs tobe understood.203 Genuinely interdisciplinary
longitudinal research is indicated. The Inquiry
notes that the ESRC is conducting a review of
longitudinal studies which will report by the
middle of 2018; it would be useful if this could takeaccount of the need for longitudinal associations tobe assessed between arts engagement, healthand wellbeing.
In the UK, we lack the kind of population records
and longitudinal cohort studies linking health andthe arts which made possible the Nordic research.
Nevertheless, we do have large-scale studies
centred on health, and interest in them seems tobe growing in a period fascinated by the potentialof big data. Longitudinal health studies
sporadically include questions about arts
engagement (as seen in the case of BCS70,
mentioned above). There are also cohort studies
that are not explicitly about health but in which
health data are gathered together with much else,such as Understanding Society, and surveys about
cultural habits, such as Taking Part and a study atKing’s College London tracking cultural attitudes
and behaviours.204
A sustained commitment to gathering data onarts engagement in cohort and panel studies would
greatly aid the development of the field. We echo
the Cultural Value Project in calling for ‘long-term
questions about arts and cultural engagement to
be included in major UK cohort studies in the
future and for these questions to be stable overtime to enable longitudinal research’.205 The
41

Chapter 3

Considering the Evidence

All-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Reportquestions used in any future longitudinal cohort
studies should be chosen so as to maintaintimeliness, and they should distinguish between
ar t forms and between attendance andparticipation.
The expansion to date of the evidence base in
the field of arts and health is encouraging. We
hope that the weight of evidence presented inthis report will convince readers of the healthand wellbeing benefits of arts engagement andencourage them to act upon that conviction. At
the same time, it is clear that more needs to bedone to consolidate the evidence base, perhaps
especially in relation to the social determinantsof health.
Arts and health research has historically
been funded by the AHRC and ESRC andoccasionally by ACE and other sources(including NIHR, particularly where arts
therapies are concerned). Filling the gaps in our
knowledge will involve the better coordinationand funding of research, including crossdisciplinary studies, perhaps especially in theareas of prevention and the management oflong-term conditions over an extended period.
It will also require better communication
between researchers, practitioners, policymakers, commissioners and funders. The
strategic centre we are proposing as one of ourrecommendations will help to enable thiscommunication.
We recognise that evidence is only one factor
informing policy. In advocating realist research,
Professor of Social Research Methodology at the
University of Leeds, Ray Pawson, notes that‘there is no such thing as evidence-based policy.
Evidence is the six-stone weakling of the policy
world. Even its most enthusiastic advocates are
inclined to prefer the phrase “evidence-informed
policy” as a way of conveying a more authentic
impression of research’s sway’.206 More than ane v i d e n c e b a s e , p o l i c y-m a k i n g a n dcommissioning is underwritten by a belief
system; some change of belief is needed. At thefirst of two round table discussions on the Care
Act held by the Inquiry, Lord Ramsbotham said
that what is required is a ‘social process rather
than a scientific process’. In this endeavour, thepolitical will to effect change and the institutional
will to deliver it will be as important as evidence.

42

43

Rusty Squid, Book Hive
Bristol Libraries

The Policy,
CommissioningandFunding
Landscape44

45

All-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Report

4 The Policy, Commissioning and Funding Landscape“More and more people now appreciatethat arts and culture can play a valuablepart in helping tackle some of the mostchallenging social and health conditions.
Active participation in the visual andperforming arts, music and dance can help
people facing a lonely old age, depression ormental illness; it can help maintain levels
of independence and curiosity and, let’s notforget, it can bring great joy and so improve
the quality of life for those engaged.”
Lord Bichard of Nailsworth, 2016

In exploring the beneficial impact of thearts in relation to a range of health andsocial care challenges, here we provide an
overview of the policy, commissioning andfunding context.

4.1

An Emphasis on Prevention
In October 2014, NHS England published the Five
Year Forward View, which argued that ‘the future
health of millions of children, the sustainability of
the NHS, and the economic prosperity of Britain

preventable conditions. In 2017, the House of Lords
Select Committee on the Long-term Sustainabilityof the NHS concurred that the health system of the
future needed a ‘greater focus on prevention,
supported by adequate and reliable funding’.208
Primary prevention relates to people who are athigh risk of encountering a health issue for the
first time; secondary prevention refers to those
who have already encountered the issue but seek
to avoid it recurring; and tertiary prevention
pertains to people undergoing treatment.209
During his time as Chair of ACE, Sir Peter
Bazalgette made the case that the arts hada signif icant part to play in meeting thepr e vent ion a gend a . 2 1 0 The ACE-f u nde d
C u lt u r a l C om m i s s ion i n g
Prog ra m me soug ht toencou rage interactions
between the arts and public
sector commissioning,
includ ing hea lth. Thisacknowledged that ‘Arts andculture has been show n,
through a range of project
examples and evaluations, to contribute toprimary and secondary prevention, which aim toprevent harm occurring’.211 While prevention
is difficult to evidence, this report provides
examples of the ways in which arts activities

Arts activities prevent conditions fromdeveloping, recurring or worsening.
all now depend on a radical upgrade in prevention
and public health’.207 This pivotal health planrequired the nation to take prevention seriously, toreduce health inequalities and ensure that healthresources are not consumed by treating
46

prevent health conditions from developing,recurring or worsening.
A research report published by DH in 2011
projected the cost of treating eight prevalentmental disorders if treatment regimes and thesocial determinants of health remained
unchanged. This showed an increase from £48.6bn
in 2007 to £88.5bn in 2026 and advocated action
across the life course, including early detection
and intervention. 212 In February 2016, an
independent Mental Health Taskforce, whichbrought health and care professionals together

4.2

Management of Long-Term
Conditions
Long-term health conditions – rather thanillnesses susceptible to a one-off cure – now
account for 70 percent of the health and social carebudget.217 This requires that we differentiate
between medical crises and sustained ill health. It
also calls for the traditional division between
primary care, hospitals andcommunity services to berevisited through the prism of
networks of care.
Since 1986, WHO has beenpromot i ng a ‘proces s ofenabling people to increase
control over, and to improve,
their health’.218 This rests on theunderstanding that ‘To reach astate of complete physical,
mental and social well-being, an individual orgroup must be able to identify and to realize
aspirations, to satisfy needs, and to change or copewith the environment. Health is, therefore, seen asa resource for everyday life, not the objective ofliving. Health is a positive concept emphasizing
social and personal resources, as well as physicalcapacities’. It also implies that ‘health promotion is
not just the responsibility of the health sector, butgoes beyond healthy life-styles to well-being’.
Throughout this report, we present ways in which
the arts contribute to public involvement in thecreation of health and the shaping of environments.
The Marmot Review pointed to the potential
benefits of ‘greater participation of patients andcitizens and support in developing health literacy
and improving health and well-being’.219 The Five
Year Forward View presaged a new era ofcommunity involvement in health and envisaged
that people would be offered intensive support tomanage their long-term conditions. NHS England’s
Self Care programme is enabling two million
people to do that,220 and health champions andcommunity activators are increasingly acting at
the interface between the health service and the
public. Arts activities are particularly importantin relation to chronic and enduring healthconditions. They can take the ‘heat out of a crisisdriven health and social care model’ by helping toalleviate the burden on GPs and acute care.221 In
this report, we encounter instances of the arts
moderating chronic conditions from diabetes to
respiratory disease and stroke to dementia.
Between May 2015 and November 2016, NHS
England funded a programme called Realising theValue which aimed to help ‘enable the health andcare system to support people to have theknowledge, skills and confidence to play an active

The arts moderate chronic conditions
from diabetes to respiratory disease andstroke to dementia.
with service users,213 issued a report to NHSEngland, entitled the Five Year Forward View for
Mental Health.214 This advocated a far moreproactive and preventative health service in orderto reduce costs and diminish the long-term
impacts of mental health problems, with children
and young people as a priority. Responding to a
recommendation made there, PHE is developing a
Prevention Concordat Programme for Better
Mental Health, which aims to act both nationallyand locally to help the relevant bodies design andimplement effective prevention planning.215
In this report, we give examples of the arts
helping to restore and maintain mental health. In
the next chapter, detailed consideration is given to
initiatives like arts on prescription, which makeup part of the social prescribing landscapementioned in the Five Year Forward View. At one of
the Inquiry Meetings, Programme Director andHead of Arts at Guy’s and St Thomas’ Charity(GSTC), Nicola Crane, alluded to the arts being
embraced as a diagnostic tool in children withmental health problems. In chapter six, a casestudy is provided of dance providing an engaging
and highly effective form of early intervention in
psychosis in young people.
In making the business case for effective
interventions in psychosis and schizophrenia, areport – supported by DH and commissioned fromresearchers at LSE, King’s College London and theCentre for Mental Health by the charity Rethink
Mental Illness – urges that cuts to services should
be avoided if they result in higher costs lateron. 216 We advocate that the arts are taken
seriously as a form of prevention and earlyintervention, as part of a humane health service
that will benefit from the savings this strategy
will yield.

47

Chapter 4

The Policy, Commissioning and Funding Landscaperole in managing their own health and to workwith communities and their assets’.222 Led by the
National Endowment for Science, Technology andthe Arts (NESTA) and the Health Foundation andbased on extensive consultation, this programme
proposed ‘person- and community-centred ways

All-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Reportmanagement and delivery of health promotion
activities. The events should be co-managed byprofessionals and members of the community andheld at a local venue’.227 An example of this way ofworking is to be found in Strabane, a border town
between the Republic of Ireland and the North
with a high level of deprivationand mental health problems.
Since 2013, Arts Care has beenworking with the Pushkin Trustto enable local residents to workwith artists across disciplines
and contexts to enhancewellbeing and quality of life.228
At the Inquiry’s evidence
meeting, the case was made for
not only the design and deliveryof ser v ices but a lso theevaluation of arts and health activities to beundertaken on a co-production basis, with service
users, artists and other stakeholders (including
commissioners) being involved in defining theparameters within which arts activities should beassessed. The Canterbury Wellbeing Scales weredeveloped through co-production, and the AHRCfunded Dementia, Art and Wellbeing Network at
the University of Nottingham has been set up toencourage co-production.229
At the round table on Devolution, Chair of theAbertawe Bro Morgannwg University Health
Board, Andrew Davies, introduced us to his
concept of Patient-Reported Outcome Measures(PROMs). At the subsequent round tableon Commissioning, the Chief Executive of
the Reader, Jane Davis, advocated ‘listening to
the actual words of people who benefit, to workout what the evidence is’. In the next chapter,we encounter self-evaluation being used to gauge
the impact of arts-on-prescription activities fromparticipants’ perspectives. The co-productionof evaluation helps services to be assessed froma user perspective with a view to their
ongoing improvement.
Another ambition of the Five Year Forward View
is better support for carers. There are an estimated
5.5 million carers in England, 225,000 of whom areyoung and 110,000 of whom are over 85. The valueof unpaid care contributed to society by carers is
estimated at £132bn, equivalent to spending on the
NHS.230 In this report, we see many instances of
the ways in which carers benefit from engagementin arts activities, with or without their loved ones.

The arts should be thought of as anintegral part of person- and communitycentred care aimed at the management oflong-term physical and mental conditions.
of working across the system, using the best
available tools and evidence’ and estimated £4.5bn
in annual savings.223 The report arising from thisprogramme acknowledged that creative group
activities could aid mental health and help people
to fulfil their potential. In this report, we present
examples of such activities across the life course.
We argue that the arts should be thought of as anintegral part of person- and community-centredcare aimed at the management of long-term
physical and mental conditions, and we call uponarts and health champions to lead this.
The Coalition for Collaborative Care, which has
NHS England as one of its members, aims torefocus the relationship between people with longterm conditions and the professionals supportingthem by encouraging collaborative care, or coproduction.224 Think Local Act Personal (TLAP) – a
DH-funded partnership of central and local
government, the NHS, provider organisations,people who use services and carers – defines coproduction as ‘an equal relationship between
people who use services and the people responsible
for services […] from design to delivery, sharing
strategic decision-making about policies as well as
decisions about the best way to deliver services’.225
TLAP is cognisant of the role of the arts in healthand wellbeing, and we look forward to seeing thisknowledge being acted upon in the future. The
participatory nature of arts and health activity
lends itself well to the co-production agenda, andexamples of people shaping the content anddelivery of their services – or expressing a desire to
do so – are provided in this report.226
NICE guidance on community engagement toimprove health recommends that all researchcou nci l s , n at ion a l a nd lo c a l r e s ea r chcommissioners and funders and research workers‘Run community workshops (for example,
community arts and health workshops) or similar
events. These should be used to identify local
community needs and to maintain a high level of
local participation in the planning, design,48

Gloucestershire ClinicalCommissioning GroupAn exemplar of innovative
local healthcare
provision is afforded by
Gloucestershire.

T

he CCG, with its visionary leadership andgood financial management, serves a
population of 630,000 with more than
80 GP practices. It understands that thehealth service has reached a tipping
point and that models of care need to change. The
CCG has the benefit of being coterminous with thehospital trust, county council and other partnerorganisations, including the police andGloucestershire Voluntary Community Sector
Alliance (GVCSA), which brings opportunities forshared planning and provides a single footprint forthe development and implementation of its
Sustainability and Transformation Plan (STP). The
CCG is a keen champion of arts and health activities,
understanding that arts practitioners and culturalvenues are rooted in the same community it serves.
The county houses an umbrella organisation,
Create Gloucestershire, which was formed by arts
organisations in 2011 as a response to the loss of thearts development team in Gloucestershire County
Council. Create Gloucestershire supports artists
and arts organisations, incubates new ideas fordelivery and forms strategic partnerships with anumber of public sector organisations. One suchpartnership was precipitated by the Cultural
Commissioning Programme, which brought it
together with the CCG, county council, GVCSA,
University of Gloucestershire and three of the six
district councils. The programme, which was
funded in large part by the CCG, identified
opportunities where cultural commissioning coulddeliver both universal and targeted health andwellbeing outcomes across various sectors throughthe arts. This partnership approach has enabled theformation of an arts and voluntary, community andsocial enterprise forum, facilitated by Create
Gloucestershire and GVCSA. This provides a means
for artists and arts organisations to share learning
around the knowledge and skills required to workin an arts and health context, and it enables the CCG

and partners to have a dialogue with the ‘provider
market’ in order to grow and develop an arts andhealth commissioning model.
Historically, there has been a fragmented
approach to arts and health activity in
Gloucestershire, which has included arts in
hospitals, the development of an arts-onprescription service in primary care andindividual cultural organisations running arts
projects aimed at various health and wellbeing
outcomes. A key element of the Cultural
Commissioning Programme pilot was theextension of arts-on-prescription practice, which
had hitherto been centred on mental health.
A series of 12 feasibility projects, each costing in
the region of £10,000, have been developed acrossthe life course, exploring whether arts-based
approaches could help in the self-management ofa range of chronic health conditions including
type 1 diabetes,231 dementia, cancer, chronic pain,
obesity, depression and anxiety. This use of nonmedical interventions to meet medical needs is
described by the CCG as social prescribing plus.
The programme has been underpinned by coproduction, whereby artists, clinicians, patient
representatives and commissioners worked
together to design, develop and deliverinterventions. It has been evaluated by the CCG,
Create Gloucestershire and the University ofGloucestershire, and a report is due before the endof 2017.
As a result of this pilot, a social prescribing
and cultural commissioning programme wasinstigated by the CCG in early 2017, managed by a
newly created team. Social prescribing, including
arts on prescription, is recognised as key toenabling delivery of the STP. Arts and culturalinterventions are being embedded into carepathways with a view to reducing healthinequalities and helping in the management oflong-term conditions. Examples include singing
for respiratory conditions and arts-based
interventions for pain management.
Discussions are taking place around thedevelopment of a formal cross-sector culturalcommissioning programme which builds on thepilot. It is envisaged that this will operate as a
strategic partnership within an integrated
planning and governance framework, supported
by its own pooled budget in the longer term.
49

Chapter 4

The Policy, Commissioning and Funding Landscape

4.3

Commissioning in Healthand Social CareIn March 2017, NHS England published Next Stepson the Five Year Forward View. This set out threepriorities for the following two years, specifically aneed to: upgrade the urgent and emergency caresystem, and better regulate flow into and out of
hospitals; strengthen access to primary care; andAll-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Report

JSNAs take account of the Marmot Review
recommendations.
DH holds NHS England accountable for
ensuring that health services, which both it andthe CCGs commission, are of high quality anddeliver value for money. However, the Health andSocial Care Act stipulates CCG autonomy inmeeting local need. CCGs have the freedom todecide which health services are commissioned,
and the Five Year Forward View urges national
managers to exercise ‘meaningful local flexibility
in the way payment rules, regulatory requirements
and other mechanisms areapplied’.236 This opens the door
to innovation, a nd CCGs
commission several of the arts
a nd hea lth initiatives
mentioned in this report.
In 2016, 44 groups (nowknown as Sustainability andTransformation Partnerships,
STPs) were set up to cover every
part of England, bringing
together health and social careleaders to discuss how the needsof the local population might
best be met and health inequalities reduced. Each
STP was required to develop a multi-year plan,showing how local services would deliver the vision
articulated in the Five Year Forward View. Only asmall number of the 44 STPs have embraced thearts, but there is scope for the arts to be included by
all at implementation stage. These plans will be
subject to review towards the end of the two-year
period they cover, which will provide an opportune
moment to revisit the role of the arts in addressing
local health and wellbeing.

There is a blind spot in many recent
health policy documents: the role thatengagement in the arts can play inimproving health and wellbeing is
consistently overlooked.
improve services for cancer and mental health. In
the new health and care landscape, emphasis isplaced on primary care – with family doctors as
the first point of contact – rather than costly acutecare in hospitals.232
The Health and Social Care Act provided for thecreation of the NHS Commissioning Board, PHE
and a series of health and wellbeing boards(HWBs).233 HWBs provide a forum in whichclinical, professional, political and community
leaders can come together to plan how best to meetthe needs of their local populations and tackle
health inequalities. The Health and Social Care Act
also legislated for the creation of 210 clinicalcommissioning groups (CCGs) across England,234
responsible for commissioning the majority of
NHS services, including elective hospital care andrehabilitative care, urgent and emergency care,most community health services, maternity
services and mental health and learning disability
services. As part of the shift towards primary carein the community, CCGs are populated by andaccountable to GPs.
CCG representatives sit on HWBs, alongsidedirectors of public health and adult and children’s
services, and together they formulate strategies
based on Joint Strategic Needs Assessments(JSNAs). CCGs play a central role in formulating
strategic priorities and have a commitment to
reducing health inequalities. Local authorities
take the lead on improving public health andwellbeing while providing ‘advice and expertise on
how to ensure that the health services [which
CCGs] commission best improve population healthand reduce health inequalities’.235 Increasingly,
50

4.4

Integration of Health andSocial Care
In 2011, the Scottish Government developed avision for 2020 that sought to ensure longer,
healthier lives for everyone, at home or in a homely
setting, which relied on prevention, self
management and the integration of health andsocial care. 237 The Five Year Forward View
recognised the interrelationship between demand
for social care and the availability and effectivenessof NHS services to advocate clear joint plans. In
parts of England, such as Northumberland,
accountable care organisations are being set up as
unitary organisations meeting health and social
care needs.238
TLAP is building bridges between health andsocial care to empower communities to share
responsibility for prevention and self-care.239 The

House of Lords Select Committee report on thelong-term sustainability of the NHS noted that the
future survival of the health service depended on
resolution of the social care crisis and increased
funding in both health and social care. The report
recommended that responsibility for adult social
care should be assumed by DH and pointed to apressing need to reinvigorate the integration ofhealth and social care and to rethink the statutory
mechanisms needed to deliver it. 240 The
Government has undertaken to produce a Green
Paper on this.
In June 2013, the Better Care Fund was set up toencourage integration of services between the
NHS and local authorities and between health andsocial care in a bid to reduce hospital admissions.241
To a great extent, this £5.2bn fund has been used toplug gaps in local authority social care budgets, but
it has facilitated social prescribing projects andoccasional arts-based community initiatives.242
Staying Out, operated at ARC – a multiform arts
centre in a deprived ward of Stockton on Tees –offers weekly creative activity to people aged 65
and over who have been discharged from hospitalor are socially isolated.243 Beginning in September
2014, the project has been commissioned to
October 2019, initially with funding throughHartlepool and Stockton on Tees CCG’s Health
Initiatives fund before transitioning to the local
authority’s Better Care Fund. An artist delivers awide range of arts and crafts activities, designed toconfer new skills and enhance existing ones andresponsive to the preferences and abilities of thegroup. Participation offers therapeutic benefits
through cognitive and physical stimulation,
particularly around the use of fine motor skills andstroke rehabilitation, while stimulating ameasurable sense of achievement and wellbeing.
The commissioners are also collating data relating
to reduced hospital admissions. We hope that, insigning off plans for the Better Care Fund, local
authorities and CCGs will remain open to local artsand health approaches, and that details of arts andhealth projects will be included in the Fund’s
published case studies.
In January 2015, NHS England invitedorganisations to become vanguards for the newdevelopment of joined-up care via partnerships
between the NHS, local government, voluntary,community and other organisations.245 There is
scope for the arts to be involved in this scheme, andwe would welcome greater dialogue between NHS
England and ACE.
The Children and Families Act of 2014 outlined
the duty of local authorities and CCGs to provide
support for children and young people with special
educational needs (SEN). The Special Educational
Needs and Disability Code of Practice and theSpecial Educational Needs (Personal Budgets)
Regulations, approved by Parliament in the same
year, made provision for education, health andcare plans tailored to individual need. From
February 2015, supported by NHS England, DH,
the Association of Directors of Adult Social
Services (ADASS), the Care Quality Commission(CQC, the independent regulator of health andsocial care in England) and the LGA, 48
Transforming Care Partnerships were set up.246
The partnerships are developing plans to improve
services for people with learning disabilities and/or autism. 247 The plans make provision forenhanced community services, which can include
arts engagement. ACE National Portfolio
Organisation (NPO) TIN Arts in Durham offers acontemporary dance course for people withlearning disabilities which is funded throughpersonal budgets.248

4.5

Parity of Esteem Between
Physical and Mental Health
Mental ill health accounts for more than 20
percent of the total disease burden in the UK,
exceeding cancer and cardiovascular disease. This
carries an annual economic and social cost of
approximately £105bn, roughly equivalent to thetotal budget of the NHS.249
The Health and Social Care Act wrote into
legislation equal priority for mental and physicalhealth. The Five Year Forward View was a tipping
point in recognition of therelationship between physicaland mental health, telling usthat ‘people with severe andprolonged mental illness die on
average 15 to 20 years earlier
than other people – one of thegreatest health inequalities inEngland’. 250 The Five Year
Forward View for Mental Healthfound that two thirds of deathsof people with mental ill health were ‘fromavoidable physical illnesses, including heartdisease and cancer, many caused by smoking’.251

The pressures now being experienced inhealth and social care force a search forinnovative solutions.
care models intended to reduce demand on
hospitals.244 Fifty vanguard sites, serving more than
five million people, have been selected to lead the51

Chapter 4

The Policy, Commissioning and Funding LandscapeMental ill health slows recovery rates fromphysical health conditions, which has sizeable cost
implications. In turn, the pain and functional
impairment associated with chronic physicalhealth conditions are known to both cause andexacerbate depression, occurring in about 20
percent of patients and proving particularly
resistant to antidepressants.252 While the intended
parity of esteem between mental and physicalhealth has been far from realised as yet,recognition of this interrelationship is highly
relevant to many arts and health approaches
which take as their starting point the inextricablelink between the mental and physical aspectsof health.
Recent health policy has been informed by anunderstanding of the contribution of inequality tomental health problems. In his foreword to a 2010
DH vision for mental wellbeing across the life

All-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Report

2020–21. In adopting these recommendations, theGovernment pledged an additional £1bn oftargeted support for new mothers and teenagers,
emergency services and community initiatives,
and the Prime Minister, David Cameron, heraldeda ‘revolution in mental health treatment in
Britain’.256 At the time, 90 percent of mental healthtrusts and 60 percent of commissioners felt thiswould be inadequate to solve the current funding
crisis.257 No mention of mental health was made in
the 2017 Budget.
Next Steps on the Five Year Forward View
reported progress in this area and restated NHS
England’s commitment to widening access tomental healthcare across the life course. The
report also made provision for 800 mental healththerapists in primary care by March 2018, rising to
1,500 by the following year and leading the way inreconciling physical and mental healthcare.
In addressing the mental
health challenge, this reportdetails ways in which arts
engagement can address ava r iety of menta l hea lth
pr oblem s , r a n g i n g f r om
conduct disorders in children
to psychotic episodes ina d o l e s c e nt s t o a n x ie t y,depression and stress in adults. Outside these
discrete sections, we reflect the arts and healthethos by not making a distinction between mental
and physical health, referring instead to healthand wellbeing.

The arts are integral to health and should
be recognised as such by health services.
course, the Minister of State for Care Services, Phil
Hope, acknowledged that ‘Pernicious social andhealth inequalities are both a result and a cause ofpoor mental health – which means the mostdeprived communities also have the poorest
health and well-being’.253 Welcome recognition of
the social causes and effects of poor mental health,
combined with a search for locally based solutions,
opens the way to thorough consideration ofarts approaches.
In January 2014, DH promulgated a series ofpriorities for tackling the mental health challenge,
published as Closing the Gap: Priorities for
Essential Change in Mental Health. The increased
prominence of mental health in the policy agendas
of many government departments (and the publichealth system) was noted, and a commitment wasmade to protecting local mental health funding
from financial exigencies.254 In October of thesame year, the Five Year Forward View citedmental ill health as the most significant cause of
disability in the UK, with one in four people foundto be suffering from a mental health problem atsome point during their lives. Yet there has
been and remains underinvestment in mental
health services.255
By 2015, almost half of NHS mental health trusts
were reporting a deficit. In 2016, the Five YearFor ward View for Mental Health maderecommendations centred on local, evidencebased strategies aimed at tackling healthinequalities and identified a need to invest an
additional £1bn in mental health services by
52

4.6

Policy for Arts, Health andWellbeing
Despite recognition of the interrelationshipbetween physical and mental health and theunderlying social determinants, there is a blindspot in many of the recent health policy documents
referenced above: the role that engagement in thearts can play in improving health and wellbeing is
consistently overlooked. Among scant exceptions,the 2010 DH framework for developing wellbeing,
mentioned in the previous section, noted that
‘Participation in the arts and creativity can enhance
engagement in both individuals and communities,
increase positive emotions and a sense of
purpose’. 258 In 2011, a cross-governmental
implementation framework called No HealthWithout Mental Health heralded a fundamental
shift towards accountable, locally led healthprovision and expressed a desire to engage allorganisations with an impact upon mental health,including independent and third-sector
providers.259 In the process, the framework

mentioned a role for the arts as a form of meaningfulactivity that could improve mental health. Prior tothis, policy had episodically embraced the role of
the arts in health and wellbeing. In 2007, DH
published a review of its role in promoting the artsand health. Commissioned by the Chief Executiveof the NHS and Permanent Secretary of DH, Sir
Nigel (now Lord) Crisp and led by Harry Cayton,
National Director for Patients and the Public,
the Review of Arts and Health Working Group
found that:•		A rts and health are, and should be firmly
recognised as being, integral to health,hea lt hca re prov ision a nd hea lt hca reenvironments, including supporting staff•		Arts and health initiatives are delivering real
and measurable benefits across a wide range ofpriority areas for health, and can enable theDepartment and NHS to contribute to key wider
Government initiatives•		There is a wealth of good practice and asubstantial evidence base•		The Department of Health has an importantleadership role to play in creating anenvironment in which arts and health canprosper by promoting, developing andsupporting arts and health•		The Department should make a clear statementon the value of arts and health, build
partnerships and publish a Prospectus forarts in health in collaboration with otherkey contributors260
DH heeded the findings of the review, collaboratingwith ACE on a Prospectus for Arts and Health. The
prospectus reiterated that ‘The arts make asignificant contribution to improving the lives,
health and wellbeing of patients, service users andcarers, as well as those who work in health and thearts’.261 It outlined many examples of practice andresearch and a strategy for embracing thecontribution of the arts to health and wellbeing.262
In 2008, the Secretary of State for Health, Alan
Johnson, made a speech at the Wallace Collection
which firmly acknowledged the therapeutic valueof the arts, from art and design in hospitals to theparticipatory arts. He pointed to a role for the arts
in building self-esteem and overcoming isolation,
in seeing us through hard times and helping us toexpress ourselves when words fail. He articulated
a wish to see the ‘benefits of participation in thearts recognised more widely by health and social
care professionals, particularly those involved incommissioning services for people with mental
health problems’, arguing that ‘This is not somekind of eccentric add-on – it should be part of themainstream in both health and social care’.263
Shortly after this, however, Alan Johnson
moved to other responsibilities and politicalpriorities shifted, leaving this moment of

optimism feeling like a ‘distant dream’.264 In
hindsight, the conditions for the widespread
uptake of the arts in health and social care were
not in place in 2007–8. The pressures now being
experienced in health and social care force asearch for innovative solutions.
This report endorses the main finding andrecommendation of the Review of Arts and HealthWorking Group – that the arts are integral tohealth and should be recognised as such by healthservices. It also makes the case that responsibility
for promoting, developing and supporting arts andhealth should be extended beyond DH to DCMS,
the Department for Communities and Local
Government (DCLG), the Department for
Education (DfE), the Ministry of Justice (MoJ) andthe Ministry of Defence (MoD).
The 2016 Culture White Paper explicitly
acknowledged the value of the cultural sectors tohealth and wellbeing,265 and it expressed a desire
for DCMS to work with ACE, PHE and others todevelop and promote their contribution. The
White Paper also stated the Government’s
intention to respond to the recommendations
made in this report, which was reiterated by the
Minister of State for Digital and Culture, Matt
Hancock MP.266
In England, various national-level initiatives are
beginning to address the relationship between thearts and health. In addition to the Cultural
Commissioning Programme, several of thevanguard sites – such as Calderdale, East Kent and
Salford, to name just three – are home to healthorientated arts activities. Other countries are inadvance of England in recognising the value of thearts in the field of health and wellbeing.
In 1991, the Permanent Secretary for Health inNorthern Ireland initiated Arts Care, initially withdirect funding from health budgets and more
recently in conjunction with national arts andhealth partners.267 The Scottish Government has acore commitment to tackling inequalities in living
standards, health and education. In thisendeavour, it acknowledges arts engagement to belife affirming in its own right while also having an
impact upon health, wellbeing and quality of life.
The 2017–18 remit letter from the Welsh
Government to Arts Council of Wales makes arts,
health and wellbeing a key priority
Marmot hails the Nordic countries, with theirhigh levels of social protection, as exemplars ofhealth equity. Reflecting their pioneering researchin the field, the Nordic countries have madeconsiderable practical advances.268
The Swedish Government has acknowledged
the relationship between culture and public healthsince 2000. In 2007, the Swedish Parliamentestablished a cross-party Society for Culture and
Health, which has brought MPs and civil servants
together with experts from the scientific and arts
communities and healthcare.269 The Centre for53

Chapter 4

The Policy, Commissioning and Funding LandscapeCulture and Health at the University of Gothenburg
has, to date, helped the Society to coordinate
fifteen seminars which depart from biomedical
approaches to consider health from a humanities
perspective. Seminars take account of innovationsin Swedish healthcare, such as a regional arts-onprescription scheme, resulting from a joint
initiative between the Ministry of Culture and theMinistry of Health and Social Affairs, which has
d ra matica l ly reduced sick ness absence
and highlighted the importance of crossgovernmental collaboration and the need for longterm planning.270
In Finland in 2008, a collaboration between the
Ministry of Social Affairs and Health and theMinistry of Education and Culture began to
explore the health and wellbeing benefits of thearts. For 2010–14, an action programme wasdeveloped which gave rise to 18 crosscutting
proposals aimed at integrating the health andwellbeing benefits of the arts into future legislativereform.271 Anchoring the arts and culture in thehealth and social care system has become one of
the Finnish Government’s key projects for 2014–18,

All-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Reportencourages arts-based strategies in the training ofcare professionals. Its target groups include
children, people with mental health problems,
older adults and people with dementia. One of thefive partner organisations is the HUNT ResearchCentre, a department of the Faculty of Medicine
and Health Sciences at the Norwegian Universityof Science and Technology, which serves as arepository of biomedical and cultural data for large
proportions of the regional population andregularly undertakes large-scale analyses of therelationship between arts engagement and various
aspects of health.274
The Australian Government has consistently
included mention of the arts in its health policy
documents, particularly in relation to mental
health. The Australian National Rural HealthAlliance, the Institute for Creative Health inAustralia and Arts and Health Australia have beenenergetic advocates of the arts and culture being
recognised in health and wellbeing as a route toaddressing the social determinants of health. In
2013, the Standing Council on Health and theMeeting of Cultural Ministers endorsed a nationalarts and health framework.
Th roug h t he f ra mework ,Australia’s Health and Culture
Ministers seek ‘to enhance theprofile of arts and health inAustralia and to promote
greater integration of arts andhealth practice and approaches
into health promotion, services,settings and facilities’.275 The
nationa l f ra mework isenvisaged as a living documentthat will regularly be revisitedby those concerned. The
Australian Centre for Arts and
Health has assumed a mission to develop nationalarts and health activity, foster cooperation,
information- and resource-sharing and provide alink between governmental and non-governmentalorganisations in the field.276
Mindful of these international precedents, weadvocate the creation of a national strategic centre
for the advancement of arts, health and wellbeing.
We advocate a different model from thosementioned above, however, established and led bypeople who are leaders in the arts, health andsocial care sectors, joined by academics andinvolving patients and service users to reflect the
principles of co-production. We hope that such acentre would be supported by philanthropic
funders. We would also seek the endorsement of
ACE, NHS England and PHE and appropriate
involvement from relevant bodies such as Health
Education England (HEE), the LGA, Healthwatch,
the Patients Association, National Council for
Voluntary Organisations (NCVO) and many others.
This centre would not be a physical building but

We advocate the creation of a national
strategic centre for the advancement ofarts, health and wellbeing, established andled by leaders in the arts, health and social
care sectors, joined by academics andinvolving patients and service users.
with the aim of making the arts and culture a partof everyday life. In furthering this objective, Arts
Promotion Centre Finland has been given a budgetof €2m to fund arts projects with the health andsocial care sector, with the aim of increasing use of
the arts in preventative and healing processes.272
Recognition of the health and wellbeing benefits of
the arts at a political level has also inspired a major
new research initiative, coordinated by the
University of the Arts Helsinki, which frames thearts as a public service and explores how they canmeet the social challenges of the 2020s.
In 2014, Arts, Health and Care: a NorwegianResource Centre was established in response to agovernmental White Paper entitled Tomorrow’sCare.273 The centre involves a partnership of fiveorganisations; it is based in and administered by
Nord University and publicly funded via the
Norwegian Directorate of Health. Bringing
together arts and health practice, education andresearch, it seeks to ensure good use of arts
resources in the health and care sectors and54

rather a gathering point of networks. Its remit
would span practice, research, f unding,communication, policy and international liaison.
The terms of reference of the centre
might include:•		Identifying and helping to fill geographical gaps
in arts and health activity•		Brokering dialogues between arts providers
and health and social care commissioners•		Sharing tools (including common metrics andterminology) and resources•		 Disseminating examples of good practice•		 Encouraging high-quality project evaluation•		Identifying gaps in the evidence base andcoordinating research to fill them•		
P romulgating research with a view toinfluencing clinical practice•		Making the case for funding to be directed
towards arts and health research•		Advocating the inclusion of arts-based methods
in the training of health and social care
professionals, and health and wellbeing asroutes to the career development of artists•		Informing relevant debates, for example about
the impact of cultural disadvantage, the mental
health of young people, the value of good design,
the management of long-term conditions,healthy ageing and many other issues•		Stimulating public interest and demand by
telling the story of arts and health•		Influencing policy development relevant to arts,
health and wellbeing•		Developing international links to learn frompolicy and practice around the world
We believe that such a centre would be morestrongly rooted and more fit for purpose if it was
not installed top-down, but led by practitioners.
The National Alliance for Arts, Health andWellbeing, which provides the secretariat to the
APPGAHW, is in the process of merging with the
National Alliance for Museums, Health andWellbeing to form a new Culture, Health andWellbeing Alliance (CHWA). The Alliance would bea key partner in supporting this initiative.
We hope, too, that DH, DCMS, DCLG and othergovernment departments would develop a crossgovernmental strategy for the arts in health inclose collaboration with the centre.

4.7

The Funding Landscape
Following the financial crisis of 2008, the NHS has
experienced standstill real-terms funding in theface of rising demand, local authority social carebudgets have been under severe pressure and ACE
lost a quarter of its funding in the period 2012–14.

Health and social care systems are struggling todeliver the services to which they are alreadycommitted. Fiscal retrenchment is forecast tocontinue until the middle of the next decade.
While these circumstances make innovationdifficult, they also demand fresh thinking andnew approaches.

4.7.1

Health and Social Care
Funding
The ev idence presented in t h is repor t
demonstrates that the arts can save money inhealth and social care by strengthening
prevention, reducing demand for medication andclinicians’ time, diverting or shortening hospital
stays, reducing sickness absence from work anddelaying the need for residential care. We believethat the existing f lows of public funding arecapable, in principle, of providing support for arts
activities within health and social care. Little
public funding, however, is f lowing in the
direction of the arts for this purpose at the
moment.277
The case study sketched in this chapter looks at
the work of Gloucestershire CCG in promoting artsand health approaches. Other CCGs, such as
Salford and Halton, support arts initiatives, butthese instances are exceptional. Chief Executive ofPHE, Duncan Selbie, has observed that ‘manyc u ltu r a l i nt er vent ion s for he a lt h a r ecommissioned through cycles of non-recurrent
pilot or grant funding. These providers have yet togain traction in the mainstream of health andsocial care commissioning’.278 We believe an
opportunity to relieve pressure on the funding ofhealth and social care and secure better value formoney is being extensively neglected.
The Five Year Forward View acknowledged thatthird-sector organisations ‘provide a rich range ofactivities, including information, advice, advocacy
and they deliver vital services with paid expert
staff. Often they are better able to reachunderserved groups, and are a source of advice forcom m is sioners on pa r t icu la r need s’. 27 9Consequently, ‘easier ways for voluntar yorganisations to work alongside the NHS’ weresought.280 In Gloucestershire, decision-making
and service delivery in the area of health andwellbeing are increasingly being devolved to
the voluntary, community and social enterprise(VCSE) sector.
A 2016 review of VCSE organisations in thehealth and care sector, commissioned by DH, PHE
and NHS England, argued that ‘Targeted support
for the very smallest social enterprises andcommunity groups can play a large part in creating
55

Chapter 4

The Policy, Commissioning and Funding Landscape

health and wellbeing, as fewer people will be left
unsupported where there is a wide range ofcommunity-based and innovative interventions
from which to choose’. 281 Ref lecting NHS
recognition that creative solutions may originate
in the VCSE sector, CCGs were given the power,
under the provisions of the Health and Social Care
Act, to award small grants to voluntary andcommunity organisations, enabling them tobypass the standard contract for procurement ofservices.282 The hundreds of excellent arts andhealth initiatives that take place in, with andthrough voluntary and community organisations
have an invaluable part to play within thelandscape envisaged in the Five Year Forward
View, and they should be considered for targeted
support from CCG and other sources.
Arts programmes in NHS hospital trusts aresupported by a mixture of funding – including
NHS charitable funds, more abundant in London
than elsewhere – which evolves if programmes
become integrated. A number of arts manager
posts are revenue funded by the health service.
Where arts managers are well integrated into NHS
trusts, they can be adept at identif ying
opportunities for the arts to be funded as part ofwider programmes. An example is Exeter
Healthcare Arts, the in-house arts programme of
the Royal Devon and Exeter NHS Foundation
Trust. The arts manager formed part of a team thatmade a successful bid to DH’s Improving theEnvironment of Care for People with Dementia
scheme, for a dementia-f riendly garden
incorporating sensory and musical installations,performance spaces and artworks.
At the round table on Funding, Chief Finance
Officer of Cambridge University Hospitals, BillBoa, described his greatest challenge assustainability and pointed to funding decisions
being taken on the basis of whether they would
deliver improvements – such as reduced hospital
admissions or shorter stays – within one year.
Short termism on the part of public funders, andthe consequent instability of budgets for arts
providers, means good work is aborted, time andenergy are wasted and potential benefits forpatients and ser vices are lost. For arts
organisations seeking NHS funding, there are,moreover, many potential challenges related tocompliance, procurement, contracts, evaluationand payment by results.283
In April 2015, NHS England and the LGA
launched the Integrated Personal Commissioning(IPC) programme,284 which unites funding fromhealth and social care sources. The programme‘empowers people and communities to takean active role in their health and wellbeing
with greater choice and control over the carethey need’. 2 85 Th is new com m ission ing
framework builds on learning from personal
budgets – which have been used in social care for
56

All-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Report

some time – to address complex health andsocial care needs.
IPC a i m s to prov ide a persona l ised
cou nterba la nce to popu lat ion-sca lecommissioning. Adoption of this model is being
trialled in eighteen demonstrator sites, reachingover 300,000 people by the end of 2018–19 and inplace in every locality by 2020. It is anticipated toaccount for around five percent of communitybased care. The programme will be delivered inpartnership with the VCSE sector, and an NHS
database of local activity is being developed. Apartfrom isolated cases of patients using their personal
budgets to undertake creative activity, there islittle sign as yet that the overall vision of IPC
includes the arts. However, South West IPC hascommissioned a film about Word/Play, a spoken
word project giving voice to people experiencing
mental health problems.286
The care home sector is more de-centralisedthan the health sector. Arts organisations andindividual artists have to negotiate with amultiplicity of care home groups and indeed
individual care homes. The CQC encourages
care homes to provide meaningful activity,
in recognition of the need for older people tospend time pur posef ully and enjoyably,
doing things that bring pleasure and meaning.
But extreme pressure on budgets means there isoften little willingness or ability to fund arts
activities that would do a great deal to enhance
the quality of life of frail elderly people.
Some organisations with a clearly defined remit
have been effective in beating a path to health andsocial care commissioners and providers. The
Reader, which is considered as a case study inchapter seven, lists eleven NHS Trusts and CCGs as
funders in its annual return to the Charity
Commission for 2015–16. The organisation has
secured a year-long commission with Royal
Liverpool Hospital and a three-year commission
from three NHS trusts working together as part ofan STP. Live Music Now, which leads A Choir In
Every Care Home, detailed in chapter eight, isfunded by the Baring Foundation and the HM
Treasury LIBOR Fund, in partnership with national
adult social care regulatory and umbrella bodies
including the CQC, Care England and the National
Care Forum (NCF), as well as such providers as the
British United Provident Association (BUPA), theformer Methodist Homes Association (MHA) and
Orders of St John Care Trust.
In rare cases, funding for arts, health andwellbeing approaches has come from government
departments, such as DH, or from the devolved
administrations, as with Arts Care. Anotherexample of enlightened commissioning uniting
the arts, health and wellbeing is provided by Kent
County Council (KCC). With funding from the
Cultural Commissioning Programme, KCC hasdeveloped a range of services that include arts andcultural organisations alongside traditional public
service providers, such as a £4m communitybased mental health service involving museums
and theatres as well as smaller, more informalgroups. The local authority now takes as one of its
three strategic objectives that ‘Kent communities
feel the benefits of economic growth by being inwork, healthy and enjoying a good quality of life’.287
Applicants for arts funding are asked how theirprojects will meet this strategic objective; an arts
team is in place to broker relationships between
the culture sector and health commissioners, andthe council has developed an Arts and Cultural
Commissioning Toolkit to help the cultural sector
bid for and deliver public sector contracts.288
Local authorities remain the largest funder of
the arts in England, with an annual contribution of£1.1bn,289 but they are experiencing standstillfunding for 2017–18.290 The House of Commons
Culture, Media and Sport Committee has notedthat ‘The biggest impact of local authority cuts toculture is likely to fall where the cultural offering isalready weak with the result that those with mostto gain from cultural investment will lose out’.291
Where local authorities might once have led onarts and health work, their arts and culture
provision is now largely delivered by externalsocial enterprises.292 This need not preclude crosssector working between health, social care and thearts. Local authorities remain, to varying degrees,

Treasury Invest to Save budget. Following the pilot
phase, which demonstrated a positive impact
through extensive mixed-methods evaluation,
Creative Alternatives was sustained by funding
from Sefton Council’s Public Health and LeisureDirectorates. The service thrived and made asignificant contribution to improving the lives ofmarginalised people in the borough until 2016,
when local authority funding was reduced. A year
earlier, Creative Alternatives had expanded into
the borough of St Helens, which has a higher
incidence of mental health problems than thenational average. Though funding was cut inSefton and the programme abandoned there,
Creative Alternatives continues providing an artson-prescription service in St Helens, fundedthrough public health sources as part of the
Cultural Hubs – Arts in Libraries programme
supported by ACE.293
The perpetual re-commissioning of often very
effective services is disruptive and expensive,
affects stability and public awareness and leads totemporary solutions. The demanding process of
re-commissioning often achieves little that could
not be achieved through regular and appropriate
reviews, and it particularly disadvantages small
community-based organisations offering new andinnovative approaches, for which a commission
may be a major proportion of their funding.
Serious consideration should be given bycommissioners to embedding
ar ts approaches into themainstream care landscape,subject to regular review rather
than re-commissioning.
The Cultural Commissioning
Programme was set up on thebasis that ‘the arts are an
essential part of a new model of
public services, one that is built
on preventing ha r m a nd
reducing people’s need for acuteservices’.294 By facilitating thea r ts a nd hea lth work ofGloucestershire CCG and KCC as exemplary pilots,
the programme shed light on the ways in which:‘New relationships were developed between
commissioners and providers; Arts and culture
were positioned to align with local priorities;
Awareness of, and attitudes to, arts and culturechanged; The pilot sites invested in capacity
building for commissioners and providers’.295 Thiswas subsequently extended into Locality projects
in Birmingham, Derby, Manchester, Torbay andYork, becoming some of the most encouraging
examples of how the current public funding
system can be a successful mechanism fordeveloping sustainable models.296
One of the greatest obstacles to the culturalcommissioning process gaining national traction
was identified as decreasing public sector budgets,Serious consideration should be given
by commissioners to embedding arts
approaches into the mainstream carelandscape, subject to regular review
rather than re-commissioning.
active in the field, with funding from public healthand mental health sources, but they do notextensively support arts organisations indelivering health and wellbeing outcomes. The
widespread loss of local authority arts officers
places the onus on cultural organisations to takemore initiative and work together, pooling
resources, experience and networks ands upp or t i n g s m a l le r, mor e v u l ne r a bleorganisations.
The damaging impact of public funding vagaries
is shown in the case of Creative Alternatives,delivered by the Alef Trust, which offers a range ofarts activities, events and outings to adults
experiencing mild to moderate anxiety, depression
and stress. The service began in Sefton, in late2006, as a three-year pilot funded through the HM

57

Chapter 4

The Policy, Commissioning and Funding Landscape

All-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Report

We believe that the existing flows of public funding are capable,
in principle, of providing support for arts activities within healthand social care. It is clear, however, that new partnershipworking will be needed.

additional examples of good practice to inform
longer-term investment. Were there to be better
recognition of the contribution of the arts and thevalue for money that they can give, we think it would
be possible for the arts to gain more from existing
publicly funded programmes.

4.7.3
which was thought likely to lead to ‘commissioners
retrenching and focusing on more traditional
service models rather than exploring and codesigning new services in collaboration with thearts and cultural sector’.297 In anticipation offurther budget cuts, one way of overcoming thislimitation was seen as bringing the arts into themainstream commissioning landscape.
The 2016 Culture White Paper noted that ‘While
many commissioners in Clinical Commissioning
Groups and local authorities are receptive to therole culture can play in improving health and careoutcomes, we want to move to a position where theevidence and practice of successful outcomes ismuch better known in both communities andwhere the relationship between commissioners
and the cultural sectors is much morecollaborative’.298 This report is intended as acontribution to the process of sharing evidence
a nd e x a mple s of go o d pr ac t ic e. The
recommendations and next steps outlined inchapter 10 are envisaged as a route to enhancing
the relationship between arts and health sectors.
Arts and cultural organisations will need tocontinue developing their skills in bidding for
health and social care funding. Such skills
development has been key in other areas,
supporting VCSE sector providers to compete forfunding from established programmes and not
rely on non-recurrent pilot funding.

4.7.2

Arts and Heritage Funding
ACE advocates great art and culture for everyone.
Historically, it has been perceived as giving greater
weight towards the first half of this formulation,but, in recent years, there has been an
acknowledgement that access to the arts,
particularly in places of low engagement, is a
key priority.
ACE’s strategic framework for 2010 –20
recognised the ‘vital contribution [of the arts] toour health and well-being’.299 We have alreadyhea r d about t he ACE-f u nde d C u ltu r a lCommissioning Programme which supported
health and wellbeing pilots. Through the Creative
People and Places scheme, ACE invested £37m
between 2013 and 2016, with a further £20m
committed to 2019 in areas where arts engagement58

has been lacking. Supported by this scheme inSouth-East Northumberland, a consortium ofcultural, heritage, educational and public healthorganisations called bait is establishingpartnerships in community, health and social caresettings which explicitly aim to improve thewellbeing of local residents.300 Data collected todate (via WEMWBS) show a 16 percent increase in
wellbeing since the start of the project. However,the House of Commons Culture, Media and Sport
Committee noted that Creative People and Places‘funding is limited and cannot come close to,nor is it designed to, replace funding by local
authorities’.301
A DCMS review of ACE concluded in April 2017
acknowledged that ‘There is […] considerable
evidence of the social value of arts and culture,with positive associations being drawn between
participation in arts and improved physical andmental health’. This led to the recommendationthat ‘To strengthen its increasingly place-based
approach, the Arts Council should create more
broad-based local partnerships across England to
identify specific cultural, economic, and social
needs and priorities and to fund projects of valuethat will contribute to local growth anddevelopment’.302 It seems clear, therefore, that new
partnership working will be needed. Arts Connect
in the West Midlands, one of ten ACE-funded
bridge organisations, has funded Creative Health
CIC to set up a Commissioners’ Network in theBlack Country on the understanding that
this contribution w ill be matched fromhealth sources.303
ACE lottery funding – on its own or in
combination with NHS and endowment funding –contributes to arts, health and wellbeing, as does
the Heritage Lottery Fund. The Great Place Scheme– established by ACE, the Heritage Lottery Fund andHistoric England – is funding a programme ofactivity in areas in which there is a commitment toembedding the arts, culture and heritage into local
plans and decision-making. Grants of between£500,000 and £1.5m are enabling 16 selected
locations in England to consolidate their existing
strengths and build new partnerships, with a viewto realising the cultural, social and economic valueof the arts, culture and heritage, including healthand wellbeing.304 Greater Manchester Combined
Authority has been granted funding under thisscheme as part of a bid with a dedicated arts andhealth strand. These pilots should provide us with

Charitable Funding
As we look to the future, the arts in health andsocial care will need to be funded through a mixed
economy, with a larger proportion of funding
coming from the philanthropic and private
sectors. Projects and programmes already rely on
a diverse range of funding models, which, in turn,reflects the diversity in practice and approach of
the organisations delivering the work. To take an
example, the Art Room (mentioned in chapter six)
derives 83 percent of its revenue from fundraising
events, donors, trusts and foundations and earned
income for activities such as training programmes.
Lacking regular government support, the outreachprogramme of Dulwich Picture Gallery is fundedalmost entirely through trusts and foundations –notably the Band Trust, the City Bridge Trust, theClore Foundation, the Garfield Weston Foundation,
the Helen Hamlyn Foundation, M&G Charitable
Giving and the Sackler Foundations – as well as
through endowments and major general donations
to the gallery such as from Lord and Lady Lupton.
Other prominent trusts and foundations
funding work in this field are the Baring
Foundation (for work with older people), Wellcome(for science and arts collaborations and public
engagement) and Paul Hamlyn Foundation (PHF,
through a focus on disadvantage and developing
potential), to name just a few. Another recurrent
funder of arts and health activity is the People’s
Health Trust, funded by 51 society lotteries
through the Health Lottery. This charity explicitly
addresses the social determinants of health bysupporting projects that increase community
control and build social bonds.305 Several arts andhealth projects have been funded under its Active
Communities programme, which offers local
grants of between £5,000 and £25,000; evaluationof this strand of work found an 85 percent
reduction in isolation among participants.306
Esmée Fairbairn Foundation is exploring social
investment alongside grant funding. Since 2008,
the foundation has made over 100 social
investments from a budget of £35m. Those eligible
must meet the charity’s priorities which include
participation (engaging marginalised andexcluded indiv iduals and groups), place(revitalising community life) and injustice(precipitating systemic change around inequality).
The foundation funds art as an instrument ofsocial change, community cohesion andparticipation, all of which is highly relevant to thefield of arts, health and wellbeing. This is a
developing area of loan finance which may beappropriate for some organisations and projects.
Few, if any, of the funders mentioned here havesupported arts work explicitly because of its
potential benefit to health. Many have, however,clearly acknowledged that the arts can confer
health and wellbeing benefits, and a considerationof outcomes and impact is expected to be a clear
part of ACE’s work in the future.307
Arts organisations need to explain how they
will satisfy the requirements of funders, but there
is great variation in the approaches of funders. At
our Funding round table, very different views wereexpressed as to requirements for evidence and the
purpose of grant-giving. Sally Bacon, Executive
Director of the Clore Duffield Foundation, a major
funder of the arts with a particular commitment tomuseums education, said that, to them, evidence
was crucial. She wanted ‘killer statistics’, which
would ‘move the dial’ with government and lead to‘systemic change’. Clore also, however, makedifferent requirements of larger and smallerorganisations, recognising that smaller ones
cannot a f ford resea rch or independent
evaluations. On the other hand, Lady Helen
Hamlyn, whose foundation has given £40m to thearts over fifteen years, took the view that there isalready plenty of evidence as to the effectiveness of
the arts and design in health, and the crucial
judgement for her is whether the leaders of a
project are convincing. If persuaded that they are,her foundation will develop a long-term
relationship with them. For Janet Morrison, Chairof the Baring Foundation, the objective was tocreate ‘joy, fun, compassion, community’ throughthe arts, to enable staff to see ‘who the people intheir care really are’, to transcend the limitationsof the medical model and to create better lives
through the arts.
We were advised by people experienced in theassessment of funding applications that all too
many organisations make elementary errors. They
fail to frame their bids precisely in relation to thestated objectives of foundations or follow their
guidelines. They do not think carefully enoughabout how to make their presentation. They
submit generic applications, maybe written inpoor English. They fail to describe how the funding
will lead to sustainable results or further
development. They are impatient and fail tocultivate and sustain a relationship with thefunder. And, notably, they fail to thank the funder.
Where there was unanimity among funders –both charitable and public – at the round table wasthat they should improve their procedures forcollaboration and information exchange. All
present agreed that a coordinating centre would
aid them, among other things, in developing
59

Chapter 4

The Policy, Commissioning and Funding Landscapecommon metrics and terminology. It was agreed,
too, that charitable funders should be a source ofinnovation and use their prestige to raise thestatus of the arts in health and social care.
Charitable funders can be leaders in making
investments in preventative strategies, which
could have an important influence on public sector
commissioning. The top 300 foundations(responsible for 90 percent of giving) account for£2.7bn f lowing into the voluntary sector, thegreater part of which goes to education, followed
by health, the arts and culture.308 This, however,compares with £15bn of public funding flowing
into the voluntary sector and £112bn into the
NHS.309 There is understandable resistance in the
charitable sector to acting as a substitute forstatutory funding.

4.7.4

Private-Sector Funding
The Private Investment in Culture Survey,
commissioned by ACE, found that, in 2014–15,£480m of private investment went to culture, of
which £245m came from individuals, £139m fromtr usts and foundations and £96m f rom
businesses,310 but the extent to which funding waschannelled to health and wellbeing was not stated.
At our Funding round table, Daniel Gerring, of theCity law firm Withers, explained that decisions on
funding for the arts are strongly influenced bystaff priorities for charitable giving, by the impactof their giving on the image and reputation of thepartnership and by other business development
considerations. In chapter seven, the commitmentof law firms and other businesses to arts andhealth approaches will be considered in relation to
workplace wellbeing.
It is worth considering the potential of Social
Impact Bonds (SIBs), whereby investors fundinterventions in areas of interest to public
commissioners; if social outcomes improve,commissioners repay the original contribution
to investors plus a return for their financialr isk. Th is scheme a i m s to encou ra ge
preventative interventions and reduce demandon acute services.311
The organisation Social Finance is supporting
Age UK Herefordshire and Worcestershire toprovide Reconnections, a service set up in 2015 tohelp 3,000 older people overcome loneliness. It isthe country’s first SIB to focus on loneliness and, as
investor repayments are only made for measurable
reductions in loneliness, establishing the best
evaluation tools is a key part of the support theSocial Finance advisors provide.
In March 2017, the Cabinet Office announced apartnership with the University of Oxford, known
as the Government Outcomes Lab, which seeks to
60

All-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Report

improve the outcomes of public sector
commissioning. 312 The House of Lords SelectCommittee on Charities has noted that the Officefor Civil Society’s Centre for Social Impact Bonds is
encouraging other government departments todevelop and commission SIBs and gives theexample of a DH initiative to support people withmental health problems into work.313 Among 32
current SIBs, attention is being paid to improving
self-care and promoting sustained lifestyle change
in people living with long-term health conditions.314
However, evidence received by the Committee
pointed to the limited viability of SIBs due to thedifficulty of attracting investment in complex
projects and monitoring their effects. This led theCommittee to conclude that SIBs ‘are only relevant
where they produce a saving that can betransferred to a private investor, and that limits
their potential contribution to the mix ofalternative finance options for charities’.315 Given
that there are likely to be costs involved indemonstrating financial viability, this scheme may
be better suited to larger consortia than small
arts organisations.

As it is, the vast majority of health-orientatedarts initiatives are funded by one-off grants.
They depend on dedicated and indefatigable
individuals, and their services are vulnerable tothe unpredictability of funding. The teamevaluating the ACE-funded Be Creative Be Wellproject noted that ‘For many years, participatory
arts projects have been observed to make asignificant contribution to the health and wellbeing of local communities – only for beneficial
outcomes to disappear without trace whenshort-term project funding runs out’.316 The
detrimental effect of this lack of continuity, on
those who benefit from and contribute toactivities, cannot be overstated. We make thecase for integration of the arts into existing anddeveloping health and care strategies anddelivery mechanisms while also calling for artsand culture providers to consider health andwellbeing as core to their work.
We may foresee that, in the health and social
care services of the future, the balance will haveshifted from the paternalistic to the selfdirected, and the boundaries between patientsand commissioners will have broken down.
Primary and acute care will work in a more
integrated and horizontal way, with each otherand with social care, and services will beorganised locally, focused on community needs
and assets. In this vision, the arts have a crucialpart to play in the prevention of illness andinfirmity and in the maintenance of health andwellbeing. In the next chapter, we see how thisconception of the future is evolving, through thedevolution agenda and beyond, and how the arts
form a vital part of the social movement inhealth that is underway.

61

Maggie’s Centre, Dundee
Architect: Frank Gehry
Sculptor: Antony Gormley
Photographer: Keith Hunter

Place,
Environment,
Community
62

63

Chapter 5

Place, Environment, Community

All-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Report

5 Place, Environment, Community“The effect in sickness of beautiful
objects, of variety of objects, andespecially of brilliancy of colours is hardly
at all appreciated [...] People say the effectis on the mind. It is no such thing. The
effect is on the body, too. Little as we know
about the way in which we are affectedby form, colour, by light, we do know this,that they have a physical effect. Variety ofform and brilliancy of colour in the objects
presented to patients are actual meansof recovery.”
Florence Nightingale, Notes on Nursing, 1859

In a 2014 report, entitled Culture and Poverty:
Harnessing the power of the arts, culture andheritage to promote social justice in Wales,
Baroness Andrews gave special consideration
to the concept of ‘place’. As she wrote, ‘Each of
us is shaped by the place in which we live, and eachgeneration reshapes that place in its own
image’.317In Roman times, genius loci referred to
the guardian spirit of a place; nowadays, the same
term is taken simply to refer to the spirit of a place,its distinctive atmosphere. 318 Transcending
generations, sense of place is bound up with
our location, identity, memories, traditions
and connections.
This chapter looks at the ways in which our local
environment impacts upon our health andwellbeing. It looks at a possible future arts andhealth infrastructure. It outlines a political vision,acknowledging the greater latitude wrought by
devolution. It highlights what may be possible if
the political will is there. In the process, it explores
the renewed interest in community that has
characterised recent debates. This leads us toconsider how local decision-making, grounded in asense of place, is coming to the fore in building ahealthier society.

64

5.1

The Natural and Built
Environments
The WHO Commission on Social Determinants ofHealth took account of the natural and built
environment in which people reside. The naturalenvironment has a part to play in maintaining
healthy lives.319 In 2014, Lord O’Donnell chaired ateam, including Lord Layard, which produced areport entitled Wellbeing and Policy. This notedthat ‘physical or visual access to green spaces,
water, or natural light appears to have asurprisingly powerful direct impact on subjective
wellbeing’. 320 The National Planning Policy
Framework embraces the value of open space tohealth and wellbeing.
The National Trust took Sheffield as a case study
to discover that parks and green spaces were greatcity assets, with every £1 spent on maintaining
them generating £34 in community benefits.321
Facing a 90 percent decrease in parks funding,
Newcastle City Council has invested £1m of antiobesity funding from the public health budget intoparks while new governance arrangements arebeing researched.322
Nature deficit disorder, brought about by humanalienation from the natural world, 323 is being
compensated for by initiatives such as green gyms,
pioneered by an Oxford-based GP and a group ofconservation volunteers in the 1990s, which
involves weekly conservation or gardening work.

power of space to be uplifting’ and described how
architecture and space ‘profoundly engage thesenses of sight, touch and sound’. Analysis of theTaking Part data suggests that people who visit
heritage sites are happier than those who do not.332
In a similar vein, analysis of data from theUnderstanding Society survey has shown that
visiting heritage sites – particularly historic towns
and buildings – increases life
satisfaction. Research informed
by English Heritage calculated
this gain at the equivalent of£1,646 per person per year.333
People who identify their local
area as beautiful enjoy bettermental and physical health,but the perception ofenv i ron ment a l beauty isunevenly distributed across thesocial gradient.334 Networked
Heritage – a collaboration between the Heritage
Lottery Fund and the Royal Society for theencouragement of Arts, Manufactures andCommerce – seeks to understand how tostrengthen the links between heritage, identityand place, including through health.335
The poorest people in the UK tend to live inenvironments with the greatest number ofhazards, such as pollution, noise and flooding.336
Lynsey Hanley has drawn on personal experience
to note that:

The arts and culture – includingarchitecture, design and heritage – enrichenvironments, making them beneficial to
our health and wellbeing.
The 2015 Spirit of the Forest pilot, delivered byHampshire Art for Recreation and Therapy incollaboration with the New Forest National Park
Authority, aimed to improve the mental health andwellbeing of participants through outdoor art
therapy activities.324 Engagement with the outdoors
is also an integral part of walk and talk therapies.
In 2016, a report commissioned by the National
Gardens Scheme from the King’s Fund pointed toevidence that gardens and gardening have a rangeof impacts upon health and wellbeing across thelife course, from encouraging healthy eating toameliorating loneliness and reducing anxiety,depression and stress.325 Gardening, as a creative
activity, is already enjoyed by many people andcould be by many more. Gardens are integral to
many healthcare environments. Gardening isoften offered alongside arts activities incommunity organisations orientated towards therestoration of health and wellbeing, and there arecalls for it to be made available on the NHS.326
Exposure to green environments has beenfound to reduce the effects of income deprivation,
particularly in relation to all-cause mortality andcirculatory disease.327 A study of more than 21,000
urban residents in 34 European nations found thataccess to open spaces also helped to diminish
wellbeing inequalities.328 Marmot argues that‘there is evidence in abundance that living nearand using green space is good for mental health.
The key issue is urban green space as a majority ofus, worldwide, now live in cities’. 329 The
Government has made a commitment tos upp or t i n g ga r den c it ie s , t ow n s a ndcommunities.330 Greening Grey Britain, a Royal
Horticultural Society campaign, encourages theconversion of concrete and asphalt areas
everywhere into green spaces.331
At the round table on the Arts and Healthcare
Environments, Paul Williams of Stanton Williams
Architects spoke of the ‘power of architecture, the[…] you can blame higher incidences of poor
health and premature death, to a large extent, on
the concentration of poorer people in a single
area, where there are fewer fresh food markets,
fewer open and green spaces, fewer sports
amenities and fewer opportunities to have asocial life outside the family. Council estates havethe effect of making people feel worse about
themselves, and in turn, physically worse thanother members of society.337
The Marmot Review advised that ‘The physical andsocial characteristics of communities, and thedegree to which they enable and promote healthy
behaviours, all make a contribution to social
inequalities in health’.338
In the late 1990s, recognition of the damage
caused by poor-quality built environments,
including their impact upon health and wellbeing,gave rise to the foundation of the Commission forArchitecture and the Built Environment (CABE),
funded by DCMS and DCLG, and to theGovernment’s Better Public Buildings campaign.
A review of public space conducted by CABE in
2004 found that 85 percent of people in Englandagreed that the quality of the built environment
influenced the way they felt.339 To coincide with a
DCLG White Paper about the powers of local
planning authorities in 2006,340 CABE published a65

Chapter 5

Place, Environment, Community

guide for community groups working to improve
public space. This advised that ‘Good design isabout creating a place that functions well, both
now and in the future. It should also be attractive,
providing an inspirational and special place
for people’.341
In April 2011, CABE was integrated into the
Design Council. Recognising the deficit caused bythis downgrading, the House of Lords SelectCommittee on National Policy for the Built
Environment published a report in February 2016,
entitled Building Better Places.342 This sought acoordinated long-term and high-quality approachto the built (and natural) environment, predicatedon a sense of place and a consideration of healthimpacts. More specifically, the report argued that
‘The places that we create have a profound effectupon the quality of life, behaviours andexperiences of people who live and work inthem’.343 Acknowledging government recognitionof the value of the built environment to health in a
debate on the Select Committee’s report in January
2017, Lord Howarth argued that ‘We needenvironments that support health and help to heal
not only the individual but society. When the sun
shines, it lifts our spirits. When we are in a
beautiful built environment, we feel better. We arehappier, saner and more secure – we are more
optimistic, and our lives are better’.344 Several of
our interlocutors reiterated the need for a longterm approach to building that prioritised thehealth and wellbeing of users.342 In this regard,
recognition by the Foresight Future of Cities
project of the contribution of cities to health andthe role of culture within cities is encouraging.346
At the round table on Place, Environment,
Community, Andrew Simpson from Dominic
Lawson Bespoke Planning asserted that ‘planning
ought to be regarded as part of the arts’. The
National Planning Policy Framework contains asection dedicated to the promotion of healthy
communities, which acknowledges the role

All-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Reporta part in reducing health inequalities.348 It is
important, therefore, that new developments areplanned on a co-production basis, with artists,architects and designers genuinely responding to
the needs and priorities expressed by local people.

5.2

Healthcare Environments
In the introduction to Better Public Buildings, DCMS
noted that ‘The best designed hospitals help
patients to recover their spirits and their health’.349
In response to this and to the advocacy of CABE, in2001 NHS Estates founded the Centre for Healthcare
Architecture and Design, and, coinciding with ashift to patient-centred care, DH launched an
initiative called Better Health Building. Since then,it has been standard practice to consider theps ychos ocia l pr oper t ie s of hea lt hc a reenvironments.350 A review commissioned by DHfrom the School of Architecture at the University of
Sheffield compiled studies showing that thephysical environment of healthcare facilities
contributed to health and psychological andsocial wellbeing.351
Chairing the round table on Place, Environment,
Community, Sunand Prasad, former President of
the Royal Institute of British Architects (RIBA),
said that ‘The environment of the arts and beautyand spirituality can all be part and parcel ofrecovery, whether it be from physical or mental
conditions’. Director of the London branch of CF
Møller, Teva Hesse, referred to the substantial
expertise that had been dedicated to thinking
about healing buildings and pointed to the vitalqualities of daylight, gardens and natural
materials.352 Associate Director of East and North
Hertfordshire CCG, Jacqui Bunce, told us that
good design need not cost more and could bemade part of the approval process.353 Gellinudd
Recover y Centre – a coproduced mental health facility,
funded through the Welsh
Government’s Invest to Save
scheme and the Big Lottery – isestimated to save NHS Wales£300,000 per year.354
At the round table on the Artsand Healthcare Environments,
Guy Eades, who manages
Healing Arts on the Isle of Wight, noted that new
health building were usually entirely defined byhealthcare professionals and technicians. At theround table on Place, Environment, Community, it
was noted that this often leads to a noisy,
mechanical system when what is required ispatient comfort and dignity and a calm
environment for staff. If artists are involved in theprocess of designing health buildings, Eades

Access to green space and natural light
improves our wellbeing and speeds ourrecovery from illness.
planning can play in ‘facilitating social interaction
and creating healthy, inclusive communities’.347 To
this end, the framework advises community
involvement in the development of residential
areas and facilities. In a briefing to local
government, NICE recognised that community
engagement – with people being involved indecisions that affect their wellbeing, including
new building or housing developments – may play66

argued, they can provide a conduit between
patients and the hospital, informing spaces andactivities in which people can breathe, think andreflect. Rather than this being a temporary post
limited to the construction phase, the artist’s role
was felt to be most significant when it was
integrated into the continuing work of thehealthcare team, operating as a system translator
and developing new opportunities for creative
activity to promote recovery.
DH issues guidance on the design and planningof new healthcare buildings and residential
supported living. One of the tools used to evaluate
new healthcare buildings is known as the British
R esea rch Establ ish ment Env iron menta lA ssessment Method (BREEAM) UK New
Construction scheme. BREEAM requirements areintended to encourage sustainable approaches toand Clyde described how she had used thesecriteria to legitimise arts strategies withinconstruction schemes while also using a percent
for art scheme as a lever for securing externalfunding. However, in the most recent version of
BREEAM (2014), these criteria have been removed.
A healthcare sector advisory group, containing
representatives from DH, NHS Scotland and Walesand the Department of Health in Northern Ireland,
determined that the involvement of an art
coordinator in building projects was now
considered standard practice, meaning thatBREEAM was no longer needed to drive bestpractice in this area.
We suggest that the wording of the BREEAM UK
New Construction scheme is revisited in the areaof arts policy, strategy and coordination,in discussion with arts coordinators. We believethat planning guidance should
ma ke clea r that new
developments should normallybe subject to post-occupancy
evaluation, after an intervals u f f ic ient t o en able a nassessment of the impact of adevelopment on the health andwellbeing of those whose lives it
affects. We also support thecontinued use of design review panels, which
are unevenly distributed around the country.
Some of them should be expanded to include
heritage professionals.
While these observations concern new
healthcare constructions, the arts can make asignificant impact within extant buildings. In
2000, in partnership with NHS Estates and DH,
the King’s Fund launched a £2.25m programmecalled Enhancing the Healing Environment (EHE).
This worked on the understanding thatenvironment was crucial to how we live andrecover, with art and design playing an integral
part, and that hospital environments were needed‘which encourage patients to feel welcomed,
looked after and cared for, and in which staff feelvalued’.355 Initially centred on acute trusts in
London, the programme was extended to mental
health trusts and primary care trusts in the capital
before being rolled out nationwide to encompass
community trusts, care homes and hospices andinvolve more than 250 health and social careor ga n isat ion s. In each or ga n isat ion, amultidisciplinary team, led by a nurse andinvolving estates staff, patients, artists and arts
coordinators, took part in staff development
activities and was given £35,000 to undertake aprogramme of environmental improvement.
In add it ion to sig n i f ica nt ly a lter i ng
environments and enhancing recognition of thevalue of the arts and design, early evaluation
showed that the EHE programme improved theways in which people related to each other andArts in healthcare facilities help todiminish our anxiety and connect uswith our humanity.
building design which go beyond the regulatory
minimum or demonstrate best practice in specificareas. In the 2011 version of BREEAM, theincorporation of visual art was encouraged,
according to the criteria that:•		An art coordinator has been appointed for the
specific projectOR•		A n art policy and an art strategy have been
prepared for the development at the feasibility/
design brief stage i.e. RIBA stage B (or equivalent)and endorsed by the senior management level.
The policy and strategy addresses the following:		 o Enhancing the healthcare environment
		 o	
B uilding relationships with the local
community		 o	Building relationships with patients andtheir families
		 o	R elieving patient and family anxiety bycontributing to treatment or recovery
areas, e.g. post-operative areas, paediatricunits, etc.
		 o	Greening the healthcare environment withinclusion of living plants (where appropriate)		 o	Training generating creative opportunities
for staff
At the round table on Devolution, Jackie Sands,
working in arts and health at NHS Greater Glasgow

67

Chapter 5

Place, Environment, Community

navigated buildings; it changed ambiences,provided a positive distraction and created anincreased sense of calm; staff morale was
improved, and local culture was celebrated.
M o r e o v e r, t h e p r o g r a m m e p r o v i d e dunderstanding of the ways in which environment
affects wellbeing.356 Longer-term benefits that

All-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Reportour best selves and it nourishes the soul’. Gilly
Angell, expert patient at UCL Hospitals Cancer
Centre, noted that, in an art-filled hospitalenvironment, ‘Acute medicine and art walk handin hand day and night […]. The first saves lives, thesecond nudges our spirit, allowing us to know what
it is to be human, to know ourselves, others’.
Established in London in
1959 and now working acrossEngland, Wales and Northern
Ireland, Paintings in Hospitals
has amassed a collection of over
4 ,000 artworks, w ith thespecific purpose of helping to
reduce sickness, anxiety andstress. The collection forms thebasis of the organisation’s loan schemes, throughwhich any health or social care site can borrow
artworks for a nominal fee. Recognising theimportance of placing patients and service users at
the centre of decision-making processes, Paintingsin Hospitals organises curator-facilitated sessions
to aid in the selection of artworks.362 Artworks mayhelp visitors to navigate often-forbidding facilities
by providing distinctive landmarks.363
Art in Hospital, a centre for best practice invisual art and medicine, which has operated in
Greater Glasgow since 1991, seeks to place theartist and their practice alongside the patient. As
we saw in the example of the Manchester Hospitals
Arts Project, artists sometimes create site-specificworks in hospitals. The performing arts can also
create a benign atmosphere for patients, visitorsand staff in healthcare environments. Across
Guy’s and St Thomas’ NHS Foundation Trust,
Breathe Arts Health Research runs the Performing
Arts programme, bringing music, dance andpoetry into clinical spaces, which has been found
to reduce anxiety.364
Laura Waters, Arts Programme Manager at
Derby Hospitals, observed that people who findthemselves in hospitals are often in a heightened
emotional state, and the arts can smooth theirjourney from diagnosis to treatment to monitoring
to discharge. The Healthcare Innovation Exchange(HELIX) Centre, funded by the Helen Hamlyn
Foundation at St Mary’s Hospital, London, is a
consortium of clinicians, researchers and designers
from Imperial College London and the Royal Collegeof Art (RCA), working together to improve thepatient experience. In response to a perceived
depersonalisation of care, designers at HELIX haveproduced a visual cartography of the care pathway
traversed by cancer patients which is available inprinted and interactive digital formats.365
Artists and arts therapists regularly leadparticipatory arts projects and programmes inhealthcare environments. In 2009, the Centre for
Medical Humanities at Durham University devised
five guidelines for arts practitioners in healthcare
settings in the Republic of Ireland. These wereAccess to the arts and culture helps us tolive well in our communities.
began to emerge from the programme included
reduced aggression from patients towards staff
and improved staff recruitment and retention. The
impact on participating trusts exceeded the scopeof individual projects, aiding ‘innovative
approaches to patient involvement’ and the‘fostering of closer links with local communities’.357
In 2004, EHE generated a practical guide forfrontline staff wishing to improve theirenvironments, which emphasised the importanceof design and included artwork as one of five main
themes.358 Much of the advice contained within
this guide remains relevant today, making it
worthy of republication.
Academic research reinforces insights gained
during the EHE programme and its precursors. A
systematic review of the impact of visual art anddesign on the health and wellbeing of service users
and staff in adult mental healthcare found thatpatient outcomes were ‘affected by noise, lighting,colour, windows, views and art’.359 Building uponknowledge gained during this review, a three-year
study of an arts-based collaboration with Avon and
Wiltshire Mental Health Partnership NHS Trustfound that the a r ts suppor ted hea ling
environments by ‘enhancing valued features anddiminishing negative aspects. Most importantly,
the arts created opportunities for service users
and staff to assert control and affirm nonstigmatised identities’.360 Most major health trusts
nowadays acknowledge the importance of the artsand design to the fabric of their buildings and act
upon this acknowledgement.361 We encouragetrusts to continue building on learning from theEHE programme and involve multidisciplinary
teams in the planning and delivery of arts
programmes in hospitals and continuing care.
At the round table on the Arts and Healthcare
Environments, Jane Willis of arts-in-healthcare
consultants Willis Newson noted that ‘Integrated
into a well-designed healthcare environment, art
can and does make a difference. It can help
welcome, reassure, soothe, engage, distract. […] It
connects us with our humanity. It touches thespirit. It reminds us who we are. It reminds us of68

that: the wellbeing of participants is paramount;
practitioners attempt to draw out the creative
potential of participants in a way that is bothchallenging and realistic; a collective creative
process is generated through the building of
mutual trust; practitioners recognise theimportance of evaluation and their duty tocontribute to it; practitioners abide by a code ofgood practice consistent with the ethos of the
supporting institution.366 More recently, ArtWorks
Cymru has produced a useful guide for artists
working in hospitals, containing information
ranging from contracts and rates of pay to advice
on working with patients and staff.367 Both of these
documents provide a useful reference point for
health and social care commissioners andmanagers seeking to work with artists.
In each of the subsequent life-course chapters,
attention is paid to the role of arts, architectureand design in health and care facilities.368

5.3

Devolution
In 1997, both Scotland and Wales voted in favour ofthe devolution of executive powers to the Scottish
Parliament and Welsh Assembly respectively.
The following year, the Northern Ireland Assembly
was created as the result of prolonged powersharing negotiations. Devolved governments ineach nation have responsibility for health andculture budgets.
On the understanding that creativity ‘makes aninvaluable contribution to our health andwellbeing – both physically and mentally’,369 thearm’s-length arts funding body Creative Scotland
works with all fourteen health boards in Scotland.
Through a combination of NHS, lottery andendowment funding, strategic posts have been

arts strategy for 2016–17 seeks to increase access.370
This is complemented by recognition of the valueof the arts and culture to education.371 In the next
chapter, we hear more about an arts-based
educational initiative in Scotland that seeks toovercome childhood inequalities.
In Wales, while arts and health boards exist, art
schemes operate in healthcare environments andarts coordinators are in post, arts and healthstrategy is less well developed than in the other
devolved nations. A 2005 Review of Arts and
Health Activities in Wales made a series ofrecommendations aimed at better coordination in
the field and a national commitment to arts andhealth. In 2009, Arts in Health and Well-being: an
Action Plan for Wales almost led to collaborative
action between the Welsh Assembly and Arts
Council of Wales, with the aim of enhancing thehealth and wellbeing of the population of Wales
through arts and creativity, but it faltered througha change of minister.
In her Culture and Poverty report, Baroness
Andrews conceived the arts as ‘an aspect of social
justice in itself and a powerful weapon against
poverty’.372 This urged the Welsh Government to‘articulate and promote the role of culture insupporting a broad range of policy objectives’.373
The Well-Being of Future Generations (Wales) Act
2015 outlined a policy of sustainable development
through a ‘process of improving the economic,
social, environmental and cultural well-being ofWales’. 374 The Welsh Government’s cultural
strategy now makes extensive recognition of thehealth and wellbeing benefits of engaging withcreative and cultural activities as a supplement tomedicine and care, and more than 50 percent ofrevenue-funded organisations are involved in artsand health projects.
In September 2016 a Cross-Party Group on Artsand Health was formed in the Welsh Assembly byAssembly Member (AM) Eluned Morgan.
The group is made up of AMs
f rom across the politica ls p e c t r u m a nd c onvene s
representatives fromhealthcare, adult social care,charities and special educationfrom across Wales who use thea r ts therapeutica l ly. The
intention is to build on existing
networks and to assess theimpact of the arts on health andc a re i n Wa les. Work i ng
a lon g s ide p ol ic y-m a k e r s
academics and practitioners in
the field, the group aims to identify best practice inWales and to develop a firm evidence base with aview to making the case for shifting resources into
the arts to facilitate improvements to people’s
health and wellbeing in Wales. The group has
promoted the commissioning of a study into the

The arts for health and wellbeing areintegral to planning in the devolved
nations of the UK; in Greater Manchester,
the arts are at the heart of population
health planning.
created to enable the development of arts andhealth strategies in response to local need. Senseof place is considered essential to developing
community wellbeing. Acknowledging theinversely proportional relationship between
poverty and arts engagement, Creative Scotland’s

69

Chapter 5

Place, Environment, Community

arts and health in Wales to be undertaken by Arts
Council of Wales. In November 2016, the Cabinet
Secretary for Economy and Infrastructure, Ken
Skates AM (who has responsibility for the arts),
harnessed the arts, libraries and heritage to thehealth and wellbeing agenda, including prevention
and early intervention, and welcomed theformation of the group.
In Northern Ireland, Arts Care supports 18
artists-in-residence working across art forms todeliver a comprehensive weekly arts service in all
five health and social care trusts in the province
and across multiple health and community careservices. The charity also enlists the services ofmany project artists who facilitate and coordinate
participatory workshops and performances aswell as taking responsibility for the content of six
Arts Care galleries in healthcare environments.

5.4

Place-Based
Commissioning
In recent years, the Government has moved incertain respects towards permitting greater
exercise of powers at local level in England,particularly through the Localism Act of 2011. It
has spoken of ‘devolution of powers to citizens andgrass roots organisations’.375 City and Growth
Deals are seeing power and discretion overextensive areas of public service spending passed
down from Whitehall. At the same time, theAll-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Report

the populations they served, orientated towards
NHS priorities and involving local and specialist
expertise. 378 In 2016, the Place-Based HealthCommission, chaired by Lord Adebowale, hailed
the NHS and local government focus on place as
the best hope for the future sustainability of thehealth system.379 In 2017, the Next Steps on the Five
Year Forward View identified that ‘Across England,commissioners and providers across the NHS andlocal government need to work closely together – toimprove the health and wellbeing of their local
population and make best use of available
funding’.380 This acknowledged the inextricabilityof health from other factors under local control,
such as housing, leisure and transport, and therelationship between the wider determinants ofhealth and demand for services. It also explicitly
avoided prescribing a particular organisational
form and called for the targeting of resourcesat those experiencing the worst health outcomes
and the genuine involvement of patientsand communities.381
This strategy of being ‘local by default’cha llenges the standardisation and thepresumption of economies of scale that haveprevailed over many years.382 It potentially enables
the resources of a community to be harnessedmore effectively to health and wellbeing. In thischapter, we see that Greater Manchester isdeveloping its own commissioning arrangements,
intended to encourage innovation by placing
responsibility with those who have access toknowledge about patients, advances in health andcare and the latest clinical evidence.
The 2016 Culture White Paper stated a desire for‘more local leaders to grasp the
potential of culture to achieve
their vision for their community,
and to put culture at theforefront of their strategies’.383
An LGA report called People,
Culture, Place published in 2017
looked at examples of cultural
assets being used to shape theplaces in which we live. This
argued that ‘there has neverbeen a better time for councils to lead local actionthat builds on the contribution of the arts, culture
and heritage in creating prosperous, healthier,stronger and happier communities’.384
The British Academy’s Where We Live Now
project found that ‘At a time when, it is clear, many
people feel increasingly disconnected from those
who make decisions, place offers a means ofreconnection, more sensitive and appropriate
policy-making, and better outcomes in terms of
our individual and societal wellbeing’.385 Morespecifically, the project urged greater attention to
health, wellbeing and quality of life, through along-term perspective and integrated planningresponsive to local need. 386 This led to theArts and cultural organisations have avaluable contribution to make to placebased commissioning strategies.
devolution of responsibility for public health tolocal authorities opens the way to a bigger role forthe participatory arts, which are delivered locallyand often regarded as a means of individual andcommunity empowerment.
Along with the movement towards integrationof primary and secondary health and social care isa focus on place-based health and care.376 In 2014,
the Local Government Innovation Taskforce called
for a ‘stronger local dynamic in the design ofservices, anchoring them in the places they
operate to build in responsiveness, relevance andimpact for people’.377 In 2015, the King’s Fund
advised service providers to establish place-based
systems of care that would best meet the needs of70

Greater Manchester
Devolution
In England, Greater
Manchester has been
the first region to takeadvantage of the transferof health and social care
powers away from
central government.

T

his new era began on 1 April 2016, when
the Greater Manchester Combined
Author ity (compr ising 37 NHS
organisations and local authorities)
took control of health and social carebudgets worth more than £6bn. For the first time,
local elected leaders and clinicians are able totailor budgets and priorities to meet the needs of
local communities according to the Marmot
principles. This will involve improving thehealth, wellbeing and long-term outcomes of 2.8
million residents, many of whom have a lower life
expectancy and lower healthy life expectancy
than people in other parts of England. In order toachieve a radical change, at scale and across thewhole range of services, the focus is being put onpeople and place, rather than organisations, and
it is taking account of the impact of air quality,
housing, employment, early years, education andskills across the life course.
An ambitious five-year plan set out ways inwhich people will be enabled to start well, live
well and age well, and it anticipated savings being
made in the longer term.387 Next Steps on the Five
Year Forward View cited Greater Manchester as
an example of partnerships being formed
between the NHS, local government and the third
sector, giving rise to wider strategic leadershipfor health and social care.
The five-year plan was accompanied by apopulation health plan which acknowledged thelong history of arts and health activity in theregion and stated an intention to ‘position thestrong inter-relationship between arts andindividual and community health as one of the
key foundations of building sustainable

and resilient communities across Greater
Manchester’.388 People will be encouraged tomake art and to connect with the resources andcapacity of local cultural organisations.
The next iteration of the population healthplan will include a programme of arts activity inhealth and social care and in social action on
wellbeing. The programme will make explicit thebenefits for people of engaging in art, becoming
active in their communities and gaining more
control over their lives. This strategy willemphasise the social aspects of arts engagement
and support individuals and communities to do
more for their own health and wellbeing. It is
intended that the arts and culture will be
integrated into sustainable partnerships withhealth service commissioners and providers,making arts activity a core element of futureplanning. In the meantime, under the banner ofLive Well Make Art, a grassroots group of artsand health commissioners and practitioners is
helping to build health as a social movement bystimulating discussion of, and demand for, thearts based on a growing understanding that they
are good for health and wellbeing.

71Chapter 5

Place, Environment, Community

recommendation that ‘specific place-based
elements e.g. heritage, arts, culture andenvironmental attributes should form a positive
part of plans rather than being seen as optional
extras’.389 In the same publication, Professor Ruth
Finnegan evoked ways in which the power of place
is captured in music, poetry and colour.390
Increasingly organisations within and beyond
health and social care are working together toserve whole communities.391 In Halton – a Well
North pathfinder and one of ten demonstratorsites being supported as part of the NHS England
Healthy New Towns initiative – creative solutions
are being applied to some of the most pressing
health and social care challenges.392 Studio-basedorganisations in Runcorn and Widnes havebecome strategic partners. Halton CCG has issued
a Cultural Manifesto for Wellbeing, which
recognised the context in which people live to be
the most important determinant of life
expectancy. The manifesto embraced acommunity-wide approach, aimed at addressing
the root causes of health, and it acknowledged theimportance and interdependence of the arts andheritage, environment and sport in this sociallyvaluable endeavour.393
Equally, strategies responding to place enhancewellbeing. Poems on the Underground, which hasreceived substantial funding over three decades
from ACE, Transport for London and the British
Council, displays 18 poems over the course of ayear in underground train carriages.394 Estimatedto reach 3.5m passengers every day, publishedversions of the collected poems have sold 250,000
copies as evidence of their popularity. Creator of
Poems on the Underground, Judith Chernaik, said
‘What we’ve been told repeatedly is that people
love the poems because they offer a momentof quiet ref lection, they are pleasurable,
consoling, illuminating’.

5.5

Arts on Prescription
In October 2013, the Prime Minister announced anew £50m Challenge Fund to improve access togeneral practice and stimulate innovative ways ofproviding primary care services; in September
2014, further funding of £100m was announced.395
In April 2016, the General Practice Forward View
acknowledged the increasing demands being
placed on GPs and announced an additional £2.4bn
a year for general practice by 2020–21.396
An estimated one in five GP visits is made forpsychosocial, rather than medical, reasons, 397
which equates to the cost of 3,750 GPs’ salaries.398
Professor Stephen Pattison, Honorary Fellow of
the Royal College of General Practitioners (RCGP),
posits that the ‘job, the skill and the satisfaction of
72

All-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Report

GPs [is] to mediate between data and facts ofvarious kinds and the subjectivity of patients,
learning from both and arriving at a satisfactory
outcome in which in some sense patients feelbetter able to engage with their lives’. 399 The
General Practice Forward View drew attention to
the merits of social prescribing.
Consistent with WHO recommendations, socialprescribing aims to address the broader causes ofill health by seeking solutions to psychosocial
problems beyond the clinical environment.400 Thismight initially involve a GP, nurse, mental healthprofessional or charity staff member referringsomeone to a voluntary, community or faithorganisation offering access to advice, education,
exercise, gardening, self-help, volunteering or arts
activities. A range of community-based creative
activity is also accessed without any kind ofreferral from a health professional. Despite theterminology of prescription, 401 a non-clinical link
worker is often involved in co-designing
programmes according to patient need. In Halton,
for example, community navigators act as a bridge
between GPs and patients, directing them tocommunity-based services.
A 2015 review found that the most common
outcomes of such community referral schemes
were: increases in self-esteem and confidence; agreater sense of control and empowerment;
improvements in psychological wellbeing; andreductions in anxiety and depression.402 The Social
Prescribing Network has identified the potential ofsocial prescribing to ‘catalyse health-creating
communities that strengthen their ability to carefor themselves and each other’. 403 As aconsequence, areas in which social prescribing is
in operation report reductions in GP visits.
While social prescribing tends not to be cost
neutral at the start because of set-up expenses, it
provides a cost-effective strategy in the medium tolonger term. Rotherham CGG projects a return on
investment of £3.38 for every £1 spent after
five years. 404 At the same time, such initiatives
require continued investment if they are toremain effective.
Social prescribing is fast becoming a national
priority in NHS England. Over 400 generalpractices in England regularly refer their patients
to take part in activities in the community, oftenwith a focus on prevention, early intervention andthe management of long-term conditions. 405 Dr
Michael Dixon, Co-Chair of the Social Prescribing
Network, has been appointed as National ClinicalChampion for Social Prescribing by NHS England.
Dr Dixon told us that every GP should have accessto social prescribing by 2019. Training courses arebeing offered to public sector commissioners,
and the RCGP offers an online course toclinical staff.406
London Voluntary Service Council and the
Healthy London Partnership maintain a map ofArtlift Arts-onPrescription Scheme
Arts on Prescription
Gloucestershire is a
primary care-based
scheme set up by a GP,
Dr Simon Opher MBE, in
response to frequent visits
by patients experiencing
depression and anxiety.

S

eed funded by ACE, the scheme is now
supported by Gloucestershire CCG and
Wiltshire County Council and operated
by the charity Artlift across ninesurgeries and community spaces in
Gloucestershire and five pilots in Wiltshire, withreach into deprived areas.407 Health professionals
refer patients with a wide range of conditions –from depression and anxiety to chronic pain to
stroke – to take part in an eight-week course of
two-hour sessions, led by a professional artist
working in poetry, ceramics, drawing, mosaic or
painting. Participants are encouraged to pursue
their own creativity in a studio-like, rather than
medical, environment. Artists have regulartraining in clinical supervision and safeguarding,to ensure they are able to identify cases where
patients need to be referred back to theirclinician. Adopting an assets-based approach tohealth and wellbeing, the goal of the programmeis to encourage and assist the self-management oflong-term conditions in the community.
Russell, who was referred to Artlift withphysical and mental health problems after
suffering a serious stroke, attended for six
months. He began painting expressionistic
portraits of people who interested him, which
helped to rid him of anxiety and stress. He no
longer takes anti-depressants and, although his
depression has not completely gone, Russell
describes how he locks himself away and paints
until he feels better. Among the portraits Russell
has painted is that of Bishop Rachel at Gloucester
Cathedral, which has been purchased by the

diocese. Russell has had several exhibitions andreceived ACE funding; he now mentors others
at Artlift.
In 2009–10, University of Gloucestershireconducted an evaluation of Artlift. The
quantitative aspect looked at the nature ofreferrals and their effect on subjective wellbeing(WEMWBS); the qualitative aspect focused on
the experiences and opinions of the artists,
health professionals and patients involved. This
found a significant improvement in wellbeing,
improved mood and enjoyment of creative
activity. 408 The University has continued tocollate data for the project, and, in both 2014 and2017, the evaluation was updated and reported
the same results but with much larger sample
sizes.409
A cost benefit analysis of Artlift counted faceto-face GP consultations in the year before andthe year after an artist had seen patients; at thesame time, health spending data (hospital
admissions) were collected. This showed that GP
consultation rates dropped by 37 percent andhospital admissions by 27 percent. Taking
account of reductions in costs to the NHS against
the cost of Artlift interventions, this represented
a saving of £216 per patient. 410 Herein lie
significant potential savings for the NHS as partof a w ider place-based, person-centred
commissioning strategy.
Many Artlift participants have been inspired
to continue pursuing their creative practice,either at home or by setting up new groups.411 This
represents an example of the kind of independentpeer-to-peer activity incited in the Five YearFor w a rd Vie w, at no e x t r a c o s t t o
the NHS.

73

Chapter 5

Place, Environment, Community

social prescribing in London. 4 12 A Local
Information System for Scotland signposts people
to health and wellbeing services in the community,
including those which might be described as socialprescribing. Responding to the prevalence ofchronic conditions and an ageing population, the
LGA has produced a useful guide for local
authorities, linking social prescribing withservices being offered by councils and via their
public health work. 413 Tower Hamlets offers asocial as well as a medical prescription, andGloucestershire is about to follow suit.
A 2007 review of social prescribing in Scotland
included a section dedicated to arts onprescription. 414 Yet, despite the fact that arts on

All-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Reportand physical distress. Such activities generallycompr ise non-cl in ica l, g roup-ba sed a r t
programmes–such as draw ing, painting,sculpture, printmaking and pottery – which aim to
improve the health and wellbeing of participants.418
Consistent with the approach advocated by the
Mental Health Taskforce, they tend to treat theperson and not the diagnosis; they are personcentred, rather than illness-centred, andencourage a multidimensional approach. As partof the Cultural Commissioning Programme, NCVO
has produced a useful overview of landmark artson-prescription schemes and their methodsof evaluation.419
At the round table on Arts on Prescription,
Director of Arts and Minds,
Gavin Clayton, emphasised thatsuch activity was active, rather
than passive, requiring the
involvement of the referring GP
and the patient. Andrew Marrnotes that ‘Perhaps it’s partly
that painting, like gardening,
like making music, is a physicalactivity as well as a mental one.
You have to stand and mix andgrind and stab’.420
Arts participation has been made integral tosome healthcare facilities, such as the GP practices
in Gloucestershire and Wiltshire mentioned in thecase study provided in this chapter. At the roundtable on Place, Environment, Community, we
heard from the Director of Kentish Town
Improvement Fund, Melissa Hardwick, about theefforts being made to engage the community in
flexible creative spaces housed inside Kentish
Town Health Centre.
Another Greater Manchester-based exemplar of
this way of working is Inspiring Minds, funded by
Salford CCG and run by Start in Salford, anorganisation shaped by local service users. People
experiencing mild, moderate or more severe andenduring mental health problems are referred tothe programme through primary or secondary
mental health services. Inspiring Minds offers
members two-hour weekly studio-based creative
workshops for between six and 18 months,
combined with a personalised support andrecovery package designed to build confidence,
resilience and self-esteem. Professional artists
lead each group, and participants are encouraged
to consider themselves aspiring artists, rather
than mental health service users. In addition tovarious validated wellbeing scales, Start
subscribes to a theory of change model, which uses
self-evaluation to gauge the impact of activities
from participants’ perspectives. This is captured
in a short film exploring the relationship between
Start’s approach and the ‘five ways to wellbeing’.421
The example of Start in Salford shows that somepeople who discover an aptitude for art throughAs an effective antidote to physical andpsychological pain, arts participation
forms a vital part of social prescribing.
prescription predates discussions of socialprescribing, there remains an absence of emphasison the arts within current thinking.415
In 1984, the incoming minister of the church at
Bromley by Bow, Andrew (now Lord) Mawson, andhis wife Susan founded a community-based
centre. 416 The centre quickly came to include adance school and various art studios andworkshops and eventually led to the creation of the
UK’s first Healthy Living Centre, incorporating a
GP surgery, in 1997. Nowadays, the centre iscommitted to overcoming deprivation in the area
by focusing on vulnerable young people, adults
and families.
A decade later, an arts-on-prescription service
was set up in Stockport, offering visual art andmusic projects to women with postnatal
depression and those at risk of developing it.
Evaluation showed that all of the mothers taking
part in arts activity experienced improvements intheir general health (using the General Health
Questionnaire 28) and all but one a reduction in
their levels of depression (using the Edinburgh
Postnatal Depression Scale). 417 This was later
substantiated with evidence of diminishing GP
visits and increasing social participation. One of
the conclusions drawn from this pilot was that arts
engagement might be considered as a preventative
measure during the antenatal period. Whilefunding for the Stockport service was lost, accessto participatory arts activity has since beenprescribed around the UK.
Many organisations exist to offer arts activities,
whether explicitly termed arts on prescription
or not, to people experiencing psychological74

health and wellbeing routes go on to excel at art
school. This was identified as an area fordevelopment by a service user at our Young People,
Mental Health and the Arts round table, who
distinguished between art as an activity and art asa practice and called for viable career paths forpeople discovering the arts through health andwellbeing. In this regard, Arts Award – a nationallyrecognised series of qualifications that support
people up to the age of 25 to develop as artists andarts leaders – may be relevant.422
In 2012, the Mental Health Policy Group,
chaired by Professor Lord Layard at LSE,e s t a b l i s h e d t h e c o s t- e f f e c t i v e n e s s o f
psychological interventions for people withphysical symptoms. 423 The year before, NHS
England had invested £400m in Improving
Access to Psychological Therapies (IAPT),
extending for a further four years a programmethat had been provided by the NHS since 2007.
Arts-on-prescription activities have been foundto enhance the results of IAPT.424
NICE advises low-intensity psychosocial
interventions for mild to moderate depression,
including mindfulness-based cognitive therapy,
but, surprisingly, no recognition is made of thearts as a form of psychosocial intervention.425 We
hope that NICE will look afresh at arts-onprescription programmes for psychological andphysical pain. We believe there are good reasonsfor NICE to review its guidance in relation to
the arts.
Dr Theo Stickley at the University of Nottingham
has conducted qualitative research into arts onprescription, holding numerous interviews withservice users and referrers. This shows that people
first need to feel safe and accepted for who they arein a non-judgemental environment. At the roundtable on Arts on Prescription, Dr Stickley
described how, once this condition has been met,
what emerges is a ‘very natural peer support that
we cannot prescribe’; in turn, this produces asense of belonging and social identity. As he put it,‘We need to trust in humanity’ for the value of thiswork to be realised.
An evidence dossier, published by Arts andMinds in 2015, stated that ‘Looking forward, one of
the long-term aspirations of the movement is thatcare packages for people with chronic conditions
include payments for arts interventions, as they
currently do for medication and other clinicalinterventions’.426 To achieve this, more needs to bedone to improve understanding and take-up ofarts-on-prescription programmes.
In the first place, awareness needs to be raisedof the existence of ar ts-on-prescription
programmes and how they fit into the socialprescribing landscape. The majority of GPs are
said to be still unaware of them. Organisationsdelivering arts on prescription would do well tomake themselves known to the Social Prescribing

Network so that they may be included in any futuredatabases of activity. Similar strategies might berelevant in Scotland, Wales and Northern Ireland.
At the round table, Programme Manager at Arts
for Health Milton Keynes, David Hilliard, notedthat social prescribing sits in a ‘grey area between
clinical provision and social activities’. While thenon-medical atmosphere is attractive toparticipants, it is less so for health professionals
with a duty of care to their patients. Several
strategies for overcoming this were discussed.
They included establishing a better standing forarts-on-prescription activities outside thecategory of ‘self help’, and offering courses not only
to GPs but also to arts professionals working withvulnerable people. At the Social Prescribing
Network launch, City and Guilds health training
was mentioned; at the round table, accreditation
was mooted.
Once clinicians have been persuaded toprescribe the arts, clear and trackable pathways
need to be in place, including the option of people
being referred back to their GP if necessary. At theround table, a representative from HEE, Gaye
Jackson, suggested that arts on prescription might
be made part of the Making Every Contact Count
agenda for all clinicians and support staff.427
Just as is happening in the health and social
care sectors, infrastructure and leadership willneed to be developed in the community sector. As
in the wider arts and health landscape, gaps inprovision will have to be filled. Some local
authorities, such as Hackney Council, are working
with the health service to co-create much-needed
services.428 In Rotherham, representatives of VCSE
organisations to which patients are referred attend
case conferences at which patient needs are
discussed. No complaints have been received fromeither doctors or patients, despite more than 4,000
people passing through the system, andcommunity organisations are in receipt of threeyear rather than short-term funding.
More than 60 percent of social prescribing
schemes lack formal evaluation, with thosefunding the activity tending to be reluctant also tofund evaluation. At the round table, it was agreed
that better evaluation was needed. Ideally, a
consortium of organisations offering arts-onprescription activities would pool evaluations
to yield a sizeable dataset. If such collective
evaluation would benefit from coordination,
the new strategic centre for arts and healthwhich we recommend could perhaps become
involved. There is also scope for international
cooperation on evidence gathering, and we learnt
that Denmark has a €1m social prescribing fundfor cultural organisations.

75

Chapter 5

Place, Environment, Community

5.6

Museums, Libraries
and Health
The Museums Association estimates there aresome 2,500 museums and galleries in the UK.429 A
survey conducted by the National Alliance forMuseums, Health and Wellbeing found over 600
different museum-based programmes targeting
health and wellbeing outcomes. 430 The great
majority of these programmes were for older
adults, particularly people with dementia, butthere was also activity supporting mental healthservice users and delivering public healtheducation programmes.431
Museums and galleries offer a non-clinical, nonstigmatising environment in which to undertake
journeys of self-exploration.432 PHF’s Our Museum
initiative encourages museums and galleries toplay a significant and enduring role in theircommunity, 433 and the case is being advanced forthem to be considered part of the public healthmilieu. 434 Much more could be done to address
health and wellbeing by cultural institutions aspart of their wider role within the VCSE sector.
However, at a round table on the Care Act, Dr DaveO’Brien made the point that many arts
organisations are struggling to survive and willfind it very hard to elaborate their work.
The Heritage in Hospitals research project(2008–11), run by UCL, took items from thecollections of the British Museum, Reading
Museum and Oxford University Museum into
hospitals and care homes. The project involved
over 300 patients and residents and assessed theimpact of a 30- to 40-minute museum objecthandling session. Psychological and subjective
wellbeing measures were used before and after
sessions, alongside qualitative analysis. 4 35
Quantitative measures showed significant
increases in participants’ wellness and happinessscores. 436 Qualitative analysis revealed thatmuseum objects provided personal routes tostimulation, self-exploration and distraction.437 In
follow-up work, the Museum Wellbeing Measure
and Toolkit was developed, containing various
approaches for assessing the impact of museum
activities on psychological wellbeing.438 A nationalframework for evaluating the community impact
of museums engagement is being developed by the
University of Cardiff and the National Museumsof Wales.
Not So Grim Up North is a research project (2015–18) funded through the ACE Research Grants
Programme. A collaboration between researchers
at UCL and the Whitworth Gallery, Manchester
Museum and Tyne & Wear Archives & Museums, its
objective is to develop a framework for assessing theimpact of activities across different audience groups
76

All-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Reportand settings. A preliminary study showed thatcreative museum sessions improved confidence,sociability and wellbeing in participants accessing
mental health and addiction recovery services.439
Full findings will be available in late 2017 and will
provide another framework for assessing theimpact of museums and galleries.
In 2015, the Association of Suffolk Museums
received funding from the Heritage Lottery Fundand Suffolk County Council to use the arts andheritage to improve mental health and wellbeing
under the title of Creative Heritage in Mind.440 This
one-year project, supported by staff at Norfolk andSuffolk NHS Foundation Trust and led by an artist,brought small groups of people together to respondcreatively to intriguing objects and artworks fromvarious museum collections. The project
culminated in exhibitions of participants’artworks, three exhibition booklets and a shortfilm. Quantitative measurement (WEMWBS)
showed improvements in subjective wellbeing,and qualitative evaluation pointed to increased
engagement with the arts and heritage having
generated improvements in conf idence,motivation and insight.
Another Heritage Lottery Fund project,delivered by Manchester Museum and theImperial War Museum in Salford (2013–16), lookedat the impact on people from deprived
communities of volunteering in 10 museums andgalleries in Greater Manchester. Among the 231
participants to Inspiring Futures, 75 percent
reported significant improvements in wellbeing
after a year and 60 percent sustained these
improvements over two to three years. Several
people found their way into education or
employment, and a social and economic return of£3.50 was calculated for every £1 invested.441
While the contribution of cultural venues tohealth and wellbeing is being recognised in certain
quarters, access continues to pose a challenge. In
chapter two, we saw that visitors to museums andgalleries are predominantly prosperous, welleducated and in the 55–74 age range. By contrast,
the over-74s and older people who are isolated,frail, from minority ethnic backgrounds, living on
low incomes or outside their own homes tend not
to visit museums and galleries. This points to arange of economic, social, psychological andlogistical barriers. A study of people aged between
60 and 92, who made three visits to contemporary
art galleries in the north-east of England, foundthat participants with a higher educational level
and a history of arts engagement tended to responddifferently to the art and its interpretation to those
who had not previously engaged with the arts.442
This suggests that museum programmes need tobe tailored to visitors. Recognition of the healthand wellbeing benefits of the arts might be made in
the Museums Association’s Code of Ethics
for Museums.

UNESCO articulates a belief in public libraries
as a ‘living force for education, culture andinformation, and as an essential agent for thefostering of peace and spiritual welfare throughthe minds of men and women’.443 As well as being
repositories of knowledge and literature, libraries
are accessible safe spaces that are essential topeople’s wellbeing and can play a central part in
the happy, healthy lives of people of all ages. 444
In this report, examples are given of the library
network being used to encourage reading amongchildren and adults and to offer creative sanctuary
to refugees. However, 500 libraries and almost
9,000 librarians have been lost in the UK
since 2010.445
Healthy Libraries is a partnership between
public health and the libraries information service
in Norfolk which has the aim of turning all
libraries in the area into health and wellbeing
hubs. In response to local need, Norfolk libraries
are offering a range of information and activities
including exercise, arts and crafts. The initiative
has been welcomed by staff and public alike, andthe activities have become integrated into the dayto-day running of libraries. 446 Building on theposition of libraries at the centre of communities,
a similar approach could be adopted throughout
the library network, which would fit well with
ACE’s role as a development agency.447

5.7

Age-Friendly Cities andCommunities
In an era of urbanisation, the Age-Friendly Cities
and Communities initiative, launched by WHO in
2006, recognises the contribution of older people
to society, makes provision for their diverse needs
and promotes their inclusion in all aspects ofcommunity life.448 It thinks about: outdoor spaces
and buildings; transport; housing; social
participation; respect and social inclusion; civic
participation and employment; communicationand information; community support and healthservices. London and Edinburgh are taking part inthis initiative, 449 and all 22 of the local authorities
in Wales have signed up to it.450
Although the arts are not specifically mentioned
as part of the Age-Friendly Cities initiative,
examples are provided in this report of the arts
intersecting with several vital areas of urban life –including the design of public spaces andbuildings, employment and social participation.451
In 2007, Age-Friendly Manchester was launched,uniting 19 cultural organisations in Greater
Manchester ‘to extend the reach of the city’s worldclass arts and culture to older people in
Manchester’. 452 Four years later, a culturalchampions scheme was inaugurated, which sees
ambassadors within local communities raisingawareness of the cultural events taking place there
and encouraging older people to attend andcontribute. An age-friendly cultural coordinator,
funded through public health and based at the
Whitworth, supports cultural organisations andmore than 150 cultural champions to tell a
different story about urban ageing.
Since 2010, the Baring Foundation has been
concentrating its funding on older people
experiencing deprivation and discrimination(beyond ageism), including poverty, isolation,
health problems, racism and sexism.453 The AgeFriendly Museums Network, supported by the
Baring Foundation and hosted by the British
Museum, encourages the sharing of good practiceand partnership working between health, social
care and museum professionals.454 A report by the
Oxford Institute of Population Ageing on thechallenges and benefits of an ageing population formuseums and galleries examines the changing
demographics not only of audiences but alsoof volunteers.455
Dovetailing with the age-friendly museums
initiative is that of age-friendly hospitals, aninternational phenomenon that is beginning to be
adopted in the UK. Trafford General Hospital, forexample, aims to become a centre for excellence
for the rehabilitation and care of frail older
patients. In this undertaking, it recognises thetherapeutic benefit of the arts not only for patients
but also for carers and staff.456

5.8

Dementia-Friendly
Communities
Alzheimer’s Society defines a dementia-friendly
community as a ‘city, town or village where people
with dementia are understood, respected andsupported, and confident they can contribute tocommunity life. In a dementia-friendly community
people will be aware of and understand dementia,
and people with dementia will feel included andinvolved, and have choice and control over their
day-to-day lives’.457 The Society has looked at therole of arts centres within such communities andpublished a guide to creating dementia-friendly
arts venues, funded by the Prime Minister’s
Dementia Friendly Communities initiative.458 Thisis based on an understanding that the 850,000
people in the UK diagnosed with dementia andtheir informal carers (approximately 700,000
people) represent a significant audience that arts
venues may have overlooked.
Carers play an essential part in enabling people
with dementia to remain in their own homes and77

Chapter 5

Place, Environment, Community

out of residential care, which represents
considerable savings to the social care system.
Alzheimer’s Society recommends a proactive
approach in which the needs of people withdementia and their families and carers are acted
on as part of a networked strategy involving
specialist dementia-based organisations. House of

All-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Reportwith dementia to do something they love ‘From
going for a stroll in the park to joining an art
class together’.459
As a separate initiative in Wakefield, allmuseum staff have undergone Dementia Friends
training, Alzheimer’s Society has provided advice
about space and signage, and five multi-sensory
resource boxes have beendeveloped for people withdementia who are unable toreach the museums. 460 This
work suggests that othercultural venues should become
dementia-friendly.
Dementia Action Allianceaims to precipitate a societywide response to dementia,
s upp or t i n g c om mu n it ie sa nd orga nisations acrossEngland to take practical action
to enable people with dementia
to live well while reducing the risk of
costly crisis inter vention. 461 The alliancehas almost 5,000 members, and there is scope

Cultural venues, including museums,
galleries and libraries, will increasingly
play a part in communities which arehealthy, age- and dementia-friendly andcompassionate.
Memories in Liverpool offers training programmes
for the carers of people with dementia. Alzheimer’sSociety also calls for volunteers to help someone

The Dragon Café
The Dragon Café, in thecrypt of St George ofthe Martyr Church inSouthwark, is open on
Mondays between
midday and 8:30pm.

F

ounded by service users in 2003 andinitially funded by GSTC and SLaM, thecafé was a response to the model of day
centres in which people were ‘parked’
between periods of residential care. It
is open to everyone who registers as a patron (byproviding minimal personal details at the door).
There are around 200 patrons, including people
with lived experience of mental ill health.
Patrons come from all over London. This nonhierarchical charity is run by a board of people
with experience of mental ill health, which
oversees eight members of staff and 50

78

volunteers, all of whom have undertaken
safeguarding training.
As well as being a safe space with low-priced
food and drinks, the café adopts what its
founder, Sarah Wheeler, described as a‘multidimensional approach’ to offer a freeprogramme which conceives the arts asnourishment. The programme explores mental
illness, recovery and wellbeing through avariety of creative activities such as danceclasses, performances, open mic events and an
ar t table. The focus is on qua lity andaccessibility, with creative activity centred on
personal narratives. The layout of the space
allows for periods of relaxation and animation,and it encourages the sharing of tables andconversations.
Evaluation of the café, using the Mental
Wellbeing Impact Assessment method, has
pinpointed the impact of environment, culture
and creativity on mental wellbeing. It has also
identified that structure, routine, trust andsafety confer confidence and self-belief.462

for many more cultural organisations tobecome involved.
The Greater Manchester devolution deal for
health and social care is taking dementia as one ofits priorities, including the creation of dementiafriendly hospitals. Dementia United aims to ‘make
Greater Manchester the best place in the world tolive for people with dementia’.463 This implies the
pursuit of measurable increases in quality of life
for people with dementia and their carers throughevidence-based co-produced interventions.
Manchester Museum and the Whitworth, together
with the University of Manchester, piloted Coffee,
Cake and Culture, offering tours around thecollection for people with dementia and theircarers. This is now part of the Health + Culture
strand of work being conducted in Manchester. In
light of the evidence presented in chapter eight, wehope that Greater Manchester’s embrace of thearts in health will extend to the dementia strandsof its work.

5.9

The Arts and Marginalised
Communities
The concept of social capital recognises theimportance of networks in sustaining solidarityand mutual support. In the words of the late artsand health researcher Mike White, ‘good
relationships are a major determinant of health’.464
The American social scientist Robert Putnam has
identified trust as a vital feature of socialorganisation.465 Jane Jacobs, who advocated placebased, community-centred approaches to urban
planning in the 1960s, pointed to casual social
contact at a local level as central to building trust.
Arts engagement – which often involves casualsocial contact at a local level – is regularly cited as aforum for building trust.
Being marginal in society has a deleterious
ef fe c t upon hea lt h. 4 6 6 The concept ofmarginalisation takes account of age, disability,
social class, race and ethnicity, educational andhousing status, experience of the criminal justice

psychological therapies, and opportunities forearly intervention are being missed. This meansthat the f irst contact members of BAME
communities have with mental health services
may well be detention under the Mental Health
Act, causing unnecessary distress and placingpressure on acute services. 468 By contrast to theprevailing pattern, BAME participants are well
represented within arts activities orientatedtowards the restoration and preservation ofmental health.
There is a relationship between homelessness
and mortality, with the average life expectancy forhomeless people being 47. 469 As in othermarginalised groups, the incidence of mental
health problems among homeless people (four infive) is much higher than in the general population(one in six). The Homeless Library, a collaboration
between Arthur + Martha and Manchester’s
homeless population, invites people to reflect on
their personal histories through art and poetry.470
In this context, art-making offers a temporary
haven for people who have no home of their own; it
offers time away from fear and intimidation; it
offers scope to begin healing. This is just one of thepersonal histories that has emerged from theHomeless Library: aurence is a man who grew up witnessingLextreme violence . As a child , he wasmalnourished and often ate dog food because hedidn’t have anything else. Now, instead of selfmedicating with continuing substance abuse, hewrites poetry and grows a garden. He’s selfmedicated with art. He treasures both the poetry
and the gardening. Laurence says, ‘There’s agenius in everyone and this has the ability tobring it out. I was a piece of detritus on the street
and they found gold winning, cup winning me. I
was excrement and I found a garden. Fromexcrement I have become compost.471
On a related note, the high proportion of
addiction among marginalised people wasaddressed in an international project led byPortraits of Recovery between 2012 and 2014. 472
The Director of Arts for Health, Clive Parkinson,
involved disenfranchised people from the UK,
Italy and Turkey in high-quality
artistic experiences, w ith
artists acting as facilitators ofsocial change within recovery
f r om s ub s t a nc e m i s u s e.
Building on ideas in the USA
Bi l l of R e cover y R ig ht s ,a sha red statement –The Recoverist Manifesto – was developed, whichattempted to dispel the myths associated with
substance misuse, reframing addiction as acu ltu ra l issue a nd recover y a s a civ i lrights concern.473

Participatory arts activities generate asafe space for marginalised communities.
s ystem, sex ua l ity a nd gender identity.
Marginalised people are at greater risk ofdeveloping mental health problems than people
with social support. 467 BAME communities, forexample, are less likely to seek access to79

Chapter 5

Place, Environment, Community

The organisation Charter for Compassion seeks
to establish and sustain cultures of compassion
locally and globally through diverse sectors
including the arts, education, the environment,
healthcare and social justice. As part of thisinitiative, Compassionate Communities have beenenvisaged which ensure that:[…] the needs of all the inhabitants of that
community are recognised and met, the wellbeingof the entire community is a priority and all
people and living things are treated with respect.
[…] A community where compassion is fully alive
is a thriving, resilient community whose members
are moved by empathy to take compassionate
action, are able to confront crises with innovative
solutions, are confident in navigating changes inthe economy and the environment, and areresilient enough to bounce back readily fromnatural and man-made disasters.474
Such a community is part of a mature, preventative
public health strategy, an exemplar of which isprovided by the West Midlands, which has adopted
Marmot principles to tackle health inequalities.475

80

All-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Report

The emphasis on place as an organisingprinciple for public service design and delivery,
combined with the integration of public budgets
to commission services, signals an important
opportunity for arts, health and wellbeing tofeature in local health and wellbeing strategies.
This will be particularly relevant to arts
providers working at a level at which they can bepart of a local ecology with other VCSE
organisations.
Our vision is of the arts playing a central partin the healthy communities of the future. New
health and social care buildings will be designedwith healing in mind, and public spaces willencourage fruitful human interaction. Social
relations in a multiplicity of aspects will nurture
good health and social care ecologies. There will
be a better balance between the management ofcrisis and the maintenance of health andwellbeing. We will draw upon resources foundwithin communities, with third-sector
organisations, including arts organisations,playing an integral part in networks of care.
GP surgeries, hospitals, care homes andhospices will welcome artists and harness theirartistry to improving the health and wellbeingof citizens. Staff in health and social careorganisations will express their creativity,
enlivening their working lives and those of theirpatients. Community hubs, among themcultural venues, will be home to participatory
creative activities for people of all ages andmeans, and doctors will confidently refer theirpatients to them. People taking part in creative
activities will be healthier, happier and more
resilient, and these positive effects will reach
into the surrounding community.

81Lady Nade Trio at the Fresh
Arts Festival, Southmead
Hospital Bristol
Producer: Willis Newson
Photographer: Clint Randall

Childhood,
Adolescence andYoung Adulthood82

83

All-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Report

6 Childhood, Adolescence and Young Adulthood“When I look back, I am so impressed withthe life-giving power of literature. If I were ayoung person today, trying to gain a sense of
myself in the world, I would do that again byreading, just as I did when I was young.”
Maya Angelou

T

he Marmot Review told us that ‘The
foundations for virtually every aspectof human development – physical,
intellectual and emotional – are laid inearly childhood. What happens during
these early years (starting in the womb) has
lifelong effects on many aspects of health and wellbeing – from obesity, heart disease and mental
health, to educational achievement and economic
status’.476 Studies show that children who grow up
in poorer households are more susceptible todisease in later life and have lower life
expectancies.477 The Children and Young People’s
Health Outcomes Forum, established by the
Secretary of State for Health in 2012, found that
‘more children and young people under 14 years ofage are dying in this country than in othercountries in northern and western Europe’,leading to the recommendation that closer
attention be paid to inequalities within the wider
health system.478 As we begin our journey throughthe life course, let us look at how the conditions inwhich we are born and grow affect our health andhow the arts contribute to the betterment of both.

6.1

Gestation and BirthA review conducted by UCL Institute of Health
Equity, set up to implement the recommendationsof the Marmot Review, highlighted the importanceof mothers’ actions before and after the birth oftheir children, particularly in terms of nutrition,smoking, consumption of alcohol, substancemisuse and breastfeeding.479 Looking more closely
at one of these factors, the British epidemiologist,
the late Professor David Barker, showed thatmaternal under-nutrition, even for a short period,
during the second half of gestation, led to babies
with a low birth weight and a greater likelihood of84

developing coronary heart disease, strokeand diabetes. 480 A study conducted within
deprived communities in London found that, of
those people who engaged with the arts, 79 percent
ate more healthily, 77 percent engaged in more
physical activity and 82 percent enjoyedgreater wellbeing.481
The most common reason for hospital
admission in England is childbirth. The durationof labour has been found to be more than twohours shorter and requests for pain relief lower
when an artist-designed screen has been installedin the delivery room.482 Listening to self-selectedmusic distracts women from the pain ofchildbirth 483 and diminishes anxiety aboutcaesarean section.484 As part of Creative Practiceas Mutual Recovery: Connecting Communities for
Mental Health and Well-being – an international
health humanities initiative supported by the
AHRC – the Birth Project found that arts
participation could enhance understanding of thebirth experience, aid in the transition tomotherhood and increase the confidence, selfesteem and wellbeing of mothers.485 This suggests
normalising arts interventions in maternity units.
The heart rate of new-born babies is positively
affected by the playing of lullabies. 486 The use oflive music in neonatal intensive care has beenfound to lead to statistically signif icant
improvements in clinical and behavioural states inpremature babies, leading to considerably reduced
hospital stays.487 A Celtic harp played in the Special
Care Baby Unit at Gloucester Royal Hospital calms
babies and mothers alike and assists parent–childbonding. 488 A visual art project at Southern
General Hospital in Glasgow alleviates the stress ofparents waiting at bedsides, simultaneously
prov id ing a welcome d istraction f rom,and a focus of artistic attention onto, theirpremature babies.489

6.2

Perinatal Mental Health
One in five mothers suffers from anxiety,depression or, in some cases, psychosis during
pregnancy or in the first year after childbirth.
Suicide is the second leading cause of maternal
death after cardiovascular disease. 490 Maternal
depression in the period immediately before orafter birth is estimated to carry a long-term cost tosociety of about £8.1bn for every annual cohort ofbirths in the UK. This equates to just under£10,000 for every birth in the country, 72 percentof which relates to adverse impacts on the childrather than the mother.491
After the CQC identified a need for better
consultation with the families of people withmental health needs at Devon Partnership Trust,Consultant Psychiatrist and regional and associatenational lead for perinatal mental health at NHS
England, Dr Jo Black, worked with the Director of
ForMed Films, Emma Lazenby, to produce ananimation called My Mum’s Got a Dodgy Brain.492
This is an excellent example of a narrative-basedarts approach in public health education.
In September 2014, a Children and Young
People’s Mental Health Taskforce was set up, cochaired by DH and NHS England. Thisacknowledged the strong link between parental(particularly maternal) mental health and that of
their children.493 Early intervention is crucial, yet
the Five Year Forward View for Mental Healthestimated that ‘fewer than 15 per cent of localities
provide effective specialist community perinatal
services for women with severe or complex
conditions, and more than 40 per cent provide noservice at all’. 494 The Health Select Committee
recommended that this uneven provision be
addressed urgently.495 The Five Year Forward View
for Maternity Care, which emerged from a National
Maternity Rev iew chaired by Ba roness
Cumberledge, highlighted an urgent need tocompensate for historic underfunding andprovision in perinatal and postnatal mental
healthcare.496 Next Steps on the Five Year Forward
View stated an aim of helping 9,000 more mothers
by 2018–19.497
Psychosocial factors, such as stress and social
isolation, are known to have an impact on perinatal
mental health. The chronic stress precipitated by
low income adversely affects parent–child bonding

and parenting ability, which has a knock-on effecton children’s long-term development. 498 The
Marmot Review argued that depression andisolation (which follow the social gradient) have anegative impact upon mother–child bonding andthat this can be overcome by supportive
interventions. 499 In the previous chapter, we
reviewed evidence of an early arts-on-prescription
activity in Stockport that helped to both preventand overcome postnatal depression. Morerecently, a study, a pilot project and an ongoing
community initiative have demonstrated the valueof the arts to perinatal mental health.
The study – led by the Centre for Performance
Science, a consortium comprising Imperial College
London, the Royal College of Music and Chelsea andWestminster Hospital, funded under the ACE
Research Grants Programme and involving 148
participants – looked at the impact of group singing
on women with postnatal depression, as comparedto either creative play or a combination ofantidepressants and psychotherapy. Every week for
ten weeks, in hour-long weekday afternoon music
workshops, women listened to, learnt, wrote andsang songs with their babies. Affection shown by
parents to their offspring in the early days of life has
been seen to produce a lifelong reduction in the
stress hormone cortisol. 500 The Music andMotherhood study suggested that singing led tofaster recovery from postnatal depression than ineither of the control groups, reducing cortisol,
stimulating a positive emotional response andpromoting mother–child bonding. The impact wasmore pronounced in mothers with severe postnatal
depression, who recovered a month faster thaneither of the control groups.501
The pilot – initiated as a co-production between
Southwark Council’s nurse-led Parental Mental
Health Team and South London Gallery, funded by
GSTC and led by artists at the gallery and three
local children’s centres – worked with mothers
experiencing mental distress and their children
under the age of five. Between January 2013 andDecember 2014, six Creative Families programmes
ran with a total of 46 mothers and 61 children. Only
28 percent of participants identified as white
British, which serves as further evidence of theoverrepresentation of members of BAME
communities within mental health services andthe success of arts and health programmes inreaching this demographic. Over the course of the
10-week art and craft programme, mothers
experienced a 77 percent
reduction in an x iety anddepression and an 86 percent
reduction in stress. They
increased in confidence andself-determination, and theirsense of isolation decreased.
Mother – ch i ld attach ment
improved, and the emotional,

Visual art and music relieve the pain andanxiety of childbirth, lead to weight gainin premature babies and encourage
parent–child bonding.

85

Chapter 6

Childhood, Adolescence and Young Adulthoodsocial and cognitive development of the children
was stimulated.502 Following the pilot, funding
from the mental health team was secured toenable the project to continue.
The ongoing initiative – Dreamtime Arts,delivered by Wellspring Healthy Living Centre,
part of Bristol Arts on Referral Alliance, in one of
the most deprived parts of Bristol, with a BAME
population of 55 percent – uses the arts as atherapeutic activity for mothers of pre-school

All-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Reportdevelop their talents, proportional investment
needs to be made across the social gradient.
It has been found that 20,000 fewer words per
day are addressed to children from poor socioeconomic backgrounds than their wealthiercounterparts, which compromises linguistic
development.506 But the relationship between
family income and early childhood development is
not fixed.507 Engagement with the arts can aid
physical, cognitive, linguistic, social and emotional
development. A wealth ofevidence demonstrates a link
between reading aloud tochildren and greater literacy
and comprehension, informing
such initiatives as Read On Get
On and the Book Tr ust’s
guidance on reading aloud.508
Reading Well for young people,
a programme run by The
Reading Agency, is available inpublic libraries across Englandas part of a wider books-on-prescription scheme.509
Housing quality correlates with mental health.
Creative Homes acknowledges the household
environment to be one of the paramounti n f luences on a ch i ld’s hea lt hy br a i ndevelopment.510 With 25 percent of children in
London living in overcrowded conditions, rising to
43 percent in the social rented sector, and low
incomes putting a strain on family relationships,
Creative Homes identifies the need to avert
consequential health and care challenges. The
charity facilitates live arts experiences in London
homes, including households in social or shelteredhousing and dependent on income support, with
one or more children under five. Trained artists,
including storytellers, dancers and musicians,
share with families skills that directly tackle thestresses of daily life. Funding comes from a rangeof sources including GSTC, ACE, local authorities
and housing organisations. An analysis of Creative
Homes showed a 64 percent improvement in thequality of household routines, a 23 percent
increase in play at home and a 27 percent increasein singing with children. 51 1 This type ofenvironmental improvement can be expected toreduce future demand on health services.
Addressing the needs of young children,
especially those with diminished economic,
social, physical and/or cognitive capacities, theresearch-driven organisation MovementWorks
provides dance movement programmes designed
to accelerate learning. Physical difficulties areoften early indicators of developmental disorder as
they mirror the neurological organisation of thebrain. The Developmental Dance Movement
programme is a multi-sensory whole-bodylearning experience which uses dance activity as a
kinaesthetic tool to accelerate children’sdevelopment in the early years. Weekly sessions ofArt, craft and singing help mothers to
overcome postnatal depression, promoteparent–child bonding and improvechildren’s mental health and wellbeing.
children who are experiencing poor mental healthand wellbeing, including postnatal depression.
Many of the participants face persistent social
issues, including poverty, unemployment, poor
housing and social isolation. Some are asylum
seekers; others are survivors of domestic violence
and abuse. Three 10-week arts courses run
throughout the year while children are cared for ina nearby crèche. Activities absorb participants,
offering respite from their anxieties (57 percent
reduction). At the same time, Dreamtime Arts isa bridge to primary mental health services,
about which there is persistent stigma, withmany mothers going on to access services andother support.503
These three examples suggest that local
authorities might ensure that health visitors,
midwives, GPs and antenatal teachers are informedof the health and wellbeing benefits of arts
participation for expectant mothers and those withpre-school and school-age children, and that thesebenefits are communicated to expectant and new
mothers. Where there is little or no provision, local
authorities might encourage partnership projects
with local arts organisations.

6.3

Early Childhood
Development
The Marmot Review advocated policies that ‘Give
every child the best start in life’. This was repeatedin the 2012 report of the Chief Medical Officer,504
and it resulted in DH making an explicit
commitment to giving every child the best start inlife.505 For all children to have a fair chance to86Participatory arts and arts therapies enhance social, emotionaland behavioural development in young people.
35 to 45 minutes across the academic year involve
various movement-based games and activities.
Sessions are not focused on learning any particular
dance style or steps, but they encourage children
to practise physical and cognitive skills which aid
overall developmental progress. Mixed-methods
research shows accelerated learning andsignif icant improvements in visual-motor
integration and developmental maturity.512
Programmes like Creative Homes andDevelopmental Dance Movement increase school
readiness,513 defined by the Government as thelevel of preparedness to succeed cognitively,
socially and emotionally in school.514 School
readiness is unevenly distributed across the social
gradient. Two in five children in London are notready for school (increasing to four in five in poorer
boroughs outside the capital), yet £1 spent on earlycare and education has been calculated to save up
to £13 in future costs.515 Sure Start Children’sCentres could be sites for delivery of the arts forhealth and wellbeing, but one third of them havebeen lost since 2010.516
At UCL Institute of Education, Professor Susan
Hallam reviewed evidence on the impact of musicmaking on the intellectual, social and personal
development of children and young people. She
concluded that ‘There is considerable andcompelling evidence that musical training
sharpens the brain’s early encoding of soundleading to enhanced performance on a range oflistening and aural processing skills’. 517

heightens self-belief. People who have learnt toplay a musical instrument score better on tests
across subjects and display a high degree of
conscientiousness, openness to new experiencesand enhanced emotional intelligence. The casestudy in this section looks at an ambitious
programme that encourages young children,
pa r t icu la rly t hose f rom d isadva nt a ged
backgrounds, to learn to play a musicalinstrument.518 In November 2016, DfE committed£300m over four years to a series of musiceducation hubs administered by ACE.519
Children with additional needs are able toexpress themselves through music. The
connection between music therapy and autism
spectrum disorder (ASD) has been explored sincethe 1970s.520 A Cochrane Review of literature inthis area found that ‘music therapy may help
children with ASD to improve their skills inprimary outcome areas that constitute the coreof the condition including social interaction,verbal communication, initiating behaviour,andsocial-emotional reciprocity’.521 Music therapy
is recognised as a psychological therapy by
NHS England, NICE and the Of f ice forStandards in Education, Children’s Services andSkills (OFSTED).
The Time-A study is an RCT being conducted at
10 sites around the world, looking at theeffectiveness of music therapy for children with
ASD. The UK part of this project is being coordinatedat Imperial College London and Anglia Ruskin
University, funded by NIHR, andis due to report in 2017. LiveMusic Now delivers music
workshops throughout the UK,in mainstream schools and forchildren with disabilities,
learning difficulties and SEN.522
Jessie’s Fund helps children
with additional and complex
needs or serious illness tocommunicate by using music.523
The Key Club, run by Turtle
Key Arts since 2003, responds to the lack of activity
being offered to people with ASD leaving the
education system (aged 16 to 30).524 Easing thetransition to adulthood and providing continuity
with peers, monthly two-hour sessions ofparticipatory visual and performing arts areoffered in London and High Wycombe at an annual
cost of £10. Evaluation points to the social andemotional benefits derived from group creative
activity by both participants and parents.525

Reading aloud to children increases
literacy and comprehension and helps tonarrow socio-economic differences in
educational attainment.
Transformations in the brain develop quickly, butmusic practice needs to be sustained over time forthese effects to be retained. Once developed,
neurological shifts lead to improved motor skills
and speech perception, contributing to language
development, literacy and spatial reasoning,
bearing a lifelong impact. Formal music practicerequires sustained attention and the encoding ofmusical passages into memory, while playing in an
ensemble requires goal-directed, pro-social
behaviour and performing to an audience87Chapter 6

Childhood, Adolescence and Young Adulthood

All-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Report

Sistema Scotland:
Big Noise
In Scotland, there is a focus
on the early years, and thearts play a part in this.

T

he Big Noise project, run by Sistema
Scotland, works on the basis that‘c h i ld r e n f r om d i s a d v a nt a ge dbackgrounds can gain significant social
benefits by playing in a symphonyorchestra’.526 Drawing on a model established in
Venezuela, tailored to local circumstances,
Sistema Scotland has a mission to transform lives
through music. In Raploch in Stirlingshire, Big
Noise has been active since 2008, offering an
immersive orchestral programme to pre-schooland school-age children and young people. In
Govanhill in Glasgow, it has been operating since2013, initially during and after school for children
in the first three years of primary education.
Funded by the Scottish Government, local
authorities and private sources, Big Noise pays
explicit attention to the role that musical learning
may have in tackling health inequalities. Neither
an audition process nor a fee is necessary toparticipate, and efforts are made to involve
children with complex needs in areas of low arts
engagement. Excellence is pursued, with teachingprovided by professional musicians and highly
skilled and motivated participants being soughtfor public performances.
Longitudinal, mixed-method, controlled
evaluation is planned over the life course of thechildren and young adults taking part in Big Noise,at the individual, familial, social, community andsocietal levels. The first phase of evaluation –conducted by the Glasgow Centre for Population
Health in partnership with Audit Scotland,
Education Scotland and Glasgow Caledonian
University – was completed in March 2015. This
demonstrated potential for improvements inhealth and wellbeing via seven pathways:
engagement with learning (improved school
attendance, confidence, diligence, linguistic andother skills); life skills (creativity, adaptability,
problem-solving and decision-making skills,
collaboration, cooperation and self-discipline);88

emotional wellbeing (gained from theenjoyment of playing music in a safe
environment and a sense of belonging); social
skills and networks (increasing cultural
tolerance); respite and protection (from homestresses, alcohol, drugs and antisocial
behaviour); musicianship; healthy behaviours(including diet and exercise). An analysis oftangible and intangible benefits showed asubstantial net gain in social value, realised
within six years of the programme beginningand increasing over the lifetime of participants.
Several local authorities in Scotland haveexpressed an interest in hosting a Big Noiseproject, and Torry in Aberdeenshire began one
in 2015. A similar project is being coordinatedby Sistema England, supporting programmes in
Lambeth, Newcastle, Norwich, Liverpool,
Telford and Stoke. In West Everton, where 52.9
percent of children are classed as living inpoverty (two and a half times the national
average), In Harmony is integrated into theschool curriculum, in association with theLiverpool Philharmonic Orchestra. Statisticalanalysis has shown significant improvements
in a ge-related ach ievement s, lead ing
researchers to conclude that the programme
h a s a ‘cont r ibutor y ef fe c t on ch i ld
development’.527 In 2016, DfE committed to In
Harmony £500,000 per year to 2018.528

The benef its of music have also been
experienced by young people fleeing war andpersecution.529 Following a 2007 tour of Bosnia
with a chamber opera, composer, Nigel Osborne,
Emeritus Professor at the University of Edinburgh,
was invited by the Bosnian Government to develop
a youth musical theatre in Srebrenica. At theround table on the Arts and Post-traumatic Stress,
Professor Osborne described how the Ministry of

The Art Room is a national charity offering
therapeutic interventions for children and young
people who find it hard to engage with learning
because of emotional or behavioural difficulties.535
These difficulties may arise as a result of family
circumstances, bereavement, trauma or
maltreatment. Every week, the Art Room works
with over 500 children and young people aged
between five and 16, providing a safe and inspiringstudio environment withinmore than 40 primary andsecondar y schools in
Ox fordshire, London and
Edinburgh.
Tr a i ne dpractitioners work with groupsof children to raise theirconfidence and self-esteem andhelp them to develop social
sk i l l s es s ent ia l to t hei r
wellbeing and engagement withlearning. Groups of no more than eight children
attend sessions lasting up to two hours every week
for at least a term. Sessions are centred on thecreative transformation of everyday objects thatthe children use in their school or home lives. An
independent evaluation of the Art Room showedthat sessions significantly reduced students’emotional and behavioural problems andincreased their pro-social behaviours, especiallywithin their peer groups. Children who hadclinical levels of difficulty at the beginning of thesessions showed an 87.5 percent improvement intheir self-reported mood and self-esteem by theend of the programme.536
Conduct disorders, manifested as sustained
disruptive and violent behaviour, affect 5.8 percent
of children under 15. Children with conductdisorders are ‘twice as likely to leave school
without any qualifications, three times more likely
to become a teenage parent, four times more likely
to become dependent on drugs and 20 times
more likely to end up in prison’ than those
without.537 The lifetime cost associated with early
conduct disorders is estimated at £260,000 per
child,538 leading DH to advocate evidence-basedand cost-effective treatment of childhood
conduct disorders.539
In two special schools for children andadolescents w ith socia l, emotiona l a nd
behavioural difficulties in London, a three-year
research project looked at the provision of art,
music and drama therapies. Many of the young
people involved had experienced insecureattachments to caregivers, which had negatively
impacted on their emotional development,
usually combined with experience of trauma
such as domestic or street violence or abuse. This
had resulted in poor regulation of emotions,aggressive behaviour and diminished empathy
and sometimes led to post-traumatic stress orconduct disorders. A sample of 52 young people

Creative activities improve the quality of
the household environment, stimulating
healthy brain development in children.
Health hailed the project as a therapeutic success,which led to its continuation and expansion into
Kosovo, Chechnya, Palestine and East Africa.
Music Action International, which works withyoung asylum seekers, refugees and torturesurvivors in the UK, won the Guardian Charity of
the Year Award in 2016.530
A 2015 literature review published in the USA
explored ways in which early childhood
engagement in not only music-based activities(including singing, playing musical instruments
and dancing) but also drama and the visual artsand crafts was linked to socio-emotional
development.531 The review compiled researchshowing a positive association between thedevelopment of socio-emotional skills and all the
branches of the arts under investigation, while
noting that low socio-economic level could delay or
distort socio-emotional development and act as asignificant barrier to arts participation.
Each child with untreated behaviouralproblems costs an average of £70,000 by the timethey reach 28, 10 times the cost of their peers.532
Two reviews have examined evidence relating arts
engagement to health and behavioural outcomesin young people. The first of these studied theimpact of performing arts in extracurricularschool environments or community settings for 11
to 18 year olds. Literature published between 1994
and 2004 showed positive impacts for young
people, especially in the areas of peer interaction
and the development of social skills.533 Building
upon this, a second review examined literature
published between 2004 and 2011, looking at the
impact of music, dance, singing, drama and visualarts undertaken in non-clinical settings over thesame age range. This established that ‘arts/
creative projects have the potential to address
young people’s sense of self-worth and life skills asa mechanism for promoting behaviour change andhealthy lifestyles’.534

89

Chapter 6

Childhood, Adolescence and Young Adulthood

All-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Report

Dance accelerates development and learning and improves
hand–eye coordination.
engaging in arts therapies was assessed over thecourse of a year and compared to a control groupon the waiting list. Participants undergoing arts
therapy showed significant improvements intheir socia l, emotiona l and behav ioura ldevelopment, particularly in relation to emotionaland conduct difficulties. Qualitative analysis
revealed that the young people felt safer and morec om for t able c om mu n ic at i n g t r au m at ic
experiences through the arts than through verbal
therapies.540 It is unfortunate, therefore, thatchildren in special schools have less support for
the arts than children in mainstream education.
Provision should, at the very least, be uniform
across the two sectors. We advocate that
resources should be distributed according
to need.
The savings that can be achieved throughparticipatory arts programmes, as a form of
upstream early years intervention,541 should berecognised and acted upon more extensively. Weurge DH and DfE to recognise the arts as a form ofevidence-based and cost-effective treatment ofchildhood behavioural problems and conductdisorders and make provision accordingly. In lightof this evidence, NICE might revise its guidance onsocial and emotional wellbeing in the early years.
A useful tool in mainstreaming arts activities
will be the Partnership Investment Programme,
brokered by Arts Connect, which is designed toencourage shifts in commissioning that support
behaviour change in children and young people.542
We look forward to other such organisations

6.4

Education
Education is one of the determinants of health, but
the benefits of education are unevenly distributed
across the social gradient.543 Children born intofamilies enjoying a high socio-economic position
are able to maintain high scores at school or
improve their scores over time from a lower
starting point, whereas the performance of highscoring children from poorer backgrounds tends
to diminish over time, and their lower-scoring
counterparts show little improvement.544 The
London Challenge – a government-funded school
improvement programme that took place in thecapital between 2003 and 2011 – coincided with adramatic overhaul of failing schools and helped tobridge the attainment gap.545 A 2017 update of the
ImagineNation report, published by the Cultural
Learning Alliance (chaired by Lord Puttnam) notedthat a quarter of children in the UK were living inpoverty and that cultural learning had a vital partto play in addressing the inequalities in educational
attainment and health arising from this.546
A study in Australia found that ‘arts education
not only has intrinsic value, but when implemented
with a structured, innovative and long-term
approach, it can also provide essential extrinsic
benefits, such as improved school attendance,
academic achievement across the curriculum aswell as social and emotional wellbeing’.547 Drawing
on this and other international research in his
2013 review of the arts in Welsh
schools, Professor Dai Smithobserved that provision bothw it h i n a nd out s ide t hecu r r icu lu m wa s u ne ven ,leading to the recommendationthat the Welsh Government
embed the arts in schools, so as
to i mprove l iter ac y a ndnumeracy and narrow theattainment gap. This impliedthat ‘students should be presented throughout
their school years with a plethora of arts
experiences, whether delighting or provoking or
challenging, across the gamut of field trips toevents, ga lleries, per formances, critica lappreciation talks, and soon, including arts
residencies in schools, in order to make every
school in Wales an arts-rich school in either
achievement or ambition’.548 It was envisaged that
this would require an enhancement of the primaryand secondary curriculum, the fostering of arts

Learning to play music enhancescognitive development and improves
health and wellbeing.
informing themselves about the health andwellbeing benefits of the participatory arts, andadvocating for them with local authorities, healthservices and cultural organisations acrossthe country.

90

champions and a joined-up approach involving
arts and educational practitioners, the arts
council, museums and galleries.
Drawing upon Professor Smith’s analysis,
Culture and Poverty made a connection between
arts engagement and academic achievement,549
and it recommended that cultural enrichment
activities were integrated into the Flying Start
programme, for children under four in the mostdeprived areas of Wales, with the arts being
encouraged within and outside school. In February
2016, the Public Policy Institute for Wales
published an analysis which found that ‘There is acompelling evidence base regarding the potential
impacts of school-based strategies that aredesigned to promote social and emotional
learning’ and led to the recommendation of both
universal and targeted approaches in schools.550
Large cohort studies show that a combinationof aspirational parents and an ambitious school
can transform life outcomes.551 In June 2016, theRoyal Shakespeare Company collaborated withKing Ethelbert’s secondary school and CliftonvillePrimary, both located in an area of multiple
deprivation in Thanet, to stage A MidsummerNight’s Dream in the streets, on the beach and atcultural venues in Margate. The head teacher ofKing Ethelbert’s School said that the projecthad ‘transformed teaching in all departments,
raised aspirations and increased parental
involvement’.552
The school achieved its best ever exam results,
exceeding government targets by a considerable
margin. My Primary School is at the Museum, an
initiative of Garbers and James architects
coordinated by King’s College London, relocatedchildren from schools in Tyne and Wear, Swansea
and Liverpool to a nearby museum for a term to
explore the benefits of cultural learning.553

the educational company Artis works to fill the gap
in cultural education, using music, drama andmovement in the classrooms of state secondary
schools to stimulate imaginative thinking that
relates to classroom learning.555 Feedback suggeststhat sessions – which map onto the curriculum –increase the self-esteem and confidence of pupils
in a way that can impact upon the whole school.
The 2016 Culture White Paper acknowledgedthat ‘being taught to play a musical instrument, todraw, paint and make things, to dance and to act’ isan important part of every child’s education andpledged that DCMS would ‘put in place measures
to increase participation in culture, especiallyamong those who are currently excluded from theopportunities that culture has to offer. In
particular, we will ensure that children and young
people from disadvantaged backgrounds are
inspired by and have new meaningful relationships
with culture’.556 Responding to this, the ACE
Cultural Citizens programme will give an initial
600 schoolchildren in disadvantaged communities
exclusive access to cultural institutions. In the2016 Autumn Statement, a scheme was announced
to promote cultural education in schools.557
When inspecting schools, OFSTED considers the‘spiritual, moral, social and cultural development of
the pupils’.558 In response, ACE has instigated ascheme called Artsmark, which ‘enables schools
and other organisations to evaluate, strengthen andcelebrate their arts and cultural provision’.559 This
pays heed to the elements of the OFSTED frameworkwith the most relevance to the arts and culture,
particularly the requirement that pupils arereflective, imaginative and curious, that they
develop an appreciation of theatre, music, art andliterature and that they respond positively to arange of artistic and cultural opportunities. Healthalso enters into the school inspection framework,
particularly the requirementthat ‘learners understand how tokeep themselves safe andhealthy, both physically andemotionally’. 560 At present,
however, no connection is madebetween health and the arts. DfEand OFSTED could usefully
encourage a ll schools torecognise the role of the arts inthe cultural development,
mental health and wellbeing of pupils and to adopt
the Artsmark application.
Of course, efforts to realise the extrinsic
benefits of the arts cannot be confined to schools,
as this would miss children and young people whohave been excluded. An independent review ofcultural education in England, commissioned
from Darren Henley by DCMS and DfE, argued forthe ‘rich provision of Cultural Education both inschool and out-of-school’. 561 The Kick Arts
programme, supported by the Heritage Lottery

Arts-based programmes improve
school readiness, yielding considerable
cost benefits.
In England, the arts remain a statutory part ofthe curriculum until key stage three, but the artsand humanities are being cut back from primaryschool onwards. The introduction of the English
Baccalaureate (EBacc) – which is awarded whengrade C or higher is achieved across five subjects
including English, maths, history or geography,
the sciences and a language but no arts subjects –is being blamed for a decline in pupils choosing
music in secondary schools.554 Supported by Lord
Puttnam, Lord Bichard and Baroness McIntosh,

91

Chapter 6

Childhood, Adolescence and Young Adulthood

All-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Report

Participatory arts have the potential to enhance educational
outcomes across whole schools.
Fund and run by the Oxford Youth Action
Partnership in Oxford and Banbury, is aimed at 11
to 16 year olds who do not attend school or are at
risk of exclusion. It encourages a wide range ofcreative activity and visits to cultural venues,
helping young people to negotiate identities
beyond the school environment. Participants
relish respite from school and stress and thechance to explore and experiment; they have also
spoken of immersion in creative activity
overcoming anxiety and negative feelings. Reengaging with learning, young people involved in
the programme have achieved different levels ofArts Award.562
The Roundhouse Trust provides ‘space to create’,with a particular focus on young people who havebeen failed by institutions and lack trust in society.
The charity involves young people in its governanceand provides neutral territory in which 11 to 25 year
olds from all walks of life can come together. It offers
access to music, performing arts and broadcast
media, through open programmes, in schools andon housing estates. Creative activity has been
observed to stimulate an understanding of theprocess of making, giving rise to a greater sense of
responsibility and self-ref lection, increased
con f idence and sel f-esteem and bettermental health.563
The Durham Commission on Creativity and
Education, supported by ACE, will look at ways inwhich an inspiring and creative cultural education
can be secured for all young people, which will
inform ACE’s strategy for 2020–30.564 DfE, DCMS
and DCLG might work together to ensure thatparticipatory arts provision is made available both
inside and outside of school.
A review conducted by Lord Laming in 2015–16
looked at why, when only one percent of children
went into care in England and Wales, 33 percent ofboys and 61 percent of girls in custody had been incare. Aside from multiple levels of risk, to whichchildren in care had been exposed since birth, thisfound lower than average educational attainmentand higher than average behavioural difficulties
and mental health problems. 565 The review
detailed examples of good practice aimed atdiverting children in care away from the criminal
justice system, but none of these mention the arts.
The Social Care Institute for Excellence (SCIE)
has been commissioned by DH and DfE to improvethe mental health and emotional wellbeing ofchildren and young people in care.566 Guidance forlooked-after children and young people publishedby SCIE and NICE urges social workers and social
work managers to ensure access to the creative arts,92

to ‘support and encourage overall wellbeing andself-esteem’.567 Arts Care’s Twilight Zone project for
looked-after young people (13 to 18 year olds),
initiated in 2011 and funded by the Public HealthAgency of Northern Ireland, aims, through highquality arts participation, to build skills, develop
self-confidence and assist young people inpreparing for the transition into life after residentialcare.568 In light of the evidence presented in thisreport, SCIE, the Care Leavers Association andothers might wish to consider the inclusion of artsbased activities in the repertoire of services.
The relationship between children in care andyoung people in the criminal justice system
confirms what we already know: that a bad start inlife can have profound consequences. On top of
this is the relationship between marginalisationand poor life chances. Muslim communities makeup 4.2 percent of the population in England andWales but up to 23 percent of the population ofyoung offender institutes, along with highnumbers of black and white working class boys. A
review conducted by Baroness Young paid specificattention to the ways in which outcomes might be
improved for young black and/or Muslim men in
the criminal justice system. This identified
persistent stereotyping as a major obstacle inrefashioning lives.569 We have seen that the arts
prov ide a place of sa fety and f reedom
from judgement.
A review of youth offending services conductedby the former Chief Executive of the National
College of Teaching and Leadership, Charlie Taylor,
noted that more than a third of children in the
youth custodial estate had a mental healthproblem and that physical health was generally
poor. Acknowledging the connection between low
educational level and offending, the review
positioned education at the heart of system reformand called for a multi-agency response, including
health, social care and other services, to help
prevent problems from manifesting themselvesin offending. 570 In the process, the review
acknowledged music-making as a form of
mea ning f ul activ ity that kept chi ld ren
occupied and much less likely to offend.
Research has shown that making culturally
relevant music increases self-confidence andmotivation, proving effective with disaffectedyoung people, the positive effects of which havebeen observed among young people in the criminal
justice system.571 A team at Bath Spa University has
conducted an evaluation of Birmingham Youth
Offending Service Youth Music Project, which
offers weekly two-hour one-to-one music sessions

to young people, typically over three months
followed by ten mentoring sessions. Mixedmethods evaluation of the programme showedstatistically significant improvements in musicalability and wellbeing. Many of the young peopleinterviewed spoke about increases in confidence
and social skills, with several re-engaging witheducation as a result of the programme.572
As part of the Connecting Communities (C2)project, more than 1,000 children have attended
TR14ers dance workshops, which takes its namefrom the postcode for Camborne, one of the mostdeprived towns in the UK with high levels ofantisocial youth behaviour and low levels of
educational attainment. The workshops have beencredited with a drop in antisocial behaviour, a 90
percent reduction in truancy and increased
educational attainment, and police estimate thatten young people a year have been prevented frombeing labelled a persistent young offender as aresult of the workshops.573

6.5

Recovery from Illness andManagement of Long-Term
Conditions
Between January and June 2013, a study was
conducted at A lder Hey Children’s NHSFoundation Trust in Liverpool.574 This looked at
the impact of improvised somatic dance onchildren and young people (14 months to 17 years)
suffering from acute pain following surgery or
rehabilitation from brain injur y, on theorthopaedic, cardiac and neuromedical wards.
Somatic dance focuses on the body to emphasiseinternal physical perception and experience;using a non-directive approach to creative dance
and movement, a duet is developed between
practitioner and participant, ranging from small
muscular movements to more expansive
gestures. A consistent finding across all the

Art therapy for children with chronic
conditions, such as that provided by the Teapot
Trust in Scotland and at Great Ormond Street
Children’s Hospital, diminishes fear and pain andhelps to build coping strategies.576 Creative writing
has been seen to increase not only literacy but also
wellbeing in adolescents with conditions thatprevent them from attending school.577
A fifth of children in England are overweight orobese when they start school, which rises to one
third by the time they leave primary school.578
Obesity affects not only health and mortality but
also emotional and behavioural development. If it
carries over into adulthood, there is an increased
risk of developing type 2 diabetes. In 2014–15, anestimated £5.1bn was spent on overweight- andobesity-related ill health. The Government’s plan
for action on childhood obesity, published inAugust 2016, acknowledged that the problem ofobesity was greatest among children from lowincome backgrounds, with children of five being
twice as likely and children of 15 three-times more
likely to be obese than their better-of fcounterparts; obesity patterns also show a racial
bias. The Government declared its aim to reducechildhood obesity significantly over the next
decade, seeking improvements to diet andencouraging active sport. 579 The arts havebeen seen to benef it the management ofchildhood obesity.
A 2012 study of Norwegian adolescents foundthat boys and girls (13–19 years) who engaged insocial activities were more likely to be obese in
adulthood (24–30 years), whereas girls who
participated in cultural activities were less likely
to be obese. These results were amplified when
considering those girls who were at therecommended weight when the survey began andwhen watching television was excluded as acultural activity. The researchers concluded thatarts participation offered a protective effectagainst obesity.580
Between 2006 and 2012, Healing Arts, inpartnership with the Isle of Wight NHS Trust,
received funding through the Invest to Save budget
to pilot a series of projects, collectively known as A
Lifetime’s Health Delivered
Creatively. One of the threeprogrammes developed under
this banner was Time Being 7, a
20-week arts and creative playcourse which sought to divert
children away from sedentaryleisure pursuits, such as
television viewing and playing
computer games, to stave off
weight-related health problems.
At the outset, more than half the group spent a
considerable amount of time with screen-based
electronic media; by their own account, 38 percent
of children reduced the time they spent watching

Arts participation has a part to play in the
management of long-term conditions suchas childhood obesity.
sessions was that participants became lessanxious and better able to move, which points toa role for improvised dance within paediatrichealthcare and pain management.575

93

Chapter 6

Childhood, Adolescence and Young Adulthood

television and playing computer games; by theirparents’ account, 46 percent of the children
reduced their screen time compared to increases
across the cohort.581

6.6

Improving Mental Healthand Wellbeing
The most recent figures on the mental health ofchildren and young people date from the ONS
prevalence study of 2004. At that time, anestimated one in ten children (aged five to 16) in
Britain had a mental health problem, including
anxiety (3.3 percent of all children), serious
depression (0.9 percent) and hyperkinetic
disorders (1.5 percent, including ADHD). 582
Reports of anxiety and depression in children
have doubled since the 1980s.583 Children from
low-income families are up to three times more
likely to experience mental ill health.584 As in thewider population, children with mental healthproblems are more likely to have physical healthproblems, some of which are connected tosmoking and obesity (with psychotropic drugs
causing weight gain and the Governmentprescribing a reduction in their use).585 Amongthe 12 percent of young people living with a longterm physical condition, there is a greater
likelihood of developing mental health problems.
In October 2014, the House of Commons
Health Committee published a report onchildren’s and adolescents’ mental health and themain service for them (CAMHS). The report
identified ‘serious and deeply ingrained problems
with the commissioning and provision ofchildren’s and adolescents’ mental healthservices. These run through the whole systemfrom prevention and early intervention throughto inpatient services for the most vulnerable
young people’. 58 6 The Select Com m ittee
condemned the lengthy waiting times, raised
referral thresholds and scarcity of local inpatient
services caused by increased demand anddiminishing funding.
Around a quarter of mental health problems arepreventable through early intervention duringchildhood and adolescence, representing both aconsiderable saving and a significant difference tothe quality of life of many young adults. The Chief
Medical Officer has highlighted prevention andearly intervention as a priority.587 The SelectCommittee report recommended that priority begiven to early intervention, that patchy provision
be ironed out and that attention be paid to securing
stable, long-term funding.

94

All-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Report

Responding to these findings, the Government
accepted that current provision fell short andpointed to the work of the Children and Young
People’s Mental Health Taskforce.588 In March
2015, the taskforce published a report, Future in
Mind, which cited data showing that only 25 to 35
percent of young people with a diagnosable mental
health condition accessed support, and what little
support was accessed was geographicallydispersed, subject to lengthy waiting times andunresponsive to individual need.589 Future in Mind
advocated a more accessible, locally organised andresponsive system providing appropriate care. It
also prioritised resilience, prevention and earlyintervention and urged a reduction of inequalities
in access and outcomes. While the arts were notmentioned in the taskforce report, Culture andPoverty recommended the integration of arts
activities in the Families First programme, whichemphasises prevention and early intervention forfamilies in Wales, particularly those living inpoverty. We believe the arts should be part of a
locally organised and responsive young people’s
mental health system.
Key Changes offers music engagement andrecovery services in the community and hospitals
for children and adolescents experiencing mental
health problems. Every year, more than 1,000
music workshops in inpatient settings and 1,500
studio sessions in the community are delivered toover 3,000 people in London, Manchester,
Sheffield, Woking and Chelmsford, including a
programme of tailored one-to-one sessions andgroup support at professionally equipped musicstudios. Targeting margina lised people,
particularly young BAME men, Key Changes offers
culturally relevant musical activities including
production and recording sessions, performanceskills, concerts and work experience placements.
Key Changes has been the subject of several
documentaries, and it won the National Positive
Practice in Mental Health Award for 2014.590
In Northern Ireland, Youth Action works acrossthe sectarian divide to help young people explore
their identities and realise their full potential
through the performing arts.591 Between 2009 and2014, Youth Action was one of four lead organisationsin the Right Here project, managed by PHF and theMental Health Foundation and aimed at improving
the mental health and wellbeing of young people
aged between 16 and 25 in the UK.592
Most serious mental health problems begin
before the age of 24, with half of conditions being
manifested by the age of 14.593 To take one example,
most first episodes of psychosis happen inadolescence or early adulthood. The longer
conditions like psychosis remain untreated, theworse the eventual outcome can be, and the largest
group in which such conditions remain undetected
is 16 to 24 year olds.594 No Health Without Mental
Health advocated early intervention for psychosis,595

Samantics:
Smile All the Time
Depression is widely
accepted to be a debilitating
condition, affecting
approximately 120 million
people worldwide andpredicted to become aleading cause of disability
by 2020.

It causes low mood, loss of appetite, disrupted
sleep patterns and diminished functioning; it
can also precipitate dementia. At its worst,
depression can lead to suicide. It is associatedwith a million deaths per year worldwide.596
Between one in 12 and one in 15 children and young
people self-harm, leading to 25,000 hospital
admissions every year.597
At the round table on Young People, Mental
Health and the Arts, we watched a music video,
called Smile All the Time, which had been posted on
the internet under the name of Samantics.598 Its
author, Sam, has suffered severe anxiety anddepression since the age of 20, and we received amoving testimony from him:
Towards the end of my twenties I couldn’t cope. I
tried everything I could think of, but I was in a lotof pain. It was a pain that nobody else could see,so it didn’t feel justifiable to me. It didn’t feel like itshould have been there. It got to a point where I
was determined that the only way out was to takemy own life.
It’s important to mention here that I had, andstill have, amazing support from my family, and I
only just made it. A lot of people, and especially
young people, don’t have that same kind of
support. I wouldn’t be here if it wasn’t for mymum and my girlfriend especially. They helpedme get help at the end of the day.
About my darkest time, I made a decision that I
had one more thing to try and that was to stop
hiding. I couldn’t keep up this double life of
portraying happiness to everybody. So it started

with a poem. Putting it into poetry made it
somehow easier to say. I filmed it and I posted
it onto social media, which was terrifying, butquite necessary for me, because the support
that I got from that was amazing, and itchanged how I saw everything that was
happening. Because, for the first time, I wasn’t
as afraid to talk about it. That was the biggest
step for me.
Poetry then turned into music when I
realised that these words that I’d written could
be lyrics. Then that became my next weapon, I
guess, in this battle against depression. It’s
kind of strange that when I write a song like
Smile All the Time, I’m able to be far morehonest than I would be if I was just in a generalconversation. When I perform, I release somuch energy that it becomes very cathartic forme. So there’s two massive releases fromwriting and performing. It helps to calm me
down, just release these negative feelings.
I think one of the most important aspects ofmusic is the people it can reach. Music is aplatform which allows me to spread amessage. Since that video has gone live, I’ve
been contacted by so many people. One
example is a 14-year-old girl who told me she
had nobody else to talk to. There were students
and young adults who were scared to be openwith the people around them. They thanked mefor saying what they feel and couldn’t. Some ofthem really opened up to me and even listenedto what advice I could give them to seek further
help. That gives me a purpose and it makes me
feel kind of happy to be me, which is rare.

95

Chapter 6

Childhood, Adolescence and Young Adulthoodand the Children and Young People’s Mental HealthTaskforce advanced a ‘compelling moral, social andeconomic case for change’.599 The Alchemy Project,using dance as an early intervention in psychosis,
which is taken as a case study in this chapter,
illustrates how the arts can be used to remarkableeffect in mental health.
NHS spending on psychosis is currently skewed
towards inpatient care, with an average cost of£350 per day and an average stay of 38 days
(equating to £13,300 per non-compulsory
admission), as compared to interventions incommunity settings estimated at £13 per day. Earlyintervention in psychosis is calculated to save
£6,780 per person over four years, or £15 in costs
avoided per £1 invested over ten years, putting itwell within the NICE guidelines for costeffectiveness.600 Early intervention diminishes theneed for antipsychotic medication, which is not
only costly but also has adverse side effects.
There is a growing body of research linking theonset of psychosis with social adversity across thelife course.601 After controlling for socio-economic
factors, people from minority ethnic groups and of
mixed race are at increased risk of all psychotic
illnesses.602 The incidence of manic psychosis inblack African communities is six times higher andin African–Caribbean communities eight times
higher than in the white population in the UK.603
This calls for urgent action in tackling the social
determinants of psychosis in marginalised
groups.604 The Alchemy Project provides anexample of an arts and health initiative overcoming
the barriers to early intervention that persist in
BAME communities.
From April 2016, the target for access to NICEapproved care packages within the first two weeks
of experiencing a psychotic episode has been set at
50 percent, rising to at least 60 percent by 2020–
21. 605 The NICE guidance for psychosis and

All-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Reportneed to embrace the healing properties of the arts
in relation to anxiety, depression, stress and more
severe mental health problems.
In November 2014, more than 90,500 membersof the UK Youth Parliament identified young
people’s mental health as a concern, leading the
topic to be set as a UK-wide priority for the following
year and form the subject of an inquiry for the 2015
Youth Select Committee. 607 The Committee
found that triggers for mental ill health in young
people included academic pressure and examstress.608 DfE has been charged with responsibility
for child and adolescent mental health in schools.
Natasha Devon, who served briefly as children’s
mental health tsar, championed the creative arts asa route to emotional intelligence and self-esteem
and an antidote to a relentless curriculum andendless testing.609
Among its recommendations, the Youth SelectCommittee included targets for young people’s
mental health akin to those for physical educationin schools.610 This would mean early introductionof emotional exploration, training of teachers torecognise the signs of mental distress and more
extensive provision of counsellors in schools. We
believe arts therapies and participatory arts
should be included in guidance on school
counselling services.611
DfE’s policy for child and adolescent mental
health includes a role for the voluntary sector,
supported by a £25m grant scheme. Head of Youth
Arts at Ovalhouse Theatre, Naomi Shoba, noted ata round table that activity outside the school
environment could support the making offriendships transcending class, race, gender andarea. Music in Mind – run by Rhythmix, a music,
social welfare and education charity based inSouth East England – offers music-making
activities to vulnerable children and young
people.612 A three-year external evaluation foundthat Music in Mind diminishedanxiety, stress and self-harmand increased communicationand coping strategies.613
DH’s Closing the Gap report
noted that far too many young
people were lost to the system
as they made the transition toadult services.614 This has been
described by NHS England andothers as a ‘cliff edge’.615 It isdisproportionately the case for vulnerable anddisadvantaged young people, whose exposure to
stressful life events – including problems with
employment, benefits, debt and housing – are acommon cause of relapse. The Youth SelectCommittee suggested that the upper age limit foraccessing children’s and adolescent mental healthservices (currently 18) might be made more flexible
at the same time as funding was targeted at better
communication between health professionals andCreative activity is a powerful tool in
overcoming anxiety, depression andstress in young people.
schizophrenia in adults recommends thatclinicians ‘Consider offering arts therapies to all
people with psychosis or schizophrenia,
particularly for the alleviation of negative
symptoms’.606 The use of the participatory arts andarts therapies should be considered across themental healthcare system. When NHS mental
health trusts and CAMHS are developing support
for children and adolescents, particularly in theareas of prevention and early intervention, they96

The Alchemy Project
Psychosis is particularly
prevalent in Lambeth,Southwark, Lewisham andCroydon, where a quarterof children live in poverty
and the rate of new casesof psychosis is double the
UK average.

T

he Alchemy Project used dance as aform of early intervention in psychosis.
It was an action research project,
developed in 2015 as a co-production
between Dance United and the earlyintervention in psychosis team at SLaM, with
input from King’s College London, funded by
GSTC, Maudsley Charity and ACE. Two cohorts of
12 participants (18 to 35 years old), with noprevious experience of dance, were encouraged
to work with professional dance artists within ateam that also included healthcare professionals
and peer mentors. Groups were mixed, and aneffort was made to involve young adult males.
Participants were not labelled according to theirconditions but treated as dance artists working
as part of a company and pushed to achieve all
they could. The groups shared healthy meals andtook part in trust- and team-building exercises,
many of which focused on touch and developing
connections, helping to overcome isolation while
also addressing bodily awareness and physicalfitness. After just four weeks, each of the twogroups performed a specially commissioned
20-minute contemporary piece, El Camino[The Path], in front of an invited audience, at the
Shaw Theatre and the Lilian Baylis Studio,
Sadler’s Wells Theatre, respectively. Patients had
become dancers.
The physical activity of dancing alleviates
symptoms of mental ill health and the effects ofmedication, such as apathy, lethargy and lack ofmotivation, and it rebalances the mind–bodyrelationship. Dance involves touch and closeness,

which are often overlooked within psychiatry asa factor in overcoming mental illness. In ameeting with the Inquiry team, Nicola Cranefrom GSTC observed that participants arrived in
one way and left as better versions of themselves,
more joyful and confident.
The project was evaluated by independent
assessors using WEMWBS and EQ-5D. Bothcohorts demonstrated clinically significant
improvements in wellbeing, communication,
concentration and focus, level of trust in others,
team working and quality of life. The project
helped participants to develop relationships with
their peers and restore relationships with theirfamilies. At the round table on Young People,
Mental Health and the Arts, Dr Lauren Gavaghan,
psychiatrist on the Alchemy Project, told us thatthe project had enabled young people to escapefrom the labels that had been assigned to themand rewrite their own stories.616
A 40-minute film, documenting the Alchemy
Project, was screened in Parliament by the APPG
on 23 May 2016. Commissioners may find thisfilm to be impressive evidence.617

97Chapter 6

Childhood, Adolescence and Young Adulthood

service users.618 We suggest that communitybased arts activity could offer valuable continuity
as young people make the transition to adulthood.
As well as helping to stabilise young people’s
mental health and wellbeing, these activities
would serve as a conduit for maintaining contact
with specialist services as necessary.
The transition from inpatient services to thecommunity can be smoothed through the arts.
Raw Material, a youth-led organisation in Brixton,
seeks to ‘improve the lives of young people andtheir economic position, their opportunities,
progression and development, including mental
and physical health issues’.619 It does this byproviding facilities and training in the world ofmusic production. With more than 400 referrals
to its Raw Sounds mental health programme,
75 percent of which come f rom BAME
communities, the organisation provides evening
access from hospital wards (primarily SLaM) andthe community.620
Children experiencing poor wellbeing are more
likely to experience poverty, unemployment and illhealth as adults.621 Research conducted by the
Cabinet Office in 2014 suggested an overall
reduction in health-damaging behaviour, such as
smoking, drinking and drug misuse, amongchildren and young people.622 However, an index ofchild wellbeing in the European Union showed the
UK to have the highest number of children injobless households and poor child health,educational attainment and relationships withparents and peers, all of which contributed todiminished wellbeing.623 A collaboration between
the Children’s Society and the University of York
looking at subjective wellbeing in children has
suggested that increases in life satisfaction evident
from 1994 halted from 2007 onwards.624 This
research has also found quality of relationships
with family and friends to be a determinantof wellbeing.
The Mental Health Foundation has called
loneliness in young people a ‘silent plague’.625 The
School Health Education Unit’s 2014 survey ofmore than 78,000 youngsters found a decline inemotional health and a clear association between
poor wellbeing and heavy social media usage.626
NICE has published guidance on social andemotional wellbeing in children and young people,
but this omits to mention a role for the arts. We
hope that NICE will look at the benefits of the artsfor this age group as part of a wider review of thearts in relation to wellbeing.627
The move to university can be an unsettling
time for young adults as they depart from familiar
support structures and face an uncertain future. A
2016 report by the Higher Education Policy
Institute found that the majority of students
experienced low wellbeing,628 with one in threeaffected by depression and loneliness. Universities
UK has acknowledged the positive impact of98

All-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Report

creativity upon mental wellbeing,629 and there isevidence that arts therapy decreases anxiety inundergraduates.630
Consistent with the recommendations of both
the Children and Young People’s Mental HealthTaskforce and the Youth Select Committee, digitalapplications have been designed to improvemental health, such as the Start wellbeing
thermometer and the Mind Emoodji, both of which
promote creative thinking and have had a hightake-up rate among students. 631 We would
encourage the Healthy Universities Network,
coordinated from MMU and the University ofCentral Lancashire, to recommend arts-related
activities as part of a whole-university approach tohealth and wellbeing. 632 At the same time,
AMOSSHE, the Student Services Organisation,
could include evidence of the benefits of arts
activities to students within the materials
it disseminates.633

6.7

Children’s Healthcare
Environments
Young people spending time in hospital experiencea range of anxieties, partly as a result of separationfrom their families, an unfamiliar environment,
investigations and treatments and a loss of selfdetermination.634 The discomfiting experience ofbeing in hospital can be salved by good informationand involving young patients in the design anddelivery of their care. Child-friendly healthcare
environments and stress-reducing activities canalso improve wellbeing. A book has been published
about the role of applied theatre in enhancing thesocial and mental wellbeing of children
in hospitals.635
Bristol Royal Hospital for Children, which
opened in 2001, was the first new children’s
hospital to be built in the UK for two decades.
Following extensive consultation with architects,
artists, designers and patients, the arts anddesign were made integral to the building andfurnishing of the hospital. The results of this areevident from the large lollipop-shaped stick
figure at the front entrance to the welcoming
reception area with its interactive artworks,
while each of the seven storeys of the building ispainted in a different rainbow colour. The workof more than 20 artists is to be seen in thehospital, from cartoon characters in the lifts to
below-banister pictures in the stairwells. An
evaluation by the University of the West of
England showed much greater satisfaction with
the new hospital among parents (94 percent
compared with 71 percent in the old hospital).
Parents particularly valued art and design for

A well-designed environment in children’s hospitals helps toovercome fear and pain.
diverting children from fear, pain, illness andunfamiliar surroundings.636
While Bristol Royal Hospital for Children
provides an example of the arts being integrated
into hospital design from the outset, there are manyother ways in which the arts enter into thehealthcare environments of children and young
people. Funded by the Children’s Hospital Charity
at Sheffield Children’s Hospital, the Artfelt
Workshop Programme offers twice-weekly
sessions, through which a variety of art, craft andmusic sessions are made available to young patients(from birth to 16). Workshops are designed toprovide a distraction during anxious moments,
such as before an operation, and to break up longstays on the wards, helping children to socialise andexpress themselves. They take place where there ismost demand, which tends to be on inpatient wards
or in the Theatre Admissions Unit. Distinct fromeither arts therapy or a focus on aesthetic outcomes,
workshops emphasise the enjoyment of arts
participation. They give a creative outlet to children
who may not usually have access to art, and they areopen to parents, siblings and staff. Participant
feedback is universally positive, and the main
problem the programme reports is in keeping up
with demand.637
For over ten years, the National Portrait Gallery
has partnered with Great Ormond Street, Evelina
London Children’s Hospital at Guy’s and St
Thomas’, the Royal London Hospital and Newham
University Hospital. As part of this collaboration,
Magical Journeys (2014–17) offered creative arts
activities to young people (aged three to 16) andtheir families, often as respite from long-term
health conditions. Centred on holiday periods
when hospital schools were closed, Magical
Journeys aimed to enhance the wellbeing ofparticipants by stimulating creativity andincreasing visual literacy. Through one-day
workshops led by artists working in pairs, amultidisciplinary approach lent variety. An annual
average of 55 free workshops was provided forapproximately 500 children who might nototherwise have engaged with the arts. External
evaluation suggested that the young people taking
part gained physical, cognitive, social andemotional benefits. Young patients said how muchthey looked forward to the workshops, and parents
expressed joy at seeing their children deriving somuch pleasure from creative activities. Staff
shared the enthusiasm of parents, while theartists gained satisfaction from the opportunity tomake a positive difference to people’s experienceof hospital.638

The significance of place in relation to
healthcare environments is not confined tohospitals. The Youth Select Committee received
evidence suggesting that GPs are often at the frontline for young people presenting with mental
health difficulties. As well as doctors being
friendly, bright and welcoming environments
were said to help,639 which might be borne in mind
during the modernisation of primary carepremises currently underway. Various initiatives
address this, from community knitting projects to
Poems in the Waiting Room.640
We hope that the evidence presented in thischapter is sufficient to demonstrate that thearts can be a powerful and cost-effective agentof better health and wellbeing. During thiscrucial life stage, arts engagement contributes
to an improved environment and leads toenhancements in health and wellbeing.
Proportional investment in such opportunities
across the social gradient would bring untold
societal benefits and avoided costs.
The first Culture White Paper to be publishedin the UK, in 1965, said that ‘If children at an
early age become accustomed to the idea of thearts as a part of everyday life, they are more
likely in maturity to accept and then demand
them’.641 At the round table on Museums and
Health, it was noted that families bringing
babies and toddlers to museums and galleries
represented their most diverse audiences, but
this picture changed as children aged. Work isneeded to nurture lifelong habits of arts
engagement beginning in early childhood.

99

Lowry Figures Heading to
the Match
Photographer: Member ofStart in Salford

Working-Age
Adulthood100101All-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Report

7 Working-Age Adulthood

7.2“A man at work, making something which
he feels will exist because he is working at it
and wills it, is exercising the energies of his
mind and soul as well as of his body”
William MorrisT

he challenges faced at this stage in life
are manifold and can include thesearch for work, the establishment of ahome and relationships and possibly
also the onset of ill health. This chapter
looks at the ways in which the arts can enhance thequality of our work, health and wellbeing.

7.1

Workplace HealthWork is one of the determinants of health, butaccess to high-quality work is unevenly distributed
across the social gradient. The social isolation thatcomes from worklessness increases the risk ofcoronary heart disease by 50 percent. Common
among responses to the call for practice examples,
we received evidence of arts-based approaches
giving people the confidence and skills to enter
into employment.
Not all work is good for our health. Marmot
identif ies that hea lth-damaging work is‘characterised by high demand with no control
over the work task, by high effort and little
reward, by social isolation at work, by job
insecurity, by organisational injustice, and byshift work’.642 These detrimental psychosocial
conditions are experienced across factories,
warehouses, construction sites, offices and theservice sector, and they challenge conventional
wisdom about work strain being confined tohigh-status jobs. A briefing on workplace healthand wellbeing commissioned by PHE from UCL
Institute of Health Equity emphasised theimportance to public health and reduced healthinequalities of improving psychosocial working
conditions.643 In Britain, the number of working
households in poverty has been increasing.644
This is causing chronic stress for affectedfamilies, with damaging physical effects.
102

Accordingly, the Marmot Review prescribed ‘fair
employment and good work for all’.
In 2015–16, an estimated 30.4 million working
days were lost to illness and injury in the UK.645
Absence from work annually costs the Government
around £13bn in health-related benefits and £2bn
in healthcare, sick pay and foregone taxes.
Employers’ share of sick pay amounts to around£9bn, while individuals lose out on earnings of£4bn per year.646
A cross-governmental initiative, known as
Health, Work and Wellbeing, has been set up to
improve and protect the health of working-age
people.647 At the time of writing, no mention ismade of the arts in this strategy. The Workplace
Wellbeing Charter supported by PHE enables
employers to commit to improving the health andwellbeing of their workforce; as yet, it does notinclude the arts in its support guides.648 A review ofhealth at work by Professor Dame Carol Black
recommended prevention and early intervention
for those in work and improved conditions for
those out of work.649 At a meeting held by theInquiry, Dame Carol told us that people sheinterviewed about workplace wellbeing had
wanted singing, dance classes and reading groups.
In the USA, creative activity undertaken outsideof work has been seen to hasten recovery fromwork stra in a nd en ha nce work-related
performance, leading researchers to conclude thatorganisations ‘may benefit from encouraging
employees to consider creative activities in theirefforts to recover from work’.650 The Five Year
Forward View suggested that ‘There would be
merit in extending incentives for employers in
England who provide effective NICE recommended
workplace health programmes for employees’.651
The arts do not yet feature in NICE guidance on
workplace health; we hope this will be looked at inconjunction with a wider consideration of the artsin health.652

bracket). The picture that emerged from the survey
prompted the observation that, ‘Despite many
areas of advances in human health we are notseeing these ref lected in mental health. Ifanything, the signs are that we are slipping back’.657
In the process, the power of the arts – to overcome
stress and lift the mood – was acknowledged.
A significant proportion of people with minor tomoderate mental health problems recovercompletely. As we saw in the discussion of arts onprescription in chapter five, creative activities haveshown beneficial effects in recovery frompsychosocial problems. The case study in this section
looks at an example of visual art on prescription
aiding recovery from anxiety and depression.
A Cochrane Review of RCTs found that
individual music therapy combined withstandard care (psychotherapy and medication)tended to show more significant improvements
in mood than standard care alone.658 This result
was replicated in an RCT of working-age people
with depression in Finland, which conceived
music as a preverbal form of communication,a prelude to s y mbol ic ex pres sion a nd
verbalisation.659 NICE has issued guidelines fordepression in adults with and without chronic

Improving Mental Healthand Wellbeing
One in six adults has a diagnosable mental healthcondition, 653 almost a third of which can be
attributed to adverse childhood experience. In
2012, mental health problems in the under-65s
accounted for almost half of all health problems
diagnosed by the NHS, the majority of them
manifesting as anxiety and depression.654 The
main causes of sickness absence from work areanxiety, depression and stress (11.7 million days).655
This is estimated to cost the economy £100bn peryear, just under the entire budget of the NHS. The
proportion of mental health-related benefit claims
has grown to twice those for musculoskeletal
complaints, and mental illness has a detrimental
impact upon employability.656
In 2017, a survey of 2,290 people commissionedby the Mental Health Foundation found that nearly
three quarters of people within the lowest
household income bracket reported poor mental
health (compared to three fifths in the highest

Arts and Minds
Arts and Minds is a mental
health charity coveringrural Cambridgeshire andPeterborough, where one
in six people is estimatedto have a diagnosable
mental health problem
at any given time.

T

he art-on-prescription programme
run by Arts and Minds comprises a
series of weekly art workshops forpeople experiencing mild to moderateanxiety and depression. Access is by
self-referral or via health or social care workers,
and funding comes from the Heritage Lottery

Fund among other sources. Led by a professional
artist and qualified mental health counsellor,sessions offer the chance to work with a wide
range of materials and techniques. Workshops
last for two hours, are open to all abilities andoffer the opportunity to undertake a creative,
stimulating and absorbing activity.
In 2014–15, a mixed-methods evaluation ofArts and Minds sought to determine whether
participants experienced changes in levels ofanxiety, depression, social inclusion andwellbeing, using valid and reliable psychologicalmeasures. Seventy-one percent of participants
reported a decrease in anxiety, and 73 percent
reported a decrease in depression. Sixty-nine
percent of participants reported an increase insocial inclusion, while 76 percent of participants
reported an increase in wellbeing. Participants
rated their experience very favourably; 77 percent
reported a development in their art skills; 64
percent reported an increase in confidence; 71
percent reported an increase in motivation and
69 percent reported feeling more positive about
themselves after taking part.660
103

Chapter 7

All-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Report

Working-Age Adulthood

Mental health problems in the under-65s account for almost halfof all health problems diagnosed by the NHS.
physical health problems,661 but no mention ismade of the arts in either case.
Between 2013 and 2015, as part of Creative
Practice as Mutual Recovery, a study was led by theCentre for Performance Science at the Royal
College of Music.662 Adults experiencing mild tomoderate mental distress were recruited to thestudy via hospitals, psychologists and psychiatrists
and invited to participate in weekly 90-minutegroup drumming sessions over six or 10 weeks.
Without having any specific therapeutic aims, thefacilitator increased the complexity of the activity
over time. A mixed-methods evaluation used arange of psychological scales, interviews, bloodpressure tests and saliva analyses. During single
sessions, stress and tiredness significantly
decreased and happiness, relaxation and energy
levels increased. Over the course of the study,group drumming led to reductions in cortisol andan enhancement of immune responses, which was
combined with a reduction in inf lammatory
activity over a six-week span and the activation ofan anti-inflammatory response over 10 weeks.663
Numerous arts organisations offer musicmaking and music therapy to overcome mental
health problems. Sound Minds, in the basement ofBattersea Methodist Mission in Clapham, houses a
spacious rehearsal room with en suite recording
facility, a smaller studio for recording, mixing andvideo editing, a visual art studio, lounge, kitchen,teaching studio, three house bands and a BAME

environments.665 The organisation also maintains
an online forum intended to build mutual support
structures. A survey conducted within this virtual
community elicited 3,545 responses from 31
countries, including from participants withdepression. Participants reported feeling calmer
and happier the more they knitted as well as
indicating increases in cognitive functioning.666
Research also suggests that knitting helps tomitigate the pain associated with long-term
conditions.667 We suggest that this might be anarea for attention as NICE considers the benefitsof the arts in dealing with pain and mental
health problems.
In Australia, SuperFriend has been set up as a‘national mental health promotion foundation
focused on creating mentally healthy workplaces
to reduce the incidence of suicide and the impact
of ment a l i l l ne s s on i nd iv idu a l s a ndorganisations’.668 Drawing on another Australianmodel, DH introduced Mental Health First Aid(MHFA) England in 2007 – an educational coursethat enables people to identify, understand andsupport mental health problems. 669 Neither
initiative yet includes the arts. We would verymuch like to see NHS England including the arts in
its work to improve the mental health of employees.
The Civil Service Health and Wellbeing agenda
focuses on mental health and musculoskeletal
complaints. At present, the programme does notinclude arts participation, but local wellbeing
representatives in different
departments engage theircol leag ues in a range of
wellbeing initiatives, which
may include trips to thetheatre, the cinema and othercultural events, based on staff
consultation and dependent
upon interest. We hope that thecentral agenda might be revised
in light of this report. Similarly,
the Thrive initiative, instigatedby the Mayor of London, would benefit fromembracing the cultural resources of the capital.
The Trades Union Congress (TUC) in the
Midlands has devised a cultural manifesto,
recognising the need for culture in creatingh e a lt h y a n d v ib r a nt e c o n o m i e s a n dcommunities.670 We hope that, in implementing
the cultural manifesto, the TUC will build on thisrecognition, including reference to the workplace.
A survey conducted by the Institute of Directors(IoD) found that more than half its members had
been approached by staff complaining of poor
mental health yet only 14 percent had a formal

Arts therapies and participatory arts
(including arts on prescription) have a
proven impact upon mild to moderate
and more severe mental health problems.
service user group. Sound Minds is the winner ofnu merous awa rd s, i nclud i ng a specia lcommendation from the RSPH, and it has beenfeatured in a Channel 4 News special on
schizophrenia. 664 Housed in non-secularbuildings, both Sound Minds and the Dragon Café(taken as a case study in chapter five) demonstrate
the value of community space. It would be
beneficial if local authorities made unusedbuildings available at low or no cost to community
groups with health and wellbeing aims.
Since 2006, Stitchlinks has been pioneering
therapeutic knitting in clinical and community
104

policy to deal with it.671 As part of the Heads
Together campaign, the IoD has committed tomusic-making for stroke survivors. Anotherinitiative, Stroke Odysseys – a collaboration
between Rosetta Life, GSTC andK ing’s Col lege London –explores the ef f icacy andcost effectiveness of singing
and movement interventions
in reducing a n x iety a nd
depression in stroke survivors.
The project has successfully codesigned models for clinical andcommunity delivery. The model is being tested andintegrated in four hospital trusts and community
settings across London.680
Arts engagement also yields improvements inemotional health and wellbeing.681 In Australia,
where stroke is the second highest cause of death,a study found that participation in group-based
community art programmes, centred on drawing
and painting, stimulated participants’ physicaland cognitive abilities while increasing theirconfidence, self-determination and quality oflife.682 The UK equivalent – a qualitative feasibility
study, funded through NIHR’s Research for Patient
Benefit programme, called HeART of Stroke –offered 10 two-hour sessions within an artistfacilitated community group over 14 weeks in
Bournemouth and Cambridge.683 The increased
and sustained self-confidence reported byparticipants provided justification for a national
multi-centred version of the project.684
At the round table on Museums and Health,stroke survivor Jason welcomed the sociability of
the hospital’s art therapy group:

Listening to music, singing and music
therapy aid recovery from stroke.
improving the conversation around mental health,and has gone as far as to recommend mindfulness
but not yet the arts.672
Founded by representatives of law firms andprofessional service companies such as Linklaters
and KPMG, with the support of MHFA England andMind, the City Mental Health Alliance seeks to
improve the climate for mental health in the City of
London.673 Leading members of the alliance havewell-funded health and wellbeing strategies andwork with large cultural organisations and thearts-inflected Mental Wealth Festival.674 We hope
this work will be extended to arts engagement for
employees at all levels.

7.3

Recovery from Illness andManagement of Long-Term
Conditions
In the UK, over 152,000 people per year experiencea stroke, a third of whom are left with disabilities,
including partial paralysis, depression andcognitive and communicative diff iculties(aphasia).675
A body of evidence is accumulating whichshows that arts engagement can alter themorphology of the brain and help speed recovery
from neural damage. Listening to music soon after
a stroke activates regions of the brain responsible
for attention, motor function, memory andemotional processing.676 People with aphasia
singing in a community choir in Australia
experienced increased confidence and motivation,enhanced mood and better communication.677
People recovering from stroke and brain injuries
attending twice-weekly concerts by Live Music
Now showed improvements in cognitive
functioning, pain and wellbeing.678 A Cochrane
Review of studies combining music therapy withstandard care, on its own or in combination withother therapies, found that rhythmic auditory
stimulation improved the speed, rhythm, stride
length and symmetry of patients’ gait following an
acquired brain injury.679
The case study in this section demonstrates
physical, cognitive and emotional benefits ofI t provided me with something I could focus onother than myself. It provided me with an interest
that was more normal and not hospital led.
Something which I could explore together withothers. Somewhere that was safe and secure,
where I could relax. The art therapy group also
developed new skills, boosted my confidence. It
helped me to slowly regain my physical skills. It
was something to look forward to each week. It
made me feel better about myself. It gave me asense of achievement. It also boosted my mood. I
found I could talk to others and help them toregain their confidence.
The strength of the evidence base in this area
renders arts initiatives for stroke particularly
worthy of consideration by all CCGs.
Pa rk inson’s Disease is a progressive,degenerative neurological condition, affecting an
estimated 127,000 (one in 500) people in the UK. It
kills dopamine-producing cells in the brain, inturn affecting physical, motor and sensory
functions, cognition and communication. In
addition to physical symptoms, such ascompromised coordination, people w ith
Parkinson’s may experience diminishing mental
105

Chapter 7

All-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Report

Working-Age Adulthood

health, including memory loss, mood swings andpsychotic episodes. Policy tends to focus on
helping people with Parkinson’s to maintain their
independence for as long as possible. While drugs

appr oache s , fo c u s i n g on f ac t or s t h at
suppor t wellbeing, so that people w ith
Parkinson’s and those closest to them are better
able to adjust to the health changes caused byt h e c on d it ion . I n b ot htherapeutic and salutogenic
models, the arts can play asignificant part.685
Singing has been foundto have a benef icial effecti n a nu mb e r of he a lt hconditions across the social
gradient, enhancing cognition,communication and physicalf unction ing a s wel l a s
wel lbeing. Singing has
been obser ved to have a positive impact
upon people with Parkinson’s disease, halfof whom experience problems with theirvoic e . 6 8 6 Pa rk i n s on’s U K m a i nt a i n s a
database of singing activities for people with

Listening to music, singing and music
therapy aid physical and cognitive
recovery from brain injury; visual arts
activities contribute to emotional recovery.
are known to be effective in managing some of thesymptoms, they have undesirable long-term sideeffects. This has led to the use of non-medical
therapies, such as speech and language, music, Taichi and massage. It has also led to use of salutogenic

Strokestra
Between May and October
2015, Strokestra, a pilot
collaboration between theRoyal Philharmonic
Orchestra (RPO) and HullIntegrated Community
Stroke Service (HICSS)
within Humber NHS Trust
was funded through a£48,000 grant from Hull
Public Health.
687

Over a for tn ig ht, professiona lmusicians led intensive musicma k ing sessions w ith stroke
survivors and their carers for twodays, interspersed with one-day
sessions led by HICSS staff who had been106

specially trained in musical leadership by
the RPO.688
Strokestra sessions ranged from percussion to
conducting, and culminated with a live
performance at Hull City Hall. Evaluation of thispilot project, approved by the Humber NHS Trust
Research and Development Department, wascentred on individual progress, evaluated through
Stroke Impact Scale scores and semi-structured
interviews. Eighty-six percent of patients felt thesessions relieved their symptoms, citing improved
sleep, reduced anxiety and fewer dizzy spells andepileptic episodes. The same proportion ofpatients indicated that the project conferredcognitive benef its, including improved
concentration, focus and memory, and they feltthat the project provided emotional benefits,
citing increases in confidence, morale and arenewed sense of self. Added to this, 71 percent ofpatients achieved physical improvements,
including walking, standing, upper arm strengthand increased stamina, while 91 percent ofpatients reported social benefits, including
enhanced communication skills and relationships.
Each of the ca rers involved repor ted
improvements in their own wellbeing, by virtue of
respite from their role as a carer and better
relationships with their relative.689

Parkinson’s. 690 Among these is Skylarks in
Canterbury, about which the Sidney De HaanR e s e a r ch C ent r e h a s c om m i s s ione d ashort film.691
Inspired by the Mark Morris Dance Group’s
Dance for PD in Brooklyn, English National Balletdeveloped Dance for Parkinson’s in 2010 withfunding from Westminster City Council, PHF andWest London CCG.692 This programme draws upona classical and contemporary repertoire to provide
weekly classes for people with Parkinson’s, theirfamily, friends and carers at a charge of £5 persession. Since 2012, with the support of PHF, themodel has been extended into areas covered by
MDI (Liverpool), DanceEast (Ipswich), National
Dance Company Wales and Oxford City Council.
Mixed-methods evaluation has been carried out at
the University of Roehampton over three years,
from physiological, social, emotional and artistic
perspectives. 6 9 3 A s m ig ht be ex pected,
participants’ physical condition degenerated overthe course of the study, but improvements wereperceptible in coordination and f luency of
movement. Participants felt their balance and gait
to have improved, even if this was not measurable
by researchers. Participants also appreciated themental stimulus of the classes and experienced
reductions in depression, anxiety and apathy
compared with a control group.694
Between September 2011 and June 2012, a teamled by Professor Clift undertook to study a weekly
group-singing programme for people with COPD.
This showed encouraging results in relation to
improved lung function and quality of life.695 In
June 2017, a similar team published results of atrial involving 60 people with breathing difficulties

hospital provider trusts are looking at integrating
singing into their care pathways for serious lungconditions. We suggest that the efficacy of suchnon-pharmacological interventions merits
consideration when NICE reviews its guidance on
COPD in the over 16s.699
A 2013 study showed a connection between
singing – as a form of guided breathing – and heartrate.700 A 2014 analysis of cystic fibrosis pointed tothe beneficial impact of singing on respiratory
function and psychological wellbeing.701 Scottish
Opera and Gartnavel General Hospital Cystic
Fibrosis Service collaborated on Breath Cycle,
funded by Wellcome and Creative Scotland, a pilot
investigation into the impact of classical singing
techniques on cystic fibrosis patients.702 As a resultof fortnightly lessons with an opera singer over
12 week s, pat ient s repor ted i ncrea sed
psychological wellbeing.703
Cancer affects one in three of us, approaching one
in two, but survival rates are improving. Both music
therapy (active engagement with music) and what issometimes referred to as music medicine (listening
to pre-recorded music) have been observed todiminish the physical and emotional suffering ofcancer patients and the side effects of its treatment.
A Cochrane Review identified 52 randomised andquasi-randomised controlled trials investigating therelationship between musical interventions and thephysical and psychological effects of cancer.704 This
found that music interventions were associatedwith modest reductions in heart rate, respiratory
rate and blood pressure and modest to moderate
reductions in fatigue; by far the largest physicaleffect was on pain reduction. Art therapy has been
seen to relax cancer patients and make them feelbetter physica l ly, 70 5 w it htechnical satisfaction, aesthetic
beauty and pleasure being
implicated in the reduction ofsymptoms.706 The evidence basefor a r t s-ba s e d t her apie s
in palliative care continues
to expand.
A trilogy of Lancet articles
published in 2014 examined therelationship between cancer
and depression.707 Analysing data from over 21,000
patients, major depression was found to be mostprevalent among patients with lung cancer (13.1
percent) followed by gynaecological cancer (10.9
percent) and breast cancer (9.3 percent). The
aforementioned Cochrane Review found thatmusic interventions might have a beneficial effecton anxiety in people with cancer and a moderately
strong positive impact upon depression. In South
Wales, Tenovus Cancer Care employs professionalmusicians to lead choirs for people affectedby cancer.708
Another Cochrane Review explored the stressreducing impact of music in coronary heartGroup singing and dance improve thevoice and movement of people with
Parkinson’s Disease.
attending ten-month community singing groups.
This showed a significant improvement insymptoms, self-management of conditions andmental wellbeing.696 Various groups have been set
up around the country to encourage singing so as
to improve breathing and wellbeing in people
with COPD.697 At the round table on Arts and Public
Health, the Chair of Breathe Easy Dover, Lizzi
Stephens, described how she had reduced her
dependence on inhaled medication, including
steroids, since joining a singing group.
The British Lung Foundation has embraced thehealth and wellbeing benefits of singing forchronic lung conditions,698 and we heard that some107

Chapter 7

All-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Report

Working-Age Adulthood

disease. This found that musical interventions had
a modest beneficial effect on distress and brought
about moderate reductions in anxiety, which were
maximised if patients selected the music
themselves. These effects were most pronounced
for people who had experienced heart attacks.

Singing enhances lung function andquality of life in people with chronic
respiratory disorders.
Several studies showed that listening to music
reduced the heart and respirator y rates
and systolic blood pressure, while two or moremusic sessions led to mild but consistent
pain reduction.709 In the management ofcardiovascular disease, researchers have foundthat the tempo of music influences heart rate andblood pressure.710
Also in relation to distress and anxiety, twofurther Cochrane Reviews explored the impact ofmusic upon patients awaiting surgery and patients
being mechanically ventilated. The first of theseacknowledged the possible
physiological effects of preoperative anxiety, including
slower wound healing andincreased risk of infection. It
found that listening to prerecorded music significantly
diminished patients’ anxiety,br i n g i n g ab out a s m a l l
reduction in heart rate anddiastolic blood pressure, and ‘One large study
found that music listening was more effective thana sedative in reducing preoperative anxiety andequally effective in reducing physiologicalresponses’.7 11 With mechanically ventilated
patients, the second review found that listening to

The Reader

Listening to music and singing diminishes the physical andpsychological effects of cancer and coronary heart disease.
music diminished anxiety and respiratory rateand caused systolic blood pressure to be reduced,
which suggested relaxation in an otherwise
stressful situation.721
NHS England’s Health as a Social Movement
programme is working with Stockport Together
across Greater Manchester to build on the
successful People Powered Health programme.
This entails co-production with people managing
long-term conditions and seeks to improve
emotional wellbeing through the arts.722 At theround table on Commissioning, we learnt about adigital application being developed in Bath andNorth East Somerset called Rover, which
integrates health and social care data. This willallow people to view their NHS records and receive
test results. It will provide details of any long-term
conditions and provision available in thecommunity to help manage these. It could also
keep track of any arts activities undertaken andpotentially generate data about whether theyenhanced outcomes.

7.4

The Reader engages with2,000 people in 400 groups
in the North West andother regions of the UK,
in workplaces, prisons,libraries, mental healthwards, care homes, schools
and local communities.

G

roup leaders facilitate the reading
aloud of serious literature – poems,
short stories and novels – and group
discussion. Participants recognise in
great literature experiences in theirown lives, and, in sharing and discussing thesewith fellow-participants, they gain insight andmutual support.712
The Centre for Research into Reading,
Literature and Society (CRILS) at the University ofLiverpool is principal research partner of The

108

Reader. Adopting an interdisciplinary, mixedmethods approach, researchers at CRILS haveinvestigated the experience of shared reading incontexts such as prisons.713 They have found thatthe act of reading aloud, in combination with theliterature being read, creates a non-judgemental,
compassionate space in which moments ofreflection and realisation can occur.714 CRILS has
established the value of shared reading for mental
health, particularly depression and dementia.715
Researchers have also explored the benefits ofliterature for mental agility and emotional
flexibility and found it to bridge the gap between acurrent unwell self and a past healthy self,716
enabling integration of fragmented parts of theself into a functioning whole.717 Research in thefield of reading and neuroscience suggests that thereading of complex text and the neural processingof language can stimulate brain pathways andinf luence emotional networks and memory
function.718 CRILS research emphasises thepotential for reading to bypass ingrained neuralchannels and find new paths.719 Analysis of theReader’s Shared Reading Scheme, conducted by
CRILS as part of the Cultural Value Project,
showed an enhanced sense of purpose in life
among participants.720

Adult Healthcare
Environments
Professor Jane Macnaughton at Durham
University has noted that the increase in hospitalbuilding around the millennium facilitatedinnovative design and the construction of
dedicated display areas, providing a community
cultural resource.723 A more recent example isSouthmead Hospital in Bristol, which opened in
2014. In this scheme, Willis Newson managed a£1.1m programme, involving professional artists
working alongside the hospital community toenhance the physical care environment and theculture of care. This led to six substantial public
art commissions integrated into the building andgrounds, a recurring arts festival and a series ofinterventions to aid the transition from old to new
hospitals.724 Andrea Young, Chief Executive ofNorth Bristol NHS Trust, who commissioned thework, has noted that ‘The art at Southmead
Hospital Bristol helps to create a more aestheticallypleasing environment, which is important forpeople’s sense of wellbeing. There are special
places where people can have a quiet moment forreflection; there are things to help you feel morecheerful and things to comfort you. The art is
helping to make Southmead Hospital a better place

to be for patients, visitors and staff ’.725 The
relationship between Willis Newson and the trust
continues, leading to new artistic commissions
a nd a n ongoing com mun ity a r ts room
programme.726
A study published in 1984 found that postoperative patients who had a view of nature fromtheir windows recovered more quickly and needed
less pain relief than patients whose rooms faced on
to a brick wall.727 Informing and informed by the
National Gardens Scheme research mentioned inchapter five, Horatio’s Garden is a charity
dedicated to providing restorative gardens in NHS
spinal injuries unit in Glasgow, Salisbury andStoke Mandeville.728
The £10m Kentish Town Health Centre, uniting
health and art, was shortlisted for the Stirling
Prize in 2009.729 Housing a large GP practice and awide range of community health services, thedesign was informed by community consultationand funded via charitable donations and ACE. The
building has a large roof terrace, a formal garden
off the main waiting room and several informal
gardens, creating a pleasing environment forpatients and staff.730
Since the mid-1990s, work has been underway
to create Maggie’s Centres at all the major British
hospitals treating cancer. Named after Maggie
Jencks and co-founded with her husband, thelandscape designer and writer Charles, thesecaring centres have been built for healing on ahuman scale. Designed by renowned architects,
including Zaha Hadid, Rem Koolhaas and Richard
Rogers, and adorned with art, the centres havegiven rise to a new genre – the architecture of hope.
The focus of the centres is psychosocial, helping
those who use them to embrace life and live well.731

7.5

The Criminal Justice
SystemThe prison population has more than doubled overthe past two decades, and we have seen thatmarginalised people and those from the lower endof the social gradient are more likely to enter thecriminal justice system. Through a combination offactors, the life expectancy of prison inmates is
between 15 and 20 years lower than that of thegeneral population.732 In public health circles, it is
ack nowledged that ‘Hea lth inequa l ities
experienced by people in contact with the criminal
109

Chapter 7

All-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Report

Working-Age Adulthoodjustice system are well above the averageexperienced by the general population’.733
It is estimated that up to 90 percent of prisoners
have mental health problems, including anger,
anxiety, depression, insomnia and substancemisuse, likely to be exacerbated by being in prison.
Rates of self-harm and suicide in prisons in
England and Wales are at an all-time high. Over 70
percent of prisoners have two or more diagnosable
mental disorders and up to 7 percent of maleprisoners and 14 percent of female prisoners haveprobable psychosis, 14 and 23 times the level in thegeneral population.734 This grim reality is reflected
in several reports, from the Five Year Forward
View for Mental Health to Investing in Recovery.
DH’s Closing the Gap set out plans to introduce anational liaison and diversion service, so that themental health needs of prisoners could be
identified sooner and the necessary support
provided.735 Next Steps on the Five Year Forward
View pointed to mental health provision for people
in secure and detained settings being put in place
during 2017.
Re-offending costs the Government between£9.5bn and £13bn per year. Much of the literaturesurrounding criminal justice and the arts focuses
on desistance – the process of personal growthdisabilities in a young offenders’ institution(HMP Aylesbury).738
Also at the round table, a former prisoner,
Arthur, set the scene:If you are sent into prison, it is a truly remarkable
and challenging experience. And ultimately you
need some way of expressing that. I don’t need totell anyone that there’s a crisis in terms of selfharm, in terms of violence. Ultimately, these arepockets of trapped individuals with limited skills
in terms of coping mechanisms, in an environment
where it’s not socially acceptable perhaps to talkabout their feelings. So expressing these things isreally important. For me, my art became a way of
externalising certain emotions, certain thoughts,
almost stabilising them. So, once I got them out
there onto a canvas, it felt like that took up lessspace in my head perhaps. And there was aphysical distance between me and them, and thatmade it much more easy to manage them.
In this way, the arts enable greater insight andexpression among people facing otherwise
unbearable crisis.
At the same event, Professor Sarah Colvin
outlined three things that happen when prisoners
engage in arts projects: their relationship withthemselves changes; theirrelat ion sh ip w it h ot herschanges; their relationship witheducation changes. In theprocess, she cor rected acommon misapprehension:‘There’s a lazy way of looking at
the arts as a soft option orsomething f luf f y. They’reactually really hard. If anybody[…] has ever done theatre or has
ever prepared for an exhibitionor has ever prepared for a concert, it’s severely
nerve wracking. It tests your nerves’ capacity. It
tests your stamina. It absolutely tests yourdetermination’. Professor Colvin described how
the sense of achievement gained from creative
accomplishment increased self-esteem andconfidence that life’s challenges could be met.
Added to which, the collaborative aspect ofparticipatory projects builds social skills, develops
empathy and trust, encourages mutual support,
emotional openness and self-ref lection andenables interpretation of the thoughts of others.
A 2016 review of prison education, conducted by
Dame Sally Coates, positioned education as the key
to rehabilitation and laid responsibility upon Prison
Governors for designing and delivering anappropriate curriculum. The review called for‘greater provision of high quality creative arts’, toimprove self-knowledge and confidence and ease
the transition into formal learning.739 It also
stipulated that ‘There should be no restriction on
the use of education funding to support the creative

In the criminal justice system, arts
participation aids self-reflection andempowerment, leading to better healthand wellbeing.
through which offenders may become nonoffenders. This concept implies consideration ofidentity and selfhood over an extended period.736
As Lord Ramsbotham put it at an Inquiry Meeting,the self-esteem that comes from taking part in arts
activity is likely to strengthen desistance, as a
stepping stone rather than an end in itself. The
provision of opportunities to participate in arts
activities in criminal justice settings has beenshown to carry economic benefits.737
The APPGAHW, in conjunction with the
National Criminal Justice Arts Alliance (NCJAA),
has looked at the role of the arts in improving
health and wellbeing in prisons. At the round table
on Arts, Health and Wellbeing in the Criminal
Justice System, Head of Health in the Justice
System for NHS England, Hong Tan, told us thatthe ‘criminal justice system is all about addressing
inequalities’ and drew attention to the success ofarts interventions in achieving constructive
participation. He singled out the work of Geese
Theatre Company with people with learning
110

arts’.740 This route to education among people who
may not have succeeded in conventional learning
environments is relevant to our consideration of
education as a determinant of health.
In the prison regime where the arts are available
through education, this is often limited to a sixweek City and Guilds course. At the round table,
the case was made that the arts should be available
to all prisoners, not only woven into educational
activities but also in leisure time as an alternative
to passive forms of entertainment. Arguing for amore sustained approach than one-off courses
permit, Arthur suggested that resources for selfimprovement, such as paints and brushes, should
be made available in cells. At the same time, more
peer mentoring could be organised, with prisoners
explaining to others the importance of engaging increative activity.
Imprisoned by fascists during the Spanish Civil
War, Arthur Koestler established a trust in his
name in 1962, dedicated to encouraging creativity

in prisons. The trust runs an awards scheme
across more than 50 categories of artistic activity,offers mentoring and artistic feedback and holds
exhibitions of the artwork of prisoners, annually in
conjunction with the Southbank Centre andthroughout the year in cities outside London.741
Women account for five percent of the prison
population, but they are responsible for a quarterof self-harming incidents. Many of the women in
the criminal justice system have experienced
abuse and trauma, which manifest themselves inmental health problems and substance misuse.742
Clean Break was set up by two women in prison 37
years ago, with the intention of putting women’s
stories on stage and delivering theatre educationin prison. Alumnae were recently involved in an
all-female Shakespeare trilogy at the Donmar
Warehouse. Clean Break creates an environment
in which women can establish agency by building
an emotional toolkit that can enable them tomanage their mental health and self-care andCombat Stress
Combat Stress is theUK’s leading veterans’
mental health charity,
providing free specialist
multidisciplinary clinicaltreatment and welfare
support to former soldiersaged 18 to 97.

It is the only charity in the UK to have offeredveterans access to art therapy since 2001.743
This forms the core of an Intensive Treatment
Programme for PTSD, offered at residential
centres in Ayrshire, Shropshire and Surrey.
This works on the basis that traumatic memories
are not stored in a coherent narrative format but
dysfunctionally retained in the central nervous
system and triggered by sensory, trauma-related
cues. By contrast, art therapy is perceived as an
insight-orientated psychological treatment thataccesses non-verbal areas of the brain associatedwith emotions, imagery and bodily sensations. An
adaptive form of art therapy has been developed in
response to the specific needs of traumatised
veterans. Informed by neuroscience, this model ismindful of military culture and shaped by aframework of short-stay admissions. Art therapy
supports veterans who may respond to a nonverbal approach by connecting with the particularqualities inherent in art-making such as symbolicand sensory expression. In this way, veterans areable to connect with and express emotions thatthey may find difficult to put into words.
The art therapy groups are 75 minutes long andcomprise free art making, in response to a theme,
followed by a discussion. Post-session groupreflection on what has been created promotes
insight, incorporates adaptive information andaids the development of a meaningful narrative oftrauma. Between 2012 and 2014, 87 percent ofveterans who completed the programme saw a
reduction in their PTSD symptoms and co-morbid
anxiety and depression, anger and alcohol use, andthis was maintained at their six-month follow-up.

111

Chapter 7

stimulate personal change and growth. At theround table, Eleanor, a student at Clean Break,overcame her nerves to relay powerfully her
experience of self-exploration, through role-playand drama, in safe, non-judgemental space.
Echoing the sense of disenfranchisement
articulated by the writers of the Homeless Libraryin chapter five, Eleanor contrasted isolation andaddiction to connection and bonding, and told of
how this experience had given her the freedom tobelieve she had a ‘right to a life again’.
Jessica Plant, manager of the NCJAA, noted at
the round table that people’s experience of the arts
in prisons was contextualised in many studies
held in the alliance’s library.744 While there is aneed for further research, there is sufficientevidence from case studies and evaluations of arange of arts interventions to inform policy.
Embedding the arts in programmes for educationand health would add value, enhancing jobprospects and improving health and wellbeing. As
the first few weeks after release from prison are
particularly vulnerable, there is scope forpreventative arts programmes in the community.

7.6

Post-Traumatic Stress
The Government’s mandate to the NHS subscribes
to the Armed Forces Covenant, which requiresthat all those who have been physically or mentally
injured while in military service are cared for in a
way that reflects the nation’s moral obligations tothem.745 Yet, ‘Only half of veterans of the armed
forces experiencing mental health problems like
Post Traumatic Stress Disorder [PTSD] seek help
from the NHS and those that do are rarely referredto the right specialist care’.746 Closing the Gap
committed to ensuring that provision was madeavailable to service personnel and evaluation was
strengthened. Next Steps on the Five Year Forward
View announced the inception of Transition,
Intervention and Liaison mental health services
for veterans, which will be available in four areas ofEngland from April 2017.
The NICE guidance for PTSD recommends thatall sufferers are offered a ‘course of traumafocused psychological treatment (trauma-focusedcognitive behavioural therapy or eye movement
desensitisation and reprocessing)’,747 but the arts
are not mentioned. The case study provided in thissection examines the role of art therapy inovercoming post-traumatic stress. Groupdrumming has also been found to facilitate thesharing of powerful emotions in young men (aged
20 to 23) with traumatic military experience.748
While the evidence base for use of the arts in theaftermath of trauma has yet to be fully established,
there are some compelling practice examples.
112

All-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Report

Working-Age Adulthood

Founded in 2009, Combat Veteran Players
focuses on Shakespearian verse and the controlled
breathing needed to deliver it. This award-winningcompany has performed full-length plays bothnationally and internationally.749 Foundation for
Art and Creative Technology, in partnership with
Liverpool Veterans Project HQ, deploys mainlycollaborative visual and digital arts strategies aspart of the Veterans in Practice programme,
founded in 2012.750 Danish Wounded Warriors, inassociation with the Royal Danish Ballet
Foundation, draws upon the physical fitness andself-discipline required of both soldiers and balletdancers to offer a Pilates-inflected programme
designed to improve motor control and functional
movement of battle-worn bodies.751
The arts also have a role in conveying thehorrors of war. Give Me Your Love, a two-hander
staged by Ridiculusmus at Battersea Arts Centre,
explored states of consciousness precipitated bypost-traumatic stress and altered by recreational
psychoactive drugs. Five Soldiers by Rosie KayeDance Company, inspired by serving and former
soldiers, ‘provides an intimate view of the trainingthat prepares soldiers for the sheer physicality of
combat, for the possibility of injury, and the impact
conflict has on the bodies and minds of everyone
it reaches’.752
At the round table on the Arts and Posttraumatic Stress, several people mentioned theimmersive quality of war – the smells, sounds andfeeling of danger – and the need to be immersed inanother kind of environment upon leaving. The
arts potentially provide another kind of
immersion. Richard, a veteran, described how, forhim, the ‘logical, disciplined, military left brain
had stopped communicating properly with theemotional, symbolic right brain’. He had foundthat this dissociation could be resolved by using
the creativity of the right brain and the skills of theleft brain, forcing the two halves to communicate
with each other.
In the USA, ‘policy recommendations havepromoted the inclusion of creative arts therapies
within healthcare teams across the militarycontinuum from pre-deployment/active duty
status to post-deployment reintegration andveteran status’, which has contributed to therecognition and use of arts therapies in a militarycontext and their funding by the National
Endowment for the Arts (NEA).753 At the roundtable, another veteran, Jason, sketched a world inwhich people were trained not to show weakness.
An eloquent advocate of the arts as the ‘notation of
our soul, our humanity’,754 he spoke of the value ofcreativity in aiding veterans to express emotion
and re-enter civilian life. Rather than subjecting
soldiers to a psychological assessment or
diagnosis, he advised offering workshops
introducing creative approaches such as art, music
and comedy to all those leaving military service.

Art therapy unlocks pathways to recovery from post-traumaticstress while participatory arts aid the transition from military tocivilian life.
This is a proposal that we hope the MoD
will consider.755
Of course, soldiers are not the only people toexperience post-traumatic stress. In the previous
chapter, we encountered children suffering as thevictims of war, violence or abuse. A service user who
contributed to the Inquiry described how, whenrecovering from post-traumatic stress, she ‘foundengagement in arts activities absolutely crucial,both in surviving the hospital environment and inintegrating back into the community’. At the roundtable, we heard about Nigel Osborne’s Bosnian
Voices, which saw Liverpool Philharmonic giving
voice to women raped during the Balkan conflict. At
the same event, we also learnt about the work of the
Mental Health Foundation with asylum-seeking
women in Glasgow, using the arts to help overcome
the trauma of migration and raise awareness of thewomen’s plight via the libraries network.756
ACE, PHF and the Baring Foundation havechampioned a role for the arts in creating
understanding, community cohesion and mutual
acceptance between host communities andrefugees while also improving the confidence andskills base of new arrivals.757 This suggests arole for the arts within the UK-wide City ofSanctuary initiative.758
At the round table on the Arts, Health andWellbeing in the Criminal Justice System, theDirector of Music in Detention, John Speyer,
distinguished between detention and the prison
system. In detention, days are counted up rather
than down. In both contexts, incarceration
compromises autonomy and assaults the sense ofself, but the arts ‘nourish the spirit and help people
get through that profound challenge’.

7.7

The Arts in Health
Education
The House of Lords Select Committee on the Longterm Sustainability of the NHS has identified the‘absence of any comprehensive national long-term
strategy to secure the appropriately skilled, welltrained and committed workforce that the healthand care system will need over the next 10–15
years’ as the ‘biggest internal threat to thesustainability of the NHS’, arguing that a ‘radical
reform of many training courses for medical
recruits is desperately needed’.759

Literature reviews examining the use of artsbased approaches in healthcare education show
growing scale and momentum.760 At a round table,
Dr Iona Heath – former GP and President of RCGP– regretted the fact that medicine has ‘prioritised
theory over practice, the disease over theexperience of the patient and number overdescription’ and argued ‘that the arts can play ahuge role in redressing this balance’. The arts andhumanities can address deficits in patient care by,for instance, promoting patient-centred
approaches and empathetic doctors and creating
an intellectual culture within healthcare which
values critical thinking and social engagement.
Between 2005 and 2009, serious failings by Mid
Staffordshire NHS Foundation Trust caused
hundreds of patients to undergo unnecessary
suffering and, in some cases, avoidable deaths. The
Inquiry into these failings, conducted by Sir
Robert Francis QC, insisted on the priority ofpatients within a committed, compassionate andcaring health service.761 The values of commitment,
compassion and care inform the Care Act and lie at
the heart of arts and health work.
Care involves attending to the needs andexperiences of others. Care, in the true sense of theterm, is altruistic and empathetic; it involves
patience, trust and encouragement, and it offershope. Care is to be found in abundance within the
NHS and social care, and the most successful arts
projects in healthcare involve artists who care.
Beyond facilitating sessions and imparting skills,
this implies a sensitive and reflective practicewhich can be refined in response to humaninteractions.762 At a discussion of the Care Act
held by the Inquiry, Sir Robert expressed his
belief that the arts had a role in delivering
better healthcare.
NHS trusts and educational institutions havebeen re-examining how commitment, compassion
and care can be nurtured and developed within
education and training. At medical school, there isoften a component addressing the social
determinants of health, which provides scope forconsidering the evidence linking the arts withhealth and wellbeing.
Some of the research considering how and why
the arts and humanities might be used inhealthcare education has come from the field of
medical humanities.763 Medical humanities are
typically rooted in departments of literature andmedicine, history or philosophy of medicine or
medical ethics.764 Themes explored within thisdiscipline include the aesthetics and narratives of113

Chapter 7

medicine and conceptualisations of health andillness. Academics in this field have drawn on thehumanities to highlight some of the deficits within
medicine and healthcare. There is scope for
medical humanities academics to be more awareof arts and health work and for more embodied
approaches to be adopted in medical education.765
The arts can make a powerful contribution to theeducation and development of healthcare
professionals at undergraduate and postgraduatelevel, and to professional development training.

7.7.1

Undergraduate andPostgraduate Education
The examples of undergraduate and postgraduate
training provided in this section are primarily
taken from medical schools, because this is wheremost progress has been made, often at theinstigation of an enthusiastic medical educatorwith a passion for the arts or humanities but notnecessarily an academic background.
At Plymouth University Peninsula Schools of
Medicine and Dentistry and Exeter School of
Medicine, core and integrated medical humanities
programmes are part of the medical curriculum,and specialist medical humanities academics arepart of the faculty. A new curriculum at Bristol
Medical School seeks to embed medical
humanities in a similar way, and Dr Louise Younie,GP, has connected students with arts projects
based at her surgery. There are many examples ofuniversities that have both medical schools andmedical humanities departments, which overlap
or collaborate on optional courses for medical
students. Some of the arts and humanities
interventions in healthcare education seek todevelop skills in doctors, while others aim to teachstudents about how arts can be used in healthcare,with patients or service users.766 An example of thelatter is provided by Creative and Therapeutic
Activities in Health and Social Care, a unit offeredas part of the Cambridge Technical certificate in
Health and Social Care.
In most arts-based programmes in medical
schools, artists and arts organisations are invitedin to provide expertise or deliver a specific aspectof a programme, with medical students sometimes
being taken into cultural environments. At
present, it is rare for arts-based activities within
medical schools to involve deeper collaboration
with artists or arts organisations. An exception tothis is the work of theatre company Clod Ensemble,
led by artist Dr Suzy Willson, who is an Honorary
Senior Lecturer at Barts and the London Schoolof Medicine and Dentistr y, Queen Mar y
University of London.767
114

All-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Report

Working-Age Adulthood

Since 2001, Clod Ensemble’s Performing
Medicine programme has delivered educationalcourses and workshops, using arts-based methods
to train medical students and practising healthprofessionals, as part of undergraduate medical
curricula, professional development within NHS
trusts and in public events. Practical courses –delivered by associate artists from backgrounds
including dance, theatre, voice coaching andsculpture – focus on a range of clinically applicablesk i l l s , such a s non-verba l a nd verba lcommunication, spatial awareness, leadershipand teamwork. Participator y approaches
stimulate collaboration and critical thinking, withstudents encouraged to embody what they learn
with a view to practising it. Performing Medicinedelivers compulsory courses throughout the corecurriculum at Barts and The London, courses
focusing on long-term conditions and student
wellbeing at King’s College London (supported by
GSTC) and courses for foundation-year doctors at
Royal United Hospitals in Bath.
Another example of engagement with practising
artists is provided by the work of Professor Roger
Kneebone, Director of the Imperial College Centre
for Engagement and Simulation Science. Professor
Kneebone runs the UK’s only Masters of Education(MEd) course in Surgical Education, which involves
experts from the social sciences, humanities andcrafts in the learning of surgeons. Underlying bothteaching and research is the aim of developing
shared insights beyond those of individual
disciplines. So, for example, a group of future
surgeons was taken to a pottery class at Central St
Martins, which gave rise to a conversation aboutthin materials on the verge of collapse, both clay
and blood vessels.768
In the faculty of Life Sciences and Medicine atKing’s College London, Dr Richard Wingate has
worked with textile maker Celia Pym to encourage
students to explore the similarities between
tailoring and dissection. The Anatomy of Value waspart of a wider Crafts Council collaboration called
Parallel Practices, which aimed to explore themutual benef its of makers and medicalor scientif ic academics working together,
the results of which are finding their way into
the undergraduate teaching of health andscience students.769
There are also examples of workshops
and courses that use the visual arts toenhance observational skills in trainee doctors.
A three-month pilot course for trainee
der matolog ists in Ma nchester involved
workshops focusing on single paintings in
the collection of Salford Museum and Art
Gallery. Discussions were centred on close
scrutiny of the colour, texture, pattern andcomposition of artworks, and the development ofdescr iptive la ng uages wa s encou raged.
Participants reported improvements in theirobservational skills that could be applicable todermatology practice; the majority also believed
their written and verbal descriptive skills had
been enhanced.770
In 2012, Jane Cummings, the Chief Nursing
Officer for England, and Viv Bennett, Director of
Nursing at DH and Lead Nurse at PHE,
supplemented Sir Robert’s three Cs withcompetence, communication and courage.771 At
the Florence Nightingale Faculty of Nursing andMidwifery (FNFNM), King’s College London, it isunderstood that the ‘creative arts in nursing andmidwifery education offers one route to explore,
expand and enhance students’ non-normative
ethics and values that underpin the sustaineddelivery of person-centred compassionate care’.772
The Culture of Care programme brought sustained
arts interventions into the faculty, including
photography, performance, musical composition
and group singing. Student feedback indicatedthat the arts programme stimulated empathy
and reflexivity.
Since the early 2000s, an undergraduate
elective module in nursing and the arts has beenoffered to trainee nurses in FNFNM; more recently,

work w ith peer groups and signposting
to community resources – provides a potential
bridge to creative approaches.773 We hope towork with the RSPH, FPH and UK Public
Health Register to ensure that the arts enter
into public health training and professional
development.

7.7.2

Improving Staff and Patient
Wellbeing
With over 1.3 million staff, the NHS is one of the
UK’s largest employers. A review of health andwellbeing in the NHS, conducted by Dr Steven
Boorman in 2009, found that NHS organisations
which valued staff health and wellbeing had better
outcomes, higher levels of patient satisfaction,better staff retention and lower sickness
absence.774 Within the NHS, some 10 million
working days are lost to sick leave every year,
costing £2.4bn – around £1 in every £40 of the total
budget. The Boorman Review
estimated that this could be cut
by a third, equating to almost
15,000 full-time staff andsaving £555m.
The R o y a l C ol le ge ofPhysicians has made explicit
the relationship between staff
health and patient care.775 The
workforce strand of STPs willbe crucial to influencing thep ub l ic ’s h e a lt h f r o m apreventative perspective. In
September 2015, NHS Chief
Executive Simon Stevens announced a major drive
to improve and support the health of healthcare
staff, dealing with burnout and stress, diet,exercise and physical and mental health.776 In
February 2016, NHS England’s Health as a Social
Movement programme set out to work with 32
CCGs, five major acute NHS Trusts and theircharities across London to address workplace
health and wellbeing.777
Fifty-one percent of ambulance staff and 43
percent of mental healthcare staff cite workrelated stress as the reason for their absence fromwork.778 A study of emergency service workers in
Canada found that attending cultural events
during leisure time improved physical health.
Cultural events included concerts, ballet, theatre
and museums, and were found to be means ofcoping with stress.779 This suggests that arts
attendance may be particularly useful inimproving staff wellbeing, which then has an
impact on patient wellbeing and outcomes. In
addition to this, ‘Art therapy-based interventions

The arts have a contribution to make to thecommitted, compassionate and caring
health service envisaged in the Francis
Inquiry, making them central to training
and development.
a separate module has been offered to midwives,and both have proven very popular with students.
Over the same period, Arts Care has been running
the Arts in Health Education training and researchdevelopment programme. This facilitates access toexpert education and training in the role of thearts in healthcare for healthcare professionals,
family and professional carers, nursing andmedical staff and artists.
In many cases, the arts and humanities enter
into the training of healthcare professionals on an
optional basis with little or no assessment. This
will need to be addressed if the arts are to gain afirmer foothold within health, and we hope that
the General Medical Council (GMC) and medical
royal colleges will recognise the importance of thearts in education and continuing professional
development. This might be dovetailed withefforts to introduce social prescribing into the
medical curriculum. Public health training –c e nt r e d o n a s h a r e d u n d e r s t a n d i n gof health and wellbeing, communication skills,

115

Chapter 7

All-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Report

Working-Age Adulthoodcan bring much needed creativity to address workstress and increase resilience and well-being’.780
Strategies to counter burnout have focused on
improving the health and wellbeing of staff outside
work. A £450m NHS initiative, operational from
April 2016, seeks to promote healthy staff
lifestyles.781 None of the three pilot sites for thisinitiative has embraced the arts, but there would
seem to be clear merits in doing so. A Taiwanese
RCT looking at the effect on nursing students oflistening to music twice a week for ten weeks founda statistically significant decrease in depression.782
During the Inquiry, a case was made for out-ofhours reading groups and creative arts groups tobe organised for staff.783
Self-care is increasingly seen as an essential
part of daily professional practice, and it isbeginning to feature in wellbeing-based strategies
in medical schools. Within the workplace, selfcare contributes to creating a caring environment.
In turn, there is scope for artworks made by healthand social care staff to be shared publicly.784
Since 2014, Performing Medicine has beencollaborating with the Simulation and Interactive
Learning Centre at Guy’s and St Thomas’ Trust to
design and deliver courses for healthcare
professionals, supported by GSTC. An outcome ofnormal practice, encourage staff to engage withthe arts and culture as a route to preserving theirown health and wellbeing and that of theirpatients. The GMC might also acknowledge that
self-awareness and self-care are crucial to highquality care and should be prioritised as part ofprofessional practice, to prevent burnout andimprove patient outcomes, and that evidencebased arts methodologies can be used to teachthese skills.

7.8

Health and Care as Routes
for Arts Professionals
There are upwards of 3,600 arts therapists in the
UK and a growing number of courses training arts
therapists to work in specific ways with patients,
such as music therapists working with lung healththrough singing.788 Arts therapists are accreditedby the HCPC and recognised as Allied HealthProfessionals (AHPs), and there is a growing
call for AHPs to become involved in transforming
hea lth and care. 7 89 At present, f unding
constraints limit access toc o nt i nu i n g p r o f e s s i o n a ldevelopment for arts therapists
compared to their medical and
AHP colleagues.
Artists who find their way toworking in the field of health are
not infrequently people whohave rejected the competitive
professional arts world. The
artists of the Hospital Arts
Team that formed in Manchester in the 1970s, forexample, describe how they found they wanted topractise their art for the community rather thanthe market.790 At the same time, research showsthat, ‘whereas artists find solace in the productionof music, the working conditions of forging a
musical career are traumatic’.791 The physical andmental rigours of the performing arts, combinedwith the precarious nature of performative work
lead to anxiety and stress, and depression in
professional performers is three times higher
than in the general population.792
At the round table on Commissioning, Basil
Wild made the point that high-quality arts andhealth provision requires trained and experienced
practitioners with good awareness skills. John
Killick, a poet and former teacher who took part in
the round table on Arts and Dementia, also notedthat practitioners needed proper training, supportand standards. In terms of training, there is a needfor courses and workshops that focus on thespecific skills required of arts professionals
working in healthcare. Educators will need toArts engagement has a part to play inthe self-care of health and social care
professionals.
this collaboration has been the creation of a newframework called Circle of Care, which helps
healthcare professionals to think about, andpractise the skills involved in, compassionate
care.785 This framework acknowledges thei mpor t a nce of sel f-ca re by hea lt hca reprofessionals and the relationship between staff
wellbeing, care between colleagues and theexperiences and outcomes of patients.786 The
Circle of Care framework articulates skills which
can help create a compassionate healthcare
service. These are: self care; verbal and non-verbal
communication; appreciation of the person;
situational and spatial awareness; leadership;
teamwork; decision-making; learning fromsuccess and error. Arts-based methodologies canhelp to develop these skills.787
In the social care sector, Equal Arts is in receiptof CCG funding to deliver artist-led staff training
for creative care involving 30 care homes inpartnership with the Tyne and Wear Care Alliance.
The discussion in this section suggests that NHS
trusts and social care providers might, as part of116

develop their understanding of how the ways ofthinking and skills that can come from the arts
can be employed in health and social care.
There are currently modules within applied
theatre courses which consider how the arts canbe applied in various settings, such as that at
Queen Mary University of London and the Royal
Central School of Speech and Drama. At the
University of Wolverhampton, Professor Ross
Prior – Principal Editor of the Journal of Applied
Arts and Health – explores the pedagogical role oftheatre in relation to health and wellbeing.
Performing Medicine helps artists to apply theirknowledge in healthcare education settings. Artis(mentioned in the previous chapter) recruits,
trains and supports professional performing
artists to work in the school environment.
The Bachelor of Music (BMus) course at
Bir m ing ha m Conser vatoire includes a n
introductory Community Engagement module
which paves the way to a Further Community
Engagement module. It a lso operates a
postgraduate module called Music, Community
and Wellbeing. All of these modules involve
training students in workshop facilitation
techniques and interactive performance skills andtaking them into a range of community settings,
including hospitals and care homes. The
conservatoire partners with Music in Hospitals,
whose musicians mentor students in thesesettings; Live Music Now, Lost Chord: Music for
Dementia and Ex Cathedra Singing Medicine at
Birmingham Children’s Hospital are also
involved, and the module teaching staff areexperienced workshop leaders and interactive
performance practitioners – in one case, aqualified music therapist.
Picking up where the Masters of Arts (MA) in
Participatory and Community Arts at Goldsmiths
left off, the MA in Inclusive Arts Practice at the
University of Brighton is aimed at artists working
in healthcare, education and the community.793 A
Masters in Arts and Health is being developed byArts for Health and Wellbeing at MMU, which
already runs an MA in Arts, Public Health andWellbeing. At Loughborough University, an MA in
Animation for Health and Wellbeing encourages
students from a wide range of backgrounds to‘explore how animation can both facilitate andcommunicate models of health and wellbeing’.794
Looking overseas, Arts in Medicine at the
University of Flor ida of fers a range ofundergraduate and postgraduate courses to arts
practitioners seeking to humanise the healthcare
experience. A Masters course is available online

and centred on training artists-in-residence tomake their own art and encourage the creativity ofothers in environments for health and wellness.795
Healthcare and Design, hosted by Imperial
College London and the RCA, comprises twooverlapping Masters programmes respectively
aimed at health and design professionals. Offeredpart-time over two years and building on the workof the HELIX Centre, the RCA course aims to ‘equip
students […] with the tools and techniques toinstigate and lead innovations in healthcare
systems, services and environments’.796 Two skills
councils (Skills for Care and Creative and Cultural
Skills) are paying attention to the arts in the
training of artists and care workers.797
UK art schools and universities might offer
health pathways as part of arts courses. Mentoring
can also work well,798 and apprenticeships in social
care could include a creative element.799 Across thearts and health field, artists are increasingly
working freelance. More needs to be done toprovide economic security for arts professionals
venturing down a health route.

7.9

Public Engagement
Platforms
Within the healthcare milieu, there is increasing
interest in creating platforms that encourage
dialogue, across disciplines and with the generalpublic, about health, medicine and our bodies at alllife stages. These involve a wide range of voicesfrom healthcare, science and the arts inconversations, performances and workshops. An
example of this way of working is provided by
exhibitions on medical themes at the Wellcome
Collection; another is the work of Operating
Theatre, which uses drama to contemplate healthand wellbeing. 800 Public engagement has apowerful role in advancing healthcare by sharing
perspectives and ways of seeing, improving
understanding of the social contexts in which
healthcare takes place and creating respect fordifferent areas of expertise and methodsof research.
Medicine Unboxed is a non-profit organisation
which holds an annual international event that ispart conference, part festival, curated by Dr Sam
Gugliani and funded by Wellcome, Summerfield
Trust and Gloucestershire Hospitals NHS Trust.
The event brings together artists, scientists,

Within the NHS, around £1 in every £40 is spent on sick leave,
including anxiety, depression and stress.
117Chapter 7

All-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Report

Working-Age Adulthood

writers, theologians, poets, patients, philosophers,
musicians, politicians and doctors. In acontribution to the Inquiry, the organisation madea succinct statement which contains resonance forour work:We contend that good medicine cannot be
understood simply as a sound evidence base forthe right technical decisions and interventions; itdemands more from the practitioner, a wider
kind of knowledge characterised by: empathy,
morality, the recognition of human suffering andwisdom. These attributes are not always
prioritised in the selection and training ofhealthcare professionals. Further, there is ahiatus of trust, understanding and expectation
between medicine and society around thepossibilities and limits of medicine. […] We
contend that arts and humanities can illuminate
this perspective, bring us to debate and foster
awe, wonder and perhaps humility.

The territory covered in this chapter is broad.
As before, we see that inequalities experienced
in early life have a continuing effect when wereach maturity and that our position on thesocial gradient to a large extent determines ourhealth and wellbeing in adulthood. Engagementin the arts has a central role to play inoverturning predestined outcomes.
Position on the social gradient also influences
the likelihood of an interaction with thecriminal justice system and determines theextent to which we are equipped to deal with
incarceration and trauma, but the arts can help
make up deficits by enabling the expressionof experience and emotion and assisting
self-reflection.

At Imperial College, Professor Kneebone leads acreative research group, made up of clinicians,
scientists and artists, which coordinates artsbased public engagement projects. Aiming to
exa m ine med icine beyond the med ica lenvironment, events have included pop-up
operating theatres involving audience members inthe simulation of surgical procedures at more than
100 scientific and literary festivals. The Sick of theFringe is a ‘celebration of the body – its problems
and potential’. 801 This series of events andperformances in Edinburgh and London includes
workshops, installations, performances andartists’ talks that provoke engagement with the
body. Clod Ensemble also presents talks,conversations, performances and workshops,
exploring themes within medicine, healthcare andthe arts and encouraging people to reimagine theplace of medicine in our culture, now and in
the future.
This kind of public engagement has flourishedin recent years, partly as a result of work by
Wellcome, which supports artists to engage thepublic with themes relevant to 21st century
medicine, science and healthcare across the life
course. This enables the exploration of particularissues and the facilitation of dialogue, as distinct
from art improving health or wellbeing while
possibly retaining elements of both. An example isprovided by the Barometer of My Heart, supported
by Wellcome and ACE, an artistic explorationof erectile dysfunction and impotence andthe relationship between the former andheart disease.802

118

119

Sophie McKeand, Artist Facilitator on Age
Cymru’s cARTrefu programme; delivering
art residencies in care homes across Wales;
Emral House care home, Wrexham
Photographer: Ticky Lowe

Older
Adulthood120

121

All-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Report

8 Older Adulthood“I have always believed that arts need noother justification than their own intrinsic
value, their capacity to lift the spirit andgive us experiences of transcendental andinspirational power. And that remains true.
But there are adjacent benefits that holdparticular force in the lives of the elderly”
Baroness Bakewell, Ageing Artfully, 2009In the developed world, people are living
longer than ever before. Over the past two
centuries, life expectancy has increased by
two years every decade, meaning that half ofpeople being born in the West can expect toreach 100. 803 If health and care remainunchanged, this will have a marked impact upon
public spending.
Freed from the ties of work, people in older
adulthood may enter a creative age.804 Longitudinal
research, as noted in chapter three, suggests anassociation between arts engagement and healthy
life expectancy. This chapter considers the role of
the arts in the lives of older adults. Whileremaining mindful of the barriers to participation,
it explores the proposition that arts engagement
may lead to longer lives better lived.805

8.1

Healthy Ageing
Older people in good health and full possession of
their faculties are referred to as being in the Third
Age, whereas older people whose health, mobility
or mental acuity is compromised are said to be in
the Fourth Age. Frailty denotes an accumulation ofhealth deficits which increases the risk of adverse
outcomes and the likelihood of hospital admission
and long-term care.806 The House of Lords SelectCommittee on the Long-term Sustainability of the
NHS noted that:Increased longevity of life was one of thetriumphs of the 20th century. The challenge fortoday is to ensure that those extra years arehealthy years. The health service in this country
122– in common with most of those in the developed
world – was designed primarily to treat shortterm episodes of ill health and today continues tooperate around individual conditions and bodyparts. Consequently, it is less adapted for frail,
elderly people with multiple health conditions.807
NHS England recognises the imperative to adapt
to the needs of frail elderly people and points to thedeceleration in hospital admissions in vanguard
areas.808 We argue that the arts are of great value inpreventing and postponing frailty.
A 2016 Foresight report responded to theopportunities and challenges of an ageing
population to advocate not only significant
adaptations to health and care systems but also
working until later in life, appropriately designed
housing and lifelong engagement with mentally
stimulating activities.809 Several of the specificpolicy areas the report identified for ensuring
wellbeing across the lifecourse overlap with those
covered in this report, including increased accessto social networks and reduced loneliness,increased independence; reduced incidence ofcognitive disorders such as dementia; increased
health and wellbeing and reduced avoidable
inequalities in health outcomes.
There is growing recognition that people
beyond working age ‘can be creative, productive,
carers, lovers, citizens, consumers and enjoyers ofwhat society has to offer’.810 Yet, while many older
people lead satisfying and fruitful lives, health inolder age is determined by income and by current
and previous experience. 811 Educational level
predicts life expectancy, and disability-free life
expectancy is unevenly distributed across thesocial gradient.812 Older people living in deprived
neighbourhoods are significantly more likely toexperience mobility difficulties than those in lessdeprived neighbourhoods, 813 with high-status
people experiencing the vitality of people fifteenArts engagement is central tohealthy ageing.
years younger at the bottom of the social
gradient.814 In turn, a lack of mobility exacerbatessocial isolation, has a negative impact upon healthand diminishes participation in leisure activities.
In Scotland, a 2007 plan for the ageing
population included the ambition that older people
should contribute to building thriving local
economies, playing their part in the voluntary
sector and fully participating in sport, culture andthe arts.815 A Scottish action plan on ageing for
2014–16 included a section dedicated to the artsand cultural activities. It acknowledged thebenefits of the arts in improving and maintaining
health and physical and mental wellbeing, and it
advocated the promotion of local and national arts
festivals and cultural activities to older people.816
The Welsh Government’s Strategy for Older
People in Wales 2013–23 set out a vision forimproving social, economic and environmental
wellbeing as key components in building a goodquality of life. Advocating lifelong learning andother activities, the strategy
made mention of the arts andcreative activities. Specifically,
it promoted the ‘participation ofolder people in the a r ts
throughout the year’, with theaim of enhancing the ‘mental
and emotional health and wellbeing of older people in Wales by enablingengagement with artistic and creative activity’.817
In Northern Ireland – where the number ofpeople aged 70 plus was projected to increase by 74
percent in the twenty years from 2009 – the Officeof the First Minister and Deputy First Minister
published a crosscutting strategy for older people,
entitled Ageing in an Inclusive Society, which
addressed economic exclusion, health andwellbeing.818 In response, Age NI took the lead on
developing a national Positive Ageing strategy,
which recommended that addressing thechallenges of an ageing society should focus on
maximising the positive contribution made bypeople in later life. However, this 2009 strategy
omitted consideration of the arts.819 The Northern
Ireland Executive’s Active Ageing Strategy for
2016–21 included the provision that older people

Silver Song Clubs
The charity Sing forYour Life offers
participatory music
activities to older people.

C

ommunity singing takes place in its
Silver Song Clubs, promoting healthy
ageing under the slogan ‘a song a day
keeps the doctor away’. In 2012, an RCT
was conducted to explore the effects ofcommunity singing. Five new singing groups were
set up in East Kent, and volunteers aged over 60
were randomly assigned to one of these groups or
to a non-singing group. Participants in the singing
groups took part in a 12-week programme led bySing for Your Life. Compared to the control group,

three months into the project the singers reported
significantly improved quality of life and lower
anxiety and depression; after six months, thesebenefits had diminished but still exceeded thosemeasured at the outset.820
In a large-scale survey of choral singers in
England, Austria and Germany, the majority ofparticipants endorsed the idea that singing
enhanced their wellbeing.821 It was found thatsinging involved focused attention and controlled
breathing, which counteracted anxiety and stress;
offered social support, helping to overcome
isolation and loneliness; promoted learning as anantidote to cognitive decline; provided a regularcommitment that discouraged inactivity; raised
the spirits and made people happy.822

123Chapter 8

All-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Report

Older Adulthoodshould have access to the cultural resources ofsociety, but it made no recognition of the value ofarts participation.823
In 2009, the Government published Building aSociety for All Ages, which signalled an intention to
enable older people to continue working beyond
retirement age, collaborating with NESTA toaddress the health impediments to doing so; in theprocess, inclusive design standards wereembraced but not the visual arts.824 A report by the
NEA finds that: esign and visual arts play an important role inD
the well-being and quality of life for older people.
The design of residential buildings for older
people can affect the amount and quality of social
interaction, physical activity, cognitive
stimulation, and emotional well-being ofresidents. The landscaping, traffic flow, building
materials, and design of activity hubs all
contribute to the success or failure of a residential
facility as a thriving community.825
Between 12 January and 19 February 2017, the New
Old exhibition at the Design Museum – curated by
the Helen Hamlyn Professor of Design at the RCA
and supported by the Helen Hamlyn Foundation –examined ways in which designers could help tomeet the challenges of our rapidly ageing society.
In the visual arts, the focus tends to be on youth,and even relatively successful artists become lessvisible as they age, yet the argument is made thatboth visibility and value could be enhanced
through the arts.826
In the USA, the late Dr Gene Cohen led theCreativity and Ageing Study, supported by the NEA
at George Washington University, which looked at
the impact of weekly participator y arts
programmes over two years. This involved 300
ethnically diverse participants (half of whom
formed a control group) aged between 65 and 103
and dispersed across three states. Activities
included painting, pottery, dance, music, poetry
and drama. The study found ‘true healthpromotion and disease prevention effects’,
including increases in self-reported health and‘reducing risk factors that drive the need for longterm care’, including falls. 827 Dr Cohen later
reviewed research suggesting that social,
psychological, and neurobiological mechanisms
were at play.828
The Mental Health Foundation advises readingbooks and playing musical instruments as a way topreserve mental health in older age.829 In chapter
five, we saw that NICE recommends singing, arts,
crafts and other creative group activities tosafeguard mental health and wellbeing in older
people.830 The European project, Long Live Arts
(2014–16) championed creative ageing for its
individual, communal and societal benefits,particularly for older people experiencing poverty
or isolation or in need of care.831
As people age, quality of life is ‘largely
determined by their ability to access needed
resources and maintain autonomy, independence,and social relationships’.832 During the round tableon Music and Health, Dr Jane Povey, GP andFounding Director of Creative Inspiration
Shropshire CIC, a social prescribing initiative,
noted that ‘We spend a lot of time in health andcare propping people up, trying to keep them alive,
trying to cure, but sometimes what we’re really
doing is extending the length of life without doing
an awful lot about quality of life. My premise is that[…] we can grow and maintain individual wellbeing
and resilience using the creative arts’.
In February 2017, Age UK published work on
wellbeing in later life. Data gathered from morethan 15,000 respondents was analysed against 40
wellbeing indicators drawn from Understanding
Society. This found that, of those older people
experiencing the lowest wellbeing, 80 percent had
not achieved a GCSE qualification, underlining theconnection between educational level andwellbeing. Engagement in creative and culturalactivities was found to make the highest
contribution to overall wellbeing.833 This suggests
that, in seeking to improve quality of life for older
people, frontline charities should include the arts
in their strategies.
In chapter six, we saw that children who learn toplay a musical instrument benefit from better
aural processing and speech
perception than their nonmusical peers. A research teamled by Professor Nina Kraus,
Director of the Auditor y
Neuroscience Laboratory at
Northwestern University in
Illinois, has found that lifelong
en ga ge ment w it h mu s ic
improves the ability of older
people to differentiate speechfrom background noise, which
is a common difficulty, caused by the slowing ofneural activity in the midbrain.834 The team also
found that, even in non-musical older adults, short-

Regular group singing can enhancemorale and mental health-related qualityof life and reduce loneliness, anxiety anddepression in older people.
wellbeing and reductions in medical appointments
and requests for medication. At the same time,arts participation led to greater independence,124

term auditory training increased the plasticity ofthe brain, aiding speech recognition in noisy
environments, though the effects were only
partially sustained after the training stopped.835
The What Works Centre for Wellbeing review ofliterature analysing the relationship between
music, singing and wellbeing in healthy adults
found that: egular group singing can enhance morale andRmental health-related quality of life and reduceloneliness, anxiety and depression in older
people compared with usual activities.
Participatory singing can maintain a sense of
wellbeing and is perceived as both acceptableand benef icial for older participants .
Engagement in music activities can help older
people to connect with their life experiences andwith other people, and be more stimulated.
Singing can maintain a sense of wellbeing in
healthy older people.836
A large-scale mixed-methods study funded by
the Baring Foundation and conducted by LiveMusic Now between June 2015 and July 2016 lookedat the impact of singing on older people in carehomes.837 This resulted in the establishment of aconsortium, with academic research led by

combined responsibilities for the arts, publichealth and wellbeing, social inclusion, community
cohesion and older people’s services. 842 Thisis echoed by the LGA strategy for healthy
ageing, which recognises social prescribing andthe arts.843
To demonstrate the contribution of the arts tohealthy ageing and beyond, a handful of examples
is considered in this chapter, complementing theaccount of Age-Friendly Cities and Communities
given in chapter five. This evidence suggests that
local authorities, PHE and local directors of publichealth, the RSPH and the FPH should promote
engagement in creative activity as a component of
successful ageing.

8.2

Dance andFalls Prevention
People are likely to become more sedentary as theyage, but dance provides a form of aerobic exercisethat can be adapted to individual capabilities.
Dance has physical health benefits, including
improvements in balance, strength, gait, postureand reaction time. The alertness
required for dancing increases
mental acuity, while the social
nature of dancing is an antidote
to isolation and increases
subjective wellbeing.844
Equal Arts has been working
across art forms in the North ofEngland since the 1990s,
particularly with older people
experiencing long-term healthconditions. Between January and May 2014,
research conducted as part of the Cultural Value
Project studied the Grand Gestures dance project
run by Equal Arts. Seeking to identify the somatic
properties of dance, the research focused on
sensory awareness, connectedness and being in
the moment. This found that, as a by-product of thecreative process, dance stimulated an expanded
sense of self and of community, providing a ‘set oftools for enhancing everyday life and navigating
the ageing process’.845 Local dance projects toenhance the health and wellbeing of older people
have been set up in many places.846
Ageing is generally accompanied by a decline insensorimotor, cognitive and physical performance.
Falls are the most significant cause of emergency
hospital admission for older people and a major
factor in people moving from their own homes into
long-term care, estimated to cost the NHS £2.3bn
per year. 847 Falls prevention strategies arecalculated to reduce falls by 35 to 54 percent, butthey are generally quite unappealing.848 One hour

Dancing strengthens balance and posture,
sharpens mental acuity and reduces thelikelihood of falls.
Professor Clift. A literature review found that
‘research on group singing for older people showsconvincingly that singing can be beneficial for
psychological and social wellbeing’. 838 Thissuggested an overarching recommendation
indicated by the project’s title – A Choir in Every
Care Home – which has been heeded in a
programme endorsed by the CQC.839
The Baring Foundation has conducted research
into older people’s theatre in the UK, shining alight on 25 initiatives and presenting 14 casestudies. 840 Another Baring Foundation report
documents a significant number of organisations,
across the UK, dedicated to bringing theparticipatory arts to older people – in their own
homes or through community organisations,
hospitals, hospices, day centres or nursing homes– with many more organisations having a strand ofwork for older people as part of a larger remit.841 A
further report looks at the position of local
authorities in securing a creative and healthy older
age for their populations by exerting their125

Chapter 8

All-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Report

Older Adulthoodof dancing per week for six months by healthyolder people has been shown to benefit cognitive,
tactile and motor performance while proving
engaging and popular.849
Dance to Health, a falls prevention exercise
programme for older people (aged 60 to 95), isbeing piloted by Aesop in partnership with ACE
NPOs specialising in dance in Cheshire, London
and Oxfordshire, with funding from a range ofsources. 850 Trained dance artists embed
physiotherapy in regular, fun, sociable andcreative dance. The programme is aimed at bothprimary and secondary prevention – in otherwords, at those who are at high risk of experiencing
their first fall and those who have already had afall. Evaluation has shown completion rates of 72
percent, which potentially represents better cost-effectiveness than NHS falls prevention exerciseswith much lower retention rates. In recognition of
their physical and mental health benefits, Age UK
supports dance classes for older people, 851 but
demand outstrips supply.852

8.3

Combating Social Isolation
Age UK estimates that 1.2 million older people in
the UK are chronically lonely. 853 The Marmot
Review found that social participation increased
healthy life expectancy. Social participation inolder age is considered even more beneficial for
health than giving up smoking.854 By contrast,social isolation – defined as lessthan weekly contact withfamily, friends or neighbours –is estimated to affect more than
two million people over 60 in
the UK, with those on low
incomes twice as likely to feeltrapped and lonely than theirEngagement in arts activities helps toovercome social isolation, acting as aprotective factor against dementia.

Dancing in Time
Leeds has an ambition to
be the best city in whichto grow old, and it has its
own Older People Forum.

I

n January 2015, Public Health Leeds
commissioned Yorkshire Dance and the
University of Leeds to investigate thefeasibility of implementing a dance
programme to improve the health andwellbeing of older adults (aged 60 to 85) living in
the community. The project considered factors
known to contribute to falls, including fearof falling.
Contemporary dance is a low-impact physicalactivity open to all, regardless of physicalcondition. It offers the opportunity to interpretmusic, either individually or as part of a larger
group, through movement which includes
elements of aerobic exercise, balance activities,
low-level resistance exercise and moves that126

enhance flexibility. During 2015, three dancecourses were offered in Leeds over 10 consecutive
weeks, each comprising twice-weekly sessions of
90 minutes, led by specially trained dance artists.
There was an 85 percent adherence rate for those
who took part in the project, compared to 40
percent for standard NHS falls prevention courses.
Researchers from the School of Biomedical
Sciences at the University of Leeds used a varietyof questionnaires and motor activities to examine
the impact of participation on physical activity
patterns, balance, fear of falling and mood. A
group discussion with participants explored theirperceptions of the ways in which the programme
had affected them. This showed decreases insedentary time and increases in physical activity,
decreases in fear of falling and increases inhappiness. Additional benefits attributed to thedance programme included reduction of pain,
easing of joint stiffness, increased energy levels,
better balance and coordination and feeling morerelaxed. Dancing in Time thus moderated thephysical and psychosocial risk factors for falls.855

more aff luent counterparts. Isolation, which
accounts for up to a third of GP visits, is associatedwith poor physical and mental health andsignificantly increases the risk of dementia.856
Arts engagement of ten involves social
interaction, which helps to overcome loneliness.
Ow Bist [How Are You?], a two-year project fundedby PHF, aims to tackle isolation in ruralcommunities in Shropshire. A pilot project (May–
June 2016) offered a programme of art, craft anddance at a charge of £5 per session. Evaluation of
the pilot showed creative strides being madeby participants and new relationships being
forged. An extension of the project began in
September 2016.857
The Campaign to End Loneliness – led by acoalition of organisations including Age UK

Oxfordshire, Independent Age, Sense, Manchester
City Council and WRVS and funded by the Calouste
Gulbenkian Foundation – has embraced arts
strategies, partly for their role in creating social
connections and empowering older people.858 The
Arts Council of Northern Ireland has implemented
a programme called Not So Cut Off, which aims to
alleviate both isolation and loneliness in older
people through the arts.859 On the strength of theevidence, the Jo Cox Commission on Loneliness,founded in 2017, might consider arts approaches
when developing its work.860

Staying Well
In November 2014, theStaying Well project was
set up across the area
covered by Calderdale
Metropolitan BoroughCouncil, which is madeup of semi-rural areas
peppered with population
centres containing diverse
communities and areasof deprivation.

T

he project seeks to reduce isolation andloneliness among older people anden able pr e vent ion a nd e a rlyintervention. It is hoped that this willdiminish pressure on health and social
care resources. Staying Well workers were initiallyplaced w ithin four community anchor
organisations, taking responsibility for identifying
isolated and lonely people and signposting them toappropriate community activities. A devolved
micro-commissioning budget of £50,000 was

allocated to each of the four community hubs,
supporting local activity providers to increaseprovision and create new opportunities, tacklingbarriers to people accessing activities.
Engagement with community groups andindividuals enabled funding to be directed tomeeting local needs. A wide range of art and craft
activities was provided, including painting anddrawing, music, singing and cinema at a charge ofless than £5 per session.
Evaluation of the first 18 months of the projectby the University of Lincoln showed almost half ofthe 779 participants to have a long-term conditionand over a third to have two or more long-term
conditions.861 Among the 55 percent of participants
drawn from deprived communities, there was ahigher incidence of long-term health conditions,lower quality of life and greater isolation andloneliness. Three of the four hubs showed areduction in loneliness over the initial period, withsome participants also reporting improvementsin their health.
Initially intended as a 12-month pilot project,with funding from Calderdale CCG matched by
the NHS Vanguard programme, the project has
been extended three times. It has expanded inscope to become a universal adult service acrossthe whole borough with funding from the council.

127

Chapter 8

All-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Report

Older Adulthood

8.4

Museums on Prescription
An AHRC-funded research project (2014–17) led byProfessor Helen Chatterjee at UCL is investigating
the potential of museums on prescription as partof the wider social prescribing landscape for older
adults.862 Building on previous work with older
adults,863 ten weekly two-hour programmes arebeing offered to vulnerable or lonely older adults(65–94) across seven museums in central London
and Kent. The sessions combine activities such as
gallery talks and tours, discussions, museum
object handling and collections-inspired creative
activities. The research involves exploration of thevalue of cultural heritage in overcoming social
isolation and of the relationship between touch
and wellbeing mediated by cultural artefacts.864 A
range of qualitative analyses and quantitative
scales is being used, including measurement of
wellbeing and loneliness. Interim findings show

A Museum Directory of SocialPrescribing and
Wellbeing Activity in North West England has been
published by HEE, showing a £3 return on every £1
invested. 867 In seeking to expand their rangeof visitors, more cultural organisations mightmake it part of their strategy to reach older
people in their communities who are at risk ofsocial isolation.868

8.5

Residential Care
More than 580,000 people over 65 live inresidential care in England and Wales,869 over
33,000 in Scotland 870 and around 15,000 in
Northern Ireland.871 Sense of meaning and purposein life can diminish with age.872 An estimated 40
percent of older people living in care homes areaffected by depression, compared with 20 percentof older people living in the community.873 The
Royal College of Psychiatrists
estimates that 85 percent ofolder people receive no NHS
help for depression, and suicide
rates are higher among older
people than in the general
population. 874 People withdepression have a 50 percent
higher risk of early death thantheir contemporaries without
depression, which isc omp a r able t o t he r i s k
associated with smoking; in the over-65s, this risk
jumps to 75 percent.875
The Commission on Residential Care, chairedby Rt Hon. Paul Burstow MP, placed an emphasison ‘self-determination, self-reliance, fun andcommunity bonding among residents, employees
and families’ and made due recognition of the arts,
suggesting the colocation of care homes with arts
and adult education colleges.876 In chapter four, we
saw that the CQC encourages care homes toprovide meaningful activity. NICE states thatpeople should be encouraged to take an active rolein choosing and defining activities that aremeaningful to them, which the guidance
anticipates may include ‘leisure activities such as
reading, gardening, arts and crafts, conversation,and singing’.877 A growing body of evidence andpractical experience shows that engagement in thearts increases the wellbeing of healthy older adults
in residential care.878
In England, 11 percent of care home provision isby local authorities. There is increasing
recognition of the arts among the bodies
representing both non-profit and for-profit carehome providers (the NCF and the English
Community Care Association). The Living Wellthrough Activity in Care Homes toolkit, developed

Museums and galleries contribute toincreased psychological wellbeing andhave a part to play in age- and dementiafriendly communities.
a progressive increase in psychologica lwellbeing across sessions and some upward trend
in social inclusion.
Dulwich Picture Gallery is located in the London
Boroug h of Sout hwa rk , wh ich ha s a n
unemployment rate of two and a half times thenational average and a 30 percent minority ethnic
population. Since 2005, the gallery has run theGood Times: Art for Older People programme,
which accepts referrals from doctors’ surgeries offrail, depressed or lonely people. A conscious effort
has been made to engage older people from thesurrounding area, particularly older men (who areless likely to engage in community activity thantheir female counterparts).865 A broad programme
is offered free of charge, comprising gallery tours
and participatory arts workshops (visual art, dramaand dance, in the gallery and in the surrounding
community), with a consistent emphasis on thequality of activities. The programme offers a chance
to socialise, and it adopts an intergenerational
approach by engaging the carers of older people andyoung people from local schools. Evaluatedby researchers at the Oxford Institute of Population
Ageing, the programme has been found to havebenefits ranging from mental stimulation toincreased confidence and a positive outlook.866
128

by the College of Occupational Therapists, includes
the arts and crafts, music and singing in its list ofsuggestions to care home owners and managers.879
In its work with older people, the Baring
Foundation has looked at good practice in the arts
in care settings across the NCF. This yielded areport, Creative Homes: How the arts cancontribute to quality of life in residential care,which found that 82 percent of NCF members
encouraged some form of arts activity, brightening
care home environments and their grounds andimproving quality of life.880 The participatory arts
were seen to inspire residents and staff in carehomes, helping to maintain physical health andflexibility as well as cognitive functioning and asense of identity. Some examples of innovative
participatory practice that we were told about as aresult of the call for practice examples are
mentioned here.
In 2012–13, the Wallace Collection was awarded
funding from the National Institute of Adult
Continuing Education and Community Learning
Innovation Fund to develop a series of resourceboxes for loan to care homes, with the aim ofproviding museum access to older people. Six
themed loan boxes were created, containing
reproduction images and objects, intended as a
stimulus for discussion and appreciation. A
booklet was written for each theme, and a tablet
with relevant digital content was included so thattrained care home staff and volunteers coulddeliver their own sessions with residents.
Sometimes a visit was made to a local museum.
Beginning in London, the project was extended
elsewhere in southern England, engaging morethan 350 participants. The project stimulated andrevived interest in the arts, inspired newconversations, ignited memories and improved
wellbeing. It also demonstrated a hunger for artsbased activities in care homes, and several of thepartner organisations continue to use loan boxes
as a popular part of their activity programmes.881
In April 2015, Age Cymru began delivering
cARTrefu [reside], a two-year project which aimed
to improve the wellbeing of care home residents
through the participatory arts, jointly funded by
the Baring Foundation and Arts Council of Wales.
Four lead mentors were recr uited f rom
performing arts (dance, drama), music, visualarts and writing (poetry, prose) to oversee thework of a further four practitioners in each art
form. The 16 artists delivered weekly two-hourparticipatory sessions over a period of eightweeks in up to 128 care homes, reaching almost
2,000 residents and making cARTrefu the largest
project of its kind in Wales. The project is being
independently evaluated by the Dementia
Services Development Centre Wales at Bangor
University, which aims to explore the impact of
the residencies on all those involved. Interim
evaluation suggested improvements in residents’

wellbeing and the quality of care being provided
by staff.882
Also in April 2015, Magic Me,883 an arts charity
mentioned by the Commission on Residential
Care, began running a two-year programme ofartists’ residencies, in partnership with Anchor,
England’s largest non-profit care home provider,and four arts partners.884 Funded by PHF and
Wakefield and Tetley Trust with a contribution
from Anchor, the focus was on high-quality artistic
activity. At the Greenhive Care Home inSouthwark, for example, Punchdrunk Enrichment
used immersive design to transform a room into
an English village square, complete withhedgerows, a post box and a pub. On a grassy areaat the centre, a long white table was installed. Carehome residents were invited to take a seat at thetable and become part of the Greenhive Green
Committee, engaging in weekly creative activities
related to village life. Interim evaluation showed
the project to have been popular with participants
and carers alike, animating and personalising thecare environment.885 We support the proposal ofartists’ residencies in every care home made by
Alice Thwaite from Equal Arts.886
In May 2016, CQC published a five-year strategy
highlighting the importance of person-centredcare.887 CQC Chief Inspector of Adult Social Care,
Andrea Sutcliffe, has pointed to the role of the arts
in enabling people to live full and meaningful lives.
She identified the best care homes to be ‘flexible
and responsive to people’s individual needs andpreferences, finding creative ways to enable people
to live a full life’.888 We hope that this positive view
will lead to more examples of the arts benefitingsocial care being included in the CQC guidance.
This would encourage care home providers tosecure culturally stimulating environments fortheir residents and staff and incorporate the arts
into care packages. In turn, an imaginative andholistic approach which impacts on the wellbeingof individuals should make care homes more
attractive to commissioners.
Inspiring architecture makes an immense
difference to the quality of life of people inresidential care. There are many examples of welldesigned residential care, such as homes provided
by MHA, the Belong Village in Wigan and theAbbeyfield dementia care home in Winnersh.
We would like to see care homes and villages
that are comparable in the quality of theirdesign to the Maggie’s Centres mentioned in theprevious chapter.

129

Chapter 8

All-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Report

Older Adulthood

8.6

The Arts and Dementia
In 2015, an estimated 850,000 people in the UK
were living with a form of dementia. The same
number was thought to be undiagnosed. As the
population ages, it is estimated that this figure will
increase to over one million by 2021 and two
million by 2051 (with a seven-fold increase in
BAME communities compared to a two-foldincrease in the general population).889 Replicating
the health inequalities that persist in society,higher educational levels and occupational
attainment, as well as participation in theintellectual, social, physical and creative aspectsof life, are associated with slower cognitive decline
in older adults.890 Diet, drinking, exercise andfamilies; and the option of personal budgets, sothat resources can be used in a way that works bestfor individual patients’. 893 The NICE quality
standard for dementia independence andwellbeing included the recommendation that
‘People with dementia are enabled, with the
involvement of their carers, to take part in leisureactivities during their day based on individualinterest and choice’.894 People with dementia canbe challenged to take part in activities theymight not have previously contemplated, withpositive outcomes.
The arts have a part to play in many aspects ofdementia, from delaying its onset and diminishingits severity to improving quality of life for people
with dementia and their carers.895 At one of ourInquiry meetings, Dr Sebastian Crutch – a clinicaland research neuropsychologist working in the
Dementia Research Centre at
UCL’s Institute of Neurology
and on a Wellcome-funded
project exploring dementia andthe arts called Created Out of
Mind896 – pointed out that there
are many different types ofdementia and everyone will
have a different journey, but
creative activity has more
f lexibility to address thatcomplexity than generic therapies or drugs.897
Chair of the APPG on Dementia, Baroness
Greengross, has said of people with dementia that
‘It is vital for their wellbeing that when given adiagnosis that their brain is degenerating, theyshould at the same time be directed to creative
activity as cognitive rehabilitation’.898 Resonate in
the City of Westminster provides an example ofperson-centred pathway-based care for people
with dementia. Group sessions in the communityand one-to-one activities in people’s homes areoffered involving music, visual arts, poetry, dance
and the performing arts. Funded by Central
London, West London and Hammersmith &Fulham CCGs and a range of trusts and foundations
including the City Bridge Trust, the programmefollows people through the dementia care pathway
from diagnosis onwards. This provides familiarity
with people’s life stories and capabilities, opening
the way for people with dementia to benefit
through the arts.899 We urge NHS England toinclude the arts in personalised post-diagnostic
support for people with dementia.
We are treating this conjunction between arts,
health and wellbeing at greater length than othersections because dementia is a national challengeof outstanding importance, and there areconsiderable bodies of both practice and researchin this field. We believe lessons learned in regard
to dementia can have application in other fields.

Arts participation in care homes helps tosafeguard mental health, wellbeing andindependence in older people.
smoking also modify the risk of dementia. Older
people who live in more deprived areas are more
likely to experience an earlier onset of dementia
and to die younger from it than those who live inmore affluent areas.891
While dementia is not confined to older
adulthood and there are approximately 65,000
people under 65 living with dementia in the UK,
onset is most common in older adulthood, with
one in 14 people over the age of 65 developing it. It is
the main cause of disability in later life, affecting
an estimated 70 percent of care home residents.
The rate of deaths with a mention of dementia has
been steadily increasing to become one of the top
five causes in the population and the main cause ofdeath in women. In 83 percent of cases, dementia ispresent alongside, and often exacerbates, other
health conditions (particularly circulatory andrespiratory diseases), extending the length of
hospital stays by up to seven times and accounting
for a quarter of inpatients (3.2m bed days).892 The
annual cost of dementia to the UK is £26.3bn; thisis expected to exceed £50bn over the next three
decades. Two thirds of the cost of dementia isborne by affected families, and there areapproaching 700,000 informal carers for people
with dementia.
The Five Year Forward View advocated a‘consistent standard of support for patients newly
diagnosed with dementia, supported by named
clinicians or advisors, with proper care plansdeveloped in partnership with patients and
130

8.6.1

Delaying Onset
If the onset of Alzheimer’s disease (which accounts
for 62 percent of dementias) could be delayed by
five years, savings between 2020 and 2035 are
estimated at £100bn.900 For every person withdementia living at home rather than in residentialcare, savings of £941 per month (£11,296 per year)
are made; if five percent of admissions could bedelayed by a year, £55m would be saved.901
As already mentioned, research suggests thatsustained later-life musical training enhances

Arts participation enhances brain
function, improving resilience todementia.
neural plasticity, potentially bolstering resistanceto dementia.902 A study of the Rhythm for Life
project at the Royal College of Music probed thispreventative effect and found a positive impact for
older adults learning to play an instrument.903
A longitudinal study of 469 people aged over 75,
who showed no signs of dementia at the outset, had
found dancing in particular to be associated with areduced risk of dementia.904 This drew upon datafrom the Bronx Ageing Study and focused on thepreventative rather than the palliative. A larger
longitudinal study of 1,375 people in Sweden foundthat both participatory creative activity (including
painting and drawing, classified as mental activity)and cultural attendance (understood as a social
activity) had a protective effect against dementia.905
In March 2012, the Prime Minister launched adementia challenge, advancing a moral, as well as
economic, argument for innovative research inthis area.906 Gathering evidence of a positiveeffect of the arts upon people with dementia isdifficult because the moment of onset is often
uncertain and the condition worsens over time.
Further research is needed into delaying onset
and admission to residential care for people
with dementia.

8.6.2

Cognitive Functioning
NICE and SCIE advocate that people with mild tomoderate dementia ‘should be given theopportunity to participate in a structured groupcognitive stimulation programme’.907 Dr Crutch
advised us that, while cognitive stimulation

therapy may make a statistically significant
difference, creative activities make an existentiallysignificant difference to the lives of people withdementia and their carers.
A 2014 study of post-retirement adults foundthat – as compared to a group engaged in art
appreciation – participants who actively produced
art over 10 weeks showed greater functional
connectivity in the brain, which was related tostress reduction and psychological resilience.908 In
2015, researchers at the University of Newcastle
worked with BBC Two’s Trust Me, I’m a Doctor toestablish which activities boosted brain function.
Healthy but fairly sedentary adults aged between
50 and 90 were randomly
assigned to groups undertaking
brisk walking, Sudoku or life
drawing. In terms of enjoyment,
the art classes were the mostpopular. When it came tocognitive functioning, all thegroups showed improvements,
but the clear winners were theart group. The combination oflearning something new, developing psychomotor
skills and staying physically and socially active(standing while drawing or painting andsocialising with others in the group) was thoughtto account for the benefit observed.909
An RCT in Finland involved coaching the
caregivers of people with early dementia to
introduce listening to music or singing into their
daily routines. This found that both listening tomusic and singing improved mood, orientation,
remote episodic memory and, to a lesser extent,
attention, executive function and general
cognition. Singing also enhanced short-term andworking memory in people with dementia.910
A 2016 review of research into communitybased literary, performing and visual arts forpeople with dementia showed that ‘arts-based
activities had a positive impact on cognitive
processes, in particular on attention, stimulationof memories, enhanced communication andengagement with creative activities’.911 Yet, whilearts attendance followed by art-making was foundto improve episodic memory, the impact of suchsessions on mood, conf idence and social
engagement were regarded as equally important.912
One approach that is often used for people withdementia is reminiscence, which focuses on thestimulation of memories. The National Museumsof Liverpool has been running reminiscenceprogrammes since 2000. The best known of theseis House of Memories – started by Executive
Director of Education and Visitors, Carol Rogers,and funded by DH – which began by offering
dementia-awareness training programmes tohealth and social care workers. Toolkits have been
produced for developing reminiscence sessions inregional and national museums, on themes that131

Chapter 8

All-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Report

Older Adulthood

encourage diverse participation, and the model
has received national and international
accolades.913 However, remembering can be
distressing and not all reminiscence programmes
have been found helpful.914

8.6.3

Personhood and Qualityof Life
The concept of personhood in dementia carerejects the idea that the mind is predominant in
defining the self, in favour of the experiential andrelational. At the round table on Music and Health,the musician Julian West eloquently articulated
the value of experiencing creativity in the moment.

Reminiscence Arts &Dementia: Impact on
Quality of Life (RADIQL)Art Exchange’s project
Reminiscence Arts &Dementia: Impact on
Quality of Life (RADIQL)
is a 24-week structured
psychosocial intervention,
developed over 30 years,
which combines areminiscence-based
approach with arts
activities.

B

etween 2012 and 2015, GSTC funded an
LSE study of RADIQL, working withpeople diagnosed with dementia in 12
c a re home s i n L a mbet h a nd
Southwark.915 Two specially trained
artists encouraged the development of non-linear
na r rat ives f rom long-ter m memor ies,
communicated through speech, drama, literature,song/utterances, art/craft, listening to/making
music, handling objects/sensory materials/props,
dancing to music or embodied through movement.
A total of 35 people participated in the RADIQL
programme of 300 sessions; six of the 12 carehomes did not receive the intervention and thus
formed a control group.

132

A report on the project by Royal Holloway
University London (RHUL) notes that
‘Reminiscence Arts recognises and values
embodied and sensory memories as well as verbal
or narrative recall. The arts activities extend
reminiscence practices, which often rely on verbal
discussion, by involving all the senses andenabling participants to communicate nonverbally through mark making and movement’.916
A mixed-methods evaluation measured thequality of life, wellbeing and behaviours ofparticipants, before, during and after the sessions
and three weeks and three months later. Levels of
wellbeing among RADIQL participants were seen
to improve by 42 percent, and positive behaviour
increased by 25 percent, discernible in the first 50
minutes of the activity, remaining for 30 minutes
afterwards and steadily improving over the 24week period of the study.
An assessment was also undertaken of the costeffectiveness of the programme, following
methods consistent with the HM Treasury Green
Book. This calculated the costs incurred inachieving improvements in behaviour (£5,754 for a
one-point change), mood and engagement (£1,252
for a one-point change), paving the way for acomparison with the cost of care without these
improvements or a monetisation of the
improvements themselves.917 A further evaluation
determined that the project created a total of 2.271
Quality Adjusted Life Years (QALYs) for the 35
participants across 24 weeks; this means that, forevery £1 spent on the RADIQL intervention, there
is a return of £1.35 in QALYs. The benefits to qualityof life outweigh the costs of the project on theaccepted QALY measurement scale used by DH.

At the round table on Arts and Dementia, held
jointly by the APPGAHW and the APPG on
Dementia, the Director of Green Candle Dance
Company, Fergus Early OBE, observed that artistic
languages enabled communication. Thissalutogenic approach suggests that arts
professionals are well placed to facilitate
meaningful relationships in the here and now,
providing a ‘style of communication and selfexpression that is particularly able to capitalize on
the emotional and social capabilities of people
with dementia’.918 Here, the focus is on engaging
the creative capacity of people with dementia,
rather than treating symptoms or addressing
disease aetiology.919
This approach is accompanied by calls for
greater attention to be paid to subjective wellbeing,enabling arts encounters to be better tailored toparticipants, on the understanding that ‘when
people are allowed to live with dementia, rather
than exclusively fight against it, the condition
becomes a “manageable disability”’.920 DH’s 2009
national strategy for living well with dementia
made passing reference to arts therapy.921
The arts have repeatedly been shown toenergise and inspire people with dementia andtheir carers. A seminal programme at the Museumof Modern Art (MoMA) in New York City saw small
groups of people with early Alzheimer’s being
invited to monthly educator-led tours of four orfive artworks, each lasting up to an hour and ahalf.922 Meet Me at MoMA focused on feelings
rather than words and involved observation,
description, interpretation and interaction.
Evaluation showed an uplift in mood in both caredparticipatory sessions in either a traditional or acontemporary gallery once a week for eight weeks.
Among several reported benefits, the cognitive
capacities (attention and concentration) andquality of life of people with dementia were seen to
improve; the carer burden was diminished, andthe relationship between carer and cared for wasenhanced. Irrespective of whether the gallery was
traditional or contemporary, participants enjoyed
the programme and the social engagement
it facilitated.926

8.6.4

Music
A 2013 DH report on dementia in England madepassing reference to the beneficial sensory aspectsof arts engagement in general and music therapy
in particular.927 An RCT comparing standard carewith music therapy over six weeks found thatagitation increased in the first group anddecreased in the second, leading to a diminution of
medication in the group receiving music therapy.928
NICE advises that people with all types andseverities of dementia who also experienceagitation may be offered ‘therapeutic use of music
and/or dancing’.929
Music in Mind is a creative music therapy
initiative run by the Manchester Camerata
chamber orchestra, which seeks to improve
quality of life for people with dementia
and enhance communication, relationships
and physical mobility and improve care practicet h r o u g h m u s i c -m a k i n g .
Evaluation showed that 67
p e r c e nt of p a r t ic ip a nt s
experienced reduced levelsof an xiety, frustration oranger and diminished useof outpatient ser v ies
and medication.930
Several quantitative andmixed-method studies havedemonstrated a relationship between dementia
and music.931 An overview of some of this evidence,alongside examples of practice, is provided inArts 4 Dementia’s report, Music Reawakening:
Musicianship and access for early to mid stage
dementia.932 Another useful overview of music andsinging projects for people with dementia isprovided by Age UK.933 The What Works Centre for
Wellbeing review of music and singing in people
with dementia pointed to a role for music listening
in enhancing wellbeing.934
Music for a While, a project led by Arts & HealthSouth West in partnership with the Bournemouth
Symphony Orchestra, provided music for people
with dementia in three acute hospitals in Poole,Portsmouth and Winchester. The project was

Across art forms, creative activity
improves quality of life for people withdementia and their carers.
for and carers, as well as an increased interaction
between them and with the rest of the group; theexperience was assessed very positively byparticipants.923 A UK equivalent is Meet Me at theMuseum at the Pitt Rivers Museum, run by
Oxford University Museums Partnership incollaboration with the Creative Dementia Arts
Network, which offers monthly dementia-friendly
access to the museum collections leading to coproduced exhibitions.924
Research validates this approach, with anaccess programme for people with dementia at the
National Gallery of Australia demonstrating
immediate value for participants.925 In the UK, 12
people with mild to moderate dementia and theircarers took part in two-hour exploratory and133

Chapter 8

funded by the Wessex Academic Health Science
Network, and the University of Winchester
conducted a research project at Winchester
Hospital. Weekly two-hour music sessions –involving listening, singing, playing percussion
instruments and occasional composition –shortened the length of stay (by 6.2 percent),
reduced the number of falls (from 47 to 31) anddecreased the use of antipsychotic drugs (by 4.26
percent during the intervention and by 27.7
percent on music days). 935 This suggeststhat arts strategies could be considered ingovernment initiatives to reduce the use of
antipsychotic medication.936
A psychosocial model of music in dementia has
been developed, predicated on the ‘accessibility ofmusic for people at all stages of dementia, close
links between music, personal identity and life
events [and] the importance of relationshipbuilding through music-making’.937 The part of thebrain responsible for storing emotional memory isunaffected by dementia, which means that theevocative effects of music endure throughout life.
A musician described at a round table how‘Seemingly disengaged patients, as soon as westarted with old war time standards, jumped up,
were singing, they were bright-eyed, they were fullof life’.938
Running since 1993 and managed by Wigmore
Hall since 2009, Music for Life offers participatory
music projects to people with dementia, fromdiagnosis to end of life, with a focus on late-stage
dementia in care homes. Professional musicians
work with professional care staff to deliver
improvised music sessions over the course of eightweeks. The core aim of the project is to improve
quality of life for people with dementia, with thesecondary aim of empowering staff to take theproject forward. Internal evaluation (Dementia
Care Mapping) has suggested that Music for Life
has a positive effect on communication; reduces
signs of depression; increases involvement in
activities and personal care; enhances appetite;
improves mood; and amplifies interaction withothers. External evaluation showed that the
programme enhanced staff sensitivity topersonhood and nurtured key skills for musiciansworking with people living with dementia.939

8.6.5

Singing
A Choir in Every Care Home found that ‘Singing
activity can positively engage people withdementia across a spectrum of severity from mild
to late-stage’.940 Singing is thought to stimulate
several different areas of the brain and influence a
feedback loop between the auditory and thesensor y-motor systems. Behavioural and
134

All-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Report

Older Adulthoodneuroimaging studies show that singing activates
regions of the brain associated with working
memory.941 Added to this, group singing has beenfound to have a positive impact on the partners
and carers of people with dementia.942
In 2003, Alzheimer’s Society piloted Singing for
the Brain in Newbury, Berkshire, combining
singing and gesture in a social setting. Led by aspecialist in speech and singing, the programme
has been seen to aid communication bystrengthening neural pathways to the vocal andbreathing mechanisms. The relative complexity ofthe songs being practised stimulates cognition;
the immersive nature of sessions contributes tostress reduction, and their social aspect increases
conf idence and encourages friendships.943
Singing for the Brain has been the subject of ashort film,944 and the programme featured in a
BBC Radio 4 documentary.945
As part of a project exploring the civic role of thearts supported by the Calouste Gulbenkian
Foundation, community musician and storyteller
Sal Tonge held a series of creative conversations
around group singing with people with dementia
in Shropshire. The film that resulted helps us tounderstand the ways in which artists ‘animate thehuman infrastructure of society’.946

8.6.6

Dance
A Cochrane Review of evidence about dance
movement therapy for people with dementia
highlighted the connection between movement,
thoughts and feelings. The review found thatdance movement therapy delayed cognitive
deterioration while reducing challenging
behaviours, improving mood and enhancing
quality of life.947 Positing dance as a form of nonverbal communication, the review paraphrased
literature speculating that movement might
unlock embodied memories, allowing an
expression of self that does not rely on cognition or
speech. A systematic review of dance for people
with dementia in care homes found evidence ofimprovements in fine motor skills, balance andgait, self-management and hope.948 South West
Yorkshire Partnership NHS Trust hosts the world’s
first centre of excellence for dance and dementia,
where kinetic neuroscience research is looking at
the impact of movement on the body.949
Committed to improving the health andwellbeing of older people through dance andmovement, Green Candle Dance Company has
developed programmes specifically for people
with dementia. Remember to Dance has beenoffered free of charge to people with early- to midstage dementia and their carers, in the community
and in the dementia unit of Mile End Hospital in

East London.950 The programme was the subject ofa two-year evaluation by the Sidney De Haan
Research Centre. This found that, in bothcommunity and hospital settings, Remember toDance made a positive contribution to the qualityof life and mental wellbeing of people in different
stages of dementia.951

8.6.7

Visual Arts
The aesthetic preferences of people with
Alzheimer’s and frontotemporal dementia havebeen seen to remain constant even when they haveno memory of specific artworks.952 Research
conducted at Dulwich Picture Gallery suggested
that the episodic memory of people with dementia
could be enhanced through aesthetic responses tovisual art.953 Added to this, various individual andsocial benefits were reported, including improved
mood and cognitive capacities and a greater senseof inclusion.954
Supported by the Big Lottery Fund between July
2015 and May 2016, Drawing Life brought life
drawing classes to people with dementia. Led by
two art teachers and involving an experienced
male life model, a total of 10 classes took place at
Hastings Court, a residential care home in West
Sussex. The main medium was charcoal, andcompleted artworks were selected for exhibitionin public galleries.955 In a submission to theInquiry, one of the teachers involved in the project
observed that ‘The act of drawing is a kind of
language for those who have lost some or all
speech, and facilitates participants and carers tocommunicate in other ways. […] The drawings
reveal something fascinating about life andmemory to both the participants themselves andothers who view their work’.
Canterbury district has the highest number ofpeople with dementia in Kent. A 2015 study at the
Beaney Museum and Gallery in Canterbury,
involving 66 people with early stage dementia andtheir carers, was the first to compare the wellbeing
impact of three activities: handling museum
objects, viewing and discussing art and a social,non-art activity (refreshment break).956 Using arigorous crossover design and the Canterbury
Wellbeing Scales, both the object handling and art
viewing activities were shown to be statisticallysignificant in increasing subjective wellbeing as
compared to the social activity alone.957 A further
research study, using the same scale to examine
the subjective wellbeing of 80 participants at theTunbridge Wells Museum and Art Gallery,compared people with early- and middle-stage
dementia who handled museum objects. Results
showed a significant increase in wellbeing for bothstages of dementia, with those at an earlier stage

showing the most difference. This led the researchteam, headed by Professor Camic, to ‘feel confident
that for most people with early- to middle-stage
dementia, handling museum objects in a
supportive group environment increases
subjective wellbeing and should be considered
par t of a hea lth promotion strateg y indementia care’.958
The Dementia and Imagination project takes as
its starting point that ‘Observing art and making
art seems to make a difference’ in people withdementia.959 Jointly funded by the AHRC and
ESRC, this research programme is adopting arealist method to look at how and why art might
improve life for people with dementia and theircarers. At the same time, it is considering ways inwhich people with dementia might be better
connected to their communities.960

8.6.8

Digital Arts
A 2012 Baring Foundation report called Digital
Arts and Older People distinguished between
digital technology being used as a tool (to researchand disseminate creative practice) and as a
medium (through which artwork is created).961 It
also pointed to the personalised and multi-sensory
experiences digital technology could provide forpeople with dementia. A 2015 update presentedcase studies of the creative use of digital technology
by older people including House of Memories andthe following example.962
The Armchair Gallery – part of the Imagine
project, delivered by a consortium in Nottingham
including the local authority and funded by the
Baring Foundation and ACE (2014–17) – worked
with artists and digital technology to enable theviewing of artworks by older people with dementia
whose circumstances do not allow for visits tocollections. Participants included people inresidential care homes and their own homes inisolated settings. The study was both formative(helping shape the programme) and summative(informing best practice and future arts
interventions). An analysis of the Imagine study
calculated an SROI of £1.63 for every £1 spent.963
The results of this study may be used to inform the
LGA’s plans to transform social care through theuse of technology.964
The Cardiff-based arts organisation Chapter
offers dementia-friendly screenings of films
without adverts or trailers and with slightly
brighter than normal auditorium lighting.965 The
British Film Institute has a Dementia Services
Development Centre.966

135Chapter 8

136

All-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Report

Older Adulthood

8.6.9

8.6.10

Performing Arts

Written and Spoken Word

The Elderf lowers programme, operated by
Edinburgh-based charity Hearts and Minds, offers
performing arts activities to people with dementia
in hospital care across Scotland.967 Funding comesfrom a range of sources, with 10 percent from the
Scottish Government. The aim is to improve
quality of life for residents through verbal and nonverbal communication with a humorous edge.
The New Victoria Theatre in Newcastle-underLyme, Staffordshire, is particularly noted for its
development of documentary theatre as a genre. A
multidisciplinary study of the role of theatre in the
lives of older people – established as a collaboration
between Keele University and the New Vic –explored lived experience and representations ofageing within a particular cultural context. This
found the performing arts challenged stereotypes
about the capacity of older people for exploring
their creativity and helped older people to adjust totransitions in their lives.968 West Yorkshire
Playhouse has issued a guide to dementia-friendly
performances.969
At the Inquiry’s round table on Arts and
Dementia, Managing Director of Ladder to theMoon, Chris Gage, made the point that the arts
should be considered as an opportunity to develop
the workforce and wider organisational culture.
Inside Out of Mind is a 90-minute play developed by
Nottingham Lakeside Arts and Meeting Ground
Theatre Company in association with the
University of Nottingham. It depicts the experienceof basic-grade health and social care support
workers caring for older people with advanced
dementia. Based on first-hand accounts andscripted by a professional writer–actress using
verbatim dialogue, its aim is to alter theperceptions of healthcare professionals andreinforce recognition of the personhood of people
with dementia. With Lottery funding from ACE
and HEE, the play was toured to six cities insouthern and central England between February
and March 2016, and a recording of the play was
subsequently screened at conferences andfestivals. A diverse audience of almost 7,500
mainly working-age people saw the production as
it travelled. Telephone interviews conducted amonth after the tour demonstrated that the
majority of those who saw the play discussed
it with friends and colleagues and said it
had improved the quality of dementia carethey provided.970

While the use of a linguistic medium with people
who are losing their words might seemcounterintuitive, creative writing projects havegenerated good results. A collection of writings byeight people with dementia, with a foreword by Jo
Brand, was published in 2014 under the title
Welcome to our World. The book is full of personal
reminiscences – of being evacuated from
Ramsgate to Stafford during the war, and runningclasses for spies and murderers at Wormwood
Scrubs. It provides an insight into the reality ofliving with dementia, with Rose writing that ‘there
are times when I really don’t know what I’m doing:“Why am I here, what’s happening?” But we’ve got
to keep going’.971
Controlled analysis of TimeSlips – a groupstorytelling programme that encourages creative
expression in people with dementia and theircarers in care homes across 10 states in the USA –found participants to be more engaged andinteractions between residents and staff to be
more frequent and of better quality.972 In the UK,
the Storybox Project is an exercise in creative
story-making which engages, enlivens andempowers people living with a dementia alongside
the people that support them.973 Originally funded
as a pilot by Manchester City Council in 2010, theproject was further developed with three years offunding from PHF and is now predominantly acommissioned project involving CCGs, publichealth teams and individual care homes.974
Poetry appeals to similar parts of the brain assong, and the case has been made that performed
poetry escapes the definitional constraints of thewritten word to communicate through repetition,rhythm, syntax and movement experienced in the
moment.975 John Killick has pioneered a method of
co-writing poetry with people with dementia,
which ‘has persistently emphasised the existenceof self hood, the ability to communicate inlanguage, and to exercise creative choice even at
relatively late stages of a dementia’.976

8.6.11

Community Festivals
Since 2012, Arts Care has run Here and Now, aseven-month annual festival across Northern
Ireland which seeks to enhance the wellbeing andquality of life of people over the age of 60 throughparticipation in a variety of arts including dance,music, drama, visual art, digital art, puppetry,
poetr y, f ilmmaking and photography. In
association with more than 85 organisations, thefestival prioritises people living with dementia,

Parkinson’s disease and respiratory conditions.
The festival has led to new links between
participants and healthcare staff and amongneighbours in rural areas.977
All this evidence suggests that, in responding tot he dement i a c h a l len ge , PH E , he a lt hcommissioners and local authorities will do well topromote the arts as community-based cognitiveand emotional engagement. PHE could usefully
inform all HWBs, GPs, diagnostic and memory
services of the efficacy of the arts in improving
brain function and enhancing communicationand quality of life, so that, when people receive adiagnosis, they may be offered a referral to anarts organisation.

8.6.12

Dementia-Friendly Design
An estimated 25 per cent of people accessing acutehospital services have dementia. The busy hospitalenvironment and disruption to routine can be
unsettling, inducing confusion and anxiety,causing feelings of isolation and precipitating adecline in social and functional skills. In 2008, theKing’s Fund submitted a report to DH, outlining
ways in which learning from the EHE programme
could be integrated into the health service andproposing to improve the environment of care forpeople with dementia. As a result, the King’s Fundwas commissioned to oversee a programmefostering supportive design for people withdementia.
Research showed that an inability todifferentiate between coloured, shiny andshadowed surfaces presented spatial challenges topeople with dementia. As a result, modifications
were made to dementia care environments inacute, community and mental health hospitals at
26 sites. Such dementia-friendly design was found
to: reduce falls, agitation and the need for
antipsychotic medication; promote independence;
improve nutrition, hydration and engagement inmeaningful activity; encourage greater carer
involvement; and improve sta f f mora le,recruitment and retention. This led to cost savingsand enhanced wellbeing among patients and staff,
and these design recommendations were endorsedby the Royal College of Nursing.978 The reportarising from the King’s Fund project specified arole for the arts in providing meaningful activity,
enhancing familiarity and aiding way-finding andorientation.979
In October 2012, the Secretary of State for
Health announced the creation of a £50m
Dementia Friendly Environments Capital
Investment and Pilot Scheme for 2013–14, for local
authorities working with social care providers to
improve design. In the same year, Dementia

Services Development Centre in Stirling launched
the Virtual Care Home – an interactive online
resource showing how dementia-friendly design
could work in care settings or at home.980
In March 2015, DH issued comprehensive
design guidance which paid heed to the layout andsensory properties of health and social careenvironments intended to help people live wellwith dementia. This advised the provision of spacefor expressive activities, including music andsinging. It also recommended the installation ofartwork on the understanding that ‘Artwork can
support people with dementia live a life as close as
possible to how they were living prior to the onset
of dementia (e.g. eat, sleep, dress and do activities);
objects of art can help overcome sensory, cognitiveand physical impairments’.981 Where possible,
DH’s dementia-friendly design guidance should be
adopted by all NHS trusts and health and social
care providers.
In 2015, Imperial College NHS Healthcare Trustdeveloped a new patient-centred dementia
strategy which aimed to provide more creative
stimulation to inpatients. This led to the inceptionof Paper Birch Workshops, which are held on
either a one-to-one basis at the bedside or in groups
within communal areas. Workshops encouragecommunication through a selection of activities
exploring the power of scents, handling craftmaterials and writing and engaging in sculpture
and fine art. The sensory properties of materials
are central to the workshops, particularly colour,
intended to stimulate the occipital lobe, which isoften affected by dementia. Workshops aredesigned to facilitate discussion and are focusedon process rather than product, tailored to eachparticipant’s needs and preferences. There isrecognition within the dementia team that theworkshops have contributed to the wellbeing ofpatients and staff, humanising what can otherwise
be a forbidding environment.982

137Chapter 8

Older Adulthood

All-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Report

The ageing population poses one of the greatest
challenges to health and social care. Thisparticularly applies to adults in the Fourth Age,with health inequalities having a profound
impact upon disability-free life expectancy.
Frail older adults place unsustainable demandon an already overloaded system, with falteringtransitions between health and social careleading to extended, expensive hospital stays
and accusatory headlines about ‘bed blocking’.
A Chief Executive of an NHS trust, consulted aspart of the Inquiry, referred to the ‘oceans ofsuffering behind closed doors’ that lie behindthese headlines.
Until the health inequalities in our society
have been substantially eliminated, it will be a
struggle to keep older people fit and active. A
viable route for this is engagement in the arts.
Numerous examples have been provided of theways in which the arts can contribute to healthy
ageing, from singing for general health to dance
for falls prevention. We have also seen theprotective effect of social participation and theways in which the arts provide a nexus formeaningful social activity in both urban andrural locations. This leads us to the conclusionthat every effort must be made to ensure thatthe current generation of older adults has accessto the arts-based resources it needs.
While there is much debate about the typesof arts activity that should be offered to people
with dementia, there is widespread agreement
as to their positive effects. People with dementia
and their carers prefer ongoing programmes,
rather than one-off experiences, but even oneoff experiences have a positive impact. The
Website of Arts 4 Dementia provides a databaseof relevant creative activities, searchable byregion,983 and the Creative Dementia Arts
Network connects people with dementia,
carers, commissioners, artists, academics,
representatives of arts and care organisations
and others working in the field.984 This kind of
information would benefit from being madeavailable in offline formats, for people with adementia diagnosis who are not web-literate,accompanied by relevant, face-to-face advice.

138

139

Dawne Solomons, Rocks,
produced during an art
therapy session with
Michèle Wood at Marie
Curie Hospice, HampsteadWith thanks to Dawne’s family

End of Life
140

141

All-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Report

9 End of Life“We are mortal beings – fragile, finite
creatures with some meaning attached to us.
The arts tell us this truth very starkly andhold important questions for us against the
hubris of science and ostensible progress”
Dr Sam Guglani, consultant oncologist

Around 500,000 people die in England
every year,985 yet there remain taboo
and embarrassment about death. Dr
Iona Heath has written of how
technical advances over the past
century have meant that ‘The whole discipline of
medicine has colluded in the wider societal projectof seeking technical solutions to the existential
problems posed by distress, suffering and thefinitude of life and the inevitability of ageing, loss
and death. Sickness and death have gradually
come to be regarded as failures of medicine, evenby doctors themselves, rather than inevitable
constituents of what it is to be human’.986
Death has provided abiding subject matter for
artists through the ages. Artists and arts
therapists working with people nearing the end of
their lives in hospices, hospitals, care homes andthe community encourage creative reflections on
the finitude of life. At the round table on Palliative
Care, Dying and Bereavement, music therapist
Bob Heath observed that people reaching the endof their lives are often drawn to creativity, finding
new ways to express themselves, overcome theirfears and maybe discover new hope and peace.
Fiona Hamilton, Director of the Orchard
Foundation, noted that ‘The desire to be creativeand feel life is meaningful can be vibrant until theend of life, in spite of physical constraints andmental challenges’. This chapter looks at the ways
in which the arts enable us to explore the passage
between life and death, to the benefit of the dying,
their loved ones and carers.

142

9.1

Dying Well: The Hospice
Movement
In 1967, Cicely Saunders founded the modern
hospice movement by opening St Christopher’s
Hospice in London as a place where the dying andtheir families could be cared for by a teamdedicated to giving physical, psychological, socialand spiritual support. Saunders believed thatevery person was unique and remained important
until the last moment of their lives. She committed
herself to enabling people to live well until the
moment they died.
The great majority of deaths in England arepreceded by a period of chronic illness. Palliative
care, provided by hospices, relieves the pain,
symptoms and physical and mental distress of
disease. At the round table, Consultant in Palliative
Care, Dr Viv Lucas, said that the role of doctors inthis context is not to cure disease but to heal theirpatients. This implies ‘addressing the subjective
experience of human suffering and facilitating aprocess of inner change – not about thetechnological doing to of the disease-orientatedmodel but of being with, bearing witness’. In thisway, it is possible to die healed.
As the 2011 Arts for Health Manifesto put it,
somewhat brutally, ‘Magic bullets don’t exist andwe can’t cheat death by painting’.987 However, ‘The
fact that the arts move us physiologically,
psychologically and emotionally’ makes them
‘important tools when dealing with common
responses to a terminal illness such as depression,lack of meaning and direction, and fear of the
future’.988 Through the arts, we can transcend
suffering and enable our own healing.989

The hospice movement acknowledges creative
work to be a vital human activity and an integral
part of lives lived to the full. This embraces thepotential of creativity not only to make ill healthmore tolerable but also to enhance wellbeing. In
hospices, creative activity is offered on an
occasional or more sustained basis, as part of day
care or as an inpatient activity.
A study of the impact of the arts on hospice staff
showed that ‘art-viewing and art-making enabled
relational processes and supported personal
insight. Several participants […] reported a positive
impact on wellbeing, creativity and improved
communication as well as some lessening of workstress, attributed at least partially to the process[of art-viewing and art-making]’.990
In the palliative care environment, researchers
have found that music therapy reduces anxiety,pain, tiredness and drowsiness991 and increases
wellbeing.992 Psychotherapist Dr Christine Mason
describes how unconscious, unresolved issues
may exacerbate, or even cause, pain, and how thearts can help in raising levels of awareness andovercoming alienation from ourselves.993 Patientdirected art therapy in palliative care settings
enables the expression of powerful, difficult

myself. I could get lost in this painting and forgot
about everything that felt bad to me at that time. It
was then that I realised that other patients could
maybe get the same benefit from it that I did. And
they did’.996
In 2008, the Director of Supportive Care (Nigel
Hartley) and the Director of Psychosocialand Spiritual Care (Malcolm Payne) at St
Christopher’s Hospice co-edited a book in which
they described how: alliative care brings to the arts the opportunityP
to interact with physical and mental
deterioration, death, pain and loss. Arts
practitioners in palliative care are present at a
crucial transition in the lives of most families,
shaped by powerful emotions and new personal
relationships and social experiences for patientsand their families. All this can bring inspirationand stimulation to artists, and generate
important opportunities for new artistic
expression.997
In return, the authors note that ‘creative work
permits patients to rehearse their personal
reactions to their illness and impending death in a
protected and sympathetic
env ironment w ith others
sharing similar experiences’.998
Creative activity helps patientscome to terms with theirown mortality.
St Christopher’s is one ofaround 300 hospices in the UK,
where end-of-life care is offered.
Yet, only four percent of deaths
take place in hospices,999 which
remain on the fringes of the NHS system. Thismeans that hospices have very limited reach into
the surrounding community, and people being
treated for terminal illnesses generally have little
access to creative experiences.

During terminal illness, arts participation
provides an antidote to physical andpsychological pain.
emotions about dying, helping to relieve thepsychological trauma of living with a terminal
illness. Image-making is a form of communicationthat can enable new identities to be described anduncomfortable feelings left behind. People do notneed experience to be able to benefit from thiskind of psychological support; the process ofmaking, the feelings aroused and the interaction
with the therapist are what matter.994
In a diary entry dated 1 April 2005, Chris
Rawlence, a filmmaker, writer, librettist andhospice artist-in-residence, observed how, ‘On
several occasions, I’ve noticed that creative
collaboration can have an analgesic effect. People
who are dependent on high doses of morphine toalleviate pain may find that they don’t need thedrug for a few hours a week that they are absorbed
creatively. Rather than simple distraction – ordiversion – this seems to be the positive outcomeof creative engagement’.995 John Lieser, a day
services patient at the Prince and Princess ofWales Hospice in Glasgow, related how ‘For thetime I was sitting painting, I forgot all about myillness. It really took me to a new depth within

9.2

Beyond the Hospice
Movement
A majority of deaths in the general population (58percent) occur in hospitals. At the round table on
the Arts and Healthcare Environments, Directorof Grampian Hospitals Art Trust, Sally Thompson,read out a letter from a woman whose husband had
been diagnosed with terminal cancer:
 o be given a terminal prognosis is devastatingTfor both the patient and family. To take away yourfuture, the opportunity to grow old and grey withyour spouse and to watch your children growand thrive. You lose your independence and your143

Chapter 9

All-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Report

End of Life

Dawne Solomons,
An Art Therapy Journey
When my daughtersuggested I try out art
therapy I didn’t knowwhat to expect.

I

had just had heart and lung surgery and wasstill in pain, and was having another roundof chemotherapy. In other words, not ingreat shape really.
So I began art therapy. I never knew what
I was going to draw so it was always a surprise tome when the pictures were finished, and thenthey were filed away and I forgot them.
I mostly talked during the sessions so thesketches were usually quickly finished and thenmy art therapist and I would always discuss themat the end of a session and what would emerge
was often a surprise too. When we had a ‘review’of the sketches I had made I was quite shocked
and surprised to see them. I had forgotten what
had prompted the drawings.
I have been in art therapy during three coursesof chemotherapy, and I can see the progression,
the journey if you like, starting with pain, thenthe struggle, the despair when it returned and I
needed more chemotherapy, always the worry
that it might return.
I have been able to release my feelings with thedrawings, never knowing what would appear on
the paper, but after each sketch, with mytherapist’s help, able to discern some hidden
feeling, or discuss some real issue that often
would only become apparent after the drawing
was finished.
Art therapy isn’t about being able todraw. Some are very quick sketches, others
more involved.
I have some inner need to put my feelings on
paper and I believe that it has helped me on an
arduous and often impossible journey when I
couldn’t express myself in any other way.

144

Journal entry 15/01/05
I see the cancer as black with long slimy tendrils,
and veiled by red.
I see needles piercing skin, turning it blackand red.
Knives thrust deep. Huge splashes, torrentsof red.
Journal entry 20/01/05[…] drew a vicious-looking serrated knife,
dripping blood – a big fist holding it – usedcharcoal. Very black.
It’s about pain – to me – the cause of pain.
Journal entry 09/06/05
In Art Therapy – there seems to be a ‘space’ in mydrawings – at the life class too – why? I seem to bedeliberately leaving a part of the page blank – is it
to do with the first surgery? Taking everythingout and leaving a space? Is it the void in my life?
Journal entry 01/11/05
I try not to think about what’s going on in my body– you can get so that every tiny twinge is a major
catastrophe.
Journal entry 05/01/06
I did a huge violent drawing in Art Therapy.
It’s how I felt.
How I’ve been feeling lately.
Maybe something is changing, but I need todeal with these feelings, not bury them.
Excerpted from Dawne Solomons, An Art Therapy
Journey, published by Marie Curie Cancer Carein December 2007, based on art therapy with
Michèle Wood at Marie Curie Hospice,
Hampstead, begun in January 2005.

sense of self, your purpose and role in life. Yet in
the midst of this suffering lies the Artroom. An
oasis of positivity and fulfilment providing a
different purpose. One of creativity and selfexpression. It is a place where the self isrediscovered and allowed to flourish. A place
where you feel valued and worth investing in. It’s
medicine for the soul and every bit as vital as
drugs and chemotherapy. A life-fulfilling
experience that has changed both our lives forthe better.
Artroom is a shared studio environment for art
and writing at the heart of two healthcare facilities
run by Grampian Hospitals Art Trust (which also
maintains a sizeable art collection). It is ‘based on
the understanding that everyone is creative andthat doing art and writing can be surprising,meaningful, challenging, playful, absorbing,reflective and exciting – and offers participants theopportunity to be fully themselves’.1000
Live Music Now provides a regular programmeof interactive music sessions for people withterminal conditions in hospitals. These havetherapeutic benefits and enhance quality of life. Ina King’s Fund report on end-of-life care, discussed
more fully in the next section, the role of hospital

be invited to articulate their contribution to dying
and bereavement.

9.3

Environment Design
In 2005, NHS Estates published a consultation
document, written by its Design Brief Working
Group and intended for NHS trusts, entitled A
Place to Die with Dignity: Creating a supportive
environment.1003 This considered how hospitaldesign might have a positive impact upon deathand dying for patients, their families, visitors andstaff. Consultation revealed demand for a homely
environment for the dying; grieving areas for the
bereaved; appropriate religious and cultural
spaces; and quiet spaces for staff. The document
set out key issues that should be borne in mind bytrusts, the strategic objectives they should aim tomeet and the ways in which these might beintegrated into design briefs.
In response to A Place to Die with Dignity andpractical experience gained during the EHE
programme, the King’s Fund launched a pilot
across eight projects in England and Scotland
known as Enhancing Care atthe End of Life (ECOL), whichran between 2006 and 2008. A
para llel literature rev iew
highlighted the importance ofrooms of a domestic scale,
allow ing private facilities
f o r p a t i e nt s , o v e r n i g ht
accommodation for family
members and appropriate places for viewing thedeceased.1004 It also highlighted the importance ofaccess to nature – whether directly or through thewindow – and the potentially soothing propertiesof colours and artworks. The focus of theconsultative pilot projects was on mortuary
viewing facilities, a bereavement suite, a visitors’room, palliative care rooms and patient rooms in a
hospice. Among all the positive feedback theseprojects generated, a surprising amount ofr e s i s t a nc e w a s r ep or t e d t o ch a n g i n g
preconceptions about appropriate environments
for end-of-life care.1005
The literature review for ECOL observed thatthe connection between spirituality and end-oflife care was notable by its absence fromdiscussions of environment. As physical failure
becomes all too evident, the internal world of
psyche, soul or spirit comes to the fore. Elaborating
the spiritual side of palliative care, Mark Cobb, asenior chaplain and clinical director at Sheffield
Teaching Hospitals NHS Foundation Trust, finds alink between the arts and the transcendent. He
describes faith as a ‘space between’ external
reality and ourselves, the realm of the abstract andCreative expression helps us to come toterms with human suffering and death.
porters was recognised.1001 GSTC is working with
Breathe Arts Health Research to train hospital
porters to discuss the art collection in Guy’s and St
Thomas’ hospitals with bereaved relatives, whichmakes demands on the resilience of porters.
Around a fifth of deaths from all causes occur athome; in deaths with dementia, this figure falls toless than a tenth, with 58 percent of deaths
occurring in care homes.1002 At the Inquiry roundtable, Academic Director of Digital HealthEnterprise Zone Health and Wellbeing Centre,
Allan Kellehear, pointed out that 95 percent of theexperience of dying takes place outside healthcare
environments. Nigel Hartley, now CEO of Earl
Mountbatten Hospice on the Isle of Wight, madethe point that artists were needed who could workwith families and groups in the community,
following people through the system andsupporting them to experience the benefitof creativity.
At the round table, it was agreed that people
would benefit from engaging with the arts muchsooner than the final weeks and months of
their lives. In the Compassionate City model
mentioned in chapter five, cultural venues would145

Chapter 9

All-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Report

End of Life

Environments for end-of-life care benefit from rooms of adomestic scale, overnight facilities for visitors, quiet spaces forfamily members and staff and soothing colours and artworks.
reflexive, which lies at the heart of both religion
and art.1006 Sacred spaces in hospitals and hospices
provide respite from the medical, allowing
stillness, reflection and contemplation, requiring‘artistic and spiritual architecture that provides a
shelter for the spiritual aspects of humanity andyet remains open to the play of the spirit’.1007 As wemove towards death, a creative response isdemanded, and Cobb suggests that ‘Without thearts, the human psyche would stand naked in theface of personal extinction’.1008
In 2008, Professor Lord Darzi, at the Institutefor Global Health Innovation, Imperial College
London, published a review of NHS England inwhich end-of-life care formed one of eight key
clinical areas.1009 In the same year, the King’s Fundpilot informed DH’s End of Life Care Strategy,
which emphasised the heightened importance ofenvironment to the dying – specifically, the extent
to which it provided private and gathering places,
communicated care and lingered in the memory
beyond the death of a loved one.1010 The pilot also
prompted DH to extend ECOL to 19 NHS trusts anda prison providing adult end-of-life care. Common
to all projects was the aim of improving the patientand carer experience and an emphasis on
consultation and engagement. Feedback fromservice users and visitors was overwhelmingly
positive, and staff members reported increased
learning in the face of persistent challenges. The
final report for this project provides usefulpointers for NHS trusts planning their end-of-life
care, bereavement and mortuary facilities.1011 We

hospices in North Wales. The bedrooms are
painted in strong colours, and the centre has amusic room and a multisensory room full ofdifferent stimuli.1012
Pioneers of the creative arts in palliative careencourage hospice patients to have a positive
influence on environments through exhibiting
their artwork.1013 Lucinda Jarrett, Artistic Directorof Rosetta Life – an artist-led organisation founded
in 1997 – has argued that ‘If a person is able todisplay their artwork on a hospice/hospital wall it
enables him/her to hold some ownership of thatspace. The artist becomes a stakeholder in theinstitution because their artwork is displayed’.1014
Designers at HELIX are developing an end-oflife care toolkit for healthcare workers, aimed at
improving the hospital experience for patients,
friends, family and staff by encouraging better
communication around treatment plans andemergency care. This design-centred approach
includes technological innovation, and it isintended to have a community application in
the future.

9.4

Finding Meaning in the
Story of LifeAt the round table, Dr Heath observed that, ‘As all
great writers demonstrate, finding meaning in thestory of life is an act of creation’. The arts can meetthe existential challenge offinding meaning in suffering,loss and death. The arts havethe capacity to make sense of
the apparent randomness and– at times – meaninglessness oflife, bringing order and a new
way of living. Professor FionaSampson, a poet who spent adozen years encouraging writing and reading in
health and social care settings, described at theround table on the Arts and Healthcare
Environments how poetry ‘speaks indirectly, tells
at a slant’. It acts as a counterpoint to institutional
jargon and case-note paraphrase to express
experience in personal terms.

Arts participation enables self-expression
and provides a chance to take stock of life.
hope that NHS trusts will continue taking accountof the King’s Fund’s recommendations for
integrating the arts and design into end-of-life,
bereavement and mortuary facilities.
As an instance of good hospice architecture, all
the rooms of Princess Alice in Esher have Frenchdoors that open onto a garden, courtyard or
decking area. The overall design combines green
space and openness with privacy and a sense ofcommunity. Similarly, a large terrace can bereached from all the bedrooms and communal
rooms of Tŷ Gobaith, one of Hope House children’s
146

There’s a game I play inside my head
Pretending that I am already dead
Just to be here to see
Those I’ve left behind me

Friends and lovers weeping
While I lie here sleeping
Some will never recall
I was ever here at all
And others will laugh out of handOr say I was a good kind man
While thinking deep inside
I was base, low and snide.
Who in this darkness
Who will hear my plea?
Who will remember me as me?
Paul, blind cancer patient at Greenwich andBexley Cottage Hospice, 2005
Artist Virginia Hearth has noted that ‘The arts
offer us a way of making sense of the world and help
us to define who we are and who we have been’.1015
The arts can provide access to deeper and morenuanced thoughts and feelings than we commonly
experience. They contain the potential for ‘selfactualisation and self-realisation’.1016 They can foster
creativity and fresh experiences, bring newunderstandings and insights and offer the ‘potential
for pleasure, transcendence and beauty’. 1017
Participation in the arts can be cathartic, enabling
the dying and their relatives to deal with transitions,giving people confidence to talk to others about
illness or dying. At the same time, the arts may
disturb us, and ‘neither powerful arts products nor
therapeutic effects are gained solely with ease andenjoyment’.1018 This places the onus on facilitators of
end-of-life creativity to channel difficult emotions
into the creative process.
In a collection of essays published as Dying,
Bereavement and the Creative Arts, Gillie Bolton –who played an early role in the British Association
for Medical Humanities – described how‘Involvement in artistic processes can offer
primary support in the rewriting of a hopeful,helpful life-towards-death narrative’. 1019 She

9.5

LegacyCreative arts projects often yield something ofvalue which can be left behind, and loved ones
treasure the artwork of those they have lost. Even
where creative activity has been undertaken on an
individual basis, the act of giving creates
relationships. Lynn Harmer, an artist at St
Christopher’s, has recounted the story of Michael,a middle-aged man who was admitted to thehospice as an inpatient, suffering with acute backpain in the later stages of a terminal illness.
Although he had not painted since school, Michael
was keen to experiment with colour and technique,and he seemed to forget about his symptoms while
he painted. Michael’s 10-year-old son, Joe, washaving difficulty visiting his father, and thenursing staff asked if he would like to be involved
in his father’s creative activities. This prospect
provided Joe with the impetus he needed to visit
the hospice, and father and son spent time together
moulding baby elephants from clay, laughing andteasing each other as they worked. When Lynn
took the clay elephants away to be fired, she left
Michael and Joe painting together. After a sudden
deterioration, Michael died a few days later, and
Lynn ensured that the baby elephants were passed
to Joe as a lasting memory of time spent withhis father.1020

9.6

Finding Voice
Dame Barbara Monroe has lamented that ‘one of
the tragic consequences of our death-denying
culture is that just when people most need social
support, the world often retreats from them in
embarrassment, anxiety anddismay, creating a kind of social
death long before physicaldemise occurs’.1021 Jarrett hasargued that ‘For patients who
are facing death, the process of
disappearing from a culturalarena is one of increasing
powerlessness. Finding voice
enables people to choose whether to regain theirrole in their social and cultural arena. […] The
creative arts clearly have a large role to play inenabling people to find a shape to hold theirindividual stories’.1022 Facilitating artists to work inpalliative care settings, Rosetta Life works on thebasis that everyone holds the potential for creative
exploration and enables the dying to find andexpress the stories that matter to them.1023
The experience of death and dying is difficult to
put into words. Art therapist in palliative care

Artistic activity generates a legacy thatcan be left behind for our loved ones.
outlined how such creative processes offer insights
into ourselves and our place in the world, enabling
us to ref lect on memories, hopes and fears.
Through metaphor, characterisation and plot, thecreation of literary and dramatic works draws
upon emotional and psychological depths. It is thisuse of the imagination, Bolton argued, which
distinguishes humans from animals, increasing
cognitive, psychological and spiritual insight into
the otherwise inexpressible while diminishingstress and anxiety.

147

Chapter 9

All-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Report

End of Life

Creative expression lends a voice to the voiceless.
Michèle Wood has explained that ‘Many factors
including social status, educational levels, andethnic backgrounds inf luence the patient’s
comfort in expressing and addressing theiremotional responses to illness with healthprofessionals’.1024 However:clients often feel that they have no control overtheir illness, their treatment, the progress and life
in general. They may also have lack of control overbodily functions’.1028 The issue of control is also
important for others caught up in the maelstromof terminal illness, and Jarrett has recounted how: n important aspect of art therapy is that it
Aprovides an opportunity to express emotions that
may feel unacceptable to the patient. The patient
may have stifled feelings of anger, envy, andsadness for fear of upsetting their family or staff.
In art therapy, pounding clay, pouring paint, andscribbling violently on paper gives the patientpermission to express strong feelings, and thepresence of the therapist ensures the patient is
not left alone with their distress. Art therapy also
allows for the development and expression of
more positive feelings such as tenderness, hope,or beauty.1025

 t a personal level, families who may feel thatA
they cannot cope with the management of adisease that is overtaking the person they love
may manage to take control of their daily lives bybecoming involved in a creative project. Sortingout the photos, editing a manuscript, viewing
rough cuts of a film quickly becomes a family
process and in this way carers are more able toget more involved in aspects of the managementof the lives of those who are seriously ill.1029

The non-verbal nature of certain creative activity
helps end-of-life care services to engage with
communities in which different languages are
spoken and provides a ‘welcome tool for patientsnegotiating their experiences of illness andtreatment in a language and cultural setting that is
not their own’.1026
Memories and experiences are often retained as
images whose non-verbal expression needs nointerpretation. Rather than retreating into
therapeutic models and professionalised
languages, Hartley asserts that ‘the art is thetherapy’. 1027 Through the process of creative

Creative activity can increase a sense of control
and self-determination, with mastery of materials
and ideas forming part of the creative process.

9.7

Bereavement
In late 2010, the Scottish Government HealthDirectorates funded a study of the socio-economic
cost of bereavement in Scotland as part of work to
inform national policy on bereavement and carepractice. Analysis of data from the Scottish
Longitudinal Study found that the loss of a spousemade early demise of the surviving spouse more
likely and led to extended
hospital stays, translating into arecurring annual cost for NHS
Scotland of around £20m.1030
Analysis of UK-wide data fromthe British Household Panel
Survey also suggested that the
bereaved were significantly
less likely than theircontemporaries to be employedin the year of bereavement and
two years after.
At the round table, Dr Simon Opher pointed outthat bereavement was a normal part of life, which
he increasingly saw being pathologised, leading toregular trips to the doctor and the prescription ofanti-depressants and sleeping pills. The Scottish
study identified costs of bereavement-related
consultations in primary care at around £2.2m
annually, and suggested that the actual figure was
likely to be much higher. People seek bereavement
support because they feel stuck and isolated intheir grieving. The symptoms of grieving –Art can have a powerful effect in easing
grief, helping those who have lost their
loved ones to find solace in their
bereavement.
activity, meanings may be released that have
not yet surfaced into the conscious mind.
Metaphor and imagery can invoke all the senses
and express the experience of dying in ways thattransform perception.
Patients at the end of their lives are often
allotted a passive status, poked and prodded withmedical instruments. As art therapist Samantha
Dobbs has observed, ‘The issue of control is often
present and powerful. In palliative care or after aparticularly lengthy period of medical treatment,148

emotional pain, loss of sleep, appetite and energy– can often feel like an illness, but giving expression
to grief can help to articulate loss and redefine theperson left behind.1031 Dr Opher described grief asa pattern of circular thoughts that deprive
survivors of peace and lead to anxiety anddepression. Art, he argued, is a healer of
bereavement, and he told of patients being released
from circular thoughts after a few brief hours of
immersion in art.
The process of creating something new after thedeath of a loved one can be part of fashioning a newlife. Exploratory personal writing, for example, canfunction as an alternative or adjunct topsychotherapy. At the round table, Jane Moss – awriter and creative writing tutor who works inbereavement support – explained that writing
could be used in a number of ways, including
keeping a journal, penning unsent letters,
describing personal belongings and resolving
unfinished conversations. Writing can be a valuablemeans of self-help, with the page as a listening
friend, available any time of day or night, hearing
whatever the writer wants to say. The results of thiscan be powerful, and include people being able togroup activities, including drawing and painting
sessions, and conveyed their perspectives on
camera, with a view to sharing the video with theirparents, teachers and members of the public. Oneof the young people involved in the project – whichbecame known as No, You Don’t Know How We
Feel – related how ‘Before, I couldn’t actually saythat my dad had cancer, in case people might laugh– but now I can, and they don’t’.1032
Life can end at any age, and every year an
estimated 12,500 parents in the UK experience theloss of a child.1033 At the round table, independent
producer Anna Ledgard observed that, in intensive
care wards, the voices of children are often leastheard. She identified a role for art in providing an‘other space’ in which terminally ill children could
articulate what was happening to them and how it
felt. She relayed the story of a 15-year-old boy,saying that ‘Death is simply a door in the room that
we have not yet noticed, and we won’t until oureyes adjust to the dark’.
Sur viving the Loss of Your World wasestablished by two bereaved mothers in North
London in 2007. Over 12 weeks in autumn 2014, six
members of the group came together with artist
Sof ie Layton as part of a
research and development
programme called REST. The
g roup ex plored d i f ferent
creative processes – including
drawing, embossing, screenprinting, sewing and audio
r e c or d i n g – t o c apt u r eexperiences and the essence
and memories of lost children.
One participant commented that a shared processof embroidery was ‘rather similar to grief itself –slow – and allowing us to talk, bond, weep, laugh as
we progressed our ideas and produced somethingthat ref lected our children’. 1034 The project
culminated in a public presentation of theinstallations made during the workshops.
Qualitative evaluation reported the value of the
project to participating mothers and to stimulatinga public conversation about childhood death.1035

In children and young people, creative
activity helps to facilitate conversation
about terminal illness and death.
return to work and adjust more effectively after
their loss, acquiring skills for their own self-carewhich will serve them through the rest of their life.

9.8

Children and Adolescents
In the UK, one in 20 children has lost a parent. At
the round table, Professor Baroness Finlay
described mismanaged bereavement in young
people as a public health disaster. A team of
palliative care social workers in East Berkshire
provides an innovative example of the arts helping
young people to deal with parental illness or death.
The team enlisted an advocate and pioneer ofparticipatory video and set up an action research
project with young people (aged seven to 15),
putting their voice, experience and expertise at thecentre of a collaborative inquiry. Nine young
people participated in seven weekly sessions,choosing which themes to cover, whether toappear in front of the camera or behind it andwhether to accept or reject footage. Within a safe,
therapeutic environment, participants engaged in

9.9

A Public Conversation
About Death
DH’s End of Life Care Strategy identified the needfor a better public conversation about death anddying, so as to change perceptions and allay
fears.1036 The National Council for Palliative Care,founded in 1991, serves England, Wales andNorthern Ireland. In 2009, it established acoalition of 32,000 members across England andWales, known as Dying Matters, to ‘help people
talk more openly about dying, death and149

Chapter 9

All-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Report

End of Life

bereavement, and to make plans for the endof life’.1037
Hartley and Payne have observed that hospices‘demonstrate how the arts can help people deal
with distress and difficulty […]. People who
experience the arts in this setting at this momentin their life experience may come to understandhow they may participate in the arts more actively
to better strengthen their resilience in dealing
with future life experiences’.1038 An example of this

9.10

Training and Professional
Development
A survey of more than 500 GPs conducted by theKing’s Fund in 2009 found that three quarters
acknowledged they had a role in helping patients
approaching death, while almost half said theywould appreciate help with this.1041 A survey ofm o r e t h a n 9 0 0 nu r s e s
conducted the following year
found that 69 percent felt they
did not know how to broach thesubject of death, with 72 percent
citing lack of training. 1042 In
2014, a report jointly publishedby t he R oya l Col lege ofPhysicians and Marie Curie
Cancer Care looked at the results of an audit of 131
NHS trusts comprising 150 hospital facilities.1043
This found that mandatory training in care of thedying had only been required for doctors in 19
percent of trusts and for nurses in 28 percent,despite national recommendations that thisbe provided.
The training of healthcare professionals should
prepare them to deal intellectually and emotionallywith issues of mortality.1044 The House of Lords
Access to Palliative Care Bill, which is passing
through Parliament at the time of writing,contains a section on education and training
which requires all health and social care providers
to understand the importance of pain control andpalliative care.1045
At the round table, nurse and psychotherapist
Olwen Minford invoked evidence that integratingarts-based approaches in the training ofhealthcare professionals can build empathy,
compassion and communication skills, andpointed to visual arts training in galleries being
used in more than 50 US universities. At the same
event, Dr Heath proposed that, in the care of thedying, healthcare professionals needed five formsof literacy: medical, physical, emotional, moral andcultural. As cultural literacy is undervalued in
medical education, young doctors are deprived ofa potent resource for making sense of both lifeand death.
Professional development is also necessary for
artists who undertake this work. Artists working
in palliative care need to have sensitivity,
knowledge, skills and conviction, as well as anability to understand and deal with a variety ofexperiences. There is a need for training andprofessional development as well as newparadigms for research and evaluation developedby artists working in this highly specialised field.
At present, we lack a central organisation for
artists, arts therapists and arts services working
in palliative care. In 2016, an International

The arts can open up a public conversation
about illness and death.
approach in action is provided by the Schools
Project, run by St Christopher’s, which brings endof-life patients and their carers together withchildren around the age of 10.1039 The aim of thisproject is to educate young people about death anddying through the eyes of those going through theprocess, thereby reducing anxiety about death. In
one version of this programme, children visitedthe hospice together with their teachers andparents, after which the hospice arts team worked
with the children in their school over two
successive weekdays, facilitating the creation ofart, music and writing on the theme of the journey.
The project concluded with a return visit to thehospice, during which the children read out theirpoems, sang songs and talked about theirexperiences, to the appreciation of patients. The
words of the children testify to this encounter
helping them to overcome their fear of death.
Dr Sandra Bertman, author of Grief and the
Healing Arts, uses the arts and humanities to
educate the general public and care staff about
death. She has elsewhere identified a synergy
between aesthetic and therapeutic approaches,
whereby ‘the arts invite us into the world of humansuffering and bereavement in a manner different
from but no less penetrating than clinicalanalysis’.1040 By being instructive and challenging,
Dr Bertman argues, the arts enable us better toinhabit our own suffering and that of others. The
Dying Matters coalition might consider the role of
the arts in stimulating a public conversation
about death.

150

Community of Practice for End of Life Care wasinitiated in Canterbury, bringing together
academics, researchers, clinicians, practitioners,
policy makers and service users. This provides anexus through which the arts in end-of-life carecan be discussed more fully.
DH’s End of Life Care Strategy for adults at theend of life identified the following features of agood death: ‘being treated as an individual, with
dignity and respect; being without pain andot her s y mpt om s; b ei n g i n f a m i l i a r
surroundings; and being in the company ofclose family and/or friends’.1046 The strategy
acknowledged that this was not the experience
for many, and it proposed a system-wide
approach to caring for patients and their loved
ones. Yet it did not mention the arts. The NHS
England End of Life Care strategy madeprovision for palliative care,1047 but neither thisstrategy nor related sector-specific guides, suchas that for care homes, made reference to thearts.1048 We hope that DH and NHS England willrevisit their strategies on end-of-life care, taking
full account of the benefits of arts engagement.
At its best, end-of-life care helps people toapproach death as well as possible. In the UK,
there is little awareness of the availability of
end-of-life care and even less recognition of therole of the arts within this. Care of the dying
needs to be recognised as one of the core
purposes of the medical profession. At the sametime, more has to be done to reconcile thephysical, psychological, social and spiritual
aspects of death, and the arts have an essential
part to play in this. The training and professional
development of many health and care staff, as
well as of more artists, should enable them togain understanding of the creative relationshipthat there can be between the arts and dying.
Easing the relentless pressures on health andcare staff would assist consideration of healing.
Further evidence is needed as to the financial
savings achievable through the arts in end-oflife care and bereavement, particularly throughreduction in GP visits, prescriptions andhospital admissions. Such research might be
combined with a study of arts practices andprocesses, using qualitative, creative methods
such as filmmaking, all with a view topersuading commissioners of the benefits ofarts engagement at the end of life. It is, of course,
self-evident that sensitive human contact
alleviates suffering. The arts can provide
such contact.

151

Claudia Phipps, Ripples,
Rosie Maternity Hospital,
Cambridge University Hospitals
Managed by Addenbrooke’s Arts
Photographer: Gilbert Park

Recommendations
and Next Steps
152

153

All-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Report

10 Recommendations and Next StepsW

e hope we have demonstrated inthis report that the arts canmake an invaluable contribution
to a healthy and health-creating
society. They offer a potential
resource that should be embraced in health andsocial care systems which are under great pressure
and in need of fresh thinking and cost-effective
methods. Policy should work towards creative
activity being part of all our lives.
The process of the Inquiry – in particular theexchanges of ideas and experience at round tablesof ser vice users, health and social care
professionals, artists and arts professionals,
funders, academics, people in local government,
policy-makers and parliamentarians – hasgenerated energy and commitment. We willcontinue to enlist the help of those who are willing
and able to join forces to shape a shared vision forchange and bring that change into being.
In this report, we have made a series ofsuggestions aimed at improving practice, research
and funding. Here, we make ten specificrecommendations as catalysts for the change ofthinking and practice that can open the way for the
potential of the arts in health to be realised.
1) We recommend that leaders from within thearts, health and social care sectors, together
with service users and academics, establish
a strategic centre, at national level, tosupport the advance of good practice,promote collaboration, coordinate anddisseminate research and inform policy anddelivery. We appeal to philanthropic funders
to support this endeavour. We hope that thecentre will also have the support of Arts
Council England, NHS England and Public
Health England as well as the Local
Government Association and otherrepresentative bodies.
Sustained and systematic work is needed to fill theextensive gaps in arts and health provision. Better
coordinated research and evaluation will
demonstrate more powerfully the effectiveness andvalue for money of arts-based approaches to healthand wellbeing. The investment of funders will be
more productive if made as part of a coherent
strategy. If personal stories are more widely shared,
they will do more to stimulate public interest anddemand.
This is why we would like to see a range ofpartners establish a national strategic centre tocoordinate leadership in the field, working topromote collaboration at all levels in the arts, healthand social care sectors. We do not propose a154physical building but rather a gathering of networks,
spanning practice, peer support, research, funding,communication, policy and international liaison.
The aim of the centre would be to support local
delivery and co-production; provide for sharedlearning and skills development; identify gaps in theevidence base and help to fill them; encouragecoordinated approaches to funding; enhance thetraining of arts and health professionals; and secure
greater awareness of the benefits of the arts for ahealthy and health-creating society.
If this recommendation finds favour with thefield and if so desired, the All-Party ParliamentaryGroup on Arts, Health and Wellbeing stands readyto assist with the formation of the centre, opening
discussions with the bodies that might be involved
and facilitating initial meetings.
While this initiative would be independent ofgovernment, we hope that the Government would
support the project.
2) We recommend that the Secretaries of State
for Culture, Media and Sport, Health,
Education and Communities and Local
Government develop and lead a crossgovernmental strategy to support thedelivery of health and wellbeing through thearts and culture.
We will seek to persuade ministers that they can
improve the effectiveness and value for money ofservices to support health and wellbeing and widen
access to the arts if they work together to develop across-governmental strategy for the arts in health.
It would recognise that the arts can help meet the
major challenges facing health and social care. The
national centre would provide expertise andcapacity to support the design and implementationof the cross-governmental strategy. The strategy
could be developed within the existing systems of
the NHS, local authorities, Public Health Englandand Arts Council England, with joint targets andshared resources. It would develop approaches
already initiated by the What Works Centre for
Wellbeing. We suggest that our Government looks
at international comparators such as Australia,
Finland, Norway and Sweden, where national
strategies have already been put in place.
3) We recommend that, at board or strategiclevel, in NHS England, Public Health Englandand each clinical commissioning group, NHS
trust, local authority and health andwellbeing board, an individual is designatedto take responsibility for the pursuitof
institutional policy for arts, health andwellbeing.
The evidence is there that the arts can help meetmajor challenges facing health and social careincluding ageing, long-term conditions, mental

health and loneliness. We ask that all relevant
institutions should ensure that a commitment tothe arts, health and wellbeing becomes integral toorganisational policy. A dedicated individual would
ensure that each organisation attaches appropriate
importance to matters relating to the arts, healthand wellbeing. The national centre would help to get
the message out and support those making
decisions at every level to realise the opportunities
provided by the arts. The national centre would
mobilise effective local leadership and networking
to support public bodies in maximising local
opportunities. Public bodies must be ready to seize
these opportunities and to collaborate in doing so.
The Government’s objective of increasing access tothe arts for all will also be powerfully advanced if
health and social care providers are willing to workwith arts and cultural organisations.
4) We recommend that those responsible for
NHS New Models of Care and Sustainability
and Transformation Partnerships ensurethat arts and cultural organisations are
involved in the delivery of health andwellbeing at regional and local level.
There are already exemplars of effective
partnership working, as shown in our case studies
of Gloucestershire and Greater Manchester.
Devolution of decision-making and budgets
provides an opportunity for better engagement of
the arts and culture in improving health andwellbeing on a local and regional basis. Partnerships
with local health providers will enable arts andcultural providers to make their contribution tomeeting major challenges in health and social care.
Greater Manchester is the first of the city regionswith a directly elected metro mayor to have madethe arts and culture integral to its health andwellbeing strategy. We hope others will make asimilar commitment.
5) We recommend that Arts Council England
supports arts and cultural organisations inmaking health and wellbeing outcomesintegral to their work and identifies healthand wellbeing as a priority in its 10-year
strategy for 2020–2030.
Arts and cultural organisations will need todevelop their knowledge and skills to enable
them to make their full contribution to thedevelopment of a healthy and health-creating
society. Many organisations would benefit fromsupport in developing the skills to bid for healthand social care funding and to work in
partnership with others in the voluntary andcommunity sector. Working with Arts Council
Eng la nd a nd t he Nationa l Counci l for
Voluntary Organisations to build on their recent
Cultural Commissioning Programme, the national

centre could identify and coordinate means forproviding this support.
6) We recommend that NHS England and theSocial Prescribing Network support clinicalcommissioning groups, NHS provider trusts
and local authorities to incorporate arts onprescription into their commissioning plans
and to redesign care pathways whereappropriate.
Developments in social prescribing offer models forarts and cultural organisations to engage with theprocess of creating a healthy society. Arts-onprescription activities help people to overcome
physical and psychological pain, playing a vital rolein the recovery and maintenance of health. Group
creative activities in the community also help toovercome social isolation in people of all ages. As
our case studies show, such initiatives improvehealth and wellbeing outcomes and save money.
Steps need to be taken within the health service toensure that these improvements and savings are
realised. Just as is happening in the health andsocial care sectors, infrastructure and leadershipwill need to be developed in the community sector.
Organisations delivering arts on prescription canbecome part of the Social Prescribing Network sothat they are included in any future databases ofactivity. As in the wider arts and health landscape,gaps in provision will have to be filled.
7) We recommend that Healthwatch, theP at i e nt s A s s o c i at i o n a n d o t h e r
representative organisations, along witharts and cultural providers, work withpatients and service users to advocate thehealth and wellbeing benefits of arts
engagement to health and social care
professionals and the wider public.
The benefits of the arts for health and wellbeing arestill not widely recognised. Practitioners andpatients need to raise the profile of this work andencourage public demand for it. The many people
who have already experienced these oftentransformational benefits are the best witnesses.
We hope that arts and cultural organisations andthose representing patients will help them tell theirstories and make them heard. We will press for thevoice of patients to be heard more clearly in service
design, research and evaluation.
8) We recommend that the education ofclinicians, public health specialists andother health and care professionals includes
accredited modules on the evidence baseand practical use of the arts for health andwellbeing outcomes. We also recommendthat arts education institutions initiate
undergraduate and postgraduate courses
155

Chapter 10 Recommendations and Next Stepsand professional development modules
dedicated to the contribution of the arts tohealth and wellbeing.
Education must underpin culture change.
Undergraduate and postgraduate courses andprofessional development for arts and healthprofessionals and for artists, producers andfacilitators exist in some places, but provision needs
to be more coherent and widespread. We will
challenge Health Education England, the Academyof Royal Medical Colleges, the General Medical
Council and others responsible for the training andcontinuing professional development of health andcare professionals to recognise the need to
introduce into curricula a stronger arts andhumanities dimension. We will also encourage art
schools and universities to play their part in raisingawareness of the opportunities for artists in healthand social care.
9) We recommend that Research Councils UK
and individual research councils consider
an interdisciplinary, cross-council researchfunding initiative in the area of participatory
arts, health and wellbeing, and that otherr e s e a r ch-f u nd i n g b o d ie s e x pr e s swillingness to contribute resources toadvancement of the arts, health andwellbeing evidence base. We recommendthat commissioners of large-scale, longterm health surveys include questions about
the impacts of arts engagement on healthand wellbeing.
We know already that the arts can help keep us well,aid our recovery from illness and support longer
lives better lived. But there are gaps in the evidencebase in areas such as prevention, management oflong-term conditions and delaying dementia onset
and admission into residential care. We need moreevidence of sustained benefits in larger populationgroups over time.
10) We recommend that the National Institutefor Health and Care Excellence regularly
examines evidence as to the efficacy of thearts in benefiting health, and, where theevidence justifies it, includes in its guidance
the use of the arts in healthcare.
We have been encouraged by the receptiveness ofmany organisations to whom we are making ourrecommendations, including the National Institutefor Health and Care Excellence. Wider endorsementand dissemination of the developing evidence baseis needed. We urge arts and health researchers toregister as stakeholders with the National Institutefor Health and Care Excellence and bring relevant
evidence to the attention of reviewers.

156

The All-Party Parliamentary Group on Arts,
Health and Wellbeing has developed policy
briefings in collaboration with the Associationof Directors of Public Health, Local Government
Association, National Council for Voluntary
Organisations, Social Care Institute for
Excellence and What Works Centre for
Wellbeing. Arts Council England and Public
Health England have provided advice and haveagreed to help with their dissemination. This is
the first step in a strategy to ensure that all
health and social care professionals are
informed of the benef its of arts-based
approaches to health and wellbeing andsupported in adopting them. We are very
pleased that the Arts and Humanities ResearchCouncil has made an award to our researcher,
Dr Rebecca Gordon-Nesbitt at King’s College
London, to support the dissemination ofevidence and innovative practice presented inthis report and to continue working with us on
advocacy of these recommendations for a year
after publication.
We will continue to work with those whohave been our partners in the Inquiry thus far.
We will seek opportunities to increase
understanding of the benefits of the arts forhealth and wellbeing, not only with ministers
and in parliament but also among the healthand social care professions and others acrossthe country. We will develop our work with theRoyal Society for Public Health to identify
priorities for future research and curriculum
reform. We will follow with close interest thepioneering work supported in London by the
Guy’s and St Thomas’ Charity. With the National
Alliance for Arts, Health and Wellbeing, we will
carry our message to the regions. We are very
fortunate that Paul Hamlyn Foundation andWellcome have provided us with funding toenable us to mount a programme of events
around the country over the next twelve
months. We hope to engage local MPs
and councillors, among many others, atthese events.
The Inquiry process has brought together
many people w ith diverse v iews andexperiences, including those who haveexperienced the benefits of the arts for theirown health and wellbeing. Their stories canhelp to convince others, and we ask all those
who believe in the value of the arts for healthand wellbeing to join forces with us and speak
up. In this way, we will increase the tempo andvolume of public discussion of the arts, healthand wellbeing. We will welcome comments andsuggestions from all who believe, as we do, thatthe arts offer an essential opportunity for the
improvement of the health and wellbeing of thenation, and we will work with all who share
our mission.
Parkinson’s Dance Class,Pavilion Dance South WestAll-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Report

Acknowledgements

The members of the All-Party ParliamentaryGroup on Arts, Health and Wellbeing (APPGAHW)
are listed below. They include the former andcurrent officers of the Group: Baroness Andrews
OBE, Rt Hon. Frank Dobson, Rt Hon. Lord Howarthof Newport CBE, Rt Hon. Fiona Mactaggart MP,
Jason McCartney MP, Sarah Newton MP, Chris
Ruane MP, Maggie Throup MP, Rt Hon. Ed Vaizey
MP and Dr Sarah Wollaston MP. Our thanks to Rt
Hon. Professor Paul Burstow, formerly MP for
Sutton and Cheam, who was a founding Co-Chairof the APPGAHW and has continued to support
the work of the Inquiry as Chair of the Advisory
Group. Other parliamentary colleagues, listed
below, have contributed their time chairing andattending meetings and offering their knowledge
and thoughts.
The National Alliance for Arts, Health andWellbeing provides the secretariat to the
APPGAHW in the person of Alexandra Coulter,
Director of Arts & Health South West. We are
extremely grateful to Alex for managing theInquiry and to the Board of Arts & Health SouthWest for their support.
The Inquiry has benefited greatly from acollaboration with King’s College London, which
has employed and supported our researcher, Dr
Rebecca Gordon-Nesbitt, and administered thecall for practice examples. Especial thanks to
Deborah Bull, Ruth Hogarth, Katherine Bond andProfessor Anne Marie Rafferty. We are deeply
indebted to Rebecca for her extensive research
and for drafting this report.
The Royal Society for Public Health Special
Interest Group on Arts, Health and Wellbeing has
provided much valued guidance on the research,specifically through the involvement of Professor
Paul Camic, Professor of Psychology and Public
Health at Canterbury Christ Church University.
Guy’s and St Thomas’ Charity has been ourpractice partner for the Inquiry, and Nicola Crane,
Programme Director and Head of Arts, has given
us much valued advice and support. Our Advisory
Group – the members of which are listed below –has provided expert oversight of this report as it
has progressed.
The Inquiry would not have been possible
without generous funding from Wellcome andPaul Hamlyn Foundation, and we would
particularly like to thank both organisations fortheir thoughtful engagement in the process.
Additional research funding has been provided by
the Arts and Humanities Research Council.
We express our very warm thanks to the morethan 300 people from all parts of the country who
have taken part in round tables and meetings inthe Houses of Parliament. We would particularly
158

like to acknowledge those who have been so
generous in telling us of their own personal
experiences of how the arts have benefited theirhealth and wellbeing.

Members of the All-Party
Parliamentary Group on
Arts, Health and Wellbeing
Debbie Abrahams MP
Baroness Andrews OBE
Luciana Berger MP
Lord Berkeley of Knighton
Lord Bichard KCB
Lord Crathorne KCVO
Lord Crisp KCB
Thangam Debonnaire MP
Rt Hon. Frank Dobson
Baroness Finlay of Llandaff
Helen Goodman MP
Baroness Greengross OBE
Kelvin Hopkins MP
Rt Hon. Lord Howarth of Newport CBE
Rt Hon. Lord Hunt of Kings Heath OBE
Baroness Jolly
Rt Hon. David Lammy MP
Lord Layard
Baroness Lister of Burtersett CBE
Lord Lupton CBE
Jason McCartney MP
Baroness McIntosh of Hudnall
Rt Hon. Fiona Mactaggart MP
Baroness Masham of Ilton DL
Baroness Meacher
Baroness Morgan of Ely
Rt Hon. Nicky Morgan MP
Rt Hon. Baroness Morris of Yardley
Baroness Neuberger DBE
Sarah Newton MP
John Nicolson MP
Dr Matthew Offord MP
Lord Ramsbotham GCB CBE
Lord Ribeiro CBE
Chris Ruane MP
Rt Hon. Lord Smith of Finsbury
Rt Hon. Lord Stunnell OBE
Maggie Throup MP
Rt Hon. Ed Vaizey MP
Rt Hon. Lord West of Spithead GCB DSC
Dr Sarah Wollaston MP
Baroness Young of Hornsey OBE

Advisory Group

Presenters at Round Tables

Katherine Bond, Director, Cultural Institute,King’s College London
Paul Bristow, Director, Strategic Partnerships,
Arts Council England
Deborah Bull, Assistant Principal (London),King’s College London
Rt Hon. Professor Paul Burstow, Chair of theInquiry Advisory Group
Professor Paul Camic, Professor of Psychology
and Public Health, Canterbury Christ Church
University
Nicola Crane, Programme Director and Head ofArts, Guy’s and St Thomas’ Charity
Professor Geoffrey Crossick, Distinguished
Professor of the Humanities at the School of
Advanced Studies, University of London
Professor Norma Daykin, Professor of Arts and
Health, University of Winchester
Professor Paul Dieppe, Emeritus Professor of
Health and Wellbeing, Exeter University
Nick Ewbank, Director, Ewbank Associates
Martin Green, Chief Executive, Care England
Jessica Harris, Cultural Commissioning
Programme Manager, National Council for
Voluntary Organisations
Dr Iona Heath, Former President of the Royal
College of General Practitioners
Damian Hebron, Director, London Arts in
Health Forum
Ruth Hogarth, Director, Cultural Partnerships &Enquiry, King’s College London
Dr Val Huet, Chief Executive, British Associationof Art Therapists
Professor Jane Macnaughton, Professorof Medical Humanities, University of Durham
Dr Simon Opher MBE, GP Lead for Cultural
Commissioning and Social Prescribing,Gloucestershire
Professor Richard Parish CBE, Professor of
Health Development, University of Chester; Board
Member, Public Health England
Heema Shukla, Public Health Consultant,
Faculty of Public HealthJane Steele, Head of Research, Paul Hamlyn
Foundation
Professor Anne Marie Rafferty, Professor of
Nursing Policy, King’s College London
Alison Raw, Professional Advisor for Allied
Health Professions, Department of Health
Dr Justin Varney, National Lead Adult Healthand Wellbeing, Public Health England
Dr Nic Vogelpoel, Insight and Analysis,
Wellcome

July 2014: The Care Act and theFrancis Inquiry
Chair: Rt Hon. Lord Howarth of Newport
Sir Robert Francis QC, leader of public inquiry
into Mid Staffordshire NHS Foundation Trust;board member CQC; President of the Patients
Association
Dr Ellen Storm, Paediatrician and winner of
Hippocrates Prize for Poetry 2014
Nicola Crane, Programme Director and Head ofArts, Guy’s and St Thomas’ Charity
Dr Suzy Willson, Artistic Director, Clod
EnsembleNovember 2014: The Care Act andCommissioning Arts and Culture
for Wellbeing
Joint event with the All-Party ParliamentaryGroup on Wellbeing Economics
Chair: Rt Hon. Paul Burstow MP
Valerie Little, Independent Consultant in
Public Health and formerly Director of Public
Health, Dudley
Steven Michael, Chief Executive of South West
Yorkshire NHS Foundation TrustJohn Nawrockyi, Director of Health and Adult
Social Care at the Royal Borough of Greenwich
Dr Justin Varney, National Lead for Adult Healthand Wellbeing, Public Health England
February 2015: Music and Health
Chair: Lord Berkeley of Knighton
Evan Dawson, Director, Live Music Now
Professor Norma Daykin, Professor of Arts and
Health, University of Winchester
Phil Hallett, Chief Executive, Coda Music Trust
Julian Lloyd Webber, Patron, Live Music Now
Gillian Moore, Head of Classical Music,
Southbank Centre
Professor Helen Odell-Miller, Professor ofMusic Therapy, Anglia Ruskin University
Dr Jane Povey, GP and Director of Creative
Inspiration CIC, Deputy Medical Director forPrimary Care, Faculty of Medical Leadership andManagement
Dr Simon Proctor, Head of Music Services,
Nordoff Robbins
Ian Ritchie, Artistic Director, the Musical Brain
Chika Robertson, Director of Mind Music Spirit
Paul Robertson, Director of Mind Music Spirit
Ian Stoutzker CBE, Co-founder with Yehudi
Menuhin of Live Music Now
Gillian Stunnell, Music Therapist
Professor Michael Trimble, Emeritus Professorof Behavioural Neurology, National Hospital
Queen Square, London

159

All-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Report

Acknowledgements

Dr Trish Vella-Burrows, Deputy Director,
Sidney De Haan Research Centre, Canterbury
Christ Church University
Julian West, Oboist and Creative Music Leader
July 2015: Dementia and the Arts
Joint event with the All-Party ParliamentaryGroup on Dementia
Chairs: Baroness Jolly and Baroness Greengross
Dr Alice Ashby, Acting Consultant Liaison
Psychiatry, West London Mental Health
NHS TrustProfessor Dawn Brooker, Director of Association
for Dementia Studies, University of Worcester
Paul Cann, Director of Age UK Oxfordshire
Richard Coaten, Dance Movement
Psychotherapist, South West Yorkshire
Partnership NHS Trust
Professor Paul Camic, Professor of Psychology
and Public Health, Canterbury Christ Church
University
Dr Sebastian Crutch, Professorial Research
Associate, Dementia Research Centre, UCLPeter Dunlop, Expert Patient
Fergus Early OBE, Director of Green Candle
Dance Company
Veronica Franklin Gould, Director ofArts 4 Dementia
Chris Gage, Director of Ladder to the MoonJohn Killick, Poet
Keith Oliver, Expert Patient
Al-La Park, Assistant Professorial Research
Fellow, London School of Economics andPolitical Science
Maria Parsons, Director of the Creative
Dementia Arts Network
Professor Justine Schneider, Professor of
Mental Health and Social Care, Universityof Nottingham
David Slater, Director of Entelechy Arts
Belinda Sosinowicz, RADIQL project manager
Robin Sweeney, Dementia Friendly Communities,
Alzheimer’s Society
Kate Whitaker, Music for Life project manager,
Wigmore Hall
Gillian Wolfe CBE, Former Director of Learning
and Public Affairs, Dulwich Picture Gallery;
Learning, Arts and Heritage Consultant
November 2015: The Arts and Palliative Care,
Dying and Bereavement
Chair: Baroness Finlay of Llandaff, Professor of
Palliative Medicine, University of Cardiff andChair of the National Council for Palliative CareDr Sam Guglani, Consultant Clinical Oncologist,
Cheltenham General Hospital
Fiona Hamilton, Writer and Director of
Orchard Foundation
Nigel Hartley, Director of Supportive Care at the
St Christopher’s Group, London
Bob Heath, Music Therapist
160

Dr Iona Heath, Former President of the Royal
College of General Practitioners
Jane Lings, Music Therapist
Professor Allan Kellehear, 50th Anniversary
Professor (End of Life Care), University of Bradford
Anna Ledgard, Arts Producer and Researcher
Dr Viv Lucas, Medical Director, Garden Hospice,
Letchworth
Olwen Minford, Nurse, Trainer andPsychotherapist
Jane Moss, Writer and Creative Writing Tutor
Dr Simon Opher MBE, GP Lead for Cultural
Commissioning and Social Prescribing,Gloucestershire
Kate Organ, Arts Adviser, The Baring Foundation
Dallas Pounds, CEO Royal Trinity Hospice
Christopher Rawlence, Co-Creative Director,
Rosetta Life
Michèle Wood, Senior Art Therapist, Marie Curie
Hospice, Hampstead
December 2015: The Arts and Post-TraumaticStressChair: Rt Hon. Lord West of Spithead
Jason Bell, Veteran, Veterans in Practice,Foundation for Art and Creative Technology
Jojo Bowman, Artist, Danish Wounded Warriors
Nicky Clarke MBE, Chair of Trustees, Military
Wives Choirs Foundation
Kevin Dyer, Writer, Farnham Maltings
Colette Ferguson, Participant, Farnham Maltings
Emily Gee, Veterans in Practice, Foundation for
Art and Creative Technology
Shaun Johnson, Veteran, Combat Veteran Players
Rosie Kay, Artist, Rosie Kay Dance
Professor Peter Kinderman, President-Elect of
the British Psychological Society
Jessie Lee, Artist, Danish Wounded Warriors
Janice Lobban, Senior Art Therapist,
Combat Stress
Jaclyn McLoughlin, Founder and Director,
Combat Veteran Players
Lis Murphy, Creative Director, Music Action
International
Professor Nigel Osborne MBE, Composer andformerly Reid Professor of Music at the Universityof Edinburgh
John Ryan, Co-Founder Lift the Lid Productions,Home Front
Maya Twardzicki, Public Health Lead,
Home Front
February 2016: Museums and HealthOrganised with the help of the National
Alliance for Museums, Health and Wellbeing
Chair: Lord Lupton, former Chair of Trustees of
Dulwich Picture Gallery; Trustee, British Museum
David Anderson, Director General, Amgueddfa
Cymru – National Museum Wales
Professor Paul Camic, Professor of Psychology andPublic Health, Canterbury Christ Church University

Professor Helen Chatterjee, Professor of Biology,
UCL School of Life and Medical Sciences; Head of
Research and Teaching, UCL Public and Cultural
Engagement
Jane Grimshaw, Director of Nursing,
Trafford Hospital
Sharon Heal, Director, Museums Association
Hilary Jennings, Director of the Happy
Museum Project
Joanna Jones, Director, Canterbury Museums
Anne Kearton, Occupational Therapist,
Trafford Hospital
Victoria Northwood, Head of Archives andMuseum, Museum of the Mind
Dr Mark O’Neill, Director of Research and Policy,
Glasgow Life
Laura Phillips, Head of Community
Partnerships, British Museum
Helen Shearn, Head of Arts Strategy, South
London and Maudsley NHS Foundation Trust
Jason Spruce, Expert Patient
Esmé Ward, Head of Learning and Engagement at
the Whitworth and Manchester Museum, part ofManchester University
Gillian Wolfe CBE, Former Director of Learning
and Public Affairs, Dulwich Picture Gallery;
Learning, Arts and Heritage Consultant
March 2016: Arts and Health Policy and
Devolution
Chair: Baroness Morgan of Ely
Dr Jenny Elliot, Chief Executive of Arts Care
Northern Ireland
Professor Andrew Davies, Former Member ofthe Welsh Assembly; Chair of the Abertawe Bro
Morgannwg University Health Board
Alan Higgins, Director of Public Health,Oldham Council
Sally Lewis, Portfolio Manager, Engagement
and Participation, Arts Council of Wales
Maggie Maxwell, Head of Equalities, Diversity
and Inclusion (EDI), Creative Scotland
Clive Parkinson, Director of Arts for Health,
Manchester Metropolitan University
Jackie Sands, Health Improvement and Public
Health, NHS Greater Glasgow and Clyde
Professor Carol Tannerhill, Director, Glasgow
Centre for Population Health
Prue Thimbleby, Arts in Health Coordinator,
Abertawe Bro Morgannwg University
Health Board
April 2016: Arts, Health and Wellbeing
and Commissioning
Chair: Lord Bichard
Paul Bristow, Director, Strategic Partnerships,
Arts Council EnglandJane Davis, Chief Executive, The Reader
Rob Elkington, Director, Arts Connect
Yvonne Farquharson, Managing Director,
Breathe Arts Health Research

Jules Ford, Cultural Commissioning ProgrammeManager, Gloucestershire ClinicalCommissioning Group
Emma Hanson, Head of Strategic Commissioning
for Social Care, Health and Wellbeing, Kent
County Council
Jessica Harris, Manager, Cultural
Commissioning Programme, National Council
for Voluntary Organisations
Sue McKie, Health Improvement Principal,
Public Health, Wolverhampton City Council
Dr Cliff Richards, Chair, Halton ClinicalCommissioning Group
Alice Thwaite, Director, Equal Arts
Basil Wild, Commissioner and Contracts Officer
for Mental Health, Bath and North East Somerset
Council
Martin Wilson, Director, Tin Arts
May 2016: Arts on Prescription
Chair: Rt Hon. Lord Howarth of Newport
Dr Hilary Bungay, Anglia Ruskin University
Professor Helen Chatterjee, Professor of Biology,
UCL School of Life and Medical Sciences; Head of
Research and Teaching, UCL Public and Cultural
Engagement
Gavin Clayton, Director, Arts & Minds
Bernadette Conlon, Director, Start in Salford
Philippa Forsey, Manager, Creative Wellbeing
Programme, Creativity Works
Thrisha Halder, Director, Artlift
Gaye Jackson, Programme Manager, Health
Education England North West
Anita Jensen, PhD student, University of
Nottingham
Tom Ling, Senior Research Lead, RAND Europe
Carolina Magdalene Maier MF, Spokesperson
for Health and Quality of Life, Alternative
Party, Denmark
Diane O’Neill, Founder and Group Leader of
Changing Creations
Dr Simon Opher MBE, GP Lead for Cultural
Commissioning and Social Prescribing,Gloucestershire
Sharon Paulger, Director, Arts for Health,
Milton Keynes
Dr Marie Polley, Senior Lecturer, University ofWestminster
Dr Gillian Rice, GP and Chair of Artlift
Lucien Paul Stanfield FRSPH, Chief Executive,
Claremont Project
Janet Stevens, Participant, Start in Salford
Dr Theo Stickley, Academic Lead for Public
Engagement and Associate Professor of Mental
Health, University of Nottingham
Lucy Wells, Inclusive Arts Manager, Bromley by
Bow Centre
Dr Kerry Wilson, Head of Research, Institute ofCultural Capital, Liverpool

161

All-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Report

Acknowledgements

May 2016: Young People, Mental Health andthe Arts, followed by showing of film about
The Alchemy Project
Chair: Baroness Meacher
Susan Blishen, Advisor, Big Lottery
Mark Brown, Writer and social media activist
Carly Annable Coop, Project Director, The
Alchemy Project
Catarina Dias, Founder, Silent Secret
Beth Elliott, Director, Bethlem Gallery
Dr Lauren Gavaghan, Senior Registrar in
Psychiatry, South London and Maudsley NHSFoundation Trust
Catherine Hearn, Director, Helix Arts
Will Lang, Artist, Helix Arts
Dr Amelia Oldfield, Professor of Music Therapy,
Anglia Ruskin University; Senior Music Therapist,
Cambridge and Peterborough NHS Foundation
Trust.
Jessica Plant, Project Manager, National Alliance
for Arts in Criminal Justice
Stephen Sandford, Strategic Lead andProfessional Head of Arts Therapies, East London
NHS Foundation TrustJohn Sayers, former patient of South London and
Maudsley NHS Foundation Trust and a Bethlem
Gallery artist.
Naomi Shoba, Head of Youth Arts, Ovalhouse
Sam Walker, Samantics
June 2016: Arts and Healthcare
Environments, followed by an event at St
Thomas’ Hospital as part of Creativity andWellbeing Week
Chair: Lord Crisp
Gilly Angell, Expert Patient, University College
Hospital Cancer Centre
Sir Quentin Blake, Artist
Paul Brooks, Associate Director of Patient
Experience and Facilities Management, Derby
Teaching Hospitals
Clare Devine, Executive Director Architecture,
Built Environment and Design, Design
Council CabeGuy Eades, Director of Healing Arts, St Mary’s
Hospital, Isle of Wight
Susan Francis, Programme Director, Architectsfor HealthProfessor Fiona Sampson, Poet and Professorof Poetry at the University of Roehampton
Dr Sue Stuart-Smith, Psychiatrist andPsychotherapist
Sally Thompson, Director Grampian Hospitals
Arts Trust
Chris Tipping, Artist
Laura Waters, Arts Programme Manager, Derby
Teaching Hospitals
Paul Williams, Stanton Williams Architects
Jane Willis, Director of Willis Newson

162

July 2016: Arts and Public Health
Chair: Baroness Young of Hornsey
Shona Arora, National Workforce Development
Lead, Public Health England
Amal Azzudin, Community Development
Facilitator, Mental Health Foundation
Lois Blackburn, Artist, arthur+martha
Sheryll Catto, Co-Director, ActionSpaceDr Nayreen Daruwalla, Programme Director for
Prevention of Violence against Women andChildren, SNEHA, Mumbai
Philip Davenport, Artist, arthur+martha
Connie Junghans, Public Health Commissioner,
Westminster City Council
Thompson Hall, Artist, ActionSpaceTim Harrison, Creative Director, SICK! Festival
Louisa Newman, Public Health Workforce
Development Manager, Public Health EnglandSouth West
Professor David Osrin, Professor of Global
Health, UCL
Deborah Munt, Representative for Yorkshire andthe Humber; Chair, National Alliance for Arts,
Health and Wellbeing
Eva Okwonga, Peer Support Advisory Board
Member for Mind; Music Workshop Leader atMusic In Mind
Professor Richard Parish CBE, Professor of
Health Development, University of Chester; Board
Member, Public Health England
Lizzi Stephens, Chair of the Dover Breatheasy
Group, musician and leader of singing for
health groups
Catherine Swann, Deputy Director of Health andWellbeing (Healthy People) Public Health England
Jennifer Wood, Arts Officer, The Royal Boroughof Kensington and Chelsea
November 2016: Arts, Health and Wellbeing in
the Criminal Justice System, organised withthe help of the National Criminal Justice Arts
Alliance, following a visit to the Koestler
Trust Exhibition ‘We Are All Human’ at theRoyal Festival Hall
Chair: Baroness Young of Hornsey
Graham Beck, Governor, HMP Kirkham
Alli Black, HMP Kirkham
Eleonor Byrne, Clean Break Graduate
Dr Laura Caulfield, Assistant Dean, College of
Liberal Arts, Bath Spa University
Sarah Colvin, Schröder Professor, Universityof Cambridge
Alison Frater, Chair of the National Criminal
Justice Arts Alliance
Arthur Mactaggart, Artist
Femi Martin, Spoken word poet and writer
Lucy Perman, Clean Break Theatre Company
Debbie Samuel, Engagement Worker, London
Community Rehabilitation Company
John Speyer, Director, Music in Detention

Hong Tan, Head of Health in the Justice System,NHS England London
Richard Ward, Learning and Skills Team,National Offender Management Service
Andy Watson, Artistic Director, Geese
Theatre Company
January 2017: Place, Environment andCommunity
Guest Chair: Sunand Prasad
Rachel Adam, Project Director (bait), Woodhorn
Charitable Trust
Jacqui Bunce, Associate Director of East andNorth Hertfordshire Clinical Commissioning
Group
Jane Duncan, Architect and President of theRoyal Institute of British Architects
Melissa Hardwick, Director, Kentish Town
Improvement Fund
Teva Hesse, Director, London Branch, C F Møller
Raheel Mohamed, Founder and Directorof Maslaha
Professor Jeremy Myerson, Helen Hamlyn Chairof Design, Royal College of Art
Lenny Naar, Design Strategist, HELIX Centre,
Imperial College London
Andrew Simpson, Planner and Development
Manager and Advisor to Royal Institute of British
Architects on healthcare design
Sandra Stancliffe, Head of Education andInclusion, Historic England
March 2017: Funding for Arts, Healthand Wellbeing
Chair: Rt Hon. Lord Howarth of Newport
Sally Bacon OBE, Executive Director, Clore
Duffield Foundation
Bill Boa, Director of Finance, Cambridge
University Hospitals NHS Foundation Trust
Elaine Burke, Arts and Health Specialist
Nicola Crane, Programme Director and Head ofArts, Guy’s and St Thomas’ Charity
Jane Davis, Chief Executive, The Reader
Liz Ellis, Policy Adviser Communities andDiversity, Heritage Lottery Fund
Daniel Gerring, Partner, Travers Smith
Rama Gheerawo, Director of the Helen Hamlyn
Centre at the Royal College of Art
Lady Helen Hamlyn, Philanthropist
Rachel Hillman, Head of Engaging Science,
Wellcome
Mary Hutton, Accountable Officer
Gloucestershire Clinical Commissioning Group
Janet Morrison, Chair, The Baring Foundation
Mags Patten, Director of Policy andCommunications, Arts Council England
Jon Siddall, Director of Funding, Guy’s and St
Thomas’ Charity

Gillian Wolfe CBE, Former Director of Learning
and Public Affairs, Dulwich Picture Gallery,
Learning, Arts and Heritage Consultant
Participants in other Inquiry Meetings
Gabrielle Allen, Visual Arts Development
Manager, Guy’s and St Thomas’ Charity
Professor Mark Baker, Director of the Centre
for Guidelines, National Institute for Health andCare Excellence
Sir Peter Bazalgette, former Chair of Arts
Council England
Dr Sam Bennett, Head of Integrated PersonalCommissioning, NHS England
Professor Dame Carol Black, Principal,
Newnham College Cambridge
Dr Jo Black, Consultant Perinatal Psychiatrist,
Devon Partnership NHS Trust; Associate National
Clinical Director for Perinatal Mental Health,
NHS England.
Steve Chalke, Founder, Oasis
Dr Simon Chaplin, Director of Culture andSociety, Wellcome
Shirley Cramer, Chief Executive, Royal Society
for Public HealthChris Day, Director of Engagement, Strategy &Intelligence, Care Quality Commission
Dr Michael Dixon GP, National ClinicalChampion for Social Prescribing, NHS England
Dr Caroline Ellis-Hill, Senior Lecturer in
Qualitative Research, Bournemouth University
Dr David Fearnley, Medical Director Mersey
Care NHS Foundation Trust and Associate
National Clinical Director for Secure
Mental HealthHarriet Finney, Director, Creative Industries
Federation
Dr Andrew Furber, President of the Associationof Directors of Public Health
Susie Hall, Head of Arts, Great Ormond Street
Hospital
Professor Susan Hallam, Emerita Professor of
Education and Music Psychology, UCL Instituteof Education
Darren Henley, Chief Executive, Arts
Council England
Nancy Hey, Director, What Works Centre
for Wellbeing
Poppy Jaman, Chief Executive of Mental HealthFirst Aid England
Tim Joss, Chief Executive, Aesop
Faiza Khan, Director of Communications andPolicy, Paul Hamlyn Foundation
Ian Leete, Senior Adviser Culture, Tourism andSport, Local Government Association
Dr David McDaid, Associate Professorial
Research Fellow in Health Policy and Health
Economics, London School of Economics andPolitical Science
Ewen McKinnon, National Wellbeing and Civil
Society Policy and Analysis, Cabinet Office163

Acknowledgements

All-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Report

Lily Makurah, Deputy National Lead, Mental
Health and Wellbeing, Public Health England
Professor Sir Michael Marmot, Director of theInstitute of Health Equity, UCL
Dr Alan Maryon-Davis, Public Health doctor,
writer and broadcasterJohn Middleton, President, Faculty of
Public HealthPeter Morton, Head of News, Public Health
EnglandCatherine Mottram, Social Researcher, Evidence
and Analysis Unit, Department for Culture, Mediaand Sport
Clive Niall, Artist Teacher
Paul Ogden, Public Health Lead, Local
Government Association
Matthew Pearce, Senior Programme Manager,
Gloucestershire Clinical Commissioning Group
Rosa Vaquero, Communications Lead, Guy’s andSt Thomas’ Charity
Duncan Selbie, Chief Executive, Public Health
England
Sir Nicholas Serota, Chair, Arts Council England
Moira Sinclair, Director, Paul Hamlyn
Foundation
Anu Singh, Director of Public and Patient
Participation and Insight, NHS England
Oliver Stannard, Marketing andCommunications Manager, King’s College London
Duncan Stephenson, Director ofCommunications, Royal Society for Public Health
Bev Taylor, Volunteering and Development
Manager, NHS England
Gillian Taylor, PR Consultant
Professor Bryan Stoten, former Chair of UK
Public Health Register
Dr Matthew Taylor, Consultant Psychiatrist,
South London and Maudsley NHS Foundation
Trust
Robert Webster, Chief Executive SouthWest Yorkshire Partnership NHSFoundation Trust
Katee Woods, Coordinator, Creativity andWellbeing Week
Peter Wyman, CBE DL, Chair, Care Quality
Commission

164

165

All-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Report

Inquiry Partners And Funders
Guy’s and St Thomas’ Charity
Guy’s and St Thomas’ Charityis an independent,
place-based foundation. It works in partnershipwith Guy’s and St Thomas’ NHS Foundation Trustand others to tackle the major health challenges
affecting people living in diverse and deprived
urban areas, concentrating its efforts on the
London boroughs of Lambeth and Southwark. Oneof the ways in which the Charity drives change is
by working with, and connecting, artists,
clinicians and others to bring fresh, creative
thinking to health challenges. The Charity also has
one of the largest fine arts and heritage collections
belonging to a health charity, with over 4,500
items. Over the next decade, the Charity aims toboth broaden its reach and narrow its focus. It willaddress its resources to complex challenges, suchas reducing childhood obesity and improving thehealth and care of people with multiple long-term
conditions.
King’s College London
King’s College London is an interdisciplinary,
research-led university and part of King’s HealthPartners, one of the largest Academic Health
Science Centres in the UK. Over recent years,
King’s has built on its extensive partnerships
across the cultural sector to explore the potentialof arts engagement in both research and education.
Innovative collaborations bring together
academics, students, patients, carers andhealthcare professionals across all disciplines totrial and test new approaches to health andhealthcare and provide new learning opportunities
for healthcare professionals.
The National Alliance for Arts, Healthand Wellbeing
The National Alliance for Arts, Health andWellbeing is a consortium of regional organisations
which aims to provide a clear, focused voice toarticulate the role creativity can play in health andwellbeing. Supported since 2012 by Arts Council
England, the Alliance seeks to act as a hub for
information and research on arts and health workin England and further afield and to advocate on
behalf of this work. The Alliance encourages theuse of the arts by health and social care providers,and strives to raise standards in this sector bysupporting artists, clinicians and patients throughsharing knowledge, modelling good practice andbringing people together.

The Royal Society for Public Health
The Royal Society for Public Health is anindependent health education charity, dedicatedto protecting and promoting the public’s healthand wellbeing. It is the world’s longest-establishedpublic health body, and it has over 6,000 members
drawn from the public health community both in
the UK and internationally. The Society’s
operations include an Ofqual-recognised awardingorganisation, a training and development arm andhealth and wellbeing accreditation. It also
produces a wide variety of public healthconferences; the publishing division includes theinternationally renowned journal Public Health,and policy and campaigns to promote better
health and wellbeing are being developed. The
Society’s vision is that everyone should have theopportunity to optimise their health andwellbeing.
Paul Hamlyn Foundation
Established in 1987, Paul Hamlyn Foundation is
one of the largest independent grant-making
foundations in the UK. Its long-term mission is tohelp people overcome disadvantage and lack ofopportunity, so that they can realise their potentialand enjoy fulfilling and creative lives. The
Foundation has a particular interest in supporting
young people and a strong belief in the importanceof the arts. Its enduring values draw on the beliefs
and instincts of founder, Paul Hamlyn, with social
justice as the golden thread that links all its work.
Wellcome
Wellcome exists to improve health for everyone byhelping great ideas to thrive. It is a global charitablefoundation, both politically and financiallyindependent. The Trust supports scientists andresearchers, takes on big problems, fuelsimaginations and sparks deb

Betty, Nottingham Carnival
Imagine, City Arts
166

167

Photographer: Kate Duncan

167All-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Report

Abbreviations
ACE
ADASS
ADHD
AHRC
AHP
AM
APPG
APPGAHW
ASD
BAME
BBC
BCS70
BREEAM
BUPA
CABE
CAMHS
CCG
CEO
CHWA
CIC
COPD
CQC
CRILS
DCLG
DCMS
DfE
DH
ECOL
EHE
ESRC
FNFNM
FPH
GP
GMC
GSTC
GVCSA
HCPC
HEE
HELIX
HiAP
HICSS
HWB
IAPT
IoD
JSNA
KCC
LGA
LSE
MHA
MHFA
MMU
MoD
MoJ
MoMA
MP
NAAHW
NCF
NCJAA
168

Arts Council England
Association of Directors of Adult Social Services
Attention Deficit Hyperactivity Disorder
Arts and Humanities Research Council
Allied Health Professional
Assembly Member
All-Party Parliamentary Group
All-Party Parliamentary Group on Arts, Health and Wellbeing
Autism Spectrum DisorderBlack Asian and Minority Ethnic
British Broadcasting Corporation
British Cohort Study 1970
British Research Establishment Environmental Assessment Method
British United Provident Association
Commission for Architecture and the Built Environment
Children’s and Adolescents’ Mental Health Services
Clinical Commissioning Group
Chief Executive Officer
Culture, Health and Wellbeing Alliance
Community Interest Company
Chronic Obstructive Pulmonary Disease
Care Quality Commission
Centre for Research into Reading, Literature and Society
Department for Communities and Local Government
Department for Culture, Media and Sport
Department for Education
Department of HealthEnhancing Care at the End of Life
Enhancing the Healing Environment
Economic and Social Research Council
Florence Nightingale Faculty of Nursing and Midwifery
Faculty of Public HealthGeneral Practitioner
General Medical Council
Guy’s and St Thomas’ Charity
Gloucestershire Voluntary Community Sector Alliance
Health and Care Professions Council
Health Education England
Healthcare Innovation Exchange
Health in All Policy
Hull Integrated Community Stroke Service
Health and Wellbeing Board
Improving Access to Psychological Therapies
Institute of Directors
Joint Strategic Needs Assessment
Kent County Council
Local Government Association
London School of Economics and Political Science
Methodist Homes Association
Mental Health First Aid
Manchester Metropolitan University
Ministry of Defence
Ministry of JusticeMuseum of Modern Art
Member of Parliament
National Alliance for Arts, Health and Wellbeing
National Care Forum
National Criminal Justice Arts Alliance

NCVO
NEA
NEF
NESTA
NHS
NICE
NIHR
NPO
OFSTED
ONS
PHE
PHF
PTSD
QALY
RCA
RCGP
RCT
RIBA
RoI
RPO
RSPH
SCIE
SEN
SIB
SLaM
SRoI
STP
TLAP
TUC
UCL
VCSE
WEMWBSWHO

National Council for Voluntary Organisations
National Endowment for the Arts (USA)New Economics Foundation
National Endowment for Science Technology and the Arts (UK)
National Health Service
National Institute for Health and Care Excellence
National Institute for Health Research
National Portfolio Organisation
Office for Standards in Education, Children’s Services and Skills
Office for National Statistics
Public Health England
Paul Hamlyn Foundation
Post-Traumatic Stress Disorder
Quality Adjusted Life Years
Royal College of Art
Royal College of General Practitioners
Randomised Controlled Trial
Royal Institute of British Architects
Return on Investment
Royal Philharmonic Orchestra
Royal Society for Public HealthSocial Care Institute for Excellence
Special Educational Needs
Social Impact Bond
South London and Maudsley NHS Foundation TrustSocial Return on Investment
Sustainability and Transformation Partnership or PlanThink Local Act Personal
Trades Union Congress
University College London
Voluntary, Community and Social Enterprise
Warwick-Edinburgh Mental Wellbeing Scale
World Health Organization

A glossary of health terms is available on the website of the National Alliance for Museums,
Health and Wellbeing.

169All-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Report

References
1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.
12.
13.

14.

15.
16.
17.

18.
19.
20.

21.

 ew NHS Alliance. (14 February 2017). New NHS Alliance callsN
for closer collaboration to achieve better community outcomesfor health and social care integration.
Crisp, N., Stuckler, D., Horton, R., Adebowale, V., Bailey, S.,et al. (7 October 2016). Manifesto for a Healthy and Healthcreating Society. The Lancet, p. 1.
Preamble to the Constitution of WHO as adopted by theInternational Health Conference, New York, 19 June–22 July
1946; signed on 22 July 1946 by the representatives of 61 States(Official Records of WHO, no. 2, p. 100) and entered into force
on 7 April 1948, since which time the definition has notbeen amended.
For a consideration of the £5.8bn funding shortfall in social care(£2bn of which was met in the 2017 Budget), see Local
Government Association. (2016). Adult Social Care Funding: 2016
state of the nation report. London: Local Government
Association. For an equivalent consideration of health, seeHouse of Lords Select Committee on the Long-term
Sustainability of the NHS. (2017). The Long-term Sustainability of
the NHS and Adult Social Care (Report of Session 2016–17 No. HL151). London: House of Lords.
Emergency hospital admissions for ambulatory care-sensitive
conditions alone cost the NHS £1.42bn every year. Tian, Y.,
Dixon, A. & Gao, H. (2012). Data Briefing – Emergency Hospital
Admissions for Ambulatory Care-sensitive Conditions:
Identifying the potential for reductions. London: King’s Fund.
See NHS England’s Year of Care programme, including NHSEngland. (2011). Thanks for the Petunias: A guide to developing
and commissioning non-traditional providers to support theself management of people with long term conditions, which
mentions arts for health. Leeds: NHS England.
Glasgow Centre for Population Health. (2014). Evaluating
Sistema Scotland: A narrative synthesis of evidence relating to
the impact of arts and community-based arts interventions on
health, wellbeing and educational attainment (Systematic
literature reviews, Work Packages 1, 2 and 3). Glasgow: Glasgow
Centre for Population Health.
Elliott, A. M., Smith, B. H., Penny, K., Cairns Smith, W. &Chambers, W. A. (1999). The Epidemiology of Chronic Pain in theCommunity. The Lancet, 354 (9186), pp. 1248–52.
World Health Organization Regional Office for Europe. (2013).
Health 2020: A European policy framework and strategy for the
21st century. Copenhagen: World Health Organization Regional
Office for Europe.
For a discussion of this, see British Medical Association. (2011).
The Psychological and Social Needs of Patients. London: British
Medical Association.
A ntonowsky, A. (1979). Health, Stress and Coping. San Francisco:
Jossey-Bass.
Manifesto for a Healthy and Health-creating Society. op. cit., p. 1.
White, S. C. (2016). The Many Faces of Wellbeing. In Cultures of
Wellbeing: Method, place, policy. Basingstoke: Palgrave
Macmillan, p. 4.
The Government Office for Science. (2008). Foresight Mental
Capital and Wellbeing Project: Final project report. (Foresight).
London: The Government Office for Science, p. 10.
Ibid, p. 61.
Loc cit.
A ked, J., Marks, N., Cordon, C. & Thompson, S. (2008). Five Ways
to Wellbeing: A report presented to the Foresight Project oncommunicating the evidence base for improving people’s
well-being. London: New Economics Foundation.
Out of the Blue: www.artshealthandwellbeing.org.uk
The Many Faces of Wellbeing, op. cit., p. 5.
Stiglitz, J. E., Sen, A. & Fitoussi, J-P. (2009). Report by theCommission on the Measurement of Economic Performance andSocial Progress, pp. 14–15.
Davies, S. C. (2014). Annual Report of the Chief Medical Officer
2013 – Public Mental Health Priorities: Investing in the evidence.
London: Department of Health (DH).

22.

 hat Works Centre for Wellbeing: whatworkswellbeing.org/
W
wellbeing-2
23. Daykin, N., Mansfield, L., Payne, A., Kay, T., Meads, C.,
D’Innocenzo, G., Burnett, A., Dolan, P., Julier, G., Longworth, L.,
Tomlinson, A., Testoni, S., Victor, C. (2016). What Works for
Wellbeing in Culture and Sport? Report of a DELPHI process to
support coproduction and establish principles and parametersof an evidence review. Perspectives in Public Health.
24. Davies, W. (2015). The Happiness Industry: How the Governmentand big business sold us well-being. London: Verso, p. 4.
25. Ibid, p. 6.
26. For a consideration of the ways in which misery and illness arenormative reactions to an unhealthy society, see Fromm, E.
(2002). The Sane Society. London: Routledge.
27. W HO Centre for Health Development. (2004). A Glossary ofTerms for Community Healthcare and Services for Older Persons.
Geneva: World Health Organization, p. 48.
28. Chapatti and Chat was a cookery and creative writing project
developed by Oldham Council’s arts development team between
2015 and 2016, which aimed to raise awareness about type 2
diabetes, particularly among South Asian families:
www.artshealthandwellbeing.org.uk
29. See Blood Makes Noise: www.mypockets.co.uk
30. Life Kitchen has been set up by Ryan Riley to offer free cookery
classes for people with cancer, in memory of his mother who losther sense of taste during her battle with lung cancer.
31. Williams, R. (1989). Culture is Ordinary [1958]. In Resources of
Hope: Culture, Democracy, Socialism. London: Verso, pp. 3–14.
32. A s an example of the latter, see the work of the Helen Hamlyn
Centre for Design, particularly the Healthcare Research Lab.
33. Voluntary Arts England. (30 March 2011). Written evidence
submitted to Culture, Media and Sport Committee: Funding of
the arts and heritage (arts 129).
34. R amsden, H., Milling, J., Phillimore, J., McCabe, Fyfe, H., et al.
(2011). The Role of Grassroots Arts Activities in Communities: A
scoping study. Third Sector Research Centre Working Paper 68.
35. Department for Culture, Media and Sport (DCMS). (9 December2010). Creative Industries Economic Estimates.
36. Value of Creative Industries: www.gov.uk/uk-economy
37. Brankin, R. (2000). Creating our Future – Minding our Past:
Scotland’s National Cultural Strategy. Edinburgh: Scottish
Executive.
38. In his book The Singing Neanderthals, Professor of Early
Prehistory and Pro-Vice-Chancellor at the University ofReading, Steven Mithen, argues that the propensity to makemusic is encoded into our DNA, providing an evolutionary
foundation for the emergence of language.
39. Camic, P. M. (2008). Playing in the Mud: Health psychology, thearts and creative approaches to healthcare. Journal of Health
Psychology, 13, p. 289.
40. The RSPH Working Group on Arts, Health and Wellbeing. (2013).
Arts, Health and Wellbeing Beyond the Millennium: How far have
we come and where do we want to go? London: The RSPH and thePhilipp Family Foundation, p. 4.
41. Fancourt, D. (2017). Arts in Health: Designing and researchinginterventions. Oxford: Oxford University Press, p. 6.
42. Arts activities as a form of guided conversation about health arebeing pioneered by Encounters Arts: www.encounters-arts.org.uk
43. Crossick, G. & Kaszynska, P. (2016). Understanding the Value ofArts & Culture: The AHRC Cultural Value Project. Swindon: Artsand Humanities Research Council, p. 42.
44. See the work of C2 Connecting Communities:
www.c2connectingcommunities.co.uk
45. For a consideration of art in hospital environments, see Arts
Council England. (2006). The Power of Art –Visual Arts: Evidenceof impact. London: Arts Council England. For a brief history ofart in hospitals from the perspective of the King’s Fund, see:www.kingsfund.org.uk

46.

47.

48.
49.
50.
51.
52.

53.
54.
55.

56.

57.

58.

59.
60.
61.
62.

63.

 or an early review of work in this area, see Health Development
F
Agency. (2000). Art for Health: A review of good practice incommunity-based arts projects and initiatives which impact on
health and wellbeing. London: Health Development Agency.
See Secker, J., Hacking, S., Spandler, H., Kent, L. & Shenton, J.
(2007). Mental Health, Social Inclusion and Arts: Developing theevidence base. Cambridge: Anglia Ruskin University, which wascommissioned by DCMS and partly funded by DH. The
relationship between the creative arts and mental wellbeing is
also recognised in Faculty of Public Health and Mental HealthFoundation. (2016). Better Mental Health For All: A public healthapproach to mental health improvement. London: Faculty of
Public Health and Mental Health Foundation.
For an insight into art therapy through the experience of clients,
visit: www.baat.org
NAAHW categories of arts and health activity: www.
artshealthandwellbeing.org.uk
For a discussion of this distinction, see Rutger, M. (2017). Knittinga PhD (PhD). University of Exeter Medical School, Exeter.
Clift, S. (2011). A Brief Introduction to Arts and Health.
Perspectives in Public Health, 131 (1).
For research into this, see Conner, T., DeYoung, C. G. & Silvia, P.
J. (2016). Everyday Creative Activity as a Path to Flourishing. The
Journal of Positive Psychology; and Understanding Everyday
Participation: www.everydayparticipation.org
Johnson, A. (2008). Open to All: Mental health, social inclusion
and museums and galleries. London: The Wallace Collection.
Breathe Magic: breatheahr.org/breathe-magicSee The Centre for Policy on Ageing. (2011). Keep Dancing:
The health and well-being benefits of dance for older people.
London: BUPA.
This discussion took place as part of the First National Arts in
Health Conference and Showcase for Health Decision Makers on
5 February 2016. Professor Grant’s comment was made in
response to Sir Peter Bazalgette’s dismissal of ‘dreadfulam dram’.
In Cuba in the 1960s, tens of thousands of arts teachers weretrained to disseminate creative skills. In its heyday, this ongoingprogramme attracted around one million amateur artists in a
population of six million. Nowadays, Cuba benefits from some of
the world’s highest levels of linguistic and cultural literacy;
people have the opportunity to practise the arts in their sparetime and to become professional artists. See Gordon-Nesbitt, R.
(2015). To Defend the Revolution is to Defend Culture: The Cultural
Policy of the Cuban Revolution. Oakland CA: PM Press.
Wood, M. J. (2015). The Contribution of Art Therapy to Palliative
Medicine. In N. Cherny, M. Fallon, S. Kaasa, R. K. Portenoy & D.
C. Currow (Eds.), Oxford Textbook of Palliative Medicine.
Oxford: Oxford University Press.
Arts, Health and Wellbeing Beyond the Millennium, op. cit.
Coles, P. (1981). The Manchester Hospital Arts Project. London:
Calouste Gulbenkian Foundation.
A rts for Health. Arts and Health Manifesto. (2012), p. 6, available
at: artsforhealth.org.
Grossi, E., Sacco, P. L., Tavano Blessi, G. & Cerutti, R. (2010). The
Impact of Culture on the Individual Subjective Well-being of the
Italian Population: An exploratory study. Applied Research in
Quality of Life, 6 (4), pp. 387–410; and Grossi, E., Tavano Blessi, G.,
Sacco, P. L. & Buscema, M. (2012). The Interaction Between
Culture, Health and Psychological Well-Being: Data Mining
from the Italian Culture and Well-Being Project. Journal ofHappiness Studies, 13, pp. 129–48.
Ings, R., Crane, N. & Cameron, M. (2012). Be Creative Be Well:
Arts, wellbeing and local communities – an evaluation. London:
Arts Council England.

64.

65.

66.

67.

68.

69.

70.
71.
72.
73.
74.

75.

76.

77.
78.

79.

80.

81.
82.

83.
84.

170

 ll-Party Parliamentary Group on Wellbeing Economics (2014).
A
Wellbeing in Four Policy Areas: Report by the All-Party
Parliamentary Group on Wellbeing Economics. A discursive
exploration of the relationship between the arts and wellbeing is
documented in Billington, J., Fyfe, H., Milling, J. & Schaefer, K.
(2011). Connected Communities: Participatory arts andwell-being past and present practices. Universities of Exeter
and Glamorgan.
In addition to Understanding the Value of Arts & Culture, seeHenley, D. (2016). The Arts Dividend: Why Investment in Culture
Pays. London: Elliot and Thompson, which contains a chapter
entitled ‘The Feel-Good Dividend’ centred on the benefits of thearts to health and wellbeing.
Set up by Langley Brown, a member of the second Hospital Arts
team, Sheltered Training in the Arts (START) worked on thebasis that creativity hastened recovery from mental distress.
Receiving an initial three years of funding, the organisation was
taken under the umbrella of Manchester Mental Health andSocial Care NHS Trust until 2015.
Commission on the Social Determinants of Health. (2008).
Closing the Gap in a Generation: Health equity through action on
the social determinants of health – Final report of the Commission
on Social Determinants of Health. Geneva: World HealthOrganization, p. 1.
See also Buck, D. & Maguire, D. (2015). Inequalities in Life
Expectancy: Changes over time and implications for policy.
London: The King’s Fund.
World Health Organization Regional Office for Europe. (n.d.).
Health at Key Stages of Life – the Life-Course Approach to
Public Health.
Marmot, M. (2015). The Health Gap: The challenge of an unequal
world. London: Bloomsbury.
Davies, S. C. (2013). Annual Report of the Chief Medical Officer 2012
– Our Children Deserve Better: Prevention pays. London: DH.
The Health Gap, op. cit.
To Defend the Revolution is to Defend Culture, op. cit
Hills, M. (2006). An Inquiry Into the Relationship Between the
Visual Arts and Psychotherapy in Post Revolutionary Cuba (PhD).
Queen Margaret University College, Edinburgh.
Clift, S., Camic, P. & Daykin, N. (2010). The Arts and Global
Health Inequities. Arts & Health: An International Journal for
Research, Policy and Practice, 2 (1), pp. 3–7.
Clift, S. and Camic, C. (2016). Introduction to the Field of Creative
Arts, Wellbeing, and Health: Achievements and current
challenges. In Creative Arts, Health and Wellbeing: International
Perspectives on Practice, Policy and Research. Oxford: Oxford
University Press, pp. 3–10.
See Lansley, S. (2012). The Cost of Inequality: Why economic
equality is essential for recovery. London: Gibson Square.
Marmot, M., Allen, J., Goldblatt, P., Boyce, T., McNeish, D., et al.
(2010). Fair Society, Healthy Lives – The Marmot Review:
Strategic review of health inequalities in England post-2010,
p. 18. If current trends continue, around 90 percent of men and
80 percent of women are predicted to be overweight or obese
by 2050.
See Lindström, B. & Eriksson, M. (2009). The Salutogenic
Approach to the Making of HiAP/Healthy Public Policy:
Illustrated by a case study. Global Health Promotion, 16 (1), pp.
17–28; and Navarro, V., Muntaner, C., Borrell, C., Benach, J.,
Quiroga, Á., et al. (16 September 2006). Politics and Health
Outcomes. The Lancet, (368), pp. 1033–37.
Public Health England. (2016). Local wellbeing, local
growth Implementing Health in All Policies at a Local Level:
Practical examples. London: Public Health England.
Fair Society, Healthy Lives, op. cit., p. 15.
HM Government. (2010). Healthy Lives, Healthy People: Ourstrategy for public health in England (White Paper No. CM7985).
London: HM Government.
Department of Health. (2012). The Public Health Outcomes
Framework for England, 2013–2016. London: DH.
Loc cit.
171

All-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Report

85.
86.
87.

HM Government. Health and Social Care Act 2012.
Ibid, p. 1.
Department of Health. (2013). Improving Outcomes andSupporting Transparency Part 1A: A public health outcomesframework for England, 2013–2016. London: DH.
88. Improvement and Development Agency. (2010). The Social
Determinants of Health and the Role of Local Government.
London: Improvement and Development Agency.
89. A s an example, see Coventry: A Marmot city – strategic
summary, 2016–19.
90. A s an example, see Royal College of Nursing. (2012). HealthInequalities and the Social Determinants of Health. London:
Royal College of Nursing.
91. The Long-term Sustainability of the NHS and Adult Social Care,op. cit., p. 9.
92. Audit Scotland. (2012). Health Inequalities in Scotland.
Edinburgh: Audit Scotland.
93. Scottish Government Strategic Objectives: www.gov.scot/
About/Performance/scotPerforms/objectives
94. Scottish Government. (2008). Equally Well: Report of theministerial task force on health inequalities. Edinburgh: Scottish
Government.
95. Creating our Future – Minding our Past, op. cit.
96. Scottish Government. (2016). The National Performance
Framework. Edinburgh: Scottish Government.
97. Department of Health, Social Services and Public Safety. (2014).
Make Life Better: A whole system strategic framework for publichealth 2013–23. Belfast: Department of Health, Social Services
and Public Safety.
98. Northern Ireland Executive. (2016). Draft Programme
for Government Framework 2016–21. Belfast: Northern
Ireland Executive.
99. Williams, A. (2013). The Listening Organisation: Ensuring care is
person-centred in NHS Wales. Cardiff: 1000 Lives Plus.
100. Well-being of Future Generations (Wales) Act 2015.
101. Friedli, L. (2009). Mental Health, Resilience and Inequalities.
Geneva: World Health Organization.
102. See Stress: the different kinds of stress, American Psychological
Association: www.apa.org
103. See Hertzman, C. & Boyce, T. (2010). How Experience Gets Under
the Skin to Create Gradients in Developmental Health. Annual
Review of Public Health, (31), pp. 329–47; Shonkoff, J. P. & Garner,
S. (2012). The Lifelong Effects of Early Childhood Adversity and
Toxic Stress. Pediatrics, (129), pp. e232–46; and Borghol, N.,
Suderman, M., McArdle, W., Racine, A., Hallett, et al. (2012).
Associations with Early-life Socio-economic Position in Adult
DNA Methylation. International Journal of Epidemiology, (41),pp. 62–74.
104. See Barker, D. (1995). Fetal Origins of Coronary Heart Disease.
British Medical Journal, 311, pp. 171–74; Barker, D. (1997). Fetal
Nutrition and Cardiovascular Disease in Later Life. British
Medical Bulletin, 53 (1), pp. 96–108; and Power, C. & Hertzman, C.
(1997). Social and Biological Pathways Linking Early Life andAdult Disease. British Medical Bulletin, 53 (1), pp. 210–21.
105. Galobardes, B., Lynch, J. W. & Davey Smith, G. (2004). Childhood
Socioeconomic Circumstances and Cause-specific Mortality in
Adulthood: Systematic review and interpretation.
Epidemiologic Reviews, 26, pp. 7–21.
106. Lewis, G. (31 July 2012). Psychological Distress and Death from
Cardiovascular Disease. British Medical Journal, 345, p. e5177.
107. Dube, S. R., Felitti, V. J., Dong, M., Giles, W. H. & Anda, R. F.
(2003). The Impact of Adverse Childhood Experiences on Health
Problems: Evidence from four birth cohorts dating back to 1900.
Preventive Medicine, (37), pp. 268–77; Felitti, V. J., Anda, R. F.,
Nordenberg, D., Williamson, D. F., Spitz, A. M., et al. (1998).
Relationship of Childhood Abuse and Household Dysfunction to
Many of the Leading Causes of Death in Adults. American
Journal of Preventive Medicine, 14 (4), pp. 245–58; and Norman,
R. E., Byambaa, M., De, R., Butchart, A., Scott, J. & Vos, T. (2012).
The Long-term Health Consequences of Child Physical Abuse,
Emotional Abuse, and Neglect: A systematic review andmeta-analysis. PLOS Medicine, 9 (11), p. 31.
108. Reiss, F. (2013). Socioeconomic Inequalities and Mental Health
Problems in Children and Adolescents: A systematic review.
Social Science & Medicine, (90), pp. 24–31.
172

109. See Chapman, D. P., Whitfield, C. L., Felitti, V. J., Dube, S. R.,
Edwards, V. J. & Anda, R. F. (2004). Adverse Childhood
Experiences and the Risk of Depressive Disorders in Adulthood.
Journal of Affective Disorders, (82), pp. 217–25.
110. The Health Gap, op. cit., p. 124.
111. R asmuson, S., Olsson, T., Henriksson, B. G., Kelly, P. A. T.,
Holmes, M. C., et al. (1998). Environmental Enrichment
Selectively Increases 5-HT1A Receptor mRNA Expression andBinding in the Rat Hippocampus. Molecular Brain Research, 53,
pp. 285–90.
112. Zimmermann, A., Stauffacher, M., Langhans, W. & Wu ̈rbel, H.
(2001). Enrichment-dependent Differences in Novelty
Exploration in Rats Can be Explained by Habituation.
Behavioural Brain Research, 121, pp. 11–20.
113. Walsh, D., Bendel, N., Jones, R. & Hanlon, P. (2010). It’s not ‘justdeprivation’: Why do equally deprived UK cities experience
different health outcomes? Public Health, 124, pp. 487–95.
114. Bygren, L. O. (2013). Intergenerational Health Responses toAdverse and Enriched Environments. Annual Review of Public
Health, 34, pp. 49–60.
115. Mill, J. and Petronis, A. (2008). Pre- and Peri-natal
Environmental Risks for Attention-deficit Hyperactivity
Disorder (ADHD): The potential role of epigenetic processes inmediating susceptibility. Journal of Child Psychology andPsychiatry, 49 (10), pp. 1020–30.
116. Hibberd, C., Yau, J. L. W. & Seckl, J. R. (2000). Glucocorticoids
and the Ageing Hippocampus. Journal of Anatomy, 197, pp.
553–56 and Olsson, T., Mohammed, A. K., Donaldson, L. F. &Seckl, J. R. (1995). Transcription Factor AP-2 Gene Expression in
Adult Rat Hippocampal Regions: Effects of environmental
manipulations. Neuroscience Letters, 189, pp. 113–16.
117. Csikszentmihalyi, M. (2004). Flow: The secret to happiness.
TED Talk.
118. Marr, A. To Make is to Live. Create. Retrieved from issuu.com/
artscouncilengland/docs/create_digital_am_essay_issuu/2.
119. The Health Gap, op. cit.
120. Taking Part: www.gov.uk
121. Inglis, G. & Williams, J. (2010). Models of Sporting and Cultural
Activity: Analysis of the Taking Part Survey.
122. Leadbetter, C. & O’Connor, N. (2013). Healthy Attendance? The
Impact of Cultural Engagement and Sports Participation on
Health and Satisfaction with Life in Scotland. Edinburgh:
Scottish Government, p. 7.
123. Calouste Gulbenkian Foundation UK Branch. (2016).
Participatory Performing Arts: Summarising our approach.
London: Calouste Gulbenkian Foundation UK Branch.
124. Wellbeing in Four Policy Areas, op. cit.
125. Serota, N. (2017). A Creative Future in a Changing World.
Presented at No Boundaries, Hull.
126. ACE guidance on investment in diversity and the Creative Case:www.artscouncil.org.uk
127. O’Brien, D., Laurison, D., Miles, A. & Friedman, S. (2016). Are theCreative Industries Meritocratic? An analysis of the 2014 British
Labour Force Survey. Cultural Trends.
128. Department for Culture, Media and Sport. (2016). The Culture
White Paper (White Paper No. Cm 9218). London: HM
Government, p. 8.
129. Parkinson, C. & White, M. (2013). Inequalities, the Arts andPublic Health: Towards an international conversation. Arts &Health, 5 (3), p. 179.
130. Navarro, V. (2009). What We Mean by Social Determinants ofHealth. Global Health Promotion, 16 (1), pp. 5–16.
131. A s a possible bridge between these two definitions of culture in
the context of arts and health, the WHO Health 2020
programme advocates locally specific approaches to developing
resilient communities as a way of addressing healthinequalities.
132. White, M. (2009). Arts Development in Community Health: Asocial tonic. Oxford: Radcliffe, p. 3.
133. Closing the Gap in a Generation, op. cit., p. 22.

134. For an overview of recent developments in the field, see Stickley,T., Parr, H., Atkinson, S., Daykin, N., Clift, S., et al. (2016). Arts,
Health & Wellbeing: Reflections on a national seminar series
and building a UK research network. Arts and Health. A book,compiling contributions to the 2012–13 ESRC seminar series on
the arts and health – which gave rise to the RSPH Special
Interest Group – edited by Dr Stickley and Professor Clift, will
be published in summer 2017.
135. New Economics Foundation. (2016). The Art of Commissioning:
How commissioners can release the potential of the arts andcultural sector. London: New Economics Foundation.
136. For a discussion of this, see: createquity.com/2016/10/
what-works-in-arts-and-culture-policy
137. Hurwitz, B. Arts and Healthcare Evaluation: An underdeveloped field. Unpublished paper, King’s College London.
138. For a discussion of research in the field of arts and health, see
Hemingway, A. & Crossen-White, H. (2014). Arts in Health: A
review of the literature. Bournemouth: Bournemouth
University; Chapline, J. & Johnson, J. K. (2016). The National
Endowment for the Arts. Guide to Community-Engaged Researchin the Arts and Health. Washington DC: National Endowment for
the Arts; and Arts in Health: Designing and researchinginterventions, op. cit.
139. Understanding the Value of Arts & Culture, op. cit., p. 111.
140. Ibid, p. 112.
141. Clift, S. (2017). On the Need for Diversity of Methods in
Researching Arts and Health Practice. In N. Rowe & M. Reason(Eds.). Evidence and Impact in Theatre, Music and Art. New York:
Bloomsbury Methuen.
142. Annual Report of the Chief Medical Officer 2013, op. cit., p. 36.
143. A nnouncement of Measuring National Well-being: www.gov.uk
144. For an analysis of this project, see Oman, S. (2016). Measuring
National Wellbeing. In Cultures of Wellbeing: Method, place,
policy, op. cit.
145. A ssessment of Change September 2016 Release: www.ons.gov.
uk
146. Understanding the Value of Arts & Culture, op. cit., pp. 37–38.
147. What Works Centre for Wellbeing reviews of music and singing:
whatworkswellbeing.org/music-singing/ For an earlier
consideration of work in this area, see R. McDonald, C. Kreutz &L. Mitchell (Eds.). (2012). Music, Health and Wellbeing. Oxford:
Oxford University Press.
148. Dolan, P., Layard, R. & Metcalfe, R. (2011). Measuring Subjective
Well-being for Public Policy. London: Office for National
Statistics.
149. For a consideration of the latter form of wellbeing, see Ryan, R.
M. & Deci, E. L. (2001). On Happiness and Human Potentials: A
review of research on hedonic and eudaimonic well-being.
Annual Review of Psychology, (52), pp. 141–66.
150. Layard, R. (2016). Common Currency: Measuring wellbeing andcost-effectiveness analysis using subjective wellbeing. London:
What Works Centre for Wellbeing, p.4.
151. OECD. (2013). OECD Guidelines on Measuring Subjective
Well-being. Paris: OECD Publishing.
152. Stewart-Brown, S. & Janmohamed, K. (2008). WarwickEdinburgh Mental Well-being Scale (WEMWBS) User Guide
Version 1. Warwick Medical School: University of Warwick, p. ii.
153. BCS70 follows the lives of more than 17,000 people born in
England, Scotland and Wales during a single week in 1970. It
adopts a life-course approach to study how exposure to certain
factors during early life can influence health outcomes in later
life. Since the original birth survey, cohort members have beensurveyed at ages 5, 10, 16, 26, 30, 34, 38 and 42.
154. Davies, C., Knuiman, M. & Rosenberg, M. (2016). The Art of Being
Mentally Healthy: A study to quantify the relationship between
recreational arts engagement and mental well-being in thegeneral population. BMC Public Health, 16 (15).
155. Healthway sponsorship of culture: www.mediastatements.
wa.gov.au
156. Thompson, L. J. & Chatterjee, H. (2014). UCL Museum Wellbeing
Measures Toolkit.
157. EQ-5D Health-Related Quality of Life Questionnaire:
www.euroqol.org
158. Dementia Care Mapping: www.bradford.ac.uk

159. C anterbury Wellbeing Scales: www.artshealthandwellbeing.
org.uk160. Mental Wellbeing Impact Assessment:
w ww.maudsleyinternational.com
161. For an example of this approach, see Devlin, P. (2010). Restoring
the Balance: The effect of arts participation on wellbeing andhealth. Newcastle upon Tyne: Voluntary Arts England.
162. Bolton, G. (Ed.). (2008). Dying, Bereavement and the Healing Arts.
London: Jessica Kingsley Publishers, p. 9.
163. See the work of the European League of Institutes of the Arts
(ELIA) in the area of artistic research and platforms such as Art& Research: A Journal of Ideas, Contexts and Methods.
164. Public Health England. (2016). Arts for Health and Wellbeing: An
evaluation framework, p. 10.
165. For details of this method, see Angell, C., Alexander, J. & Hunt, J.
(2014). ‘Draw, Write and Tell’: A literature review andmethodological development on the ‘draw and write’ researchmethod. Journal of Early Childhood Research. 13 (1), pp. 17–28;
Dearn, L. K. & Pitts, S. E. (2017). (Un)popular music and young
audiences: Exploring the classical chamber music concert fromthe perspective of young adult listeners. Journal of PopularMusic Education, 1 (1), pp. 43–62; and Gardner, P. & Dearn, L. K.
Understanding Cultural Experiences: Interdisciplinary uses of
the write-draw method (under review).
166. Viney, W., Callard, F. & Woods, A. (2015). Critical Medical
Humanities: Embracing entanglement, taking risks. Medical
Humanities, 41 (1), pp. 2–7.
167. The Academy of Medical Sciences. (2016). Improving the Healthof the Public by 2040: Optimising the research environment for ahealthier, fairer future. London: The Academy of Medical
Sciences, p. 20.
168. For a tangible example of this, see Clive Parkinson’s CriticalCare, which will be published in September 2017.
169. Fujiwara, D., Kudrna, L. & Dolan, P. (2014). Quantifying andValuing the Wellbeing Impacts of Culture and Sport. London:
DCMS.
170. Wellbeing in Four Policy Areas, op. cit., p. 36.
171. Loc cit.
172. The British Academy. (2017). Where We Live Now: Making thecase for place-based policy. London: The British Academy, p. 3.
173. See NHS England. What Actions Could be Taken to Reduce
Emergency Admissions? and the NHS England House of Careresource, designed to support commissioners in reducing
hospital admissions.
174. Core Arts. (2016). Arts in Health: End of Q4 Results. London:
Core Arts.
175. The Art of Commissioning, op. cit., p. 19.
176. Bourgeon, S., Dates, M., Harper, G., Mallender, J. & Pritchard, C.
(2016). Approaches to Return on Investment (ROI) in Other Sectors:
Technical report. London: Public Health England.
177. Zeilig, H., Killick, J. & Fox, C. (2014). The Participative Arts for
People Living with a Dementia: A critical review. International
Journal of Ageing and Later Life, 9 (1), p. 6.
178. HM Treasury. (2011). The Green Book: Appraisal and evaluation inCentral Government. London: HM Treasury, p. 10.
179. Cabinet Office. (2015). Social Value Act Review. London: Cabinet
Office.
180. The Social Prescribing Network is a collaboration between theCollege of Medicine, the University of Westminster andWellcome: www.nationalhealthexecutive.com
181. Creative Minds: www.southwestyorkshire.nhs.uk
182. Whelan, G. (2016). A Social Return on Investment: Evaluation of
the St Helens Creative Alternatives Arts on Prescription
Programme. Liverpool: John Moores University.
183. National Institute for Health and Care Excellence (NICE). (2014).
Developing NICE guidelines: the manual. London: NICE.
184. A list of published topics and those in development or
consultation can be found at: www.nice.org.uk. At the time ofwriting, guidelines in development include Depression in Adults
and ADHD.

173

All-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Report185. I n 2014, researchers made a preliminary attempt at this at the
Glasgow Centre for Population Health (a partnership between
the Scottish Government, the NHS, the University of Glasgow
and Glasgow City Council). See Jindal-Snape, D., Morris, J., Kroll,T., Scott, R., Toma, M., et al. (2014). The Impact of Art Attendanceand Participation on Health and Wellbeing: Systematic literature
review (Work Package 1). Glasgow: Glasgow Centre forPopulation Health.
186. Emily Cousins maintains a blog on her project: idea.nottingham.
ac.uk/blogs/posts/creativity-and-dementia.
187. See, for example, Visual to Vocal at Dulwich Picture Gallery, which
took inspiration from the collection to formulate an opera.
188. Pawson, R. (2013). The Science of Evaluation: A realist manifesto.
London: Sage Publications.
189. Be Creative Be Well: Arts, wellbeing and local communities,
op. cit., p. 16.
190. Clift, S. (2012). Creative Arts as a Public Health Resource:Moving from practice-based research to evidence-based
practice. Perspectives in Public Health, 132 (3), pp. 120–27. For areconciliation of practice and research, see Arts in Health:
Designing and researching interventions, op. cit.
191. Culture Case at King’s College London provides an example ofthis approach, endeavouring to translate into everyday
language the findings of academic research into the impacts of
the arts and culture: www.culturecase.org. NCVO has also
produced a resource to help arts and cultural organisations
seeking to demonstrate impact in this area: knowhownonprofit.
org/funding/cultural-commissioning/evidencing-the-socialvalue-of-arts-and-culture
192. University of Florida arts and health database: arts.ufl.edu/
academics/center-for-arts-in-medicine/research-database/193. RSPH SIG arts and health repository:
www.artshealthresources.org.uk
194. Quinn, J., Blandon, C., & Batson, A. (2017). Beyond Words Project
Report. Plymouth: Plymouth University Institute of Education.
195. The Happiness Industry, op. cit., p. 2.
196. Wellcome-funded study of mindfulness in schools: wellcome.
ac.uk/press-release/large-scale-trial-will-assess-effectivenessteaching-mindfulness-uk-schools
197. Creative and Credible: creativeandcredible.co.uk
198. Aesop arts and health evaluation: www.ae-sop.org
199. Arts for health and wellbeing, op. cit. www.gov.uk
200. A list of submissions, together with details of projects which
opted to do so, appear online at: www.artshealthandwellbeing.
org.uk201. Submission by Professor Norma Daykin following the evidence
meeting.
202. The evidence base was compiled online(longitudinalhealthbenefits.wordpress.com), containing a
précis of each study and links to the original research articles
where copyright clearance was possible to secure.
203. Gordon-Nesbitt, R. (2015). Exploring the Longitudinal
Relationship Between Arts Engagement and Health. Manchester:Arts for Health.
204. K ing’s College London culture tracking study: www.kcl.ac.uk
205. Understanding the Value of Arts & Culture, op. cit., pp. 8 and 112.
206. Pawson, R. (2006). Evidence-based Policy: A realist perspective.
London: Sage Publications, p. viii.
207. NHS England. (2014). Five Year Forward View. Leeds: NHS
England, p. 9.
208. The Long-term Sustainability of the NHS and Adult Social Care,op. cit., p. 9.
209. World Health Organization Regional Office for Europe. Essential
Public Health Operation 5: Disease prevention, including early
detection of illness. www.euro.who.int
210. Bazalgette, P. (28 December 2014). Use the arts to boost thenation’s health. The Observer.
211. The Art of Commissioning, op. cit., p. 19.
212. K napp, M., McDaid, D. & Parsonage, M. (2011). Mental Health
Promotion and Mental Illness Prevention: The economic case.
London: DH.
213. This term will be used throughout the report to describe people
who have interacted with health and social services.

174

214. The Mental Health Taskforce. (2016). The Five Year Forward View
for Mental Health: A report from the independent Mental HealthTaskforce to the NHS in England. See also the implementation
plan at www.england.nhs.uk
215. Prevention Concordat Programme for Better Mental Health:preventionconcordat.com/
216. K napp, M., Andrew, A., McDaid, D., Iemmi, V., McCrone, P.,
et al. (2014). Investing in Recovery: Making the business case for
effective interventions for people with schizophrenia andpsychosis. London: Rethink Mental Illness, p. 6.
217. House of Commons Health Committee. (2014). Managing theCare of People with Long-term Conditions (Second Report ofSession 2014–15). London: House of Commons.
218. World Health Organization. (1986). The Ottawa Charter for
Health Promotion.
219. Fair Society, Healthy Lives, op. cit., p. 155.
220. NHS England’s Self Care programme: www.england.nhs.uk
221. This observation was made by Emma Hanson, Head of Strategic
Commissioning at Kent County Council as part of a conversation
with Professor Sir Malcolm Grant, Chair of NHS England, andProfessor Kevin Fenton, Director of Health and Wellbeing at
Public Health England, and the science journalist Vivienne
Parry at the First National Arts in Health Conference andShowcase for Health Decision Makers, 5 February 2016.
222. Realising the Value: Ten key actions to put people andcommunities at the heart of health and wellbeing. (2016), p. 2.
223. Ibid, p. 9.
224. See Coalition for Collaborative Care. (2016). Personalised careand support planning handbook: The journey to person-centredcare. Leeds: NHS England; and Coalition for Collaborative Care,Our vision for the future: dev.coalitionforcollaborativecare.org.
uk/news/our-vision-for-the-future/; and the ensuing guidance
www.england.nhs.uk
225. Information produced by the National Co-Production Advisory
Group of Think Local Act Personal. Co-Production: It’s along-term relationship: www.thinklocalactpersonal.org.uk
226. ResearchNet is a network of linked co-production groups ofservice users, carers and staff who come together to use lived
experience to improve health services.
227. National Institute for Health and Care Excellence (NICE). (2014).
Community Engagement to Improve Health. London: NICE, p. 28.
228. Elliott, J. & Skinner, J. (2014). Let the Dance Begin: A creative
community well being partnership project. Belfast: Arts Care.
229. Dementia, Art and Wellbeing Network: www.nottingham.ac.uk
230. Carers UK. (2016). State of Caring 2016. London: Carers UK.
231. See I’m Controlling It! at: www.youtube.com
232. A £1.8bn Sustainability and Transformation Fund has been set
up to help hospitals to reduce their deficits. In the 2016–17
session, the House of Commons Public Accounts Committee
found that the financial performance of NHS bodies had‘worsened considerably’. NHS trusts’ deficits had reached£2.5bn in 2015–16, up from an £859m deficit in 2014–15.
According to the same source, two-thirds of NHS trusts (65percent) and NHS foundation trusts (66 percent) reported
deficits in 2015–16, up from 44 percent and 51 percent in theprevious financial year.
233. Health and Wellbeing Boards: www.local.gov.uk
234. Clinical Commissioning Groups: www.england.nhs.uk
235. NHS Commissioning Board. (2012). Commissioning fact sheet
for clinical commissioning groups.
236. Five Year Forward View, op. cit., p. 14.
237. 2020 Vision: www.gov.scot/Topics/Health/Policy/2020-Vision
238. Integrated Care Pioneers: www.england.nhs.uk
239. Think Local Act Personal. (2016). Engaging and Empowering
Communities: Our shared commitment and call to action. London:
Think Local Act Personal.
240. The Long-term Sustainability of the NHS and Adult Social Care,op. cit.
241. Better Care Fund: www.england.nhs.uk
242. For an example of integrated care, see Thistlethwaite, P. (2011).
Integrating Health and Social Care in Torbay: Improving care for
Mrs Smith. London: The King’s Fund.
243. Staying Out: arconline.co.uk/whats-on/community-workshopsand-classes-adults/staying-out

244. NHS England. (2016). New Care Models: Vanguards – developing
a blueprint for the future of NHS and care services. Leeds: NHS
England.
245. NHS Confederation, Local Government Association, NHS
Providers, NHS Clinical Commissioners. (2016). New Care
Models and Prevention: An integral partnership.
246. Transforming Care Partnerships: www.england.nhs.uk
247. Services for people with learning disabilities and/or autism:
www.england.nhs.uk
248. TIN Arts: www.tinarts.co.uk
249. Five Year Forward View, op. cit.
250. Ibid, p. 26.
251. The Five Year Forward View for Mental Health, op. cit., p. 6. See
also Steptoe, A. & Kivimäki, M. (2013). Stress and Cardiovascular
Disease: An update on current knowledge. Annual Review of
Public Health, (34), pp. 337–54.
252. National Institute for Health and Care Excellence (NICE). (2009).
Depression in Adults with Chronic Physical Health Problems:
Recognition and management. London: NICE.
253. Department of Health: Mental Health Division. (2010). Confident
Communities, Brighter Futures: A framework for developing
well-being. London: DH, p. 5.
254. Department of Health. (2014). Closing the Gap: Priorities foressential change in mental health. London: DH.
255. The Five Year Forward View for Mental Health, op. cit.
256. Cameron, D. (2016). Prime Minister’s Speech on Life Chances.
257. NHS Confederation Mental Health Network: nhsconfed.org/
resources/2016/06/funding-for-mental-health258. Confident Communities, Brighter Futures, op. cit., p. 15.
259. Department of Health. (2011). No Health Without Mental Health:A cross-government mental health strategy for people of all ages.
London: DH.
260. Cayton, H. (2007). Report of the Review of Arts and HealthWorking Group. London: DH, p. 3.
261. A rts Council England. (2007). A Prospectus for Arts and Health.
London: Arts Council England, p. 4.
262. The prospectus drew upon an earlier literature review:
Staricoff, R. (2004). Arts in Health: A review of the medical
literature. London: Arts Council England; and Arts Council
England. (2007). The Arts, Health and Wellbeing. London: Arts
Council England.
263. Open to All, op. cit.
264. Inequalities, the Arts and Public Health, op. cit., p. 178.
265. To view the health case studies included in the Culture White
Paper, visit: www.gov.uk
266. Culture, Media and Sport Committee. (2 November 2016). Oral
Evidence: Countries of culture, HC 114, Q315.
267. Arts Care: www.artscare.co.uk
268. For an overview of arts-on-prescription activities in Denmark,Norway and Sweden, see Jensen, A., Stickley, T., Torrissen, W. &Stigmar, K. (2016). Arts on Prescription in Scandinavia: A review
of current practice and future possibilities. Perspectives in
Public Health.
269. Society for Culture and Health: ckh.gu.se/english/our-area/atopic-in-the-parliament
270. To watch a persuasive film about the Prescribed Culture project,featuring the Swedish Minister of Culture, visit: www.skane.se/
Halsa-och-vard/Halsa/Kultur-pa-recept
271. Liikanen, H-L. (2010). Art and Culture for Well-being: Proposal foran action programme 2010–2014. Helsinki: Ministry of
Education and Culture, Finland. A book, entitled Managing Art
Projects with Societal Impact, has been published in Helsinki,
aimed at stakeholders, researchers and students, and can be
downloaded in its entirety from www.mapsi.eu.
272. A rts Promotion Centre Finland: www.taike.fi/en/frontpage273. A rts, Health and Care: kulturoghelse.no/english
274. HUNT Research Centre: www.ntnu.edu/hunt/hunt-researchcentre
275. Links to the Australian National Arts and Health Framework
are available at: www.arts.gov.au
276. Australian Centre for Arts and Health: www.artsandhealth.org.au

277. F or an overview, see Hebron, D. & Taylor, K. (2012). A New Age: An
examination of the changing state of health funding for arts
activity with, by and for older people in England. London: London
Arts and Health Forum. For an international comparator, see
Cutler, D. (2013). Colder, Older and Wiser: Arts and older people inFinland. London: The Baring Foundation.
278. The Art of Commissioning, op. cit., p. 3.
279. Five Year Forward View, op. cit., p. 14.
280. Ibid, p. 13.
281. Department of Health. (2016). Joint Review of Partnerships andInvestment in Voluntary, Community and Social Enterprise
Organisations in the Health and Care Sector: Final report
produced in partnership by representatives of the VCSE sector
and the Department of Health, NHS England and Public Health
England. London: DH, p. 9.
282. NHS England. (2015). A Bite Size Guide to Grants for the Voluntary
Sector. Leeds: NHS England.
283. For a useful guide, see Bagwell, S., Bull, D., Joy, I. & Svistak, M.
(2014). Opportunities for Alignment: Arts and culturalorganisations and public sector commissioning. London: New
Philanthropy Capital. For a concrete example, see Cartwheel
Arts, funded by Heywood, Middleton and Rochdale CCG, a casestudy of which is available at: www.ncvo.org.uk. DCMS is taking
steps towards putting small charities at the heart of public
services: www.gov.uk
284. Integrated Personal Commissioning: www.england.nhs.uk
285. Local Government Association & NHS England. (2016).
Integrated Personal Commissioning: Emerging Framework.
Leeds: NHS England, p. 3.
286. Word/Play: www.youtube.com
287. Kent County Council. (2015). Increasing Opportunities,
Improving Outcomes: Kent County Council’s Strategic Statement
2015–2020. Canterbury: Kent County Council, p. 5.
288. A rts and Cultural Commissioning Toolkit:
artscommissioningtoolkit.com
289. Harvey, A. (2016). Funding Arts and Culture in a Time of Austerity.
London: New Local Government Network.
290. Department for Communities and Local Government (DCLG).
(2017). Final Local Government Finance Settlement: England, 2017
to 2018. London: DCLG.
291. House of Commons Culture, Media and Sport Committee. (2016).
Countries of Culture: Funding and support for the arts outside
London. London: House of Commons, p. 10.
292. See, for example, Generator CIC in Loughborough, which has arelationship with Leicestershire County Council and cites artsand health work as one of its priorities.
293. Creative Alternatives: www.creativealternatives.org.uk
294. The Art of Commissioning, op. cit., p. 10.
295. Ibid, p. 30.
296. Locality projects: www.ncvo.org.uk
297. Parkinson, A. & Wilkie, S. (2016). Evaluation of the Cultural
Commissioning Programme: Final report. Newcastle upon Tyne:
Consilium, p. 6.
298. The Culture White Paper, op. cit., p. 32.
299. A rts Council England. (2013). Great Art and Culture for Everyone:
10-year strategic framework 2010–2020 (2nd edition). London:
Arts Council England.
300. Bait: creativepeopleplaces.org.uk/project/bait
301. Countries of Culture, op. cit., p. 10.
302. Department for Culture, Media and Sport. (2017). Tailored
Review of Arts Council England. London: DCMS, pp. 17 and 11.
303. Arts Connect: www.artsconnect.co.uk
304. Great Place Scheme: www.greatplacescheme.org.uk
305. People’s Health Trust: www.peopleshealthtrust.org.uk
306. Ecorys and People’s Health Trust. (2016). Active Communities
Summary Report: based on Ecorys evaluation findings 2016.
London: People’s Health Trust.
307. Tailored Review of Arts Council England, op. cit.
308. Pharaoh, C., Jenkins, R., Goddard, K. & Walker, C. (2016). Giving
Trends: Top 300 foundation grant-makers 2016 report. London:
Association of Charitable Foundations.
309. Flows of public funding into the voluntary sector: data.ncvo.org.
uk/new-interactive-visualisations-of-almanac-data/flows-ofmoney-in-and-out-of-the-voluntary-sector

175

All-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Report

310. M TM. (2016). Private Investment in Culture Survey 2012/13,
2013/14 and 2014/15. London: MTM.
311. Social Impact Bonds: www.gov.uk
312. Government Outcomes Lab: golab.bsg.ox.ac.uk
313. House of Lords Select Committee on Charities. (2017). Stronger
Charities for a Stronger Society (Report of Session 2016–17 No.
HL133). London: House of Lords.
314. Ways to Wellness: waystowellness.org.uk
315. Stronger Charities for a Stronger Society, op. cit., paragraph 425,
p. 86.
316. Cameron, M., Crane, N., Ings, R. & Taylor, K. (2013). Promoting
Well-being Through Creativity: How arts and public health canlearn from each other. Perspectives in Public Health, 133 (1), p. 52.
317. A ndrews, K. (2014). Culture and Poverty: Harnessing the power of
the arts, culture and heritage to promote social justice in Wales,p. 48.
318. Jivén, G. & Larkham, P. J. (2003). Sense of Place, Authenticity andCharacter: A commentary. Journal of Urban Design, 8 (1), pp.
67–81. For recent work on the early years and sense of place, see
5x5x5creativity.org.uk
319. Natural England. (2009). Our Natural Health Service: The role ofthe natural environment in maintaining healthy lives. Sheffield:
Natural England.
320. O’Donnell, G., Deaton, A., Durand, M., Halpern, D. & Layard, R.
(2014). Wellbeing and Policy. London: Legatum Institute, p. 65.
321. National Trust, Our Vision for the Future of Parks, available atwww.nationaltrust.org.uk
322. Ungoed-Thomas, J. (26 February 2017). Newcastle Uses Public
Health Cash to Save City Parks. The Sunday Times.
323. This non-scientific term was coined by the author Richard Louv
in his 2005 book Last Child in the Woods.
324. Information available at: www.hart.works
325. Buck, D. (2016). Gardens and Health: Implications for policy andpractice. London: The King’s Fund.
326. Bird, W. & Van den Bosch, M. (2014). Gardening Should be
Available on the NHS. Royal Horticultural Society John MacLeod
Lecture.
327. Mitchell, R. & Popham, F. (8 November 2008). Effect of Exposure
to Natural Environment on Health Inequalities: An
observational population study. The Lancet, 372 (9650), pp. 1655–60.
328. Mitchell, R., Richardson, E., Shortt, N. & Pearce, J. (2015).
Neighbourhood Environments and Reduced Socio-economic
Inequalities in Mental Wellbeing: An international study ofurban dwellers. American Journal of Preventive Medicine, 49 (1),pp. 80–84.
329. The Health Gap, op. cit., p. 250. See also Commission forArchitecture and the Built Environment (CABE). (2010).
Community Green: Using local spaces to tackle inequality andimprove health. London: CABE.
330. Department for Communities and Local Government (DCLG).
(2016). Locally-Led Garden Villages, Towns and Cities. London:
DCLG.
331. Greening Grey Britain: www.rhs.org.uk
332. Quantifying and Valuing the Wellbeing Impacts of Culture andSport, op. cit.
333. Fujiwara, D., Cornwall, T. & Dolan, P. (2014). Heritage andWellbeing. Swindon: English Heritage.
334. Harvey, A. & Julian, C. (2015). A Community Right toBeauty: Giving communities the power to shape, enhance andcreate beautiful places, developments and spaces. London:
ResPublica.
335. Networked Heritage: medium.com/networked-heritage/
networked-heritage-in-practice-c578440ea1
336. Joseph Rowntree Foundation. (2005). Environmental Problems
and Service Provision in Deprived and More Affluent
Neighbourhoods. London: Joseph Rowntree Foundation. See
also Sacker, A. & Bartley, M. (2016). Never Too Early, Never Too
Late: Social and Biological Influences on Health and Disease
Over the Lifecourse. London: UCL Research Department of
Epidemiology and Public Health.
337. Hanley, L. (2007). Estates. London: Granta. pp. 19–20.
338.  Fair Society, Healthy Lives, op. cit., p. 30.
339. Commission for Architecture and the Built Environment(CABE). (2004). The Value of Public Space. London: CABE.

176

340. Department for Communities and Local Government (DCLG).
(2006). Strong and Prosperous Communities: The Local
Government White Paper. London: DCLG.
341. Commission for Architecture and the Built Environment(CABE). (2007). It’s Our Space: A guide for community groups
working to improve public space. London: CABE, p. 15.
342. Select Committee on National Policy for the Built Environment.
(19 February 2016). Building Better Places: Report of session 2015–16.
343. Ibid, line 94.
344. Howarth, A. (24 January 2017). National Policy for the Built
Environment. London: House of Lords, 778, column 188.
345. Initiatives like the Healthy City Design International
Conference address this need.
346. Future of Cities: www.gov.uk
347. Department for Communities and Local Government (DCLG).
(2012). National Planning Policy Framework. London: DCLG,
p. 17.
348. Community Engagement to Improve Health, op. cit.
349. Department for Culture, Media and Sport (DCMS). (2000). Better
Public Buildings: A proud legacy for the future. London: DCMS, p.
1. This was followed by Commission for Architecture and the
Built Environment and the Department for Culture, Media andSport. (2006). Better Public Building. London: HM Government.
350. See Department of Health. (2014). Health Building Note 00-01:
General design guidance for healthcare buildings. London: DH.
351. Phiri, M. (2006). Does the Physical Environment Affect Staff andPatient Health Outcomes? A review of studies and articles
1965–2005. London: DH.
352. See, for example, Phiri, M. (2015). Design Tools for EvidenceBased Healthcare Design. London: Routledge; and the
Healthcare Environment Architectural Reference (HEAR) tool:
hear.group.shef.ac.uk.
353. See Sadler, B. L., Berry, L. L., Guenther, R., Hamilton, D. K., Hessler,
F. A., et al. (2011). Fable Hospital 2.0: The business case for building
better health care facilities. The Hastings Center Report, 41 (1).
354. Williams, R. (10 May 2017). Designed by Patients: The mental
health centre saving the NHS £300,000 a year. The Guardian.
355. Department of Health and The King’s Fund. (2006). Celebrating
Achievement: Enhancing the Healing Environment Programme
2000–2003. Norwich: The Stationery Office, p. 7.
356. NHS Estates. (2003). Improving the Patient Experience:
Evaluation of the King’s Fund’s Enhancing the Healing
Environment Programme. Norwich: The Stationery Office.
357. Celebrating Achievement, op. cit., p. 7.
358. Waller, S. & Finn, H. (2004). Enhancing the Healing Environment:
A guide for NHS Trusts. London: The King’s Fund.
359. Daykin, N. & Byrne, E. (2006). The Impact of Arts in Mental
Healthcare: A systematic review of the literature. Bristol:
University of the West of England, p. 22.
360. Daykin, N., Byrne, E., Soteriou, T. & O’Connor, S. (2010). Arts &Mental Health: Enhancing mental healthcare environments.
World Health Design, p. 62.
361. A s an example of cutting-edge contemporary art in a hospitalenvironment, see the work of Vital Arts: www.vitalarts.org.uk
362. Paintings in Hospitals: www.artshealthandwellbeing.org.uk
363. Brown, B., Wright, H. & Brown, C. (Spring 1997). A PostOccupancy Evaluation of Wayfinding in a Pediatric Hospital:
Research findings and implications for instruction. Journal ofArchitectural and Planning Research, 14 (1).
364. Details of the programme can be found here: breatheahr.org/
performing-arts/ and a film watched here: www.youtube.com
365. See www.helixcentre.com. For an introduction to carepathways, see Schrijvers, G., Van Hoorn, A. & Huiskes, N. (2012).
The Care Pathway – Concepts and Theories: An introduction.
International Journal of Integrated Care, 12.
366. White, M. & Robson, M. (2009). Participatory Arts Practice in
Healthcare Contexts: Guidelines for good practice. Durham:
Centre for Medical Humanities.
367. A rtWorks Cymru. (2015). Artist’s Toolkit: A guide for artists
working in the hospital environment. Cardiff: ArtWorks Cymru.

368. See also Macnaughton, J., Collins, P., Coleman, S., Kellett, P.,
Purves, G., et al. (2005). Designing for Health: Architecture, artand design at the James Cook University Hospital. London: NHS
Estates; and Daykin, N. & Byrne, E. (2008). The Impact of Art,
Design and Environment in Mental Healthcare: A systematic
review of the literature. The Journal of the Royal Society for the
Promotion of Health, 128 (2), pp. 85–94.
369. See the Social Value section of the Creative Scotland website:www.creativescotland.com
370. Creative Scotland. (2016). Creative Scotland Arts Strategy
2016-17. Edinburgh: Creative Scotland.
371. Creative Scotland. (2014). Unlocking Potential Embracing
Ambition: A shared plan for the arts, screen and creative
industries 2014–2024. Edinburgh: Creative Scotland.
372. Culture and Poverty, op. cit., p. 1
373. Ibid, p. 6.
374. Well-being of Future Generations (Wales) Act 2015.
375. Communities and Local Government Committee. (9 May 2011).
Third Report: Localism.
376. NHS Confederation. (2016). Stepping Up to the Place: The key tosuccessful health and care integration. London: NHS Confederation.
377. Local Government Innovation Taskforce. (2014). The Case for Change.
London: Local Government Association Labour Group, p. 3.
378. Ham, C. & Alderwick, H. (2015). Place-based Systems of Care:
A way forward for the NHS in England. London: The King’s Fund.
379. Place-Based Health Commission. (2016). Get Well Soon:
Reimagining place-based health. London: Collaborate and New
Local Government Network.
380. NHS England. (2017). Next Steps on the Five Year Forward View.
Leeds: NHS England, p. 30.
381. With regard to the latter, attention is drawn to the five principles
of good engagement drawn up by Healthwatch:www.healthwatch.co.uk/sites/healthwatch.co.uk
382. Locality & Seddon, J. (2014). Saving Money by Doing the Right
Thing: Why ‘local by default’ must replace ‘diseconomies of scale’.
London: Locality.
383. The Culture White Paper, op. cit., p. 30.
384. Local Government Association. (2017). People, Culture, Place:
The role of culture in placemaking. London: Local Government
Association, p. 6.
385. Where We Live Now, op. cit., p. 2.
386. To view an animation outlining the current situation and thedesired changes, visit videopress.com/v/flRtmTEK. For apractical guide on how place might be borne in mind during
policy making, see Local Government Association Leadership
Centre for Local Government. (2010). Total Place: A practitioner’s
guide to doing things differently. London: Leadership Centre for
Local Government.
387. Greater Manchester Combined Authority. (2015). Taking Chargeof Our Health and Social Care in Greater Manchester.
Manchester: Greater Manchester Combined Authority.
388. Greater Manchester Combined Authority. (2016). The Greater
Manchester Population Health Plan 2017–2021. Manchester:Greater Manchester Combined Authority, p. 26.
389. Where We Live Now, op. cit., p. 7.
390. Finnegan, R. How to Capture – and Create – Place and‘Placeness’. In Ibid.
391. For one such example, see Little, V. A. (2013). Arts and Health– Inspire Engage Involve: Dudley annual report 2013. Dudley:
Dudley Office of Public Health.
392. For Well North, which targets provision according to need, see:www.wellnorth.co.uk; for the Healthy New Towns initiative, see:www.england.nhs.uk
393. Ward, J. (2017). A Cultural Manifesto for Wellbeing. Halton:
Halton Clinical Commissioning Group.
394. Poems on the Underground: tfl.gov.uk/corporate/about-tfl/
culture-and-heritage/poems-on-the-underground395. Challenge Fund: www.england.nhs.uk
396. NHS England. (2016). General Practice Forward View. Leeds:
NHS England.
397. Dixon, M. & Polley, M. (2016). Report of the Annual Social
Prescribing Network Annual Conference. London: Universityof Westminster.
398. Citizens Advice. (2016). A Very General Practice: How much time do
GPs spend on issues other than health? London: Citizens Advice.

399. Pattison, S. (2016). Redundant Subjectivity.
400. Friedli, L. (2007). Developing Social Prescribing and Community
Referrals for Mental Health in Scotland. Edinburgh: Scottish
Development Centre for Mental Health; Brandling, J. & House, W.
(2009). Social Prescribing in General Practice: Adding meaning to
medicine. British Journal of General Practice, pp. 454–56; andManning, L. (2015). Social Prescribing. Leeds: NHS England.
401. For a discussion of the inappropriate prescriptiveness of theterminology, see Ward, J. (2016). Social Prescribing at a Glance: A
scoping report of activity for the North West. Manchester: Health
Education England.
402. Thomson, L. J., Camic, P. & Chatterjee, H. (2015). Social
Prescribing: A review of community referral schemes. London:
University College London.
403. Report of the Annual Social Prescribing Network Annual
Conference, op. cit., p. 1.
404. Rotherham CGG social prescribing: participation.southeastcsu.
nhs.uk/wp-content/uploads/2015/01/Rotherham-CCG-socialprescribing-project1.pdf
405. Realising the Value, op. cit.
406. RCGP course in social prescribing: www.rcgp.org.uk
407. A rtlift: artlift.org
408. Crone, D., O’Connell, E., James, D., Tyson, P. & Clark-Stone, F.
(2011). ArtLift, Gloucestershire. Cheltenham: University ofGloucestershire; Crone, D., O’Connell, E. E., Tyson, P. J., ClarkStone, F., Opher, S. et al. (2012). It Helps Me Make Sense of theWorld: The role of an art intervention for promoting health andwellbeing in primary care – perspectives of patients, healthprofessionals and artists. Journal of Public Health, 20 (5), pp.
519–24; and Crone, D., O’Connell, E. E., Tyson, P. J., Clark-Stone,F., Opher, et al. (2013). Art Lift Intervention to Improve Mental
Wellbeing: An observational study from UK General Practice.
International Journal of Mental Health Nursing. 22 (3), pp. 279–89.
409. Loughren, E., Matthews, J., Baker, C., Speke, C. & Crone, D.
(2014). Artlift Gloucestershire Update Report 2011–2014.
Cheltenham: University of Gloucestershire; and Crone, D., Sumner,
R., Baker, C. M., Loughren, E. A., Hughes, S., et al. (manuscript in
preparation).
410. Opher, S. (2011). Cost-benefit Evaluation of Artlift 2009–2012:
Summary. Gloucester: Gloucestershire County Council and NHS
Gloucestershire.
411. At the round table on Arts on Prescription, we heard about one
such group, called Changing Creations.
412. Map of social prescribing in London: www.lvsc.org.uk
413. Local Government Association. (2016). Just What the Doctor
Ordered: Social prescribing – a guide for local authorities.
London: Local Government Association.
414. Developing Social Prescribing and Community Referrals for
Mental Health in Scotland, op. cit. See also Friedli, L., Jackson, J.,
Abernethy, H. & Stansfield, J. (2009). Social Prescribing for
Mental Health – A guide to commissioning and delivery. London:
Care Services Improvement Partnership and North West
Development Centre.
415. For an introduction to arts on prescription, see Bungay, H.
& Clift, S. (2010). Arts on Prescription: A review of practice in the
UK. Perspectives in Public Health, 130 (6); Hamilton, K.,
Buchanan-Hughes, A., Lim, S. & Eddowes, L. (2015). Evidence
Dossier: The value of arts on prescription programmes for themental health and wellbeing of individuals and communities.
Cambridge: Arts & Minds; and Potter, S. (2015). Arts on
Prescription 2010–12. Cambridge: Arts & Minds.
416. Bromley by Bow Centre: www.bbbc.org.uk
417. Tyldesley, R. & Rigby, T. (1997). Postnatal Depression Support
Service: An Evaluation of a 12-Week Pilot, kindly made available
to the author.
418. Evidence Dossier, op. cit.
419. National Council of Voluntary Organisations. (2015). Arts on
Prescription: Arts-based social prescribing for better mental
wellbeing is available online at: www.ncvo.org.uk
420. To Make is to Live, op. cit.
421. Watch the film at: www.youtube.com
422. For details about this scheme, which is managed by Trinity
College London in association with ACE bridge organisations,see: www.artsaward.org.uk

177

All-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Report

423. London School of Economics and Political Science (LSE). (2012).
How Mental Illness Loses Out in the NHS. London: LSE.
424. McDaid, D. & Park, A-L. (2013). Investing in Arts on Prescription:
An economic perspective. unpublished.
425. National Institute for Health and Care Excellence (NICE). (2011).
Depression in Adults. London: NICE.
426. Evidence Dossier, op. cit., p. 4.
427. Making Every Contact Count: makingeverycontactcount.co.uk
428. City and Hackney Clinical Commissioning Group. (2015). Social
Prescribing: Integrating GP and community assets for health.
London: The Health Foundation.
429. See also NESTA, The Museums Map: Mapping access toEngland’s museums.
430. Lackoi, K., Patsou, M., Chatterjee, H. J., et al. (2016). Museums for
Health and Wellbeing: A preliminary report from the National
Alliance for Museums, Health and Wellbeing. Available at:museumsandwellbeingalliance.wordpress.com
431. For an overview of arts, health and wellbeing activity inmuseums, see Chatterjee, H. & Noble, G. (2013). Museums, Healthand Well-Being. Farnham: Ashgate; and Chatterjee, H. (2016).
Museums and Art Galleries as Settings for Public HealthInterventions. In Creative Arts, Health and Wellbeing, op. cit., pp.
281–89. For activity in Greater Manchester museums, see Health+ Culture. (n.d.). How Museums and Galleries Can Enhance
Health and Wellbeing. Manchester: Health + Culture; for the
East Midlands equivalent, see Dodd, J. & Jones, C. (2014). Mind,
Body, Spirit: How museums impact health and wellbeing.
Leicester: Research Centre for Museums and Galleries.
432. Colbert, S., Camic, P., Cooke, A. & Springham, N. (2013). The Arts
in Psychotherapy: The art-gallery as a resource for recovery forpeople who have experienced psychosis. The Arts in
Psychotherapy, 40, pp. 250– 56.
433. Our Museum: ourmuseum.org.uk
434. Camic, P. & Chatterjee, H. (2013). Museums and Art Galleries as
Partners for Public Health Interventions. Perspectives in Public
Health, 133 (1), pp. 66–71.
435. Solway, R., Thomson, L.J., Camic, P.M. & Chatterjee, H.J. (2015).
Museum Object Handling in Older Adult Mental HealthInpatient Care. International Journal of Mental Health
Promotion, 17 (4), pp. 201–14; and Solway, R. Camic, P.M.,
Thomson, L. & Chatterjee, H. J. (2015). Material Objects andPsychological Theory in Arts and Health: A conceptual
literature review. Arts & Health: An International Journal of
Research, Policy and Practice. 7 (3).
436. A nder, E., Thomson, L., Lanceley, A., Menon, U., Blair, K.,
et al. (2013). Using Museum Objects to Improve Wellbeing in
Psychiatric and Rehabilitation Patients. British Journal of
Occupational Therapy. 76 (5), pp. 208–16; Thomson, L., Ander, E.,
Lanceley, A., Menon, U., Noble, G., et al. (2012). Enhancing
Cancer Patient Wellbeing with a Non-pharmacological,
Heritage-focused Intervention. Journal of Pain and Symptom
Management, 44 (5), pp. 731–40; Thomson, L., Ander, E.,
Lanceley, A., Menon, U., Noble, G., et al. (2012). Quantitative
Evidence for Wellbeing Benefits from a Heritage-in-healthIntervention with Hospital Patients. International Journal of Art
Therapy, 17 (2), pp. 63–79; and Thomson, L., Ander, E., Menon, U.,
Lanceley, A. & Chatterjee, H. J. (2011). Evaluating the Therapeutic
Effects of Museum Object Handling with Hospital Patients: A
review and initial trial of wellbeing measures. Journal of Applied
Arts and Health, 2 (1), pp. 37–56.
437. A nder, E., Thomson, L., Lanceley, A., Menon, U., Noble, G., et al.
(2013). Heritage, Health and Wellbeing: Assessing the impact of aheritage focused intervention on health and wellbeing.
International Journal of Heritage Studies, 19 (3), pp. 229–42;
Lanceley, A., Noble, G., Johnson, M., Balogun, N., Chatterjee, H.
J., et al. (2011). Investigating the Therapeutic Potential of a
Heritage-object Focused Intervention: A qualitative study.
Journal of Health Psychology, 17 (6), pp. 809–20; and Paddon, H.,
Thomson, L., Lanceley, A., Menon, U. & Chatterjee, H. J. (2013).
Mixed Methods Evaluation of Wellbeing Benefits Derived from a
Heritage-in-health Intervention with Hospital Patients. Arts &Health: An International Journal for Research, Policy andPractice, 6 (1), pp. 24–58.

178

438. Thomson, L. J. & Chatterjee, H. J. (2014). Wellbeing with Objects:
Evaluating a museum object handling intervention for older
adults in healthcare settings. Journal of Applied Gerontology, 29,
pp. 155–79; and Thomson, L. & Chatterjee, H. J. (2014). Assessing
Well-being Outcomes for Arts and Heritage Activities:
Development of a museum well-being measures toolkit. Journalof Applied Arts and Health 5 (1), pp. 29–50.
439. Morse, N., Thomson, L. J., Brown, Z. & Chatterjee, H. J. (2015).
Effects of Creative Museum Outreach Sessions on Measures ofConfidence, Sociability and Well-being for Mental Health andAddiction Recovery Service-users. Arts & Health, 7 (3), pp. 231-46.
440. Creative Heritage in Mind: www.artshealthandwellbeing.org.
uk441. Inspiring Futures – Volunteering for Wellbeing:
volunteeringforwellbeing.org.uk
442. Goulding, A. (2003). Older People Learning through Contemporary
Visual Art – Engagement and Barriers. International Journal of
Art and Design Education, 32 (1), pp. 18–32.
443. UNESCO Public Library Manifesto: www.unesco.org
444. This is reflected in Libraries Taskforce. (2016). Libraries Deliver:
Ambition for Public Libraries in England 2016–2021. London:
Libraries Taskforce.
445. This formed the subject of a House of Lords debate initiated by
Lord Bird on 13 October 2016. The Libraries Taskforce has beencreated to reinvigorate the public library service.
446. To watch a short film about Healthy Libraries, visit:www.youtube.com
447. See Libraries and Health: librariesandhealth.com
448. World Health Organization. (2007). Global Age-friendly Cities: A
Guide. Geneva: World Health Organization.
449. Help the Aged. (2007). What Makes a City Age-friendly? London’sContribution to the World Health Organization’s Age-friendly
Cities Project. London: Help the Aged.
450. See research into age-friendly cities being carried out at Heriot
Watt University: www.hw.ac.uk
451. For insight into the built environment in relation to ageing, see
RIBA Building Futures. (2013). Silver Linings: The active third age
and the city. London.
452. Age Friendly Manchester: campaigntoendloneliness.org/
guidance/case-study/culture-champions-age-friendlymanchester-2
453. For details of the rationale behind this and projects fundedwithin the first five years, see The Baring Foundation. (2015).
Getting On – arts and older people A Baring Foundation
programme 2010–2014. London: The Baring Foundation.
454. Age-Friendly Museums Network: ageactionalliance.org/
what-is-the-age-friendly-museums-network-formally-agecollective
455. Hamblin, K. & Harper, S. (2016). The UK’s Ageing Population:
Challenges and opportunities for museums and galleries. Oxford:
Oxford Institute of Population Ageing.
456. Jane Grimshaw, Director of Nursing at Trafford General
Hospital, Museums and Health round table.
457. A lzheimer’s Society. (2013). Guidance for Communities
Registering for the Recognition Process for Dementia-friendly
Communities. London: Alzheimer’s Society, p. 2. See also Local
Government Association. (2015). Dementia Friendly
Communities: Guidance for councils. London: Local Government
Association.
458. A llen, P., Brown, A., Camic, P., Cutler, D., Harvey, L., et al. (2015).
Becoming a Dementia-friendly Arts Venue: A practical guide.
London: Alzheimer’s Society.
459. A lzheimer’s Society Side by Side: alzheimers.org.uk/sidebyside
460. Dementia-friendly museums in Wakefield:
www.artshealthandwellbeing.org.uk
461. Dementia Action Alliance: www.dementiaaction.org.uk
462. Internal document kindly made available to the author.
463. Dementia United: dementiaunited.net/what-is-it464. Arts Development in Community Health, op. cit., p. 3.
465. Putnam, R. D. (1993). Making Democracy Work: Civic traditions
in modern Italy. Princeton: Princeton University Press.
466. The Health Gap, op. cit.
467. The Five Year Forward View for Mental Health, op. cit.

468. Fitzpatrick, R., Kumar, S., Nkansa-Dwamena, O. & Thorne, L.
(2014). Ethnic Inequalities in Mental Health – Promoting Lasting
Positive Change: Report of findings to Lankelly Chase Foundation,
Mind, The Afiya Trust and Centre for Mental Health. London:
LankellyChase Foundation.
469. Crisis. (2011). Homelessness: A silent killer: A research briefing on
mortality amongst homeless people. London: Crisis.
470. The Homeless Library: www.artshealthandwellbeing.org.uk.
See also Streetwise Opera: streetwiseopera.org
471. This story was recounted at the round table on the Arts andPublic Health.
472. Portraits of Recovery: portraitsofrecovery.org.uk/projects/iam-memoirs-of-addiction-recovery
473. To read The Recoverist Manifest, visit: issuu.com/artsforhealth/docs/rm_online_version
474. Charter for Compassion: www.charterforcompassion.org
475. See, for example, West Midlands Fire Service. (2014). The Plan:
Making West Midlands Safer 2014–17. Birmingham: West
Midlands Fire Service.
476. Fair Society, Healthy Lives, op. cit., p. 22.
477. See, for example, Acheson, D. (1998). Inequalities in Health:
Report of an Independen Inquiry. London: HMSO; and Berkman,
L. F., Kawachi, I. & Glymour, M. M. (2000). Social Epidemiology.
New York: Oxford University Press.
478. Children and Young People’s Health Outcomes Forum. (2012).
Report of the Children and Young People’s Health Outcomes Forum.
479. Donkin, A. (2014). Local Action on Health Inequalities: Good
quality parenting programmes and the home to school transition.
London: Public Health England.
480. See Fetal Origins of Coronary Heart Disease and Fetal Nutrition
and Cardiovascular Disease in Later Life, op. cit.
481. Renton, A., Phillips, G., Daykin, N., Yu, G., Taylor, K. et al. (2012).
Think of your Art-eries: Arts participation, behavioural
cardiovascular risk factors and mental well-being in deprived
communities in London. Public Health, (126), pp. S57–64.
482. Staricoff, R., Duncan, J. P. & Wright, M. (2004). A Study of theEffects of Visual and Performing Arts in Healthcare. London:
Chelsea and Westminster Hospital.
483. Browning, C. A. (2000). Using Music During Childbirth. Birth.
27 (4), pp. 272–76.
484. Chang, S-C. & Chen, C-H. (2005). Effects of Music Therapy on
Women’s Physiological Measures, Anxiety and Satisfaction during
Caesarean Delivery. Research in Nursing & Health, 28, pp. 453–61.
485. Hogan, S. (2016). The Birth Project: Using the Arts to Explore BirthInterim Report. Derby: University of Derby.
486. Hernandez‐Reif, M., Diego, M. & Field, T. Instrumental andVocal Music Effects on EEG and EKG in Neonates of Depressed
and Non-depressed Mothers. Infant Behavior and Development,
29, pp. 518–25.
487. See Arts in Health: A Review of the Medical Literature, op. cit. For
an update of this review, see Staricoff, R. & Clift, S. (2011). Arts
and Music in Healthcare: An overview of the medical literature:
2004–2011. London: Chelsea and Westminster Health Charity.
488. Take Art: www.takeart.org
489. White, M. P., Anderson, S., Stansfield, K. E. & Gulliver, B. (2010).
Parental Participation in a Visual Arts Programme on a
Neonatal Unit. Creativity in Health, 6 (5), pp. 165–69.
490. The Five Year Forward View for Mental Health, op. cit.
491. Bauer, A., Parsonage, M., Knapp, M., Iemmi, V. & Adelaja, B.
(2014). The Costs of Perinatal Mental Health Problems. London:
Centre for Mental Health.
492. To watch the animation, visit: www.formedfilms.co.uk
493. NHS Commissioning Board. (2015). Future in Mind: Promoting,protecting and improving our children and young people’s mental
health and wellbeing. London: DH.
494. The Five Year Forward View for Mental Health, op. cit., p. 6.
495. House of Commons & Health Committee. (2014). Children’s andAdolescents’ Mental Health and CAMHS: Third report of session
2014–15. London: House of Commons.
496. National Maternity Review. (2016). Better Birth – Improving
Outcomes of Maternity Services in England: A five year forward
view for maternity care.
497. Next Steps on the Five Year Forward View, op. cit.
498. Local Action on Health Inequalities, op. cit.
499. Fair Society, Healthy Lives, op. cit.

500. Meaney, M. J. (2001). Maternal Care, Gene Expression, and theTransmission of Individual Differences in Stress Reactivity AcrossGenerations. Annual Review of Neuroscience, (24), pp. 1161–92.
501. Music and Motherhood: www.rcm.ac.uk
502. South London Gallery. (2015). Making it Together: An evaluative
study of Creative Families, an arts and mental health partnership
between the South London Gallery and the Parental Mental
Health Team. London: South London Gallery.
503. Dreamtime Arts: www.wellspringhlc.org.uk
504. Annual Report of the Chief Medical Officer 2012, op. cit.
505. Department of Health. (2013). Improving Children and Young
People’s Health Outcomes: A system wide response. London: DH.
506. Hart, B. & Risely, T. R. (2001). The Early Catastrophe: The 30
million word gap by age 3. American Educator. 27 (1), pp. 4–9.
507. Kelly, Y., Sacker, A., Del Bono, E., Francesconi, M. & Marmot, M.
(2011). What Role for the Home Learning Environment andParenting in Reducing the Socioeconomic Gradient in Child
Development? Findings from the Millennium Cohort Study.
Archives of Disease in Childhood.
508. See Save the Children. (2015). Ready to Read: Closing the gap inearly language skills so that every child in Wales can read well.
London: Save the Children; and Book Trust guidance: www.
booktrust.org.uk
509. Reading Well: readingagency.org.uk/adults/quick-guides/
reading-well510. Creative Homes was part of the Knee High Design Challenge
instigated by the Design Council in partnership with GSTC andLambeth and Southwark Councils. See Design Council, New
Economics Foundation & Narativ. (2016). Knee High Design
Challenge Impact Evaluation: Final report. London: Design
Council.
511. Creative Homes: creativehomes.tdlp.co.uk/wp-content/
uploads/2016/05/Impact-report-summary_digital.pdf
512. Golding, A., Boes, C. & Nordin-Bates, S. M. (2016). Investigating
Learning Through Developmental Dance Movement as a
Kinaesthetic Tool in the Early Years Foundation Stage. Researchin Dance Education, 17 (3), pp. 235–67.
513. See Golding, A. (2016). Can Dance Help Children to Become School
Ready? Early Arts UK; and Brown, E. D., Benedett, B. &Armistead, M. E. (2010). Arts Enrichment and School Readinessfor Children at Risk. Early Childhood Research Quarterly, 25,
pp. 112–24.
514. For an alternative definition, recognising the importance of
creativity to early childhood development, see Professional
Association for Childcare and Early Years. (2013). What Does
‘School Ready’ Really Mean? Bromley: Professional Association
for Childcare and Early Years.
515. Public Health England. (2015). Improving School Readiness:
Creating a better start for London. London: Public Health
England.
516. Data taken from a Freedom of Information request submitted by
the Labour Party in 2017.
517. Hallam, S. (2015). The Power of Music: A research synthesis of the
impact of actively making music on the intellectual, social andpersonal development of children and young people. London:
University College London, p. 10.
518. See also Barnes, J., Vella-Burrows, T. (2015). Music for Change:
Health and education outcomes through music in early years
settings; an evaluation. Canterbury: Canterbury Christ Church
University.
519. Department for Education (DfE). (18 November 2016). Thousandsof children to benefit from music and arts investment.
520. For a history of work in this area, see Oldfield, A. (2016). The
Future of Music Therapy with Persons with Autistic Spectrum
Disorder. In C. Dileo (Ed.). Envisioning the Future of Music
Therapy. Philadelphia: Temple University’s Arts and Quality ofLife Research Center, pp. 96–103. Another useful resource is
Nordoff Robbins www.nordoff-robbins.org.uk. An instructive
guide to working with children with autism, made available byLive Music Now, is at: vimeo.com/151003375.
521. Geretesegger, M., Elefant, C., Mössler, K. A. & Gold, C. (2014).
Music Therapy for People with Autism Spectrum Disorder.
Cochrane Database of Systematic Reviews.
522. Live Music Now and SEN: www.livemusicnow.org.uk
523. Jessie’s Fund: jessiesfund.org.uk
179

All-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Report524. The Key Club: www.turtlekeyarts.org.uk
525. Black, C. (n.d.). Key Club in Practice. London: Turtle Key Arts.
526. Harkins, C. (2014). Evaluation plan: Sistema Scotland’s Big Noise
programmes in Raploch, Stirling and in Govanhill, Glasgow.
Glasgow: Glasgow Centre for Population Health, p. 4.
527. Burns, S. (2016). In Harmony Liverpool: Impact on early years
education. Liverpool: In Harmony, p. 7.
528. Thousands of children to benefit from music and arts
investment, op. cit.
529. In the USA, both the Arts Education Partnership and the
National Association of Music Merchants strongly advocate
music education, via Arts Education Partnership. (2011). Music
Matters: How music education helps students learn, achieve,and succeed. Washington DC; and National Association of Music
Merchants. (n.d.). Why Learn to Play MUSIC?
530. Music Action International: musicaction.org
531. Menzer, M. (2015). The Arts in Early Childhood – Social andEmotional Benefits of Arts Participation: A literature review and
GAP analysis (2000–2015). Washington DC: Office of Research &Analysis, National Endowment for the Arts.
532. Edwards, T., Céilleachair, A., Bywater, T., et al. (2007). Parenting
Programme for Parents of Children at Risk of Developing
Conduct Disorder: Cost effectiveness analysis. British Medical
Journal, 334 (75), p. 682.
533. Daykin, N., Orme, J., Evans, D., Salmon, D., McEachran, M., et al.
(2008). The Impact of Participation in Performing Arts on
Adolescent Health and Behaviour: A systematic review of theliterature. Journal of Health Psychology, 13 (2), pp. 251–64.
534. Bungay, H. & Vella-Burrows, T. (2013). The Effects ofParticipating in Creative Activities on the Health and Well-beingof Children and Young People: A rapid review of the literature.
Perspectives in Public Health, 133 (1), p. 51.
535. The Art Room: www.theartroom.org.uk
536. Eaude, T. & Matthew, S. (2005). Making Space for Re-Engagement:
An evaluation of educational provision at the Art Room, Oxford.
Oxford: New Perspectives.
537. The Five Year Forward View for Mental Health, op. cit., p. 5.
538. Parsonage, M., Khan, L. & Saunders, A. (2014). Building a Better
Future: The lifetime costs of childhood behavioural problems andthe benefits of early intervention. London: Centre for Mental Health.
539. No Health Without Mental Health, op. cit.
540. Cobbett, S. (2016). Reaching the Hard to Reach: Quantitative andqualitative evaluation of school-based arts therapies with young
people with social, emotional and behavioural difficulties.
Emotional and Behavioural Difficulties, 21 (4).
541. A llen, G. (2011). Early Intervention: The next steps (Anindependent report to Her Majesty’s Government). London:
Cabinet Office; Allen, G. (2011). Early Intervention: Smartinvestment, massive savings (The second independent report to
Her Majesty’s Government). London: Cabinet Office.
542. The Partnership Investment Programme: www.artsconnect.
co.uk
543. Perry, E. & Francis, B. (2010). The Social Class Gap for
Educational Achievement: A review of the literature. London:
Royal Society for the Encouragement of Arts, Manufactures andCommerce.
544. The Health Gap, op. cit.
545. K idson, M. & Norris, E. (2014). Implementing the London
Challenge. London: Joseph Rowntree Foundation and Institutefor Government.
546. Cultural Learning Alliance. (2017). ImagineNation: The value of
cultural learning. London : Cultural Learning Alliance.
547. Vaughan, T., Harris, J. & Caldwell, B. J. (2011). Bridging the Gap in
School Achievement Through the Arts. Victoria: The Song Room,p. 3.
548. Smith, D. (2013). An Independent Report for the Welsh
Government into Arts in Education in the Schools of Wales, p. 11.
549. Culture and Poverty, op. cit.
550. Banerjee, R., McLaughlin, C., Cotney, J., Roberts, L. &Peereboom, C. (2016). Promoting Emotional Health, Well-being
and Resilience in Primary Schools. Cardiff: Public Policy
Institute for Wales, p. 3.
551. Pearson, S. (2016). The Life Project: The extraordinary story of
our ordinary lives. London: Allen Lane.

180

552. Cassidy, S. (21 June 2016). School’s Results go from Bottom to Top,
Thanks to Shakespeare, The Guardian.
553. My Primary School is at the Museum: www.kcl.ac.uk
554. Research conducted by Dr Ally Daubney and Duncan Mackrill at
the University of Sussex in the second half of 2016 showed that59.7 percent of state schools reported negative consequences of
the EBacc on the provision and uptake of music both within andoutside of schools.
555. A rtis: www.artiseducation.com
556. The Culture White Paper, op. cit., p. 8.
557. Autumn Statement 2016. (2016). HM Treasury. Section 6.3. The
grassroots network researchED exists to develop and shareeducational research.
558. Office for Standards in Education, Children’s Services and Skills.
(2015). School Inspection Handbook: Handbook for inspecting
schools in England under section 5 of the Education Act 2005, p. 34.
559. For details of the Artsmark scheme in the context of the 2012
OFSTED assessment, see Arts Council England, Artsmark andthe new Ofsted framework at: www.artsmark.org.uk
560. School Inspection Handbook, op. cit., p. 64.
561. Henley, D. (2012). Cultural Education in England: An independent
review by Darren Henley for the Department for Culture, Mediaand Sport and the Department for Education. London: DCMS and
DfE, pp. 4–5. In this regard, heed might be paid to the Cultural
Education Challenge, through which partnerships between
cultural organisations, educational institutions and local
authorities are being established by ACE bridge organisations tobring participatory arts to areas of greatest need: www.
artscouncil.org.uk and to the Creative Talent Plan, a 25-year
strategy being developed through a partnership between ACE
and De Montford University, which will provide a long-term
vision for efforts like the Cultural Education Challenge:
www.artscouncil.org.uk. Creativity Culture and Education is
the international foundation for creative learning: www.
creativitycultureeducation.org, and the Education Endowment
Foundation is looking at ways in which successful methods
might be scaled up: educationendowmentfoundation.org.uk
562. Tawell, A., Thompson, I., Daniels, H., Elliott, V. & Dingwall, N. (2015).
Being Other: The effectiveness of arts based approaches in engaging
with disaffected young people. Oxford: University of Oxford.
563. The Roundhouse Trust: www.roundhouse.org.uk
564. The Durham Commission on Creativity and Education: www.
dur.ac.uk
565. Prison Reform Trust. (2016). In Care, Out of Trouble: How the life
chances of children in care can be transformed by protecting
them from unnecessary involvement in the criminal justicesystem. London: Prison Reform Trust.
566. Social Care Institute for Excellence: www.scie.org.uk
567. National Institute for Health and Care Excellence. (2010).
Looked-after children and young people. London: NICE, p. 42.
568. Twilight Zone: www.artscare.co.uk
569. Mullen, J. (2014). The Young Review: Improving outcomes foryoung black and/or Muslim men in the criminal justice system.
London: Black Training and Enterprise Group and Clinks.
570. Taylor, C. (2016). Review of the Youth Justice System in Englandand Wales. London: Ministry of Justice.
571. De Viggiani, N., Daykin, N., Moriarty, Y., Pilkington, P. &Superact CIC. (2013). Musical Pathways: An exploratory study ofyoung people in the criminal justice system, engaged with acreative music programme. Bristol: University of the Westof England.
572. Caulfield, L., Simpson, E. & Jacobs, C. (2017). An Evaluation of the
Birmingham Youth Offending Service Youth Music Project(Compliance, Completion and Success). Bath: Bath Spa
University, kindly made available to the author.
573. The health and wellbeing effects of the TR14ers have been
acknowledged by the NHS Live awards. clahrc-peninsula.nihr.
ac.uk/research/c2-connecting-communities
574. Somatic Dance at Alder Hey Hospital:
www.artshealthandwellbeing.org.uk
575. Dowler, L. (2013). Improvising on the Ward: Exploring somaticdance and potential in paediatric healthcare. Journal of Applied
Arts and Health, 4 (2), pp. 163–78.
576. The Teapot Trust: www.teapot-trust.org

577. S ee Beyond Words, run by Cheltenham Festivals 2015–18:
www.cheltenhamfestivals.com
578. Figures taken from the National Child Measurement
Programme.
579. HM Government. (2016). Childhood Obesity: A plan for action.
London: HM Government.
580. Cuypers, K., De Ridder, K., Kvaløy, K., Skjei Knudtsen, M.,
Krokstad, S., et al. (2012). Leisure Time Activities in Adolescencein the Presence of Susceptibility Genes for Obesity: Risk orresilience against overweight in adulthood? The HUNT study.
BMC Public Health, 12 (820).
581. Matrix Insights. (2009). Evaluation of Time Being Seven. Isle ofWight: Healing Arts.
582. Future in Mind, op. cit., using data from Green, H., McGinnity, Á.,Meltzer, H., Ford, T. & Goodman, R. (2005). Mental Health ofChildren and Young People in Great Britain, 2004. London: Officefor National Statistics.
583. Nuffield Foundation. (2012). Social Trends and Mental Health:Introducing the main findings. London: Nuffield Foundation.
584. Socioeconomic Inequalities and Mental Health Problems inChildren and Adolescents, op. cit.
585. Investing in Recovery, op. cit.
586. Children’s and Adolescents’ Mental Health and CAMHS: Third
report of session 2014–15. op. cit. p. 3.
587. Annual Report of the Chief Medical Officer 2013, op. cit.
588. HM Government. Children’s and Adolescents’ Mental Healthand CAMHS: Government response to the Committee’s third
report of session 2014­–15 – Health Committee.
589. Future in Mind, op. cit.
590. Key Changes: www.keychanges.org.uk
591. Youth Action: www.youthaction.org
592. Right Here: www.phf.org.uk
593. Future in Mind, op. cit.
594. Investing in Recovery, op. cit.
595. No Health Without Mental Health, op. cit.
596. World Health Organization. (2000). Mental Health: New
understanding, new hope – The World Health report 2001.
Geneva: World Health Organization.
597. Children and Young People’s Mental Health Coalition. (n.d.).
Improving Children and Young People’s Mental Health: The
business case.
598. Smile All the Time by Samantics can be viewed at:
www.youtube.com
599. Future in Mind, op. cit., p. 13.
600. Investing in Recovery, op. cit., p. 3.
601. K irkbride, J., Barker, D., Cowden, F., Stamps, R., Yang, M., et al.
(2008). Psychoses, Ethnicity and Socio-economic Status. The
British Journal of Psychiatry, (193), pp. 18–24.
602. Morgan, C., Charalambides, M., Hutchinson, G. & Murray, R. M.
(2010). Migration, Ethnicity, and Psychosis: Toward asociodevelopmental model. Schizophrenia Bulletin, 36 (4), pp.
655–64.
603. Fearon, P., Kirkbridge, J. B., Morgan, C., Dazzan, P., Morgan, K.,
et al. (2006). Incidence of Schizophrenia and Other Psychoses inEthnic Minority Groups: Results from the MRC AESOP Study.
Psychological Medicine, (36), pp. 1541–50.
604. Morgan, C. & Hutchinson, G. (2009). The Social Determinants of
Psychosis in Migrant and Ethnic Minority Populations: A publichealth tragedy. Psychological Medicine, (39), pp. 1–5.
605. The Five Year Forward View for Mental Health, op. cit., p. 12.
606. National Institute for Health and Care Excellence (NICE). (2014).
Psychosis and Schizophrenia in Adults: Prevention andmanagement. London: NICE, p. 25.
607. The Youth Select Committee (YSC) is a British Youth Council
initiative, supported by the House of Commons, which takes
evidence in public and has its proceedings televised andrecorded in Hansard. The 11 committee members are aged
between 13 and 18 and include Members of UK Youth Parliament,
youth councillors, a young mayor, reserved seats andrepresentatives from each of the devolved nations.
608. British Youth Council Youth Select Committee 2015. (2015).
Young People’s Mental Health. London: Youth Select Committee.
609. A itkenhead, D. (13 May 2016). Sacked Children’s Mental Health
Tsar Natasha Devon: ‘I was proper angry’, The Guardian.

610. S peaking to the Commons Education Committee in January
2016, the Children’s Commissioner for England called for all
schools to provide counselling for pupils.
611. See PSHE Association. (2015). Teacher Guidance: Preparing toteach about mental health and emotional wellbeing. London:
PSHE Association; and Department for Education. (2016).
Counselling in Schools: A blueprint for the future – Departmental
advice for school leaders and counsellors. London: DfE.
612. Music in Mind: www.artshealthandwellbeing.org.uk
613. Daubney, A. & Daubney, G. (2017). Music in Mind Evaluation.
Tunbridge Wells: Rhythmix.
614. Closing the Gap, op. cit.
615. Young People’s Mental Health, op. cit., p. 11.
616. The Alchemy Project: www.artshealthandwellbeing.org.uk
617. To negotiate access to the film, please contact Gwen Van Spijk:
gwen@cueperformance.com
618. Young People’s Mental Health, op. cit. See also Youth HealthParliament. (2016). Mental Wealth Initiative. London: Youth
Health Parliament.
619. R aw Material: rawmusicmedia.co.uk/ See also Saturday Studioat Bethlem Gallery.
620. R aw Sounds: www.rcpsych.ac.uk
621. With thanks to the Cultural Learning Alliance for making thisconnection.
622. Cabinet Office. (2014). Risk Behaviours and Negative Outcomes:
Trends in risk behaviours and negative outcomes amongst
children and young people. London: Cabinet Office.
623. Bradshaw, J., Hoelscher, P. & Richardson, D. (2007). An Index ofChild Well-Being in the European Union. Social Indicators
Research, 80, pp. 133–77.
624. The Children’s Society. (2015). The Good Childhood Report 2015.
London: The Children’s Society.
625. The Mental Health Foundation. (2010). The Lonely Society?
London: The Mental Health Foundation.
626. School Health Education Unit. (2014). Young People into 2015,
summarised in PSHE Association. (2015). Current Trends in
Health, Wellbeing and Risky Behaviours Amongst Children andYoung People: A synthesis of recent evidence. This is addressed in
the work on ‘Growing up with the Internet’ undertaken by theHouse of Lords Select Committee on Communications.
627. National Institute for Health and Care Excellence (NICE). (2016).
Social and Emotional Wellbeing for Children and Young People:
Overview. London: NICE.
628. Brown, P. (2016). The Invisible Problem? Improving students’mental health. Oxford: Higher Education Policy Institute.
629. Universities UK. (2015). Student Mental Wellbeing in Higher
Education: Good practice guide. London: Universities UK.
630. Wu, S.M. (2002). Effects of Music Therapy on Anxiety,Depression and Self-esteem of Undergraduates. Psychologia, 45(2), pp.104–14.
631. Start wellbeing thermometer: start2.co.uk/course/wellbeingthermometer; Mind Emoodji: emoodji.co.uk
632. Healthy Universities Network: www.healthyuniversities.ac.uk
633. AMOSSHE: www.amosshe.org.uk
634. Coyne, I. (2007). Children’s Experiences of Hospitalization.
Journal of Child Healthcare, pp. 326–36.
635. Sextou, P. (2016). Theatre for Children in Hospital: The gift ofcompassion. Bristol: Intellect.
636. Redshaw, M. (2008). Design for Health: The impact of a new
hospital environment on children, families and staff. Norwich:
The Stationery Office.
637. A rtfelt Workshop Programme: www.artshealthandwellbeing.
org.uk638. Adam, S. (2016). The National Portrait Gallery Hospital Arts
Programme Evaluation Report. London: National Portrait
Gallery.
639. For a consideration of this, see Rice, G., Ingram, J. & Mizan, J.
(2008). Enhancing a Primary Care Environment: A case study ofeffects on patients and staff in a single general practice. British
Journal of General Practice, 58 (552), pp. e1–8.
640. Poems in the Waiting Room: www.poemsinthewaitingroom.org
641. Lee, J. (1965). A Policy for the Arts: First Steps (White Paper No.
Cmnd. 2601). London: HM Government.
642. The Health Gap, op. cit., p. 172.

181

All-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Report643. UCL Institute of Health Equity. (2014). Local Action on HealthInequalities: Workplace interventions to improve health andwellbeing. London: Public Health England.
644. Research commissioned by the Joseph Rowntree Foundationshows that 55 percent of people in poverty are part of a working
family, the highest proportion since records began. Tinson, A.,
Ayrton, C., Barker, K., Born, T. B., Aldridge, H., et al. (2016).
Monitoring Poverty and Social Exclusion 2016. London: Joseph
Rowntree Foundation.
645. Data taken from the Labour Force Survey.
646. Data taken from literature for Health at Work and the Fit forWork scheme.
647. Health, Work and Wellbeing: www.nhshealthatwork.co.uk
648. The Workplace Wellbeing Charter: www.wellbeingcharter.org.uk
649. Black, C. (2008). Working for a Healthier Tomorrow: Dame Carol
Black’s Review of the health of Britain’s working age population.
London: The Stationery Office.
650. Eschleman, K. J., Madsen, J., Alarcon, G. & Barelka, A. (2014).
Benefiting from Creative Activity: The positive relationships
between creative activity, recovery experiences, andperformance-related outcomes. Journal of Occupational andOrganizational Psychology, p. 1.
651. Five Year Forward View, op. cit., p. 11.
652. National Institute for Health and Care Excellence (NICE). (2016).
Workplace Health: Policy and Management Practices Overview.
London: NICE.
653. Adult Psychiatric Morbidity Survey: Survey of mental healthand wellbeing in England, 2014
654. How Mental Illness Loses Out in the NHS, op. cit.
655. Data taken from the Labour Force Survey.
656. Five Year Forward View, op. cit. NHS England is supporting an
Individual Placement and Support programme in threegeographical areas as part of an RCT due to report in 2020.
657. Mental Health Foundation. (2017). Surviving or Thriving? The
state of the UK’s mental health. London: Mental HealthFoundation, p. 21.
658. Maratos, A., Gold, C., Wang, X. & Crawford, M. (2008). Music
Therapy for Depression. Cochrane Database of Systematic
Reviews.
659. Erkkilä, J., Punkanen, M., Fachner, J., Ala-Ruona, E., Pöntiö, I.,et al. (2011). Individual Music Therapy for Depression:
Randomised Controlled Trial. The British Journal of Psychiatry,
199, pp. 132–39.
660. Arts on Prescription 2010–12, op. cit.
661. Depression in Adults and Depression in Adults with Chronic
Physical Health Problems, op. cit.
662. Creative Practice as Mutual Recovery involves health, social
care and educational professions, people with mental healthneeds and carers in creative strategies to enhance health,wellbeing and community resilience.
663. Fancourt, D., Perkins, R., Ascenso, S., Atkins, L., Kilfeather, S., etal. (2016), Group Drumming Modulates Cytokine Response in
Mental Health Service Users: A preliminary study.
Psychotherapy and Psychosomatics, 85, pp. 53–55; Fancourt, D.,
Perkins, R., Ascenso, S., Carvalho, L. A., Steptoe, A., et al. (2016).
Effects of Group Drumming Interventions on Anxiety,Depression, Social Resilience and Inflammatory Immune
Response Among Mental Health Service Users, PLoS ONE, 11(e0151136), pp. 1–16; and Perkins, R., Ascenso, S., Atkins, L.,
Fancourt, D. & Williamon, A. (2016). Making Music for Mental
Health: How group drumming mediates recovery. Psychology of
Well-Being: Theory, Research and Practice, 6 (11).
664. Channel 4 News special on schizophrenia: www.youtube.com
665. Stitchlinks: stitchlinks.com
666. Riley, J., Corkhill, B. & Morris, C. (2013). The Benefits of Knittingfor Personal and Social Wellbeing in Adulthood: Findings froman international survey. British Journal of Occupational
Therapy, 76 (2), pp. 50–57.
667. Corkhill, B. & Davidson, C. (2009). Exploring the Effects ofKnitting on the Experience of Chronic Pain – a Qualitative
Study. Poster presentation at the Annual Scientific Meeting of
the British Pain Society.
668. SuperFriend: www.superfriend.com.au
669. Mental Health First Aid England: mhfaengland.org/
670. Trades Union Congress Midlands Region. (2017). Cultural Manifesto.
182

671. Institute of Directors: www.iod.com
672. Silvester, A. (2017). A Little More Conversation: Mental health in
the changing world of work. London: Institute of Directors.
673. City Mental Health Alliance: www.citymentalhealthalliance.org
674. Mental Wealth Festival: www.mentalwealthfestival.co.uk
675. Ellis-Hill, C., Gracey, F., Thomas, S., Lamont-Robinson, C.,
Thomas, P. W., et al. (2015). ‘HeART of Stroke (HoS)’, a
Community-based Arts for Health Group Intervention to
Support Self-confidence and Psychological Well-being
Following a Stroke: Protocol for a randomised controlled
feasibility study. BMJ Open.
676. Särkämö, T., Tervaniemi, M., Laitinen, S., Forsblom, A., Soinila,
S., et al. (2008). Music Listening Enhances Cognitive Recovery
and Mood After Middle Cerebral Artery Stroke. Brain, (131), pp.
866–76; Särkämö, T. & Soto, D. (2012). Music Listening After
Stroke: Beneficial effects and potential neural mechanisms.
Annals of the New York Academy of Sciences, (1252), pp. 266–81;
and Särkämö, T., Ripollés, P., Vepsäläinen, H., Autti, T.,
Silvennoinen, H. M., et al. (2014). Structural Changes Induced by
Daily Music Listening in the Recovering Brain after Middle
Cerebral Artery Stroke: A voxel-based morphometry study.
Frontiers in Human Neuroscience.
677. Tamplin, J., Baker, F. A., Jones, B., Way, A. & Lee, S. (2013). ‘Strokea Chord’: The effect of singing in a community choir on moodand social engagement for people living with aphasia following
a stroke. NeuroRehabilitation, 32 (4), pp. 929–41.
678. Live Music Now: www.livemusicnow.org.uk
679. Bradt, J., Magee, W., Dileo, C., Wheeler, B. L. & McGilloway, E.
(2010). Music Therapy for Acquired Brain Injury. Cochrane
Database of Systematic Reviews.
680. Stroke Odysseys: strokeodysseys.org
681. Matrix Insights. (2012). Final Report and Evaluation of the
Research Programme ‘Exploring the meaning and value of aperson-centred arts programme to stroke survivors during ahospital stay’. Isle of Wight: Healing Arts.
682. Beesley, K., White, J. H., Alston, M. K., Sweetapple, A. L. &Pollack, M. (2011). Art After Stroke: The qualitative experience ofcommunity dwelling stroke survivors in a group art programme.
Disability and Rehabilitation, 33 (23–24), pp. 2346–55.
683. HeART of Stroke: www.youtube.com research.bournemouth.
ac.uk/2015/08/heart-of-stroke-study
684. ‘HeART of Stroke (HoS)’, op. cit.
685. Batt-Rawden, K. (2010). The Role of Music in a Salutogenic
Approach to Health. International Journal of Mental Health
Promotion, 12 (2), pp. 11–18.
686. Vella-Burrows, T. & Hancox, G. (2012). Singing and People with
Parkinson’s. Canterbury: Sidney De Haan Research Centre forArts and Health.
687. Strokestra: www.rpo.co.uk
688. Strokestra: www.artshealthandwellbeing.org.uk
689. Nicholson, C., Rodio, L. & Wilson, M. (2016). STROKESTRA Stroke
Rehabilitation through Creative Music-Making Pilot Programme
Report. London: Royal Philharmonic Orchestra.
690. Parkinson’s UK Singing for Parkinson’s: www.parkinsons.org.uk
691. The film about Skylarks is available online at:www.youtube.com
692. Dance for Parkinson’s: www.ncvo.org.uk
693. Houston, S. & McGill, A. (2012). A Mixed-methods Study into Balletfor People Living with Parkinson’s. Arts & Health, 5 (2), pp. 103–19.
694. Houston, S. & McGill, A. (2015). English National Ballet, Dance for
Parkinson’s: An Investigative Study 2 – A report on a three-year
mixed methods research study. London: English National
Ballet.
695. Clift, S., Morrison, I., Skingley, A., Page, S., Coulton, S., et al.
(2013). An Evaluation of Community Singing for People with COPD
(Chronic Obstructive Pulmonary Disease). Canterbury: Sidney
De Haan Research Centre for Arts and Health.
696. Clift, S., Skingley, A., Page, S., Stephens, L., Hurley, S., et al.
(2017). Singing for Better Breathing: Findings from the Lambeth
and Southwark Singing and COPD Project. Canterbury: Sidney
De Haan Research Centre for Arts and Health.
697. Examples include Singing for Better Breathing in Lambeth andSouthwark: www.s4bb.org.uk; Singing for Breathing in
Middlesex and London: www.rbht.nhs.uk; and Sing to Live, Liveto Sing in Kensington and Chelsea: www.rbkc.gov.uk

698. British Lung Foundation Singing for Breathing: www.blf.org.uk
699. National Institute for Health and Care Excellence (NICE). (2010).
Chronic Obstructive Pulmonary Disease in Over 16s: Diagnosis
and management. London: NICE.
700. Vickhoff, B., Malmgren, H., Åström, R., Nyberg, G., Ekström,
S-R., et al. (2013). Music Structure Determines Heart Rate
Variability of Singers. Frontiers in Psychology, 4 (334).
701. Irons, J. Y., Petocz, P., Kenny, D. T. & Chang, A. B. (2014). Singing
as an Adjunct Therapy for Children and Adults with Cystic
Fibrosis. Cochrane Database of Systematic Reviews.
702. Breath Cycle: www.breathcycle.com
703. Drury, R. (2014). Evaluation of Breath Cycle: Scottish Opera andGartnavel General Hospital Cystic Fibrosis Service. Glasgow:
Scottish Opera.
704. Bradt, J., Dileo, C., Grocke, D. & Magill, L. (2011). Music Interventions
for Improving Psychological and Physical Outcomes in Cancer
Patients. Cochrane Database of Systematic Reviews; and Bradt, J.,
Shim, M. & Goodill, S. W. (2015). Dance/Movement Therapy for
Improving Psychological and Physical Outcomes in Cancer
Patients. Cochrane Database of Systematic Reviews.
705. Lin, M-H., Moh, S-L., Kuo, Y-C. & Wu, P-Y. (2012). Art Therapy for
Terminal Cancer Patients in a Hospice Palliative Care Unit in
Taiwan. Palliative and Supportive Care, 10 (1), pp. 51–57.
706. Lefèvre, C., Ledoux, M. & Filbert, M. (2015). Art Therapy Among
Palliative Cancer Patients: Aesthetic dimensions and impacts
on symptoms. Palliative and Supportive Care, 0, pp. 1–5.
707. Walker, J. Holm Hansen, C., Martin, P., Symeonides, S.,
Ramessur, R., et al. Prevalence, Associations, and Adequacy ofTreatment of Major Depression in Patients with Cancer: A
cross-sectional analysis of routinely collected clinical data. The
Lancet Psychiatry, 1 (5), pp. 343–50.
708. Tenovus Cancer Care: www.tenovuscancercare.org.uk
709. Bradt, J., Dileo, C. & Potvin, N. (2013). Music for Stress andAnxiety Reduction in Coronary Heart Disease Patients.
Cochrane Database of Systematic Reviews.
710. Bernardi, L., Porta, C. & Sleight, P. (2011). Cardiovascular,
Cerebrovascular and Respiratory Changes Induced by Different
Types of Music in Musicians and Non‐musicians: The
importance of silence. Heart, 92, pp. 445–52.
711. Bradt, J., Dileo, C. & Shim, M. (2013). Music Interventions forPreoperative Anxiety. Cochrane Database of Systematic Reviews.
712. The Reader: www.thereader.org.uk
713. Billington, J. (2012). Prison Reading Groups in Practice andTheory. Critical Survey, 23 (3), pp. 67­– 85.
714. Longden E., Davis, P., Billington, J. & Corcoran, R. (2015). Shared
Reading: Assessing the intrinsic value of a literature-based
intervention. Medical Humanities, 41 (2), pp. 113–20.
715. Dowrick, C., Billington, J., Robinson, J., Hamer, A. & Williams, C.
(2012). Get into Reading as an Intervention for Common Mental
Health Problems. Medical Humanities, 38, pp. 15­–20; andBillington, J., Carroll, J., Davis, P., Healey, C. & Kinderman, P.
(2013). A Literature-based Intervention for Older People Livingwith Dementia. Perspectives in Public Health, 133 (3), pp. 165–73.
716. Billington, J., Humphreys, A.L., Jones, A. & McDonnell, K. (2014).
A Literature-based Intervention for People with Chronic Pain.
Arts & Health, 8 (1), pp. 13–31.
717. Gray, E., Kiemle, G., Billington, J. & Davis, P. (2016). An
Interpretative Phenomenological Analysis of Experience of a
Reader Group. Arts & Health, 8 (3), pp. 248–61.
718. Davis, P., Thierry G., Martin, C.D., Gonzalez-Diaz, V., Rezaie, R.,
et al. (2008). Event-related Potential Characterisation of the
Shakespearean Functional Shift in Narrative Sentence
Structure. NeuroImage, 40, pp. 923–31; and Davis, P., Keidel, J.,
Gonzalez-Diaz, V., Martin, C. & Thierry, G. (2012). How
Shakespeare Tempests the Brain: Neuroimaging insights.
Cortex, 48 (5), pp. 21–64.
719. O’Sullivan, N., Davis, P., Billington, J., Gonzalez-Diaz, V. &Corcoran, R. (2015). The Neural Basis of Literary Awareness, andits Benefits to Cognition. Cortex, 48 (5), pp. 21–64.
720. Longden, E., Davis, P., Billington, J., Lampropoulou, S.,
Farrington, C., et al. (2015). Shared Reading: Assessing the
intrinsic value of a literature-based health intervention. Medical
Humanities, 41 (2), pp. 113–20.
721. Bradt, J. & Dileo, C. (2014). Music Interventions for MechanicallyVentilated Patients. Cochrane Database of Systematic Reviews.

722. Health as a Social Movement: www.england.nhs.uk
723. Macnaughton, J. (2007). Art in Hospital Spaces. International
Journal of Cultural Policy, 13 (1), pp. 85–101.
724. A film about the role of the art commissions within the hospitaldevelopment is available at: www.youtube.com; to view a film
about the Fresh Arts Festival of Creativity and Wellbeing, visit:
youtu.be/l4R978IB2U8?list=PLb_7ZfZjCnFpWjS0zSlqvV35iqn5L2foC
725. Willis Newson. Quotes and Comments: Southmead Hospital
Public Art Programme, kindly supplied to the author.
726. Willis Newson at Southmead Hospital: www.willisnewson.
co.uk
727. Ulrich, R. S. (1984). View Through a Window May Influence
Recovery from Surgery. Science, 224 (4647), pp. 420–21.
728. Horatio’s Garden: www.horatiosgarden.org.uk
729. Kentish Town Health Centre: www.ahmm.co.uk
730. See Lawson, B. R. & Phiri, M. (2003). The Architectural
Healthcare Environment and its Effect on Staff and Patient Health
Outcomes. Norwich: The Stationery Office.
731. Jecks, C. & Heathcote, E. (2010). The Architecture of Hope.
London: Frances Lincoln Ltd.
732. For a response to health inequalities in the prison population,
see Clinks. (2015). The Challenges and Solutions to Better
Investment in and Partnership with the VCSE Sector: Clinks
response to the Department of Health VCSE Review discussion
paper, which points to Creativity Works as a case study.
733. Revolving Doors Agency. (2013). Balancing Act: Addressing healthinequalities among people in contact with the criminal justicesystem: A briefing for Directors of Public Health. London:
Revolving Doors Agency, p. 3.
734. The National Federation of Women’s Institutes & Prison Reform
Trust. (2010). Care Not Custody. London: The National Federationof Women’s Institutes and Prison Reform Trust.
735. Closing the Gap, op. cit.
736. See Bilby, C., Caulfield, L. & Ridley, L. (2013). ReImagining Futures: Exploring arts interventions and theprocess of desistance. London: Arts Alliance; and Cheliotis, L,
Jordanoska, A. & Sekol, I. (2014). The Arts of Desistance:
Evaluation of the Koestler Trust Arts Mentoring Programme for
Former Prisoners. London: Koestler Trust.
737. Johnson, H., Keen, S. & Pritchard, D. (2011). Unlocking Value: The
economic benefit of the arts in criminal justice. London: New
Philanthropy Capital.
738. Geese Theatre Company: www.geese.co.uk
739. Coates, S. (2016). Unlocking Potential: A review of education inprison. London: Ministry of Justice, p. ii.
740. Ibid, p. 27. For practicalities about how the creative arts might beencouraged in the criminal justice system, see Parkinson, A.
(2016). Arts, Culture and Innovation in Criminal Justice Settings: A
Guide for Commissioners. London: National Criminal JusticeArts Alliance.
741. Koestler Trust: www.koestlertrust.org.uk
742. McNeish, D. & Scott, S. (2014). Women and Girls at Risk: Evidence
across the life course. North Dalton: DMSS Research.
743. Combat Stress: www.combatstress.org.uk. For a consideration of
the acceptability of such programmes among veterans, see
Lobban, J. (2016). Factors that Influence Engagement in an
Inpatient Art Therapy Group for Veterans with Post TraumaticStress Disorder. International Journal of Art Therapy,
21 (1), pp. 15–22; and Palmer, E., Hill, K., Lobban, J. & Murphy, D.
(2017). Veterans’ Perspectives on the Acceptability of Art Therapy:
A mixed-methods study. International Journal of Art Therapy.
744. National Criminal Justice Arts Alliance evidence library:artsevidence.org.uk
745. Shared Intelligence, Local Government Association and Forcesin Mind Trust. (2016). Our Community – Our Covenant: Improving
the delivery of local Covenant pledges. London: SharedIntelligence, Local Government Association and FiMT.
746. The Five Year Forward View for Mental Health, op. cit., p. 7.
747. National Institute for Health and Care Excellence (NICE). 2005.
Post-Traumatic Stress Disorder: Management. London: NICE, p. 5.
748. Bensimon, M., Amir, D. & Wolf, Y. (2008). Drumming ThroughTrauma: Music therapy with post-traumatic soldiers. The Arts in
Psychotherapy, 35 (1), pp. 34–48.

183

All-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Report749. Combat Veteran Players: www.combatveteranplayers.org.uk
750. Liverpool Veterans Project: www.liverpoolveterans.co.uk
751. Danish Wounded Warriors: www.danishwoundedwarriors.com
752. Five Soldiers: rosiekay.co.uk/5-soldiers/753. Lobban, J. (2016). Art Therapy for Military Veterans with PTSD: A
transatlantic study, p. 5, paraphrasing National Initiative forArts and Health in the Military. (2013). Arts, Health andWell-Being across the Military Continuum: White Paper andFraming a National Plan for Action. Washington DC: Americans
for the Arts.
754. Bell, J. (2015). Man Down: Who Really Survives and What Life Is
Left? unpublished report submitted to the Inquiry.
755. See also Dent-Brown, K. (2010). An Evaluation of Six Community
Mental Health Pilots for Veterans of the Armed Forces: A reportfor the Ministry of Defence. Sheffield: University of Sheffield.
756. Mental Health Foundation work with asylum seekers andrefugees: www.mentalhealth.org.uk
757. K idd, B., Zahir, S. & Khan, S. (2008). Arts and Refugees: History,
impact and future. London: Arts Council England, The Baring
Foundation and Paul Hamlyn Foundation.
758. City of Sanctuary: cityofsanctuary.org
759. The Long-term Sustainability of the NHS and Adult Social Care,op. cit., p. 4.
760. Strickland, M. A., Gambala, C. T. & Rodenhauser, P. (2002).
Medical Education and The Arts: A Survey of U.S. Medical
Schools. Teaching and Learning in Medicine, 14 (4), pp. 264–67;
Schwartz, A. W., Abramson, J. S., Wojnowich, I., Accordino, R.,
Ronan, E. J., et al. (2009). Evaluating the Impact of the
Humanities in Medical Education. Mt Sinai Journal of Medicine,76 (4), pp. 372–80; Ousager, J. & Johannessen, H. (2010).
Humanities in Undergraduate Medical Education: A literature
review. Academic Medicine, 85 (6), pp. 988–98; Perry, M.,
Maffulli, N., Willson, S. & Morrissey, D. (2011). The Effectivenessof Arts-based Interventions in Medical Education: A literature
review. Medical Education, 45, pp. 141–48; Lake, J., Jackson, L. &Hardman, C. (2015). A Fresh Perspective on Medical Education:
The lens of the arts. Medical Education, 49, pp. 759–72; andHaidet, P., Jarecke, J., Adams, N. E., Stuckey, H. L., Green, M. J.,
et al. (2016). A Guiding Framework to Maximise the Power of theArts in Medical Education: A systematic review and metasynthesis.
Medical Education, 50, pp. 320–31.
761. Francis, R. (2013). Report of the Mid Staffordshire NHSFoundation Trust Public Inquiry. London: The Stationery Office.
762. Tan, M. (2014). Arts in Healthcare – A Human-­Centered Art
Practice? Some conceptual considerations towards better
practice for artist in care settings, available at researchgate.net.
763. Evans, M. & Finlay, I. G. (Eds.). (2001). Medical Humanities.
London: BMJ; Hurwitz, B. (2013). Medical Humanities: Lineage,
excursionary sketch and rationale. Journal of Medical Ethics, 39,
pp. 672–74; McManus, I. C. (28 October 1995). Humanity and the
Medical Humanities. The Lancet, 346 (8983), pp. 1143–45; andShapiro, J., Coulehan, J., Wear, D. & Montello, M. (2009). Medical
Humanities and Their Discontents: Definitions, critiques, andimplications. Academic Medicine, 84, pp. 192–98.
764. See Crawford, P. (30 March 2015). Health Humanities: We arehere to collaborate, not compete. The Guardian.
765. As an example of this, see the postgraduate diploma in Integrative
Medicine, offered by the College of Medicine, which includes asocial prescribing component: www.collegeofmedicine.org.uk
766. Performing Medicine has undertaken a literature review of artsbased learning in healthcare education, funded throughWellcome, which is being submitted for publication.
767. Clod Ensemble: www.clodensemble.com
768. A short introductory film on Professor Kneebone’s work may beviewed at: www.youtube.com
769. Parallel Practices: www.craftscouncil.org.uk
770. Griffin, L., Chiang, N., Tomlin, H., Young, H. & Griffiths, C. (2016).
A Visual Literacy Course for Dermatology Trainees. British
Journal of Dermatology. For a USA equivalent, see Yale School of
Medicine: ymm.yale.edu/spring2014/people/reunion/191342/
771. Commissioning Board Chief Nursing Officer & DH Chief Nursing
Adviser. (2012). Compassion in Practice: Nursing, Midwifery andCare Staff. Leeds: Nursing, Midwifery and Care Workers Team.

184772. Noonan, I., Rafferty, A. M. & Browne, J. Creative Arts in HealthProfessional Education and Practice: A case study reflection andevaluation of a complex intervention to deliver the Culture andCare programme at the Florence Nightingale School of Nursing
and Midwifery, King’s College London. In Creative Arts, Healthand Wellbeing, op. cit., p. 309.
773. Public Health England. (2016). Public Health Skills andKnowledge Framework 2016. London: Public Health England.
774. Boorman, S. (2009). NHS Health and Well-being: Final report.
London: DH.
775. Royal College of Physicians. (2015). Work and Wellbeing in the
NHS: Why staff health matters to patient care. London: Royal
College of Physicians.
776. In September 2015, NHS Chief Executive Simon Stevens
announced a major drive to improve and support the health ofhealthcare staff.
777. Health as a Social Movement: www.england.nhs.uk
778. The Five Year Forward View for Mental Health, op. cit.
779. Iwasaki, Y., Mannell, R. C., Smale, B. J. A. & Butcher, J. (2005).
Contributions of Leisure Participation in Predicting Stress
Coping and Health among Police and Emergency Response
Services Workers’, Journal of Health Psychology, 10 (1),pp. 79–99.
780. Huet, V. (2015). Literature Review of Art Therapy-basedInterventions for Work-related Stress. International Journal of
Art Therapy, 20 (2), p. 75.
781. NHS England initiative to improve staff health: www.england.
nhs.uk782. Chen, C.J., Sung, H.C., Lee, M.S. & Chang, C.Y. (2015). The Effects
of Chinese Five‐element Music Therapy on Nursing Students
with Depressed Mood. International Journal of Nursing Practice,21 (2), pp. 192–99.
783. For an example of a philosophical forum for clinicians in theUSA, see: www.rishiprograms.org
784. See www.outofourheads.net and www.graphicmedicine.org
785. To see an animation about Circle of Care, please visit:
performingmedicine.com/project/circle-of-care
786. NHS Health and Well-being, op. cit.
787. Willson, S. & Jaye, P. Circle of Care: Pioneering arts basedlearning at Guy’s and St Thomas’ Trust. The Lancet (forthcoming)
788. Music therapy for lung health: www.linkedin.com
789. Chief Allied Heath Professions Officer’s Team. (2017). AHPs into
Action: Using Allied Health Professions to transform health, careand wellbeing. London: NHS England.
790. Gordon-Nesbitt, R. (2013). Preliminary Mapping of the Archival
Holdings of Arts and Health Organisations in Greater
Manchester, unpublished report.
791. Gross, S. A. & Musgrave, G. (2016). Can Music Make You Sick?
Music and Depression: A study into the incidence of musicians’
mental health Part 1: Pilot Survey Report. London: University ofWestminster and Music Tank, p. 12.
792. Organisations geared up to respond to this include the British
Association for Performing Arts Medicine and Help Musicians UK.
793. Inclusive Arts Practice: www.brighton.ac.uk
794. A nimation for Health and Wellbeing: www.lboro.ac.uk
795. A rts in Medicine: artsinmedicine.ufhealth.org/resources/
education
796. Healthcare and Design: www.rca.ac.uk
797. See also International Longevity Centre – UK. (2000). The
Implications for Training of Embracing a Life Course Approachto Health.
798. A n example of this is provided by Flourish mentors in
Oxfordshire, which sees emerging and more experienced
artists working together in settings like care homes.
799. Apprenticeships in social care: careindustrynews.
co.uk/2015/11/real-apprenticeships-will-revolutionise-socialcare
800. Operating Theatre: operatingtheatre.org.uk
801. The Sick of the Fringe: thesickofthefringe.com
802. Froggett, L., Manley, J. & Wainwright, J. (2017). The Barometer of
My Heart: Visual matrix research and evaluation project.
Preston: University of Central Lancashire.
803. Gratton, L. & Scott, A. (2016). The 100 Year Life. London and New
York: Bloomsbury.

804. A s evidence of demand, see Kaleidoscope. (2016). Imagine Arts
Evaluation Report. Newry: Kaleidoscope.
805. The Age of Creativity website brings together a network ofprofessionals who share this view. www.ageofcreativity.co.uk
806. NHS England definition of frailty: www.england.nhs.uk
807. The Long-term Sustainability of the NHS and Adult Social Care,op. cit., p. 12.
808. Next Steps on the Five Year Forward View, op. cit.
809. Government Office for Science. (2016). Future of an Ageing
Population (Foresight). London: Government Office for Science.
810. The Health Gap, op. cit., p. 203.
811. Morris, J., Wilkinson, P., Dangour, A. D., Deeming, C. & Fletcher,A. (2007). Defining a Minimum Income for Healthy Living(MIHL): Older age, England. International Journal of
Epidemiology, (36), pp. 1300–07.
812. The Health Gap, op. cit.
813. Lang, I. A., Llewellyn, D. J., Langa, K. M., Wallace, R. B. & Melzer,
D. (2008). Neighbourhood Deprivation and Incident Mobility
Disability in Older Adults. Age and Ageing, 37, pp. 403–10.
814. The Health Gap, op. cit.
815. Scottish Executive. (2007). All Our Futures 2: Planning for a Scotlandwith an Ageing Population. Edinburgh: Scottish Executive.
816. Joint Improvement Team. (n.d.). Active and Healthy Ageing:
An Action Plan for Scotland 2014–2016.
817. Welsh Government. (2013). The Strategy for Older People inWales 2013–2023. Cardiff: Welsh Government, p. 24.
818. Office of the First Minister and Deputy First Minister. (2005).
Ageing in an Inclusive Society. Belfast: Office of the First
Minister and Deputy First Minister.
819. Age Concern Help the Aged NI. (2009). Positive Ageing? Is
Government’s Ageing Strategy Fit for Purpose? Belfast: Age
Concern Help the Aged NI.
820. Coulton, S., Clift, S., Skingley, A. & Rodriguez, J. (2015).
Effectiveness and Cost-effectiveness of Community Singing on
Mental Health-related Quality of Life of Older People:
Randomised controlled trial. The British Journal of Psychiatry,
207 (3), pp. 250–55.
821. Livesey, L., Morrison, I., Clift, S. & Camic, P. M. (2012). Perceived
Benefits of Choral Singing on Health: A comparison of singers
with high and low psychological wellbeing. Journal of Public
Mental Health, 11 (1), pp. 10–12.
822. Clift, S. & Hancox, G. (2010). The Significance of Choral Singing
for Sustaining Psychological Wellbeing: Findings from a surveyof choristers in England, Australia and Germany. Music
Performance Research, 3 (1), pp. 79–96.
823. Northern Ireland Executive. (2015). Active Ageing Strategy
2016–2021. Belfast: Northern Ireland Executive.
824. HM Government. 2009. Building a Society for All Ages. London:
HM Government.
825. Kent, M. & Li, R. (2013). The Arts and Aging: Building the Science.
Washington DC: National Endowment for the Arts, p. 1.
826. See Baker, D. (Ed.). (2016). Ageing in Public: Creative practice inageing and the public realm from across the UK. London: Cubitt,
which includes details of Live Your Questions Now, an exhibitionby older artists curated by Jenny Brownrigg at Glasgow Schoolof Art.
827. Cohen, G. D., Perlstein, S., Chapline, J., Kelly, J., Firth, K. M., et al.
(2006). The Impact of Professional Conducted Cultural
Programs on the Physical Health, Mental Health and Social
Functioning of Older Adults. The Gerontologist, 46 (6), pp. 726–34.
828. Cohen, G. (2009). New Theories and Research Findings on the
Positive Influence of Music and Art on Health with Ageing. Arts
& Health, 1 (1), pp. 48–63.
829. Mental Health Foundation. (n.d.). How to Look After Your Mental
Health in Later Life. London: Mental Health Foundation. For an
overview of ways in which ‘active engagement in music-making
has been found to support cognitive, social, and emotional
wellbeing in older age’, see Creech, A., Hallam, S., McQueen, H. &Varvarigou, M. (2014). Active Ageing with Music: Supporting wellbeing in the Third and Fourth Ages. London: IOE Press.
830. National Institute for Health and Care Excellence (NICE). (2015).
Older People: Independence and Mental Wellbeing. London: NICE.
831. Long Live Arts Manifesto – Feel the Arts: www.longlivearts.eu
832. A Glossary of Terms for Community Healthcare and Services forOlder Persons, op. cit., p. 48.

833. Green, M., Iparraguirre, J., Davidson, S., Rossall, P. & Zaidi, A.
(2017). A Summary of Age UK’s Index of Wellbeing in Later Life.
London: Age UK.
834. White-Schwoch, T., Woodruff Carr, K., Anderson, S., Strait, D. L.
& Kraus, N. (2013). Older Adults Benefit from Music Training
Early in Life: Biological evidence for long-term training-driven
plasticity. The Journal of Neuroscience, 3 (45), pp. 17667–74.
835. A nderson, S., White-Schwoch, T., Choi, H. J. & Kraus, N. (2014).
Partial Maintenance of Auditory-based Cognitive Training
Benefits in Older Adults. Neuropsychologia, 62, pp. 286–96.
836. Daykin, N., Julier, G., Tomlinson, A., Meads, C., Mansfield, L., etal. (2016). Music, Singing and Wellbeing in Healthy Adults.
London: What Works Centre for Wellbeing, pp. 4–5.
837. A Choir in Every Care Home: www.artshealthandwellbeing.org.
uk838. Clift, S., Gilbert, R. & Vella-Burrows, T. (2016). A Choir in Every
Care Home: A review of research on the value of singing for older
people. London: The Baring Foundation, p. 5.
839. To find out more about this project and access the toolkits it has
generated for musicians and care home providers, visit:
achoirineverycarehome.wordpress.com
840. Organ, K. (2016). A New Form of Theatre: Older people’s involvementin theatre and drama. London: The Baring Foundation.
841. Cutler, D. (2009). Ageing Artfully: Older people and professional
participatory arts in the UK. London: The Baring Foundation.
842. Cutler, D. (2013). Local Authorities + Older People + Arts = A
Creative Combination. London: The Baring Foundation.
843. Local Government Association. (2015). Ageing: The silver lining– The opportunities and challenges of an ageing society for local
government. London: Local Government Association.
844. The Centre for Policy on Ageing. (2011). Keep Dancing: The healthand well-being benefits of dance for older people. London: BUPA;
and Connolly, M. K. & Redding, E. (2010). Dancing Towards
Well-being in the Third Age: Literature Review on the impact ofdance on health and well-being among older people. London:
Trinity Laban Conservatoire of Music and Dance. See Dance forLifelong Wellbeing at the Royal Academy of Dance.
845. Winter, T. (2015). Grand Gestures: A Somatic Ethnography.
Project Report. Sunderland: University of Sunderland, p. 28.
846. Examples include classes offered by Green Candle Dance
Company in London; Dance Base in Edinburgh; Dance Houseand Still Dancing in Glasgow; Generation Dance in Livingston;
and weekly workshops supported by Arts Care at four locationsin Northern Ireland.
847. Age UK. (2016). Later Life in the United Kingdom. London: Age UK.
848. Age UK. (2013). Falls Prevention Exercise: Following the evidence.
London: Age UK.
849. Kattenstroth, J-C., Kalisch, T., Holt, S., Tegenthoff, M. & Dinse,
H. R. (2013). Six Months of Dance Intervention Enhances
Postural Sensorimotor and Cognitive Performance in Elderly
without Affecting Cardio-respiratory Functions. Frontiers inAging Neuroscience, 5 (5).
850. Dance to Health: dancetohealth.org
851. Age UK dance classes: www.ageuk.org.uk
852. See also People Dancing at www.communitydance.org.uk
853. Age UK collaborated with the LGA and the Campaign to End
Loneliness to produce Local Government Association. (2016).
Combating Loneliness: a guide for local authorities. London: Age UK.
854. The Health Gap, op. cit.
855. A research paper will be published in the autumn of 2017.
856. Ageing Artfully, op. cit.
857. Ow Bist: qube.onlinetoolbox.co.uk/projects/ow-bist/. In asimilar vein, Gwynedd Council is funding Memories ThroughMusic, an intergenerational community project designed toalleviate isolation in older people.
858. Cutler, D. (2012). Tackling Loneliness in Older Age – The Role of theArts. London: The Baring Foundation.
859. Lynch, U. & Alexander, J. (2016). ‘Not So Cut Off’: Case study
evidence to illustrate the impact of the Arts and Older People’s
Programme in alleviating isolation and loneliness. Belfast: Arts
Council Northern Ireland.
860. Jo Cox Commission on Loneliness: www.jocoxloneliness.org
861. Windle, K., George, T., Porter, R., McKay, S., Culliney, M., et al.
(2016). ‘Staying Well in Calderdale’ Programme Evaluation: Finalreport. Lincoln, University of Lincoln.
185All-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Report862. Chatterjee, H. J. & Thomson, L. (2015). Museums and Social
Prescribing. In H. L. Robertson (Ed.). The Caring Museum: Newmodels of engagement with ageing. Edinburgh and Boston:MuseumsEtc, pp. 304–41.
863. A ssessing Well-being Outcomes for Arts and Heritage Activities,
op. cit.
864. Chatterjee, H., Vreeland, S. & Noble, G. (2009). Museopathy:
Exploring the healing potential of handling museum objects.
Museum and Society, 7 (3), pp. 164–77.
865. For a guide on overcoming this trend, see The Whitworth. (n.d.).
A Handbook for Cultural Engagement with Older Men.
Manchester: The Whitworth.
866. Harper, S. & Hamblin, K. (2010). ‘This is Living’ Good Times: Art
for Older People at Dulwich Picture Gallery. London: Dulwich
Picture Gallery.
867. Health Education England. (2016). More than Heritage: A
museum directory of social prescribing and wellbeing activity innorth west England. Manchester: Health Education England.
868. For a discussion on how this might be achieved, see Entelechy
Arts. (2014). Older People, Isolation and Civic Engagement:
Symposium report. London: Entelechy Arts.
869. Changes in the Older Resident Care Home Population between
2001 and 2011, Office for National Statistics.
870. Care Home Census 2012, Statistics on Adult Residents in Care
Homes in Scotland.
871. Who Cares? Social Care Provision in Northern Ireland.
872. How to Look After Your Mental Health in Later Life, op. cit.
873. The Five Year Forward View for Mental Health, op. cit.
874. Moore, S. L. (1997). A Phenomenological Study of Meaning in Lifein Suicidal Older Adults. Archives of Psychiatric Nursing, XI (1),pp. 29–36.
875. Confident Communities, Brighter Futures, op. cit.
876. Demos. (2014). Commission on Residential Care: Final report.
London: Demos, p. 10.
877. National Institute for Health and Care Excellence (NICE). (2013).
Mental Wellbeing of Older People in Care Homes. London: NICE, p. 17.
878. See, for example, Daykin, N., Julier, G., Tomlinson, A., Meads, C.,
Mansfield, L., et al. (2016). Music, Singing and Wellbeing in
Healthy Adults. London: What Works Centre for Wellbeing; andDaykin, N., Julier, G., Tomlinson, A., Meads, C., Mansfield, L., etal. (2016). Music, Singing and Wellbeing for Adults with Diagnosed
Conditions. London: What Works Centre for Wellbeing.
879. Living Well through Activity in Care Homes toolkit:
www.cot.co.uk
880. The Baring Foundation. (2011). Creative Homes: How the arts cancontribute to quality of life in residential care. London: The
Baring Foundation.
881. Out of the Frame: www.wallacecollection.org
882. cARTrefu: www.artshealthandwellbeing.org.uk
883. Magic Me: magicme.co.uk
884. Magic Me artist residencies: www.artshealthandwellbeing.org.
uk885. The first year of activity has been written up as Langford, S.
(2016). Magic Me’s Artists’ Residencies in Care Homes
Programme: Learning from phase one, April 2015–March 2016.
London: Magic Me.
886. Thwaite, A. (14 June 2017) The Arts in Later Life. Retrieved fromlahf.wordpress.com/2017/06/14/the-arts-and-later-life/. See
also Thwaite, A. (2017). Growing the Creative Ageing Movement:International lessons for the UK. London: The Baring
Foundation.
887. Care Quality Commission. (2016). Shaping the Future CQC’s
Strategy for 2016 to 2021. Newcastle upon Tyne: Care Quality
Commission.
888. Sutcliffe, A. (2016). The Art of Being Outstanding. London: Care
Quality Commission.
889. Figures taken from Alzheimer’s Society. (2014). Dementia UK:
Update. London: Alzheimer’s Society. Of those people diagnosed
with dementia, 84 percent live in England, eight percent in Scotland,
five percent in Wales and two percent in Northern Ireland.
890. Scarmeas, N. & Stern, Y. (2004). Cognitive Reserve: Implications
for diagnosis and prevention of Alzheimer’s Disease. Current
Neurological and Neuroscience Reports, 4 (5), pp. 374–80.

186

891. S ee Daly, S. & Allen, J. (2016). Inequalities in Mental Health,Cognitive Impairment and Dementia Among Older People.
London: Institute of Health Equity; and National Dementia
Intelligence Network & National End of Life Care Intelligence
Network. (2016). Dying with Dementia. London: Public Health
England.
892. Five Year Forward View, op. cit.
893. Ibid, p. 15.
894. National Institute for Health and Care Excellence (NICE). (2013).
Dementia: Independence and Wellbeing. London: NICE, p. 13.
895. Cowl, A. L. & Gaugler, J. E. (2014). Efficacy of Creative Arts
Therapy in Treatment of Alzheimer’s Disease and Dementia:
A systematic literature review. Activities, Adaptation & Aging,
38 (4), pp. 281–330.
896. Created Out of Mind: www.createdoutofmind.org
897. For an analysis of dementia journeys, see Prince, M., Prina, M. &Guerchet, M. (2013). World Alzheimer Report 2013 Journey ofCaring: An analysis of long-term care for dementia. London:
Alzheimer’s Disease International.
898. Franklin Gould, V. (2015). Music Reawakening: Musicianship andaccess for early to mid stage dementia – the way forward.
London: Arts 4 Dementia, p. 1.
899. Westminster Arts: www.westminsterarts.org.uk
900. Department of Health. (2015). Prime Minister’s Challenge on
Dementia 2020. London: DH, citing Knapp, M., Comas-Herrera,
A., Wittenberg, R., Hu, B., King, D., et al. (2014). Scenarios of
Dementia Care: What are the impacts on cost and quality of life?
901. Figures provided by Alzheimer’s Society.
902. Partial Maintenance of Auditory-based Cognitive Training
Benefits in Older Adults, op. cit.
903. Korte, M., et al. (2013). Learning to Perform in Older Adulthood:
Implications for physical and mental wellbeing. London: Royal
College of Music, paper to the International Symposium on
Performance Science in Vienna, reprinted in The Author.
904. Verghese, J., Lipton, R. B., Katz, M. J., Hall, C. B., Derby, C. A., etal. (2003). Leisure Activities and the Risk of Dementia in the
Elderly. The New England Journal of Medicine, 348, pp. 2508–16.
905. Wang, H.-X., Karp, A., Winblad, B. & Fratiglioni, L. (2002).
Late-life Engagement in Social and Leisure Activities is
Associated with a Decreased Risk of Dementia: A longitudinal
study from the Kungsholmen Project. American Journal of
Epidemiology, 155 (12), pp. 1081–87.
906. Older People and Dementia Team. (2012). Prime Minister’s
Challenge on Dementia: Delivering major improvements indementia care and research by 2015. London: DH.
907. National Collaborating Centre for Mental Health. (2007).
Dementia: The NICE-SCIE guideline on supporting people withdementia and their carers in health and social care. Leicester andLondon: The British Psychological and The Royal College of
Psychiatrists, pp. 25–26.
908. Bolwerk, A., Mack-Andrick, J., Lang, F. R., Dörfler, A. &Maihöfner, C. (2014). How Art Changes Your Brain: Differential
effects ofvisual art production and cognitive art evaluation on
functional brain connectivity. PlosONE, 9 (7). See also The Arts
and Aging, op. cit.
909. The Big Brain Maintenance Experiment: www.bbc.co.uk
910. Särkämö, T., Tervaniemi, M., Laitinen, S., Phil, L., Numminen,
A., et al. (2013). Cognitive, Emotional, and Social Benefits ofRegular Musical Activities in Early Dementia: A randomized
controlled study. The Gerontologist, 54 (4), pp. 634–50.
911. Young, R., Camic, P. & Tischler, V. (2016). The Impact ofCommunity-based Arts and Health Interventions on Cognitionin People with Dementia: A systematic literature review. Aging& Mental Health, 20 (4), p. 337.
912. Eekelaar, C., Camic, P. & Springham, N. (2012). Art Galleries,
Episodic Memory and Verbal Fluency in Dementia: An
exploratory study. Psychology of Aesthetics, Creativity, and theArts, 6 (3), pp. 262–72.
913. A detailed case study is provided in The UK’s Ageing Population,
op. cit.
914. Woods, R. T., Bruce, E., Edwards, R. T., Elvish, R., Hoare, Z., et al.
(2012). REMCARE: Reminiscence groups for people with dementia
and their family caregivers – effectiveness and cost-effectivenesspragmatic multicentre randomised trial, 16 (48). HealthTechnology Assessment.

915. A ge Exchange. (n.d.). RADIQL a Guide: Empowering people withdementia through Reminiscence Arts. London: Age Exchange;
Cole, L. & Keating, F. (2014). The RADIQL Study: Reminiscence
Arts & Dementia: Impact on Quality of Life; and Rolling out a
RADIQL model for Dementia Care. (2015).
916. Cole, L., Keating, F. & Grant, R. (2015). Reminiscence Arts &Dementia Care: Impact on Quality of Life, 2012–2015. London:
Royal Holloway University, p. 4.
917. Fujiwara, D. & Lawton, R. (2015). Evaluation of the Reminiscence
Arts and Dementia: Impact on Quality of Life (RADIQL)
programme in six care homes. London: Simetrica.
918. Swinnen, A. M. C. (2014). Healing Words: A study of poetry
interventions in dementia care. Dementia, 0 (0), p. 2.
919. The Participative Arts for People Living with a Dementia, op. cit.
920. Beard, R. L. (2011). Art Therapies and Dementia Care:
A systematic review. Dementia, 11 (5), p. 647.
921. Department of Health. (2009). Living Well with Dementia:
A national dementia strategy. London: DH.
922. See Rosenberg, F. (2009). The MoMA Alzheimer’s Project:
Programming and resources for making art accessible to people
with Alzheimer’s disease and their caregivers. Arts & Health, 1(1), pp. 93–97.
923. Mittelman, M. & Epstein, C. Evidence-based Evaluation of Meet
Me at MoMA. New York: MoMA.
924. Meet Me at the Museum: www.youtube.com
925. MacPherson, S., Bird, M., Anderson, K., Davis, T. & Blair, A.
(2009). An Art Gallery Access Programme for People with
Dementia: ‘You do it for the moment’. Aging & Mental Health,13 (5), pp. 744–52.
926. Camic, P., Tischler, V. & Pearman, C. H. (2014). Viewing and
Making Art Together: A multi-session art-gallery-based
intervention for people with dementia and their carers. Aging &Mental Health, 18 (2), pp. 161–68.
927. Department of Health. (2013). Dementia: A state of the nation
report on dementia care and support in England. London: DH.
928. Ridder, H. M., Stige, B., Gunnhild Qvale, L. & Gold, C. (2013).
Individual Music Therapy for Agitation in Dementia: An
exploratory randomized controlled trial. Aging & Mental Health,17 (6), pp. 667–78.
929. Dementia: The NICE-SCIE guideline, op. cit., p. 29.
930. Manchester Camerata: www.manchestercamerata.co.uk
931. See, for example, Vasionyt, I. & Madison, G. (2013). MusicIntervention for Patients with Dementia: A meta-analysis.
Journal of Clinical Nursing, 22 (9-10), pp. 1203–16; and Raglio, A.,
Bellelli, G., Mazzola, P., Bellandi, D., Giovagnoli, A. R., et al.
(2013). Music, Music Therapy and Dementia: A review ofliterature; and the recommendations of the Italian
Psychogeriatric Association. The Gerontologist, 54 (4), pp.
634–50.
932. Music Reawakening, op. cit.
933. Age UK on music and singing for dementia: www.ageuk.org.uk
934. Victor, C., Daykin, N., Mansfield, L., Payne, A., Grigsby Duffy, L.,et al. (2016). Music, Singing and Wellbeing for Adults Living with
Dementia. London: What Works Centre for Wellbeing.
935. Daykin, N., Walters, D., Ball, K., Henry, A., Parry, B., et al. (2016).
Arts and Dementia – Using Participatory Music Making to
Improve Acute Dementia Care in Hospital Environments: An
exploratory study. Winchester: University of Winchester.
936. See Banerjee, S. (2009). The Use of Antipsychotic Medication forPeople with Dementia: Time for action. London: DH and HM
Government.
937. McDermott, O., Orrell, M. & Ridder, H. M. (2014). The Importanceof Music for People with Dementia: The perspectives of people
with dementia, family carers, staff and music therapists. Aging& Mental Health, 18 (6), p. 706.
938. See, for example, Playlist for Life: www.playlistforlife.org.uk
939. Music for Life: www.artshealthandwellbeing.org.uk
940. A Choir in Every Care Home, op. cit., p. 5.
941. K leber, B., Veit, R., Birbaumer, N., Gruzelier, J. & Lotze, M. (2010).
The Brain of Opera Singers: Experience-dependent changes infunctional activation. Cerebral Cortex, 20, pp. 1144–52.

942. See Unadkat, S., Camic, P. M. & Vella-Burrows, T. (2016).
Understanding the Experience of Group Singing for Couples
Where One Partner Has a Diagnosis of Dementia. The
Gerontologist; and Camic, P. C., Williams, C. M. & Meeten, F.
(2011). Does a ‘Singing Together Group’ Improve the Quality ofLife of People with Dementia and Their Carers? A pilot
evaluation study. Dementia, 12 (2), pp. 157– 76.
943. Montgomery-Smith, C. (2006). Musical Exercises for the Mind.
Journal of Dementia Care, pp. 10–11; and Bannan, N. &Montgomery-Smith, C. (2008). ‘Singing for the Brain’:
Reflections on the human capacity for music arising from a pilot
study of group singing with Alzheimer’s patients. The Journal of
the Royal Society for the Promotion of Health, 128 (2), pp. 73–78.
944. Singing for the Brain: www.youtube.com
945. R adio 4 documentary: www.bbc.co.uk
946. To watch this film, visit: vimeo.com/videobiker/
review/190929340/ae2af31b3d
947. Karkou, V. & Meekums, B. (2017). Dance Movement Therapy for
Dementia. Cochrane Database of Systematic Reviews.
948. Guzmán-García, A., Hughes, J., James, I. & Rochester, L. (2013).
Dancing as a Psychosocial Intervention in Care Homes: A
systematic review of the literature. International Journal of
Geriatric Psychiatry, 28 (9), pp. 914–28.
949. South West Yorkshire Partnership NHS Trust dance fordementia: www.southwestyorkshire.nhs.uk
950. Remember to Dance: www.youtube.com
951. Vella-Burrows, T. & Wilson, L. (2016). Remember to Dance:
Evaluating the impact of dance activities for people in different
stages of dementia. Canterbury: Sidney De Haan ResearchCentre for Arts and Health; and Walmsley, B. D. & McCormack,
L. (2014). The Dance of Communication: Retaining Family
Membership despite Severe Non-Speech Dementia. Dementia,
13 (5), pp. 626–41.
952. See Halpern, A. R., Ly, J., Elkin-Frankston, S. & O’Connor, M. G.
(2008). ‘I Know What I Like’: Stability of Aesthetic Preference in
Alzheimer’s Disease. Brain and Cognition, 66, pp. 65–72;
Graham, D. J., Stockinger, S. & Leder, H. (2013). An Island of
Stability: Art images and natural scenes – but not natural faces– show consistent esthetic response in Alzheimer’s-relateddementia. Frontiers in Psychology, 4 (107), pp. 1–8; and Halpern,
A. R. & O’Connor, M. G. (2013). Stability of Art Preference in
Frontotemporal Dementia. Psychology of Aesthetics, Creativity
and the Arts, 7 (1), pp. 95–99.
953. See Eekelaar, C., Camic, P.M. & Springham, N. (2012). Art
Galleries, Episodic Memory and Verbal Fluency in Dementia: An
exploratory study. Psychology of Aesthetics, Creativity and theArts, 6 (3), pp. 262–72; and Young, R., Tischler, V., Hulbert, S. &Camic, P. M. (2015). The Impact of Art-viewing and Art-making
on Verbal Fluency and Memory in People with Dementia.
Psychology of Aesthetics, Creativity and the Arts, 9, pp. 368–75.
954. Camic, P. M., Tischler, V. & Pearman, C. (2014). Viewing and
Making Art Together: An eight-week gallery-based intervention
for people with dementia and their caregivers. Aging & Mental
Health, 18 (2), pp. 161–68.
955. Selected drawings and a short video can be viewed at:www.drawinglife.org
956. Beaney Art Viewing and Object Handling:www.artshealthandwellbeing.org.uk
957. Johnson, J., Culverwell, A., Hulbert, S., Robertson, M. & Camic,
P.M. (2015). Museum Activities in Dementia Care: Using visual
analogue scales to measure subjective wellbeing. Dementia, 0 (0).
958. Camic, P. M., Hulbert, S. & Kimmel, J. (2017). Museum Object
Handling: A health promoting community-based activity toenhance subjective wellbeing in dementia. Journal of Health
Psychology, p. 1.
959. Dementia and Imagination: dementiaandimagination.org.uk
960. A rts for Health: www.artsforhealth.org
961. R andall, J. (2012). Digital Arts and Older People: What is
distinctive about working with older people using creativetechnology? London: The Baring Foundation.
962. R andall, J. (2015). Technically Older: An update on digital arts andcreative ageing. London: The Baring Foundation.

187

All-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Report

963. Bosco, A. & Schneider, J. (2016). The Social Value of the Arts forCare Home Residents in England: A Social Return on Investment(SROI) analysis of the Imagine study. Nottingham: University of
Nottingham.
964. Local Government Association. (2016). Transforming Social Care
Through the Use of Information and Technology. London: Local
Government Association.
965. Chapter dementia-friendly screenings: www.chapter.org
966. BFI Dementia Services Development Centre: www.bfi.org.uk
967. The Elderflowers: www.heartsminds.org.uk
968. Bernard, M., Rickett, M., Amigoni, D., Munro, L., Murray, M., etal. (2015). Ages and Stages : The place of theatre in the lives ofolder people. Ageing and Society, 35 (6), pp. 1119–45.
969. West Yorkshire Playhouse. (2016). Dementia Friendly
Performances. Leeds: West Yorkshire Playhouse.
970. Schneider, J. (2016). Evaluation of the Impact on Audiencesof Inside Out of Mind, Research-based Theatre for Dementia
Carers. Arts & Health.
971. Jennings, L. (Ed.). (2014). Welcome to Our World: A collection oflife writing by people living with dementia. Canterbury:
Forget-Me-Nots.
972. Fritsch, T., Kwak, J., Grant, S., Lang, J., Montgomery, R. R., et al.
(2009). Impact of TimeSlips, a Creative Expression Intervention
Program, on Nursing Home Residents With Dementia and their
Caregivers. The Gerontologist, 49 (1), pp. 117–27.
973. Storybox Project: www.artshealthandwellbeing.org.uk
974. Harries, B., Keady, J. & Swarbrick, C. (2013). The Storybox Project:Examining the role of a theatre and arts-based intervention forpeople with dementia. Manchester: University of Manchester.
975. Healing Words, op. cit.
976. The Participative Arts for People Living with a Dementia, op.
cit., p. 16.
977. Elliott, J., Morison, S. & Grant, D. (2010). ‘Forever Growing:
Creative Ageing’: A practical exploration of the arts in thehealthcare of older people. Belfast: Queen’s University.
978. Thompson, R. & Heath, H. (2013). Dementia: Commitment to thecare of people with dementia in hospital settings. London: Royal
College of Nursing.
979. Waller, S., Masterson, A. & Finn, H. (2013). Developing
Supportive Design for People with Dementia. London: The King’s
Fund.
980. Virtual Care Home: dementia.stir.ac.uk/design/virtualenvironments/virtual-care-home
981. Department of Health. (2015). Dementia-friendly Health and Social
Care Environments (General design guidance for healthcarebuildings: Health Building Note 08–02). London: DH, p. 44.
982. See Wray, F. (2016). Creating Moments and Memories for People
with Dementia at www.imperial.nhs.uk.
983. A rts 4 Dementia: www.arts4dementia.org.uk
984. Creative Dementia Arts Network: www.creativedementia.org
985. Department of Health. (2008). End of Life Care Strategy:
Promoting high quality care for all adults at the end of life.
London: DH.
986. Heath, I. Memento Mori: Death and care at the end of life:
www.artshealthandwellbeing.org.uk
987. A rts for Health Manifesto Part One: www.artsforhealth.org
988. Hartley, N. The Palliative Care Community – Using the Arts in
Different Settings. In N. Hartley & M. Payne (Eds.). (2008). The
Creative Arts in Palliative Care. London: Jessica Kingsley
Publishers, p. 43.
989. Lidzey, A. (2008). Visual Art in Cancer Care and Palliative Care:
The power of personal imagery and visualisation within art
therapy. In Dying, Bereavement and the Healing Arts, op. cit.
990. Huet, V. (2016). Case Study of an Art Therapy-based Group forWork-related Stress with Hospice Staff. International Journal of
Art Therapy.
991. Horne‐Thompson, A. & Grocke, D. (2008). The Effect of Music
Therapy on Anxiety in Patients Who Are Terminally Ill. Journalof Palliative Medicine, 11 (4), pp. 582–90.

188

992. Wlodarczyk, N. (2007). The Effect of Music Therapy on the
Spirituality of Persons in an In-patient Hospice Unit as
Measured by Self-report. Journal of Music Therapy, 44 (2),pp.113–22; and Warth, M., Keßler, J., Hillecke, T. K. &Bardenheuer, H. J. (2015). Music Therapy in Palliative Care: A
randomized controlled trial to evaluate effects on relaxation.
Deutsches Ärzteblatt International, 112 (46), p. 788.
993. Mason, C. (2007). Healing Arts in Palliative Care. In Dying,
Bereavement and the Healing Arts, op. cit.
994. Dobbs, S. Art Therapy. In The Creative Arts in Palliative Care, op.
cit., pp. 128–39.
995. R awlence, C. John’s Song. In Jarrett, L. (Ed.). (2007). Creative
Engagement in Palliative Care: New perspectives on user
involvement. Oxon: Radcliffe, p. 10.
996. Macleman, M. Arts in Palliative Care: The Prince and Princess ofWales Hospice. In Ibid, p. 34.
997. The Creative Arts in Palliative Care, op. cit., p. 13.
998. Ibid, p. 16.
999. End of Life Care Strategy, op. cit.
1000.A rtroom: www.ghat-art.org.uk
1001. Waller, S., Dewar, S., Masterson, A. & Finn, H. (2008). Improving
Environments for Care at End of Life: Lessons from eight UK pilot
sites. London: The King’s Fund.
1002. National Dementia Intelligence Network and National End ofLife Care Intelligence Network. (2016). Dying with Dementia.
London: Public Health England.
1003. NHS Estates Design Brief Working Group. (2005). A Place to Die
with Dignity: Creating a supportive environment. London: NHS
Estates.
1004. Improving Environments for Care at End of Life, op. cit.
1005. Waller, S. & Finn, H. (2011). Improving the Patient Experience:
Environments for care at end of life. London: The King’s Fund.
1006. Cobb, M. & Legood, G. Spiritual and Artistic Care: Memorial
Services. In Dying, Bereavement and the Healing Arts , op. cit., p.
177.
1007. Ibid, p. 179.
1008. Ibid, p. 182.
1009. Darzi, A. (2008). High Quality Care For All: NHS next stage review
final report. Norwich: The Stationery Office.
1010. End of Life Care Strategy, op. cit.
1011. Improving the Patient Experience : Environments for care atend of life, op. cit.
1012. T ŷ Gobaith: www.youtube.com
1013. The Creative Arts in Palliative Care, op. cit.
1014. Creative Engagement in Palliative Care, op. cit., p. x.
1015. Hearth, V. Community Arts. In The Creative Arts in Palliative
Care, op. cit., p. 142.
1016. Ibid, p. 14.
1017. Jane Lings at the round table on the Arts and Palliative Care,
Dying and Bereavement.
1018. Bolton, G. In Dying, Bereavement and the Healing Arts, op. cit.,p. 18.
1019. Ibid, p. 16.
1020. Harmer, L. Pottery and Painting. In The Creative Arts in
Palliative Care, op. cit.
1021. Hartley, N. (2014). End of Life Care: A guide for therapists, artists
and arts therapists. London: Jessica Kingsley Publishers, p. 9.
1022. Creative Engagement in Palliative Care, op. cit., p. x.
1023. Rosetta Life: www.rosettalife.org
1024. Wood, M. J. (2015). The Contribution of Art Therapy to Palliative
Medicine. In N. Cherny, M. Fallon, S. Kaasa, R. K. Portenoy & D.
C. Currow (Eds.). Oxford Textbook of Palliative Medicine. Oxford:
Oxford University Press, p. 6.
1025. Ibid, p. 2.
1026. Ibid, p. 6.
1027. End of Life Care, op. cit., p. 69.
1028. The Creative Arts in Palliative Care, op. cit., p. 133.
1029. Creative Engagement in Palliative Care, op. cit., p. xi.
1030. Birrell, J., Corden, A., Macduff, C., Newsom, C., Petrie, D., et al.
(2013). Socio-economic Costs of Bereavement in Scotland: Mainstudy report. Aberdeen: Robert Gordon University.
1031. Dying, Bereavement and the Healing Arts, op. cit.
1032. Creative Engagement in Palliative Care, op. cit., p. 79.

1033. See Lambert, C. (2015). The Value of Live Art: Experience,
politics (Cultural Value Project report), which explores theimpact of a live arts and photographic project on a children’s
cancer ward.
1034. Surviving the Loss of Your World: slowgroup.co.uk
1035. Evaluation: annaledgard.com/wp-content/uploads/
REPORT25FEB20152.pdf
1036. End of Life Care Strategy, op. cit.
1037. Dying Matters: www.dyingmatters.org
1038. The Creative Arts in Palliative Care, op. cit., p. 13.
1039. St Christopher’s Hospice. (2008). The St Christopher’s School
Project: Creating healthier attitudes towards death and dying –A guidance and information pack. London: St Christopher’s
Hospice.
1040. Dying, Bereavement and the Healing Arts, op. cit., p. 51.
1041. K ing’s Fund GP survey: www.kingsfund.org.uk
1042. Middleton, J. (2010). Nurse Preparation for End of Life Care is
Sadly Lacking. Nursing Times.
1043. Royal College of Physicians and Marie Curie Cancer Care. (2014).
National Care of the Dying: Audit for Hospitals, England. London:
Royal College of Physicians and Marie Curie Cancer Care.
1044. See Living Well Dying Well: www.lwdwtraining.uk
1045. Access to Palliative Care Bill: services.parliament.uk/
bills/2015-16/accesstopalliativecare.html
1046. End of Life Care Strategy, op. cit., p. 9.
1047. NHS England. (2014). Actions for End of Life Care: 2014–16. Leeds:
NHS England.
1048. NHS End of Life Care Programme. (2006). Introductory Guide to
End of Life Care in Care Homes. London: DH.

189

“As we grow to appreciate the social
determinants and cultural contextsof health and wellbeing, it seems
self-evident that the arts, broadly
defined, will play an increasingly
important role, eliding the boundary
between the medical, social andcultural spheres. But, if we are tomobilise resource and effort
effectively, we need to move beyond
broad definitions and presumptionsof efficacy and take a robust, criticaland evidence-based approach to theinteraction between arts and health.
As an organisation that seeks to
improve health for everyone,
Wellcome is pleased to have beena supporter of the research which
has informed this review.”
Dr Simon Chaplin, Director ofCulture and Society, Wellcome“As a dancer, I enjoyed the physical“This is clearly a first class collation
benefits of artistic practice; later on, of evidence which provides powerfulworking in community settings, I
support for the importance of seeing
saw the psychological and social
as one the health and wellbeing of thebenefits that participation in arts
individual, and of the vital role theand cultural activities brings. I’marts can play in supporting bothvery proud that King’s has played athroughout our lives. The
role in this Inquiry, advancing thecontribution the arts can make inconversation about art’s potential to this regard has been recognised
contribute to health and wellbeing
since the time of Hippocrates but
throughout the various stages ofappears to have received less
our lives.”
prominence in recent times. It could
Deborah Bull, Assistant Principal, be argued that the huge advances inKing’s College London
medicine in the last century havebeen at the cost of our forgetting theneeds of our minds and bodies for the
stimulation and nutrition offered by
the creative arts. I would like to thinkthat this report might result in areversal of this trend.”
Sir Robert Francis QC“Having used artists to deliver care
“We know, through everyday
in GP surgeries for the last 17 years,
examples from across the country,
I strongly believe that healthcarethat the arts and creativity areprofessionals need to take account ofmaking an important contribution toan ever-growing range of evidence
helping people stay well for longer,
which supports the premise that artsand live a better quality of life. Theseand culture can seriously improve
approaches support both the NHS
and communities to meet the very real people’s health. Some of the
improvement in patients’ healthchallenges of improving population
has been astounding.”
health. I welcome this thoughtDr Simon Opher, GP Lead for
provoking report; it is a significant
Cultural Commissioning andmilestone in making the case for theSocial Prescribing,benefits of the arts in improving andsustaining good health and wellbeing.” Gloucestershire
Anu Singh, Director of Patient andPublic Participation and Insight,
NHS England“Our wellbeing is vital to our health,to our sense of who we are and to
our self worth and effectiveness.
The arts play a vital role in creating
and supporting feelings of wellbeing.
Exploring our creativity offers
myriad ways to connect, move,
give, learn and notice – the five
ways to wellbeing.”
Alice Wiseman, Director of
Public Health, Gateshead“At a time of immense emotional“The detail and breadth of Creative“This excellent report highlights
stress and pressure, the critical
Health does justice to the exciting
the important role that arts andanalysis skills that I had been
field of arts and health.
culture can play in the lives ofdeveloping making art and theUnderstanding the arts as ‘everyday people who receive care andthought of my work kept me going,
human creativity’, it shows how
support. Access to arts and culture
giving me the weapons to fight myworking with that can bringis vital to maintaining a sense ofsomething new across the life
identity, and it clearly improves
own demons. I have noticed overcourse. Engaging with arts andpeople’s quality of life. Care services time a marked increase in my own
health means engaging with artists
that have embraced the arts andability to rationally deal with thetrials and tribulations of day-to-day
who think differently, are moreculture as an essential part ofexistence and particularly in
ambitious, have high expectationsdelivering holistic support aremonitoring, regulating andof people. This report establishes ahighly regarded by people who use
adjusting my own behaviour
platform, and a challenge, to realise services and their families, andand my emotions.”
more of the enormous potential in
there are also many benefits to the
Jason Bell, Veteran, Veterans in
the contribution of the arts tostaff who work in care.”Practice, Foundation for Art anda different way of thinking about,
Professor Martin Green,
Creative Technology
Chief Executive Care England;
and acting on, wellbeing.”
Independent Dementia
Alan Higgins, Director of PublicChampion, Department of Health
Health, Oldham“Art allowed my soul and spirit to be “This is a fascinating report ofnurtured and fly as my physical and interest to all who are looking
mental being collapsed with cancer. for better ways of measuring
the success of policies.”
Art reminded me who I was before
Lord O’Donnell
cancer, a conversational lifeline tothe possibility of life post cancer.
Art manifested hope, beauty andultimately the sublime in thedarkest moments of treatment hell.”
Gilly Angell, Patient
Representative, Board,
University College Hospital“It has been heart-warming to hear
about many examples in our system
where, through involvement in thearts, people have been able todevelop their talents and live fuller
lives, taking more control of theirhealth and wellbeing. We believethat the arts and cultural sector
has a major part to play in thetransformation of health andcare in Gloucestershire.”
Mary Hutton, Accountable Officer,
NHS Gloucestershire ClinicalCommissioning Group and Leadfor Gloucestershire Sustainability
and Transformation PartnershipYou can download the full report here:
www.artshealthandwellbeing.org.uk
To contact the All-Party Parliamentary Group on
Arts, Health and Wellbeing, please email
Alexandra Coulter: coultera@parliament.uk
More information about our work can befound here:
www.artshealthandwellbeing.org.uk
You can view submissions to the Inquiry’s call forpractice examples here:
www.artshealthandwellbeing.org.uk

This is not an official publication of
the House of Commons or the Houseof Lords. It has not been approved byeither House or their committees.
All-party parliamentary groups are
informal groups of Members of bothHouses with a common interest in
particular issues. The views
expressed in this report are thoseof the group.
This work is licensed under theCreative Commons AttributionNonCommercial-NoDerivatives 4.0
International License. To view acopy of this license, visit
creativecommons.org or send a
letter to Creative Commons, PO Box
1866, Mountain View, CA 94042,
USA.
Designed by Steers McGillan Eves

The All-Party Parliamentary Group on Arts,
Health and Wellbeing has developed policy
briefings in collaboration with the Associationof Directors of Public Health, Local Government
Association, National Council for Voluntary
Organisations, Social Care Institute for
Excellence and What Works Centre for Wellbeing.
Arts Council England and Public Health Englandhave provided advice and have agreed to help with
their dissemination.
You can download the policy briefings here:
www.artshealthandwellbeing.org.uk