Ixia

ABOUT THE AUTHOR: Mike White is Director of Arts in Health at The Centre for Arts and Humanities in Health and Medicine (CAHHM) at Durham University. He has over 20 years’ experience of managing and researching arts projects addressing community health issues and has been awarded a fellowship of the National Endowment for Science, Technology and the Arts to research community-based arts in health and build national/international links in this field.

DATE: March 2011

INTRODUCTION: In recent years the arts in health field has acquired the expertise to address a wide spectrum of medical, health and social care issues.  It has the resilience and resourcefulness to weather the impending health service reforms in an era of austerity. But it will need to adapt conceptually and in delivery to healthcare environments in which patient choice, GP commissioning power and a new public health workforce are the drivers of change.

ARTICLE: A formative connection between public art and public health occurred for me in the mid-1990s.  At that time I was managing Gateshead Council’s commission of Antony Gormley’s Angel of the North whilst also developing arts in community health programmes with the support of the King’s Fund.  These projects got me thinking about the effect of public art on the pathology of the environment and about the ‘new public health’ movement’s assertion that health is ‘creative potential’ (Seedhouse 1980).  Could there, I wondered, be an alignment between the social determinants of health and bio-cultural imperatives to produce art? (White 2009).  It was working through how that question might be applied to arts in health practice that later drew me into the Centre for Medical Humanities at Durham University to contribute to its interdisciplinary enquiry into what makes for human flourishing (www.dur.ac.uk/cmh).

Flourishing seems a more dynamic concept than ‘well-being’ – it implies resilience and emergence, and it presumes inter-dependency; one cannot flourish at the expense of others. A key ally for arts in health in exploring flourishing is public health, and its associated discipline of epidemiology, the study of illness patterns within population, has become a prime source for delineating a social framework in which arts in health interventions could be developed and studied.  The Marmot review of health inequalities in the UK (Marmot 2010), which influenced the coalition government’s White Paper on public health (Dept. of Health 2010), asserts that a priority of future health policy should be to “create and develop healthy and sustainable places and communities”, noting that the determinants of health are “affected by the socio-political and cultural and social context in which they sit”.  What must not be forgotten, however, in the ‘market fundamentalism’ of the current austerity regime (Pullman 2011) is Marmot’s core argument that differences in population health status are due to economic inequalities.  There are no indications yet as to whether a promised ‘health premium’ for the poorest areas will include funding for cultural interventions to improve health through arts and recreation schemes.  Yet it is clear that the established evidence base for improving the quality of health services, combined with patient preferences and think-tank advocacy, all favour a role for arts in health and that it is fundamentally relevant even across different health care systems and cultures.  For example, the European Charter on Environment and Health (1989) declares that “good health and wellbeing require a clean and harmonious environment in which physical, psychological, social and aesthetic factors are all given their due importance”.

Closer to home, the Department of Health’s review of arts in health (2007) declared “arts and health initiatives are delivering real and measurable benefits across a wide range of priority areas for health” and that “there is a wealth of good practice and a substantial evidence base”. A recent British Medical Association report, ‘The psychological and social needs of patients’, (2011) looks at the evidence of effects of specific art forms and design features on improving health and wellbeing and it concludes that all healthcare organisations should:

• ensure that patient-centred care is applied in healthcare environments;
• put measures in place to ensure patients have the option to partake in both recreational and creative therapies;
• promote wellness by creating physical surroundings that are psychologically supportive.

This is a vital argument for retaining arts in health in healthcare facilities, but it now needs to work in tandem with the current re-configuration of public health and the emergence of GP consortia to deliver primary healthcare, especially if we are to prevent government just sidelining cultural interventions in health into the ‘Big Society’. With the key aims of the current NHS infrastructure changes set out in the health service White Paper (Dept. of Health 2010) being to shape services around the needs and choices of patients and to impress upon the new GP consortia that with their commissioning powers they have a duty of public involvement, it is time for arts in health to prove that it is not just an asset in environmental healthcare design but also a powerful communication tool in realising a participatory healthcare system, addressing the ‘fully engaged scenario’  preferred in both the Wanless report on long–term healthcare finance (2002) and the Darzi review of NHS reform (2008).

There could also be significant opportunity for research-guided arts in health through the impending transfer of the public health function into local authorities. Previously, the primary care trusts were so target driven that often arts practice within them would find itself so compartmentalised and instrumentalised to address health promotion priorities that there would be little breathing space to explore what makes for the effective public engagement of creativity with health. In local authorities, on the other hand, the attention and aims have been more broadly on quality of life and environment, overall healthy communities and public satisfaction with service provision. As the public health function now becomes embedded in local authorities, strategies to deliver on these aims must remain sensitive to local culture and circumstances or the inherent advantage of having local authorities as a commissioning nexus for services relevant to local population needs may be lost.   As the Marmot review asserts, effective health promotion to tackle inequalities is more than addressing topical health issues and priorities, but rather it is also about issues of identity, meaning and place – and these are essential factors in the development of public art, in expressing the ethos of healthy schools and workplaces, and in maintaining the kind of community morale that Bertholt Brecht described as “the greatest art of all; the art of living together” (Willett 1964).

The foundations of the ‘Big Society’ plan were, ironically, already being laid in the final term of the Labour government.  A framework that could practically assist public health’s work with communities was set out in the Department of Communities and Local Government White Paper (2006) which proposed arrangements for local authorities to lead on health and well-being issues in local communities. It aimed to shift the pattern of healthcare provision to prevention, with particular attention to complex issues of social exclusion. A follow-up White Paper on community empowerment (Dept. of Communities 2008) had an accompanying strategy for third sector commissioning which paved the way for the current culture shift in commissioning, providing opportunities for the voluntary sector to bid to run programmes and services.  What also needs to be factored in now is the Localism Bill (House of Commons 2011) with its provision for decision-making on local planning and environmental issues to be devolved directly into communities.

There are other, possibly overlooked, factors that need to be taken into account in the practice and research of arts in health in respect of sustainability:  namely, the resonance within the experience of an artwork, the aesthetic agency of participatory arts, and how arts development can harness the communal will.  In the public health arena there has been growing interest in Antonovsky’s theory of ‘salutogenesis’ (Lindstrom & Eriksson 2006), which identifies the origin of health in the human quest for coherence and a harmonious environment (Antonovsky 1979), and this could have application across the whole public art in health field. Furthermore, through sustained programmes of participatory arts, shared creativity can make committed expressions of public health, simultaneously identifying and addressing the local and specific health needs in a community. Importantly, this collective action still proceeds from the personal, facilitating engagement by individuals with their own health needs, but also creating commitment to a communal will for a shared experience.

To help give substance to a community empowerment strategy, public health services should work directly with communities in developing the ‘health assets model’ (Morgan & Ziglio 2007). This contends that historically health promotion has worked on a deficit model that is focused on the problems and needs of communities to be addressed through health resources. An asset model on the other hand looks at communities’ capability and capacity to identify problems and activate their own solutions, so building their autonomy and self-esteem. Some researchers have gone so far as to suggest that identifiable health assets in a community could include wisdom, creativity, talent and enthusiasm and that these reveal values-based potentiality. Tapping into this potential would require new training and re-orientation of existing social welfare and economic delivery and development systems so that “community cohesion may be a very significant value-based asset with cultural determinants” (Harrison et al 2004).

So which way now for arts in health?  Should it be primarily in supporting patient-centred care in locally-run healthcare facilities, in delivering arts-led social prescribing schemes via GP consortia, or in neighbourhood development working with public health services?  There will be a need to explore which models work best in what contexts, but what I think is becoming clear is that the practice of arts in health needs first to re-adjust conceptually and in delivery.

In arts in hospitals programmes it may be necessary to move from the well-established commissions-based model within a grand design to one that is led through unit-based artists’ residencies that respond to the patient choice agenda.  This will require a clearer articulation of what an artist, as opposed to an arts therapist, can contribute to the healthcare environment and patient recovery.  Arts input to communication technologies in healthcare, such as ‘virtual visiting’ or sensory environments, would provide utility within a cutting-edge aesthetic.

The changes planned for primary care are likely to see involvement of a much wider range of stakeholders than in a traditional health or social care model – including not just the voluntary sector but also the business community, and education, leisure and other community services.  Social prescribing schemes have become more widely adopted in primary care trusts and these may at least transfer into the GP consortia and ‘buy time’ to prove their worth for future joint commissioning with local government.  The coalition government’s early commitment to providing £400 million investment for greater access to talking therapies reveals the mental health burden within primary care and a willingness in the medical professions to look for better patient engagement through complementary interventions. As government seeks a shift to a social model of mental health care (Dept. of Health 2011), bolstered by devolved and personalised care budgets, strategies and interventions will have to be more broad-based, culturally focussed and meaningfully engaged with the patient/public’s preferences.  Elderly care too is accelerating the need for this kind of relationship-based working as tackling dementia becomes the eighth biggest item of expenditure in the developed world (Guardian 21/9/10).

Current research in arts and mental health is moving beyond single project studies that attempt to measure therapeutic impact to multi-site studies using combined methodologies in a ‘theory of change’ model to assess the social and environmental as well as clinical dimensions of benefit.    Evaluation here still needs to refine definitions of key concepts of social inclusion and empowerment, and resolve problems of reliable attribution of benefit to the effect of arts interventions.  But what is clear is that capacity building is becoming a central factor in the practice of arts in health, and so in respect of staff involvement it can be evaluated as a learning programme.  The quality of professional partnership is a crucial factor that is so far being under-examined in evaluation of arts in health.

The transfer of public health into local government is likely to demonstrate even more the development of health service delivery by hybrid professions and partnerships rather than by traditional specialists.  Workforce development is an important growth area for arts in health, exploring through the joint learning and collaboration of diverse but relevant professions how creativity can be applied to health promotion. It can be an effective incubator for arts in health commissions, residencies and longitudinal research in arts in community health.  In fact, workforce development has been a mainstay of the arts in health work of the Centre for Medical Humanities where I am based, and we find it increasingly shaping international partnerships for exchange of both practice and research.

BIBLIOGRAPHY

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