Arts on Prescription: A review of practice in the UK

Abstract

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

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Hilary Bungay and Stephen Clift
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Arts on Prescription: A review of practice in the UK
PAPER
Copyright © Royal Society for Public Health 2010 November 2010 Vol 130 No 6 l Perspectives in Public Health 277
SAGE Publications
ISSN 1757-9139 DOI: 10.1177/1757913910384050
Arts on Prescription: A review of
practice in the UK
Authors
Hilary Bungay
SRR, HDCR, MA, PhD,
PGCLT, Senior Research
Fellow, Sidney de Haan
Research Centre for Arts &
Health, Canterbury Christ
Church University, University
Centre Folkestone, Mill Bay,
Folkestone, CT20 1JG, UK
Tel: 01303 220870
Email: hilary.bungay@can-
terbury.ac.uk
Stephen Clift
BA (Hons) PhD, FRSPH,
Professor of Health
Education, Director of
Research, Sidney de Haan
Research Centre for Arts &
Health, Canterbury Christ
Church University,
Folkestone, UK
Corresponding author:
Hilary Bungay, as above
Key words
social prescribing; arts on
prescription; mental health;
evaluation
Abstract
The current levels of psychosocial distress in society are significant, as evidenced by the
number of prescribed antidepressants and the numbers of working days lost as a result of
stress and anxiety. There is a growing body of evidence that active involvement in creative
activities provides a wide range of benefits, including the promotion of well-being, quality of life,
health and social capital. In the UK there are currently a number of projects operating that offer
Arts on Prescription for people experiencing mental health problems and social isolation. The
purpose of such schemes is not to replace conventional therapies but rather to act as an
adjunct, helping people in their recovery through creativity and increasing social engagement.
Although the schemes are varied in their approaches and settings, the common theme is that
there is a referral process and creative activities take place in the community facilitated by
artists rather than therapists. This paper explores whether such schemes can be part of the
solution to the current challenge of mental ill-health, and looks at the evidence supporting the
value of such schemes which may influence government, funders and healthcare professionals
to implement Arts on Prescription more widely.
INTRODUCTION
Arts on Prescription (AoP) is a type of social
prescribing and operates in a similar manner to
that as Exercise on Prescription and Books on
Prescription. Essentially, in social prescribing there
is a referral process whereby health or social care
practitioners refer people to a service or a source
of support. Over the past decade the number of
AoP programmes has increased throughout the
UK. A distinctive feature of AoP is that rather than
a trained art therapist working with individuals or
small groups in an acute setting, AoP
programmes are facilitated by artists or musicians
and engage groups of people living in the
community. The first programme, AoP Stockport,
came into being in 1994 and offers a range of
creative activities to people with mild to moderate
depression with the aim of increasing their level of
mental well-being. Since then other schemes
have emerged throughout the UK (Box 1). Not all
programmes formally call themselves ‘Arts on
Prescription’ and there are a variety of
approaches, settings, and ‘Arts’ offered by the
different schemes, but generally the overarching
aim is to provide access to the arts, in the belief
that active participation in a creative activity can
promote health and well-being. This paper
discusses the development of AoP initiatives in
the context of the current challenges posed by
mental ill-health in the UK and the more generic
notion of ‘social prescribing’. It goes on to review
current initiatives and considers the challenge of
providing evidence for their effectiveness in the
light of proposed changes in the structure of the
NHS and future arrangements for the
commissioning of health services.
CHALLENGE OF MENTAL DISTRESS IN
THE UK
Interest in the potential role of the arts in
healthcare and health promotion in the UK is
Arts on Prescription Stockport
Good Times
Prescription for Art
Creative Alternatives
Arts on Prescription Nottingham
Arts on Prescription Devon
Arts on Prescription Pendle
Arts and Health Blackpool
Arts and Minds
Creative Health Lab
Start in Salford
Art for Well-Being
Box 1 Arts on Prescription projects
All these projects have websites and a simple Google
search will find them.

Arts on Prescription: A review of practice in the UK
278 Perspectives in Public Health l November 2010 Vol 130 No 6
PAPER
particularly focused on addressing the
considerable challenge of poor mental
health and well-being. Current levels of
psychosocial distress are significant as
evidenced by the number of prescribed
antidepressants and the numbers of
working days lost as a result of stress
and anxiety. It is reported that spending
on antidepressants in 2006 was more
that £291 million.1 The need to reduce
dependence on antidepressants has
been highlighted by the Mental Health
Foundation,2 with prescriptions for
antidepressants having increased by 95%
since 1998 (18.4 million to 35.9 million in
2008). Furthermore, it is estimated that
approximately 13.8 million working days
were lost in 2006/07 due to work-related
stress, depression and anxiety, and that
each case of work-related stress leads to
an average of 30.2 working days lost.3
Consequently, poor mental health has
major implications for policy not only due
to its economic costs but also the costs
associated with increasing pressure on
GPs and primary care practitioners, and
the social costs to individuals, their
families and their communities. It was
estimated in 2004 that mental health
problems cost the country £77 billion a
year through costs of care, economic
losses and premature death.4
PRESCRIBING SOCIAL ACTIVITIES
When an activity is ‘prescribed’ the
inference derived from medicine is that it
has the potential to benefit the health
and well-being of recipients. ‘Social
prescribing’ has been described as a
means of helping people experience
support from the community, through
promoting the use of community and
voluntary sector resources in primary
care.5 There are several other definitions
of social prescribing, each of which
suggests a different model of referral and
provision, for example, Friedli et al.6
define social prescribing as:
‘… a mechanism for linking patients in
primary care with non-medical
sources of support within the commu-
nity. These might include opportuni-
ties for arts and creativity, physical
activity, learning, volunteering, mutual
aid, befriending, and self-help, as well
as support with, for example, benefits,
debts, legal advice and parenting
problems.’ (p. 11; emphasis in
the original)
In this example, patients are linked to
sources of support through the provision
of information about what is available in
their local community. A form of such
social prescribing was featured in Our
Health, Our Care, Our Say,7 where
proposals were set out for introducing
‘well-being prescriptions’ for those with
long-term conditions, to provide specific
information on how to help manage a
health problem and to enable people to
access a wider provision of services.
These information prescriptions were
piloted in 2007/08 and are currently
being implemented throughout the NHS.8
The prescriptions may include
information on a condition and its
treatment, care services, benefits,
support groups, information for carers,
employment and training, and leisure.
A more precise model of social
prescribing has been put forward by
Brandling and House9 who define it as:
‘… a formal means of enabling pri-
mary care services to refer patients
with social, emotional or practical
needs to a range of local non-clinical
services and provides a framework for
developing alternative responses to
meet need.’ (p. 3)
From this it is understood that people are
referred to community services in the
same way that they may be referred to
any healthcare service or person, with a
letter or prescription form. Use of the
word ‘prescribing’ in this context has
been criticized because of its obvious
medical connotations and the link with
the biomedical model; in response, the
phrase ‘community referral’ has been
suggested as an alternative.6 However,
using ‘community referrals’ in this
context may not be appropriate because
the phrase is already used in relation to
referral to healthcare services based in
the community.
The significant difference between the
two models of social prescribing outlined
above is the procedure through which
people are given access to services.
Nevertheless, whichever model is
adopted, social prescribing is considered
to have three key benefits: improving
mental health outcomes for patients;
improving community well-being; and
reducing social exclusion.10 Such
benefits are a result of additional support,
whether through practical advice or
through activities, which is believed to be
beneficial to health and well-being.
POLICY CONTEXT FOR SOCIAL
PRESCRIBING
It has long been recognized that health is
influenced by a broad range of social,
economic and cultural factors, and
indeed the current political emphasis
appears to be on the wider community
and the sociocultural factors that may
impact on health and well-being. This is
a more holistic approach to care which
takes account of wider social factors
impacting on the individual and their
specific illness or condition. Mental health
problems, for example, are more
common in areas of deprivation, and
poor mental health is consistently
associated with unemployment, less
education, low income or material
standard of living.11 In the National
Service Framework Health Improvement
and Prevention: A Practical Aid to
Implementation in Primary Care, it was
recognized that to promote health and
well-being it is necessary to strengthen
social support and to bring resources
into deprived communities and improve
the community infrastructure.12 The
Healthy Communities Programme13 was
set up with the purpose of putting local
government at the forefront of improving
health and tackling inequalities in
partnership with the NHS, and was
followed by Our Vision for Primary Care
which set out a strategy based on four
keys areas, one of which is to promote
healthier lives. As part of this, it suggests
services need to evolve to reflect
changes in healthcare and society and
that patients require access to a greater
range of services in the local
community.14 This echoed the Local
Government Association approach
outlined in The Future of Mental Health:
A Vision for 2015, which acknowledged
that mentally healthy communities require

Arts on Prescription: A review of practice in the UK
November 2010 Vol 130 No 6 l Perspectives in Public Health 279
PAPER
initiatives that build confidence and
self-esteem, such as affordable access
to sport and leisure, cultural, artistic
and other activities.15, 16
More recently, New Horizons: A
Shared Vision for Mental Health aims to
improve the mental health and well-being
of the population, and to improve quality
and accessibility of services for people
with poor mental health.17 Suggested
interventions include such activities as
community arts projects, reading
initiatives, inner-city sports projects and
older people’s lunch clubs, which fit
within the Five Ways to Well-Being
Framework18 – therefore, mental well-
being is improved by connecting with
others, being active, taking notice of
one’s surroundings, continued learning
and giving to others.
With the well-known difficulties facing
the UK and world economies, and the
recent change in the British government,
interventions such as those suggested in
Our Vision for Primary Care and New
Horizons: A Shared Vision for Mental
Health, may receive a new impetus, as
the emphasis shifts to community and
voluntary engagement in social care, and
there is an ideological shift from the ‘Big
State’ to the ‘Big Society’. As yet it is too
early to be certain what will happen with
respect to mental health policy, but there
is a drive to transfer power away from
central government to local communities
in decision-making for public services
including healthcare. The white paper,
Equity and Excellence: Liberating the
NHS,19 proposes that the views of local
people will be taken into account in local
commissioning by local consortia of
general medical practitioners of health
and social care services. There is also a
focus on outcome measures and quality
standards, which will inform the
commissioning of all NHS care. Both
changes could have implications for the
development of social prescribing
schemes, including AoP, as will be
discussed below.
ARTS ON PRESCRIPTION:
EVIDENCE AND PRACTICE
There is a body of evidence that
supports the notion that active
involvement in creative activities can
provide a wide range of benefits,
including the promotion of well-being,
quality of life and health,20–24 increased
levels of empowerment, positive impacts
on mental health and social inclusion for
people with mental health difficulties.25
As such, arts and creativity contribute to
the ‘health’ not only of the individual but
also of the wider community.
While there is a body of available work
about the benefit and value of ‘arts in
health’ and ‘arts for health’, extensive
searches of databases such as Medline
and Cinahl found little published
empirical research that focuses
specifically on AoP. However, examples
of programmes were found through
contacts with key people, existing
networks and web searches. Much of
the available information found is ‘grey’
literature and consists of reports on
individual projects and discussion of
issues around implementation.26 A
number of AoP schemes have websites,
and some include reports that are free to
download (for example, Start in Salford:
http://www.startinsalford.org.uk; and
AoP Devon: http://www.petroc.ac.uk/
information/14/artsopresp/aop_home.
htm). Communications with AoP project
managers of schemes including those
listed in Box 1 found that outcome
measures such as HADS and the
Warwick-Edinburgh Mental Well-Being
Scale (WEMWBS) are being used to
assess the impact of interventions on
participants and qualitative accounts
from clients and facilitators are being
collated. These often provide striking
testimony of the power of creative
activities on well-being. The lack of
published peer-reviewed evaluations
may be due to the small sample sizes,
as a result of the necessarily small
cohorts of participants – typically 12
people per group. If schemes continue,
however, they will eventually accrue a
more substantive body of data.
Furthermore, many of the schemes start
as small-scale pilots to test feasibility and
do not have the resources to conduct
independent rigorous evaluations; others
are required to provide outputs imposed
by funding bodies which do not
adequately capture all the project
outcomes.27
Where empirical work does exist
(mostly using qualitative methods), the
findings are positive and researchers are
enthusiastic about the role of AoP and its
impact on health and well-being. For
example, the evaluation of AoP
Stockport found that participation in
creative activities raised self-esteem,
provided a sense of purpose, helped
people engage in social relationships and
friendships and enhanced social skills
and community integration.28 This
scheme also contributed to a major
national project on arts, mental health
and social inclusion undertaken by
Secker et al.29 on behalf of the
Department for Culture, Media and Sport
and the Department of Health. The study
undertook a survey of arts and mental
health projects in England to ascertain
the extent of participatory art work and
to explore the approaches to evaluation.
It also provides a retrospective analysis
of outcomes from two ongoing projects
(AoP Stockport and Time Being on the
Isle of Wight) and presents a series of
qualitative case studies. Overall, the
project found that arts participation
positively benefits people with mental
health problems, increasing levels of
empowerment and social inclusion.25
An evaluation of two arts for mental
health projects in Scotland utilized
in-depth interviews with artists to explore
whether people with enduring mental
health problems experience a sense of
belonging through participation in the
arts, and the perceived contribution of art
work to building social capital.30 A total of
40 interviews were conducted, 35 with
project artists who discussed how
participation in the arts provided stability
in their lives, enhanced their well-being
and contributed to their ability to relate to
and work with others. Within one of the
projects there was a strong sense of
collective artistic endeavour which
facilitated the building of social bonds
and friendships and thus social capital.
On the Isle of Wight, Time Being was
established as AoP by Healing Arts in
2002 until 2005. Time Being provided a
series of self-contained, 12-week
programmes of two-hour sessions in
different art forms (visual arts, music and
singing, creative writing, and dance and

Arts on Prescription: A review of practice in the UK
280 Perspectives in Public Health l November 2010 Vol 130 No 6
PAPER
movement). An extensive evaluation of
the project in the form of interviews,
focus groups and questionnaires
demonstrated the impact that creativity
had had in terms of improvement to
individual health and his/her appreciation
and understanding of their own health.31
However, although the findings from the
evaluation were very positive, the authors
reported that it was evident that the
primary care trust (PCT) required
quantified health gains, and detailed cost
benefit analysis on the role of arts in
healthcare before it would consider it as
part of mainstream health services. This
suggests that although qualitative
methodologies have become more
acceptable as a research paradigm in
healthcare, as evidenced by the
increasing number of papers using
qualitative methodologies published in
the British Medical Journal over the past
decade,32 for some commissioners there
remains an issue surrounding the nature
of the evidence provided by such
methodologies. Yet qualitative
methodologies are most appropriate to
capture the experiences of participants,
but it will take effort to convince funders
in the current economic and political
climate that the current research
evidence is valid and reliable.
CHALLENGES FACING ARTS ON
PRESCRIPTION SCHEMES
As with all innovations, implementing
AoP programmes is challenging. The
lack of a scientific evidence base can
mean that it is difficult to secure
resources and overcome institutional
barriers and professional isolation.33 This
is corroborated in reports from ongoing
programmes. Stickley and Duncan,34 for
example, reported that the successful
implementation of AoP initiatives
depends on the enthusiasm and interest
of the individual GP practice manager. An
evaluation of the Community Health
Advice Team in Bradford South and West
PCT concluded that the success of
social prescribing relies on the presence
of a link worker with a good knowledge
of the voluntary sector and of community
development principles and practice, and
a flourishing local voluntary and
community sector.5 It is also necessary to
increase the awareness of both patients
and health and social care practitioners
working in primary care of the potential of
non-medical resources and support.6
CONCLUSION
There is evidence to indicate that AoP
may contribute to recent government
policy objectives through building social
capital and community engagement, and
enhancing health and well-being. AoP as
a form of social prescribing could be
used as an adjunct to conventional
therapies in the treatment of mental ill
health and to promote social
engagement in the isolated. Participating
in the arts (where ‘arts’ encapsulates a
broad range of creative activities)
operates at two levels. First, at an
individual level people may experience
improved health and well-being; second,
at the community level participating
within a group promotes social
engagement and therefore inclusion.
There may be some critics who say that
any group activity, such as playing bingo
or watching a competitive event as part
of a crowd, could have the same impact.
There may be others who argue that in
the current economic climate, AoP will
incur costs to the NHS that are
unacceptable when new treatments for
those with terminal and/or debilitating
illnesses are not available or are restricted
because of funding cuts. All new drug
therapy is reviewed by National Institute
for Clinical Excellence, which
recommends whether or not it should be
made available. These recommendations
are based on a detailed review of the
research evidence, and as yet there is not
a sufficient body of evidence about AoP
to conduct such a review or support its
wide-scale implementation. However, the
evidence does indicate that participation
in creative activities with others promotes
well-being and social inclusion. The
mechanisms involved are as yet uncertain
but it is clear that creating something
tangible, whether it is music, a painting, a
dance or a community garden,
engenders a sense of achievement and
an opportunity to share with others. AoP
is not just about supporting recovery for
people with mental health problems; it is
also about prevention, helping socially
isolated people with mild to moderate
anxiety and depression, and the lonely, to
prevent them succumbing to more
serious illness with all its attendant social
and economic costs to the individuals
and our wider society.
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