Policy context
The NHS faces major challenges in meeting the needs of an ageing population and changing patterns of disease which mean that people are living with multiple long-term conditions (LTCs) for longer. It is estimated that £7 out of every £10 the NHS spends is on LTCs. The backlogs caused by Covid-19 have placed further pressure on the service. In order to meet these challenges, reform plans emphasise prevention, performance and personalisation.
The NHS comprehensive model of personalised care aims to support people across the life-course and their carers to manage their health and make informed decisions about their healthcare. This incorporates initiatives such as social prescribing, personal health budgets and supported self-management.
Personalised care is particularly relevant for people with long-term and complex mental or physical health conditions, and those who are traditionally underserved by NHS services, as it allows the person to identify how their needs can be best supported. Within this, supported self-management refers to the ways that health and care services can encourage and empower people to manage their own ongoing physical and mental health conditions.
How can Creative Health approaches help?
Creative health approaches can help to prevent the onset of LTCs through health promotion, and working at the level of the wider determinants of health to reduce risk factors. There is also good evidence that creative health contributes to the management and treatment of long-term and mental health conditions.
Activities such as listening to music or participating in singing groups can reduce stress and anxiety and improve wellbeing, helping people to cope with their illness. Group arts activities can facilitate expression of feelings and experience and provide support through connection with peers. In other examples, described below, creative health approaches help to alleviate symptoms of particular conditions.
Social Prescribing can be one route through which patients can be linked to creative health opportunities and has been shown to reduce healthcare appointments. The following examples demonstrate the evidence for the use of creative health in managing priority health conditions highlighted by the NHS Long Term Plan.
Key areas of focus
Cancer
Arts activities, including music and visual art making have been used in cancer treatments to relieve the side-effects of chemotherapy, reduce pain, and reduce anxiety, depression and stress. Creative activities such as painting, dance or writing can be used with both adults and children to facilitate emotional expression, reduce fear and enhance hope, helping people to cope with cancer and reflect on their experiences.
Artlift has partnered with Macmillan Cancer Support to co-produce a bespoke offer for adults living with and beyond cancer. Flourish includes courses of 8 – 12 sessions and individualised ‘Creative Check-ins’ with artists, as well as opportunities to share work and celebrate with family members. Participants have reported improved sleep and feelings of wellbeing, strengthened social connections, as well as positive impact on family members and, in some cases, end of life plans.
Move Dance Feel: A Dance Project for Women Living With or Beyond Cancer (2019) expressed feelings about cancer experience. Participants reported enhanced wellbeing related to positive emotions, connection, self-expression and accomplishment and demonstrated meaningful increases in self-reported ‘flourishing’. The programme had an impact on stress and anxiety and body image and reduced fatigue.
The Arts Officer at the Royal Marsden Cancer Centre explores ways of encouraging people living with cancer to communicate and improve their experience of their care by participating in art curating. The Arts and Health programme at the Clatterbridge Cancer Centre offers a range of creative activities and performances for patients and staff, as well as a collection of artwork to enhance the environment of its cancer centres.
Fresh Arts on Referral (2019) - Cancer, chronic pain and dementia sufferers were referred to a 6 week arts programme and found significant increases in wellbeing among cancer patients, who reported the programme provided a safe space to express emotions and make sense of their experiences.
Mental Health
The prevalence of mental health conditions is significant and increasing. It is estimated that 1 in 6 adults in England have a common mental health condition. Inequalities are evident in mental health outcomes, with more socially and economically disadvantaged people having a higher risk of mental health conditions, and accessing support later. There are also inequalities in vulnerable population groups.
IAPT (Improving Access to Psychological Therapies) has increased the number of people able to access talking therapies for anxiety and depression but many people still cannot or do not access services. The NHS Long Term Plan and mental health implementation plan set out priorities in mental health care, including additional funding.
Creative approaches can improve everyday wellbeing, either through individual engagement or by improving the environments in which people live. Arts activities have been shown to have positive benefits for management of emotions, stress, coping skills, confidence and self-esteem and contribute to prevention and management of depression and anxiety across a range of settings. The MARCH Network research programme provided extensive evidence for the benefits of the arts for mental health and how this can be made available more equitably.
Studies included in the WHO scoping review find that creative activities during childhood, adolescence or older age can prevent the development of anxiety and depression. There is evidence that listening to music, drawing or creative writing can remove stress, anxiety and depression associated with other health conditions. Group engagement in creative activities such as choirs or group drumming reduces symptoms of mental ill health and provides additional benefits though social connection.
A systematic review from What Works Centre for Wellbeing found evidence that visual arts activities can reduce depression and anxiety and increase confidence and self-esteem.
Many people found engagement in the arts to have a positive effect on their mental health during Covid-19 and that it reduced depression and anxiety. Arts activities are effective in reducing loneliness and during the pandemic programmes adapted to provide creative opportunities to those who were shielding or vulnerable. Many are collated here.
A project in Shropshire, Telford and Wrekin a project is using creative health as a central element to Personalised Care Planning to support Children and Young People seeking help in relation to their mental health from the BeeU service (CAMHS).
The March Network provides examples and case studies of best practice in using the arts to improve mental health.
Creatively Minded and the NHS produced by the Baring Foundation presents case studies of NHS organisations offering creative artist-led participatory arts programmes to people with mental health problems. Creatively Minded: The Directory also compiled by the Baring Foundation lists around 320 UK organisations working in arts and mental health.
Severe Mental Illness (SMI)
In England, around half a million people have a severe mental illness (SMI), such as schizophrenia or bipolar disorder. The number of suicides has also increased over the past decade. People with SMI face significant health inequalities and SMI is considered a clinical priority in the CORE20PLUS5 inequalities framework.
The mental health implementation plan aims to give people with SMI more personal choice over their care. The NHS Long Term Plan commits to developing new and integrated models of primary and community mental health care for adults with SMI, working with primary care networks and the VCSE as well as service users and families and carers.
Arts therapy is commonly used with people with severe mental illnesses such as schizophrenia and bipolar disorder, and is included in NICE Guidance for treatment of psychosis and schizophrenia in adults. The WHO Scoping Review collates studies which have demonstrated a range of positive effects. The design of mental health inpatient facilities has also been shown to have an effect on mental health and patient experience and behaviour.
There is also a role for participatory and community-based arts activities. A recent rapid realist review from the Baring Foundation, ‘Arts and Creativity for people with severe mental illness’ provides a summary of literature on creativity and SMI. Creative activities were found to allow people flexibility to express themselves, and to identify the outcomes that were important to them, but increased confidence, self-worth and wellbeing were common themes.
Hospital Rooms is an arts and mental health charity that commissions extraordinary artworks for NHS mental health inpatient units across the UK.
City of London Sinfonia – Sound Young Minds Creative activities using instruments and technology for young psychiatric patients.
Linking with a Mental Health Transformation process in Calderdale, a design group with lived experience has created replacement letters and info sheets about annual physical checks; the group commissioned an artist to produce 30-40 illustrations including illustrated envelopes so they aren’t as intimidating to open. They have also produced top tips for GPs and a brief for four short films with the overriding concept that everything should be ‘like a friend guiding me’.
Cardio Vascular Disease and Stroke
The NHS identifies CVD as the biggest single condition where lives can be saved over the next 10 years. For people already diagnosed with CVD, music has been shown to have been shown to have positive effects on heart-rate, blood pressure and hypertension. It can also reduce anxiety and pain in people with myocardial infarction (WHO). Dance, as a form of exercise can improve exercise capacity (WHO).
Music has also been shown to have positive effects on recovery from stroke, through improvement in neural pathways and memory, as well as reductions in depression and confusion (WHO). Participation in arts activities can have physical, cognitive, emotional and social benefits for stroke survivors. Research is ongoing into mechanisms through which singing may support the recovery of speech, but post-stroke singing groups can aid recovery through social interaction and increased confidence.
Strokestra is a stroke rehabilitation programme developed by the Royal Philharmonic Orchestra (RPO) in partnership with Hull and East Riding Community Stroke Services. The programme adapts musical techniques to support stroke survivors in their recovery. A programme guide provides details of planning, delivery and evaluation. The programme was successfully transferred online during 2020.
Stroke Odysseys is a post-stroke performance arts intervention, which can take place in hospital setting (neurorehabilitation wards) or in the community. Participants gain skills in movement, music and song and use these to contribute to a performance related to their own stroke stories. A handbook has been produced to with advice on establishing similar programmes.
Dance for Health is CUH Arts’ flagship project; weekly creative movement & music group sessions delivered on adult inpatient wards including stroke & neuro rehabilitation, diabetes & endocrinology and the department for medicine of the elderly. Patients are supported to move and interact with one another, helping to engage not just the body, but the mind and heart too.
Diabetes
Creative activities to help people, particularly children, to understand and express their feelings or anxieties about their illness. Creative activities such as dance and listening to music which can relieve stress and high blood pressure have also been shown to regulate blood glucose levels (WHO).
Art Shape, Artspace and The Music Works work together to devise programmes in to help young people self-manage long-term health conditions including epilepsy, diabetes, persistent pain, physical symptoms, respiratory, allergic conditions, chronic fatigue, cancer and ME. Programmes are co-developed in consultation with young people, their families and the NHS to maximise impact. A range of art activities have been offered, including a programme that used circus with young people with diabetes.
Aakash Odedra Company and Moving Together are working in partnership with Leicester Diabetes Research Centre to provide active dance classes with a Shiamak Bollywood dance instructor to encourage participants to engage in physical movement, learn about nutrition and on leading healthy lifestyles and whilst delivering opportunities to monitor progress on risk factors such as weight, BMI and heart disease.
Chronic Respiratory Disease
There is good evidence to support the use of singing to improve respiratory conditions such as COPD through improving lung function and capacity, and the ability to regulate breathing patterns (WHO). Similar benefits have been seen in asthma and more recently Long Covid. A number of Long Covid clinics are now using singing to help people to manage their breathing and reduce breathlessness.
rb&hArts Singing for Breathing programme has been running since 2007 supporting inpatients and outpatients with COPD and other chronic respiratory conditions. It led to the BLF-funded training programme for singing leaders to support lung health which led to a proliferation of expertise. It was the subject of two RCTs in 2010 and 2012 (Lord et al.) demonstrating significant impacts on self-perceived wellbeing.
Children and Young People’s Asthma Personalised Care Programme, Shropshire Telford and Wrekin. Embedding non-clinical approaches to support children and young people with a diagnosis of asthma through Personalised Care Planning with the aim of reducing A&E attendances for those presenting with an exacerbation of Asthma.
Long Covid Clinic, Suffolk and North East Essex. A 12-week pilot for patients of the Long Covid Assessment Clinic to artist led sessions of singing, creative writing, art, or movement to support general wellbeing, social isolation, and confidence to self-manage their symptoms.
Singing for Health Network The network provides resources for healthcare professionals, practitioners and researchers, including guides for social prescribing to singing groups.
Singing for Better Breathing – Findings from the Lambeth and Southwark Singing and COPD Project This evaluation of the establishment of a network of community singing groups across London for people with COPD showed a reduction in symptoms, as well as improvements in psychological outcomes and overall wellbeing.
Breathtaking Lungs VOCAL, a patient involvement charity associated with Manchester NHS Foundation Trust, used creative techniques to work with people with a range of respiratory conditions in a relatively deprived area of the city to open up discussion and discuss research priorities.
English National Opera – Breathe long Covid Programme Developed jointly by ENO and Imperial Collage Healthcare, this programme is specifically for people suffering with breathlessness and anxiety. People can be referred via a GP or long Covid clinic. It offers six weekly online sessions using singing techniques to control breathlessness. Pilot results showed over 90% of participants felt that their breathing and anxiety had improved as a result of the sessions.
Asthma + Lung UK Singing for Lung Health provides information about singing for lung health and singing group provision.
Maternity
Maternity services are a key clinical priority in the NHS Long-term plan, with particular concerns about the disparity in outcomes for pregnant women highlighted by the MBRACE reports. A maternity disparities taskforce has been established to explore inequalities in maternity care, and help meet the CORE20PLUS5 target of ensuring continuity of care for 75% of women from ethnic minority communities and the most deprived groups.
The WHO Scoping Review identifies a number of studies linking creative health to maternity. The arts can be used prior to birth to reduce anxiety and improve readiness for parenthood during childbirth (for example, listening to music to reduce anxiety and pain), in neonatal care (to alleviate stress in parents and children to reduce anxiety and mental health conditions such as postnatal depression in new mothers. Music has been shown to play an important role in mother-infant bonding.
Responding to a 30% increase in perinatal mental health referrals support those with post natal depression, Calderdale’s Lullaby Project provides new and expectant parents with the opportunity to lift their voices, connect with their children in a meaningful way, and share their experiences with a broader audience, raising awareness of their aspirations, creativity, and role in making a more equitable society for themselves and their children.
Music in Hospitals & Care award winning Lullaby Hour project offers babies, children and their parents or carers the chance to experience peaceful songs and melodies. Professional musicians create special moments and memories for families in hospital wards, neonatal units and hospices.
Manchester Museum's Muso Baby programme is a social prescribing programme for mums experiencing postnatal depression. It was designed to encourage an emotional connection between parent and child as well as offering parents the chance to develop peer relationships and support in a safe space.
Mothers Who Make Exeter offers a 6 week creative programme for people who are pregnant or had a baby during in the last 3 years using journaling to promote positive mental health and well-being in mother/parenthood.