Socially Prescribing the Arts – Will it happen? Will it work?

The media has been full of reports that doctors can now prescribe ‘the Arts’ for a range of physical and mental health conditions. In July 2017 an All-Party Parliamentary Group in the UK published a comprehensive report on the importance of the Arts for health and wellbeing. They concluded that it was ‘time to recognise the powerful contribution the Arts can make to health and wellbeing’.

Members of the Montreal-based Médecins Francophones du Canada are able to prescribe up to 50 museum visits at the Montreal Museum of Fine Arts to patients in recognition that a visit can boost mood and wellbeing. Men’s Sheds are popular in many countries. Creative writing, therapeutic knitting, reading groups, gardening and singing are recognised as effective ways of improving wellbeing.

This growing movement towards social prescribing goes beyond the Arts to include being in nature, exercise referral schemes, dance, cookery courses, gardening, even courses in money management and legal advice. Schemes in the Shetland Islands, off the North coast of the UK, and New Zealand involve ‘green prescriptions’ that encourage those living with a range of physical and mental health problems to become ‘immersed’ in nature – listening to the sounds and smells, building dens, walking in nature or engaging in the Japanese practice of ‘forest bathing’ or ‘Shinrin-Yoku’. Given that many people who attend GP appointments have issues that can’t be fixed with medication or medication alone, social prescribing has the prospect of offering a holistic approach with many potential avenues or solutions to living a more fulfilled life and improving wellbeing. Problems with no solution when using an approach based on medication alone, could now have many solutions to explore.

In the UK’s Somerset town of Frome the wellbeing of many of its residents has been transformed through social prescribing. Known as the Frome Model it is based on the idea of nurturing compassionate communities. Run by the Frome Medical Practice it is thought to have reduced emergency admissions to hospital by 30% over three years. This project aims to reconnect people to their own local support networks as well as to networks that support the basic activities of life, such as help with shopping, gardening, looking after pets or providing transport. In addition participants are linked to a range of community activities.

It seems like the need to address health and wellbeing from a whole person perspective is finally beginning to take hold. Our minds, brains and bodies do not function in isolation. The brain’s influence extends so far into our body that we can no longer view them as separate entities. It’s a case of mind, brain, body working as one, embedded in our environment and culture. Our ‘hardware’ – physical body – and our ‘software’ – the workings of our mind and the YOU that is YOU are intricately woven together with each other, as well as with our environment, culture and past.

We tend to know a lot more about our ‘hardware’ than about our ‘software’ and the issues that keep that ticking along healthily. The Arts have the capacity to fuel our souls, to nourish our ‘software’. Knowledge and appreciation of this is getting there slowly. A study commissioned by Aesop found that two-thirds (66%) of the 1,002 GPs surveyed believed that public engagement in the Arts can make a significant contribution towards preventing ill health, while 44% agreed that arts-based activities are a cost-effective way of delivering primary care to improve health outcomes. Arts-based activities are important for the health of clinicians too. In the same study 62% of the GPs surveyed thought art-based activities could make a significant contribution to improving the health and wellbeing of NHS staff.

The range of possibilities for social prescribing is huge. This makes the benefits experienced difficult to measure. A UK study, quoted on the Government website, found that 80% of people referred to schemes have a reduced number of A&E attendances, inpatient admissions and outpatient appointments. However a study based in Bristol found that the improvements in health and wellbeing from social prescriptions came at a higher cost than routine GP care over a year. The reality is almost certainly more complex. Wellbeing is complex. Measuring it is even more so. Activities involved are so diverse that comparison between schemes is really difficult. It’s likely that people also benefit in other ways, and over a longer period of time than a year. Science and evidence-based practice don’t tend to like things that are hard to accurately assess which may make access to funding and implementation more difficult.

What’s in it for me?

So where does this leave Joe Public?

The problem lies in the fact that the ‘Arts’ covers a mind-bogglingly wide variety of activities from painting, pottery and art therapy to playing music, concert and museum visits and walks in the park. Some involving physical exertion, others mental and creative stimulation, social contact or a combination of all.

So how does an over-burdened GP know what to prescribe to who? Indeed, do they have a choice? Or does it depend solely on what social prescribing schemes are available locally? These can be a rather haphazard collection of arts-based projects that have been lucky enough to get funding rather than a well-thought out plan based on the needs of potential participants?

A lot will depend on the personal preferences of the person needing help. However, to enjoy the full benefit, prescribers should also be thinking about introducing new, previously unexplored activities to individuals in order to expand their knowledge base and creative experience to nurture healthy brains. We should be asking ‘do certain medical conditions respond better to certain activities?’ and really starting to consider suitability for, and response to, arts-based activities in much the same way as we do when prescribing drugs and other treatments. After all every one of our emotions and feelings has a biological/chemical basis. We should be asking the questions, ‘What can this do for their biology?’ ‘Will there be any adverse effects to this particular activity?’ ‘Will this person benefit more from an individual approach or a group-based activity?’

The question of acceptance raises its head too. Without a comprehensive education programme for the general public to highlight the benefits of the Arts, ‘Mrs Smith’, who visits her GP with low back pain, is still likely to want pain-relieving medication. She might, at best, regard an art class as a ‘nice little add on’, and at worst be completely unimpressed and highly sceptical, even angry that she is being off loaded to what is often seen as the ‘cheaper option’.

I have been researching the therapeutic benefits of knitting since 2005 and a frequent comment in response to my telling people that we were using therapeutic knitting for the treatment of pain was, ‘Can’t the NHS afford to give us the drugs we need now?’ Prescribing the Arts and continued engagement with activities will struggle to work until people have an understanding and knowledge that it has a direct biological / chemical effect. Arts-based activities really can change our biology, our chemistry, our thinking, our behaviour, and ultimately provide a more sustainable and considerably safer means of improving wellbeing.

A framework for creativity?

Whilst researching the therapeutic benefits of knitting it became clear that those most in need require more direct instruction or a framework to follow. Simply saying ‘hobbies are good for you, think about taking one up’ doesn’t work because the choice of available hobbies is so huge. The learning process without onging support is often too daunting too. Sustained engagement is far more likely if frameworks are in place both for choosing appropriate activities and for guiding participants into how to get started on a chosen activity. It CAN work and I am a passionate believer in the power of arts-based activities. They have the potential to transform lives.

I have developed the idea of therapeutic knitting based on my research. It is different from knitting in that it enhances the benefits. Therapeutic knitting is a combination of knitting and knowledge. Knowledge about how to enhance the benefits to improve general wellbeing for preventative measures, as well as knowledge about any medical condition and how to use knitting as a tool to manage symptoms. Project choice influences the type of mind state achieved. Choice of yarn colour and texture is important too. We need to start thinking about this detail plus putting in place initial frameworks and guidance across the range of crafts, hobbies and activities. However, first there needs to be a recognition that to maximise benefits and uptake of art-based activities that this is necessary.

But will structure ‘kill’ the enjoyment, the creativity?

My works suggests that an initial instruction and framework is necessary to encourage engagement particularly in those people who need it the most – the more vulnerable or those living with ongoing health problems where energy, focus and perseverance are often limited. Creative ability, curiosity, a desire to learn, inspiration and a sense of exploration can be gently nourished within this initial framework which can then be gradually withdrawn.

Social prescribing to arts-based schemes could be a solution but one that may be limited by the availability of schemes and how best to ‘fit’ individuals to the best programme for them. It certainly seems like a good way of introducing people to new activities and social groups. It is currently (January 2019) estimated that there are over 300 schemes in England. However the Government’s much talked about boost of £4.5million funding for social prescribing is only being awarded to 23 schemes.

Those living with ongoing medical conditions and the more vulnerable will need longer-term support. Socially prescribed art-based activities are generally time and budget limited so there is a need to develop a system that encourages and supports longer-term engagement. With this in mind, Arts-based activities should be focusing on an introduction to, the teaching of and giving of skills plus, most importantly, the sparking of inspiration to enable participants to want to continue to ‘do it themselves’. This will undoubtedly require ongoing support and encouragement when needed plus a means to up skill levels and progress techniques when required.

Social activity groups can play a big part in ongoing support. To maximise benefits these would be more effectively led by people who not only have a good practical knowledge of the activity but also an understanding of how their practice can improve the health of the participant relevant to the individual’s condition, financial status and lifestyle. Activities need to fit into the ‘real life’ of each participant or they won’t be continued.

Attending a new group for the first time is not that easy, either. Most people will tell you it’s difficult. Social activity groups make it a little easier because at least you have a common interest with others and potential topics of conversation. However, for those who need it the most, it remains a challenging thing to do, so they may opt out unless support and a planned introduction are offered.

Where visits to museums and galleries are considered, accessibility and environment should be taken into account. Are there places to sit, to rest? Are there easily accessible toilets? How noisy or busy is the environment? Parking or accessible public transport? What is the current exhibition and is it suitable? Is it likely to raise mood or could it potentially trigger unpleasant memories because of the subject matter?

In order to work well, all these issues need to be considered so I’m pleased to see the introduction of non medical link workers who will hopefully have the skills to assess the individual’s needs and point to the appropriate Arts pathway. Such individuals need to be appropriately trained. These go-betweens will alleviate the need for over-worked GPs to have an encyclopaedic knowledge of the options available.

Without public information and education, engagement is likely to be difficult, particularly where arts-based activities are offered in place of traditional drug prescriptions, which after all is the money-saving intention. Arts-based activities are perceived to be a cheaper option to the heavy financial burden of drugs-based approaches but as the Bristol study suggested this might not be the case if done properly. There is a lot of work to be done before we get to the stage where the Arts are seen as a viable substitute for pills.

However, given that social connectedness has a bigger impact on improving health than other preventative interventions, social prescribing has the potential to improve people’s lives as well as take some of the strain off struggling health systems over-burdened with too many people seeking help.

So is your doctor likely to prescribe the Arts to you next time you visit… maybe, if you are lucky… but probably not…yet! The practice of treating problems that arise from social issues with medication is increasingly being recognised as both futile and expensive so with social prescribing set to be at the heart of the UK’s NHS 10-year plan, we can only hope its practice will flourish. At this moment in time schemes are scattered sparsely but hold on to the fact that this is improving.