AHSW's Director, Trustees, and Members reflect on various aspects of arts, health and wellbeing.

Shared Territories

The transcript of a talk Alex Coulter gave at the Royal Society for Public Health

I have taken the title of my talk from a report written by Ruth Hecht in 2006. It was an audit and analysis of arts and health in the South West region and the report helped inform Arts Council England South West’s strategic planning on arts and health. At that time I was the arts coordinator at Dorset County Hospital and a member of the steering group that set up Arts & Health South West. Most of us worked in acute hospitals. Hospital arts coordinators are still some of the few arts and health administrators who are employed by the NHS over sustained periods. I worked at Dorset County Hospital for 15 years and the post continues, funded by the NHS (not charitable funds).

Originally my remit was framed as educational as well as administrative. Over those 15 years I moved towards a greater emphasis on participatory and experiential work, while maintaining the role of curator and manager of what was a substantial collection of high quality artworks of significant asset value to the hospital trust.

To me, then, it seemed that the main continuum, if you like, was between a high level public art commissioning programme with a rather top down structure, which in our case was led by the Vice-Chair of the Trust and delivered by an external consultant from the Contemporary Art Society in London, and a more grassroots community arts development movement that was engaging with health issues through participatory work and/or providing artworks that were made by communities for community hospitals, for instance, and everything in between in terms of the professional status of artists and the engagement of participants in the process.

My presence in the organisation enabled more participatory work to be embedded in the life of the hospital for both staff and patients. Even so, arts therapies were in quite separate territory. There was a dearth of arts therapists working in the Dorset health system. Later on in my time there, I was ‘outsourced’ to support the re-development of a mental health inpatient unit and then I worked closely with an art therapist who was employed as part of that unit.

Although aware of Medical Humanities through conferences and literature it was only once I became Director of AHSW in 2010 that I developed direct links with the Medical Schools, in particular the Peninsula Medical School in Plymouth. It has always struck me that far more connection could be made between students working with the arts to explore their own humanity within medical training, and the use of the arts within treatment of patients. At Bristol Medical School that is now an overt link. Dr Louise Younie, a Bristol GP, had artists in residence working with her patients and an exchange was set up with students in the medical school enabling them to communicate with the patients through the arts project. There could be much more of this.

I think we would all agree that the field of arts and health practice has mushroomed, and more or less flourished, in the last 10 years, and that the shared territories are more complex and multi-faceted. I have in mind a whole series of continuums, multiple continuums in a three-dimensional matrix! Sometimes the complexity of the territory is quite overwhelming.

One overarching continuum is:

The importance of access to the arts and cultural venues throughout the life course as integral to long lives lived well, perhaps arguably in itself a social determinant of health and wellbeing.. through to the arts as an intervention to help heal, to mitigate ill health or support recovery

Within that some of the issues and threads that come to mind:

  • The arts to support prevention, at community, primary and secondary level.
  • The arts as a targeted intervention for a specific health condition
  • Empowering individuals to be creative and emphasising co-production, service-user led groups; and concepts of health creation
  • Issues about the artists’ role and the complications of artistic quality: quality in process, outputs, who decides, issues of power and empowerment
  • Voice, the voice of the artist as mediator or facilitator, the voice of the patient enabling them to tell their story; the voice of the clinician or perhaps of the system: management, funding, structures.
  • The involvement of the wider cultural sector, particularly museums, libraries and arts venues, in public health, healthy cities, and how the arts can enhance places and communities, asset-based approaches to community development and the potential role of the arts in that.
  • A holistic and social model of health through to a medical model.
  • Risk taking to risk averseness – what is safe risk taking – how does this relate to risk as a fundamental in the creative process

I will return to that complex world in which we all exist and play our part, but first I would like to look at some recent activity that has been influencing my thinking:

I said I would talk a little about the APPG Inquiry which many of you will be familiar with in some form or other. The aim of the Inquiry is stated as: to inform a vision for political leadership in the field of arts, health and wellbeing in order to support practitioners and stimulate progress. The method by which this will be achieved is through policy recommendations to a large number of different bodies. The Inquiry researcher, Dr Rebecca Gordon-Nesbitt, is working through a vast range of material and I won’t attempt to explain her process or the emerging findings, because I wouldn’t do it justice. The Report will be launched in June next year.

The part of the process that I will talk a little about is the series of round tables that the APPG has hosted in parliament, 13 to date, on many different themes ranging from policy orientated such as the Care Act, the Francis Inquiry and training; the Care Act, Local Authorities and Wellbeing; Commissioning; Devolution; then others on health conditions: dementia and the arts, Post-traumatic stress and the arts, young people’s mental health and the arts; the Arts, Dying and Bereavement, on art forms such as Music and Health; and on aspects of the health system: Public Health and the Arts, Arts on Prescription.

In parliamentary parlance they are seen as Evidence Sessions. But, rather than a select committee model where some experts in the field are more or less interrogated by parliamentarians, we have used the opportunity to bring together groups of people that have a shared commitment to arts, health and wellbeing in a specific context, but may bring to bear very different lenses.

As an example, the last one was a collaboration with the National Criminal Justice Arts Alliance, one of those organisations that represents different, but overlapping, territory with arts and health.

Participants in the round table were:

  • A Prison Governor;
  • 2 ex-prisoners,
  • two academics,
  • a mental health practitioner working in a prison,
  • a writer
  • 3 arts organisations (one working specifically in detention centres),
  • the head of health in the justice system from NHS England,
  • someone from the National Offender Management Service.

And they were asked to respond to the following questions

  1. What are the benefits of the arts for the health and wellbeing of those in the Criminal Justice System?

  2. What changes to policy or practice at local, regional, national level would facilitate more arts and health work happening in Criminal Justice settings?

Parliamentarians attend the round tables and this one was chaired by Baroness Lola Young.

The point of the round tables has not been to convert the unconverted, everyone in the room tends to believe in the work, but rather to create a space in which the shared territory can be explored. I have found them profoundly moving experiences. There is an atmosphere of intense listening in the room, leading to an almost tangible 3-dimensional new understanding emerging. The service providers, whether they be from, in this case, the Prison service or the arts sector, bring to bear the challenges of systems and delivery, the academics help us frame the deep issues at play. When service users, or in this case ex-prisoners, speak, the atmosphere is electrifying. I recently went to Medicine Unboxed and a wonderful Edinburgh GP quoted Carl Rogers, who wrote: ‘there is a peculiar satisfaction in really hearing someone: it is like listening to the music of the spheres, because beyond the immediate message of the person, no matter what that might be, there is the universal.’

At AHSW’s annual conference last week, a strong thread emerged that reflects a similar theme.  Dr Jo Black, Associate National Lead for Perinatal Mental Health at NHS England spoke about her work with animator, Emma Lazenby, Director of ForMed Films. Jo is also regional lead and works out of Devon Partnership Trust. When CQC criticised the Trust, for not taking into account the views of children in the families of adults with mental health, Jo decided to work with Emma Lazenby to create an animated film with children and families. The film, My Mum’s Got a Dodgy Brain, is very moving and beautifully made and has the voices of the children right at the heart of it. Jo Black’s view is that we should focus on what the NHS doesn’t do well and in her experience that is often connected to really listening to patients.

On the second day, we had sessions involving patients, commissioners, artists and arts organisations related to the Gloucestershire Cultural Commissioning Programme at Gloucestershire CCG, and specifically a project with men and chronic pain. The discussions were facilitated by Ruth Ben-Tovim who runs an organisation called Encounters Arts and sees her role as convening dialogue. Jules Ford, who manages the Gloucestershire CCG work and Professor Diane Crone gave a presentation on the co-production methodology used to develop the projects. Jules talked about her experience in community development working in health services in the middle east and how she brought some of the skills learnt there to her work at the CCG. We had several presentations and discussions focussed on Voice – the artistic voice as mediator or facilitator, the patient or participant voice, and hearing the needs of commissioners and clinicians.

Many of you will know Dr Simon Opher and I used to think that what we needed was to clone Simon, and for him to persuade his peers to follow his path, peer to peer influence. But in the session on the Gloucestershire work, Simon said that other GPs won’t really listen to him they just think Oh God here comes Simon again wittering on about the arts, but they will listen to, as we had there, three men with chronic pain who might normally find it hard to get out of the house let alone drive from Gloucestershire to Totnes to speak at a conference about how the arts project they have been involved in has changed their lives.

After the presentations we were asked to imagine ourselves into being in a consultation as either a patient or a clinician, and discussed how we would feel about giving or being given a non-medical prescription by our doctor. It’s an exercise worth doing. There is the ‘expert’ knowledge of the patient – knowing how they feel – and there is the ‘expert’ knowledge of the doctor, reading signs that might or might not be serious and need a medical intervention. It is the listening space in the middle that is so important.

But it is not just about listening to participants and patients but also about welcoming them into our world as equals from whom we can learn. I’d like to quote Eva Okwonga here who has been involved in a couple of our Inquiry meetings. She says:
When recovering from PTSD and schizoaffective disorder (a form of personality disorder) I found engagement in arts activities absolutely crucial, both in surviving the hospital environment and in integrating back into the community. I engaged in visual art, craft and music, eventually specializing in music and running my own music for health project. (Music in Mind).

Before developing her Music in Mind project she did a course in community arts at Goldsmith’s. She is not a professional artist or arts therapist, she is an expert patient with community arts training, who wants to share with others who are experiencing mental ill health her own journey with the arts. She is a volunteer and her work may be different to ours but is certainly of equal value.

How we involve and engage with patients, participants, service-users is, of course, fundamental to our work. Co-production is one methodology that we can apply to our work, which can bring together all these rich and diverse perspectives.

Co-production aligns well with ideas of Health Creation and other terms associated with the theory of Salutogenesis. It is something more than Prevention because it has a proactive message.

So if we are to embrace Co-Production what does that actually mean?

NEF’s six principles of co-production are:

  1. Building on people’s existing capabilities: altering the delivery model of public services from a deficit approach to one that provides opportunities to recognise and grow people’s capabilities and actively support them to put them to use at an individual and community level.
  2. Reciprocity and mutuality: offering people a range of incentives to engage which enable us to work in reciprocal relationships with professionals and with each other, where there are mutual responsibilities and expectations.
  3. Peer support networks: engaging peer and personal networks alongside professionals as the best way of transferring knowledge.
  4. Blurring distinctions: removing the distinction between professionals and recipients, and between producers and consumers of services, by reconfiguring the way services are developed and delivered.
  5. Facilitating rather than delivering: enabling public service agencies to become catalysts and facilitators rather than central providers themselves.
  6. Assets: transforming the perception of people from passive recipients of services and burdens on the system into one where they are equal partners in designing and delivering services.

Between us we are creating the narrative and the collective endeavour, none of us holds it all in our heads or our practice.

I have been trying to find appropriate theories to help articulate and reflect on this. Paul Dieppe, Professor of Health and Wellbeing at Exeter University and a Trustee of AHSW, is very helpful to me. He made the point that, whereas other sciences such as Physics have embraced complexity theory, Medicine is still in a Cause and Effect mindset. I was looking at Theory of Change but as Geoff Mulgan at NESTA has said Theory of Change can still tend towards linear thinking – an assumption that inputs lead to outputs, and that outputs lead to outcomes and outcomes lead to impact. He recommends Systems Thinking.

I remembered that John Wyn Owen, in his keynote at the Culture, Health and Wellbeing International Conference in 2013, talked about Systems Thinking and quoted Nigel Crisp in his book 24 hours to save the NHS where he wrote “systems thinking and leadership holds the key to the many improvements we can make in health and healthcare”. John Wyn Owen ended his speech with recommending that in arts and health we should work with the Cynefin Framework and said: ‘The Cynefin framework draws on research into complex adaptive systems theory, cognitive science, anthropology and narrative patterns as well as evolutionary psychology to describe problems, situations and systems. It explores the relationship between people, experience and context and proposes new approaches to communications, decision making, policy making, and knowledge management in complex social environments.’!

The Cynefin Framework has disorder at its heart, which is where most of us are most of the time. One section is Simple – that is where Cause and Effect is obvious and where ‘Best Practice is possible’ because you know what works and you can repeat it. The section above is Complicated, cause and effect is more varied over time and you may need some expert knowledge to understand it. This is where Good Practice resides – different approaches are appropriate for different situations and problems. The Complex section is where cause and effect can only be seen in retrospect and practice is emergent. Finally Chaos where there is no obvious relationship between cause and effect and you get novel practice, one off responses that may move you into one of the other areas. Simple is the most risky zone because you can very easily fall off a cliff edge into Chaos.

Things might appear Simple but they rarely are:

In Systems Frameworks I found some guidance about how one starts the process of describing the system and the relationships within it. The first level is to conduct a group activity to identify all the Actors. They are Actors rather than Stakeholders because it is not about ownership but about relationships and activities. I have recently started using the term ‘an ecology of practice’ and perhaps what I am hoping we can articulate is an ecosystem for culture, health and wellbeing. Each of us will see that ecosystem from our own perspective. My concern is that we don’t create divided territories and polarise our thinking. None of us can function without the others. We have different, and evolving, roles, levels of engagement and purposes.

To quote Peter Senge from the Stanford Social Innovation Review:
The deep changes necessary to accelerate progress against society’s most intractable problems require a unique type of leader – the system leader, a person who catalyses collective leadership.

Looking again at our Inquiry’s aim which is “to inform a vision for political leadership in the field of arts, health and wellbeing in order to support practitioners and stimulate progress” I think that that political leadership should be systems leadership which catalyses collective leadership. Our collective leadership, along with all those we work with.

In preparing for this conference Stephen asked us to consider who are the key professionals and practitioners doing the work, what are the existing infrastructures, networks, training programmes and journals supporting the field.

I would like to suggest that we start to work together on creating a Systems Framework and the first step would be to plot who all the Actors are.


Alexandra Coulter

Director, Arts & Health South West

December 2016

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