Arts on Prescription (or Arts on Referral)

AHSW FACT SHEET

1.

What is Arts on Prescription?

Arts on Prescription or Arts on Referral is a type of social prescribing. In social

prescribing there is a referral process whereby health or social care professionals
refer people to a service or a source of support. Social prescribing can also
include referral from other professionals or self-referral. Arts on Prescription
schemes provide arts and creative activities for people experiencing a range of
challenges such as mental health problems, bereavement, chronic pain and longterm conditions. The purpose of such schemes is to help 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.1
The first scheme which used the name was Stockport Arts on Prescription, which
has been running for more than 15 years. The continuing success of Stockport
Arts on Prescription has largely stemmed from its securing mainstream health
funding, retaining its highly skilled and committed artists and other supporters.2

2.

What is the evidence?

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 wellbeing, quality of life and health, increased levels of empowerment, positive
impacts on mental health and social inclusion for people with mental health
difficulties3.
The Stockport Arts on Prescription evaluation found that participation in creative
activities raised self-esteem, provided a sense of purpose, helped people engage

Bungay, H and Clift, S. (2010) Arts on Prescription: A review of practice in the UK, Perspectives in Public
Health, 130, 6, 277-281.
2
Greater Manchester Arts and Health Network Case Study: www.wlct.org/gmahn
3
Bungay, H and Clift, S. (2010) Arts on Prescription: A review of practice in the UK, Perspectives in Public
Health, 130, 6, 277-281.

in social relationships and friendships and enhanced social skills and community
integration4.
The Time Being project, delivered by Healing Arts on the Isle of Wight, was
evaluated by interviews, focus groups and questionnaires. The programme
achieved a statistically and clinically significant range of mental health-related
benefits for patients with depression and a willingness to engage in creativity.
The reports from the project are available on the Healing Arts website5. The site
also includes short film/video sequences with the participants, clinicians, artists,
and researchers and toolkits available to download.
Arts and Minds in Cambridgeshire Arts on Prescription scheme was evaluated by
Susan Potter and sought to determine whether participants experienced any
change in self-reported levels of social isolation, anxiety, depression and
wellbeing across the duration of the programme. Scales included the Generalised
Anxiety Disorder Assessment (GAD-7), the Patient Health Questionnaire (PHQ-9),
the Warwick Edinburgh Mental Wellbeing Scale (WEMWBS) and a measure of
social isolation (SI). The Arts on Prescription programme resulted in positive
outcomes for 78% of participants, through an increase in mental wellbeing
and/or decrease in social isolation, anxiety or depression. David McDaid and A-La
Park from the London School of Economics conducted an economic analysis.
Considered from a health system perspective and compared to low intensity
Improving Access to Psychological Therapies (IAPT), if a recovery rate of 37.5%
is achieved, Arts on Prescription is demonstrated to be cost effective.6
Artlift in Gloucestershire was evaluated by the University of Gloucestershire in
2011. The evaluation was a mixed method design; the quantitative aspect
investigated the nature of all referrals and the effect of the intervention on
personal subjective wellbeing, whilst the qualitative aspect focused on the
experiences and opinions of the artists, health professionals and patients
involved in Artlift. It was found that in comparison to other primary care health
referral programmes, such as exercise referral schemes, Artlift had better
completion and attendance rates. The effect on the participants personal
subjective wellbeing was measured by the WEMWBS scale pre- and postintervention. A significant improvement in wellbeing was found. A cost-benefit
analysis by Dr Simon Opher showed that the number of times a patient visited a
GP after taking part in an arts intervention was observed to fall, the overall NHS
health spend was observed to reduce. With 500 patients there was a reduction in
GP consultations per patients of 2.7 with a saving of 105 per patient and a total
reduction in NHS costs of 576 per patient. There is also an update to the 2011
evaluation available on the Artlift website.7

4
5
6
7

Huxley P. Arts on Prescription. Stockport: Stockport NHS Trust, 1997

http://195.217.160.2/ASP/HealingArts/indexvideo.asp?record=1871
http://artsandminds.org.uk/reports-and-documentation/
http://www.artlift.org/evaluations/

3. How do you go about

Prescription scheme?

evaluating

an

Arts

on

To build a body of evidence it is essential that any new schemes are rigorously
evaluated. The Warwick Edinburgh Mental Wellbeing Scale (WEMWBS),
developed for Health Scotland, is a popular tool. It is a scale of 14 positively
worded items, with five response categories. You can download the scale and it is
free to use, but permission and registration are required for use8. If you decide
to evaluate your scheme in line with national programmes such as Improving
Access to Psychological Therapies9 you should, in discussion with your health
colleagues/partners, consider working with a professional researcher or
university. The three suggested depression severity measures validated for use
in a primary care setting are the Patient Health Questionnaire (PHQ-9), the Beck
Depression Inventory Second Edition (BDI-II) and the Hospital Anxiety and
Depression Scale (HADS).
The PHQ-9 is a nine question self-report measure of severity that takes
approximately three minutes to complete. It was developed and validated in the
US and can be downloaded free of charge10. Both the HADS11 and the BDI-II12
need to be purchased.
If you decide to evaluate the scheme in house then it is worth considering using
an Outcomes framework. See the AHSW Fact Sheet on Outcomes
Measurement as a starting point13.

4.

When and how are patients referred?

Often referral or recruitment of participants is a significant challenge. You may

wish to target hard to reach individuals but inevitably there are many barriers
to participants finding out about or accessing such services. Partnership working
is key, particularly with service user groups or forums, social care and health
charities and health care professionals and services.
The most common referral route is through GPs. Arts on Prescription schemes
can be perceived by GPs as a valued additional offer, and an alternative to antidepressants, for patients they see regularly, who may suffer from isolation,
depression, anxiety or stress. GPs vary in their knowledge of, support of, and
interest in such schemes.

8
9

http://www2.warwick.ac.uk/fac/med/research/platform/wemwbs/
http://www.iapt.nhs.uk

10
11
12
13

http://www.depression-primarycare.org/clinicians/toolkits/materials/forms/phq9/
http://shop.gl-assessment.co.uk/home.php?cat=417&gclid=CPPr3fjJhpkCFQ6wQwodI2Krlw
www.psychcorp.co.uk
http://www.ahsw.org.uk/factsheets.aspx?x=1&id=45

Schemes rely on advocates and champions amongst GPs and other health care
professionals; GP Practice Managers are important gatekeepers and may be a
barrier to communication with GPs. Leaflets and posters are often used. The
wording is very important with regard to challenging stigma and should be
written in conjunction with health care staff and/or service user groups or
forums.
Participants may be able to self-refer via a website. Access to selfreferral is
often desirable but may be hard to manage regarding numbers. Where
participants self-refer you should consider screening to make sure the
course/service is suitable for their level of need.

5.

What progression routes are there for participants?

When setting up schemes progression routes are a primary concern. The model
of a time limited course is often perceived as desirable because it fits with the
way that other treatments and therapies are delivered, it allows for more people
to benefit from the experience and it allows for final evaluation of the benefits.
There is often a suggestion that ongoing support will create dependency, but
this is a contentious issue. It is vital to consider progression routes once a time
limited course ends.
User groups and forums can be invaluable in helping schemes consider ways of
supporting participants at the end of a course. This could be through existing
peer support networks or through support for the group to be self-sustaining.
Signposting to further activities provided through adult education or local arts
providers may be appropriate. Where one of the aims of the scheme has been to
combat social isolation it may be equally appropriate to provide signposting to
other, non-arts, services and opportunities. Partnerships with community
organisations can help facilitate this.

6.

How are schemes funded?

The aim of many schemes is to be commissioned by health commissioners.

Currently health commissioning sits across Local Authorities, including Public
Health, and NHS Clinical Commissioning Groups. There are moves to integrate
funding and care pathways more fully. In September 2015, in a period of
ongoing austerity measures, the likelihood is that Public Sector funding will be
cut further in the coming years.
In discussing how Arts on Prescription is, or can be, funded through health and
social care budgets, it is necessary to explore where Arts on Prescription fits into
health and social care services and care pathways relating to a range of
conditions. At present Arts on Prescription is most likely to be commissioned by
NHS Clinical Commissioning Groups and Mental Health Services, for example
4

Artshine in Bristol14. Although every situation differs, this would normally place
Arts on Prescription within, or in parallel to, an Improving Access to Psychological
Therapies framework. This has implications for the nature of the arts intervention
and for the way it is evaluated.
Where Arts on Prescription is within a broader social prescribing offer it is more
likely to be considered a preventative measure in public mental health. Social
prescribing may include referral to voluntary community sector provision of
physical activity and walking; gardening and the natural environment; debt and
housing advice and support; and peer support. There is a clear role for the arts
and culture in this context. An example of this is Creativity Works in Bath15.
However, health commissioners may be more likely to fund infrastructure for the
referral process, rather than the services themselves. It is likely that personal
budgets will play a greater role in funding social prescriptions in the future.
There are examples of Arts on Prescription being integrated into mental health
services more fully, most notably the South West Yorkshire Partnership NHS
Trusts Creative Minds project, which recently won the Health Service Journal
Award for Compassionate Patient Care.16 Another funding model is provided by
PETROC Arts on Prescription service in North Devon where it is integrated into
further education provision.17 Otherwise Arts on Prescription is likely to be
funded on a short term project basis by Trusts and Foundations, perhaps with a
contribution from participants themselves.

7.

What kind of training or supervision is provided for

practitioners?

Training and supervision for artists is an important consideration in planning

schemes. Training might be provided through adult education in the form of
teacher training or it might be provided via the managers of the scheme and be
tailored specifically to the needs of participants. Schemes need to consider the
ratio of numbers of participants to artists and any support artists might need
from mental health care trained staff. Supervision and support for artists will
vary from scheme to scheme. In some cases it may be appropriate for a mental
health support worker to attend all sessions.
This Arts & Health South West Fact Sheet was updated in September
2015 for the Cultural Commissioning Programme event in Liverpool The
Art of Social Prescribing, delivered by the New Economics Foundation
www.ahsw.org.uk

14
15
16
17

http://www.wellspringhlc.org/arts-on-referral
http://www.creativityworks.org.uk/what-we-do/for-mental-health/
http://www.southwestyorkshire.nhs.uk/quality-innovation/creative-minds/
https://www.petroc.ac.uk/support-help/arts-on-prescription