This paper, and the Creative Health Delivery Action Plan that will follow it, arise from the commitment and insight of a large collective of inspired, talented and committed professionals from across the East Sussex County system.

Inspired and informed by the artistic, cultural, heritage, health and social care practitioners and systems we are so lucky to have in place across the county, this position paper would not exist without the dedication, leadership, and vision of a truly vast collective of people.

Of special note for their contributions in enabling, shaping, and generating this paper, thanks are extended in particular to the following:

Jo	Alner	Liis	Hirvoja
Jayne	Barnett	Tracey	Houston
Ross	Bosely	Helen	Johnson
Phoene	Cave	Gemma	Jolly
Alex	Coulter	Stewart	Marquis
Jo	Crease	Edward	Marshall Scheldt
Rosie	Crichton	Caroline	Osella
Sarah	Dance	Jane	Povey
Nick	Ewbank	Naomi	Roche
Darren	Gale	Miranda	Scrambler
Alex	Hagger	Sally	Staples
Joe	Hill	Lucy	Watts

Glossary

There are a number of key terms and concepts that will be introduced and explained below:

Term	Abbreviation	Meaning
Creative Health	CH	The broad range of artistic, cultural, heritage and creative activities that can contribute directly or indirectly, to improving the health of the population.
East Sussex County Council	ESCC	The County Council for East Sussex covering the five local government districts of Lewes, Wealden, R\other Eastbourne and Hastings
NHS Sussex Integrated Care System	NHS Sussex ICS	The wide area local health authority for Sussex that works in partnership across both East and West Sussex County Council areas, supporting all NHS commissioned health services in the area; from Primary Care, to Acute, and Mental Health Care.
Social Determinants of Health	SDoH	The underlying drivers and context for individual health at a societal level that include a wide range of factors, including poverty, housing, social cohesion, educational, employment and cultural opportunities, and environmental impacts. See Chapter 6: social determinants of health - GOV.UK (www.gov.uk) for more detail.
Primary Care	PC	Primary Care is any structured health care offer in the community, including General Practice, community Pharmacy, Dentistry, and Optometry, and is often simply described as GPs; a significant component, but not the sole provider of “high street” health services. With the creation of the Integrated Care Boards in July 2022, Primary care is increasingly being delivered via Primary Care Networks: federations - or collaboratives - of co located services. These services include Social Prescribing, a key offer in support of communities requiring low level or sub clinical support, and an essential linkage for the Creative Health Agenda to develop further.
Acute Care	AC	This encompasses both planned care (i.e., outpatient and inpatient stays), and unplanned care (Emergency department), delivered via hospital sites and services.
Health Improvement	HI	Health Improvement includes the work that is done to address the underlying social determinants of health (see Social Determinants), to improve the health and wellbeing of individuals or communities through enabling and encouraging healthy choices, as well as addressing health inequalities and disparities of access to services.
Social Prescribing	SP	Social Prescribing describes a wide range of activities that people who may be seeking support from health and social care providers can be referred into. The activities typically provided by voluntary and community sector organisations can include a broad range of opportunities, including volunteering, arts activities, group learning, gardening, befriending, cookery, healthy eating advice, and a range of sports. They contribute directly and indirectly to supporting and improving the health and resilience of communities in several ways. See Social prescribing \| Arts Council England or The National Academy for Social Prescribing \| NASP (socialprescribingacademy.org.uk) for further information
Life course	LC	The segmentation of a population by age, developmental stage, and needs, from birth to death. See Health matters: Prevention - a life course approach - GOV.UK (www.gov.uk)
Special Educational Needs and Disabilities	SEND	Special educational needs and disabilities (SEND) can affect a child or young person’s ability to learn. They can affect their: · behaviour or ability to socialise; for example, they struggle to make friends. · Reading and writing; for example, because they have dyslexia. · Ability to understand things. · Concentration levels: i.e., because they have ADHD. · Physical ability. See Children with special educational needs and disabilities (SEND): Overview - GOV.UK (www.gov.uk)

Introduction By Teresa Salami-Oru – Consultant in Public Health

Arts, creativity, culture, and heritage are central elements to human existence. They provide a method of expression, exploration, and understanding that can be found at the heart of every culture and at every period that human beings have existed. From architecture to art history, from dance and drama to design, and from painting to poetry, there are so many different artistic, cultural, creative, and heritage-based activities and opportunities; each one contributing to the diversity and richness of the many cultures and perspectives that make up our world.

The global power of creativity to articulate feelings, thoughts, and experiences; to help us explain and understand our lives; to help us to empower and support others; and to help us celebrate and share experiences and insights, all aid in informing what it is to be human. So far, so familiar. But there is so much more to creativity; increasingly we have begun to understand that alongside these more familiar aspects of artistic, cultural, heritage and creative disciplines, there are less familiar direct and indirect health and wellbeing impacts that flow from engagement with creativity.

This position paper introduces East Sussex County Council’s Creative Healthier Lives - Arts in Public Health Delivery Action plan and sets out some of the approaches and ideas that have informed the Creative Health Programme. A wealth of evidence already exists - and is constantly emerging - that demonstrates the positive impact that arts and creativity can have on our individual and collective health and wellbeing, and our ability to live rich, meaningful lives.

Within East Sussex County Council Public Health, we are seeking to explain, promote and explore the concept of “Creative Health” – the broad range of opportunities and options for arts, creativity, heritage, and culture that can contribute directly or indirectly to improving the population’s health. Our approach will rely on partnerships, working with both targeted and universal approaches, to harness the potential of creativity and the arts across East Sussex. We seek to harness the health and wellbeing benefits of arts, creativity, and culture to help communities to recover and renew post pandemic and contribute to reducing health inequalities.

As the programme evolves, we hope that you will join us in building and strengthening the Creative Health offer in East Sussex. Through the positive sharing of your ideas, energy, and insight, we can make it an effective and positively impactful approach which supports the needs of peoples, communities, and organisations, working to deliver health improvement, fulfilment and creative opportunities across the county.

Teresa Salami-Oru

Consultant in Public Health

East Sussex County Council

August 2023

What is the Delivery Action Plan?

The Creative Healthier Lives, the Arts in Public Health Delivery Action Plan (The Action Plan) will follow on from this position paper. It will provide a roadmap and central strategy in support of East Sussex County Council’s aim to use the arts, culture, heritage, and creativity to support the health and wellbeing of residents. It will set East Sussex on the path to becoming the first Creative Health County in the UK, by outlining our statement of intent and commitment to developing a sustainable approach to Creative Health. An approach that can contribute directly and indirectly to health of people of all ages, and all communities, across the Life Course.

The Action Plan will set out a large range of connections with other ESCC strategies, most notably the exemplary ESCC Culture Strategy 2013 to 2023, which is currently in the process of being rewritten.

In terms of governance, the Delivery Action Plan will report formally into ESCC structures and wider Sussex systems via the Public Health Board, and have a direct feed into the Culture East Sussex Board and network.

Overview of the Delivery Action Plan

Aims: To embed arts and creativity into place and system approaches, with a view to improving and sustaining the wellbeing of the population, as well as advancing the research and evaluation of the impacts of creative health approaches in East Sussex.

Creative Healthier Lives – Arts in Public Health will detail actions to sustain, improve and prevent ill health and promote wellbeing through arts, creativity, and culture. The plan will link in with the East Sussex Cultural Strategy and support community recovery and renewal.

It will be underpinned by three strategic priorities, focusing on three distinct levels of effect:

Micro – Individual level impacts

Meso - Community level impacts

Macro -System Level Impacts

Fig 1 Micro, Meso and Macro Impacts

Micro, Meso and Macro are used to consider context at structural levels within a system. They are often used in healthcare and social work literature to help people understand the differences in both scale and affect, the breadth and depth of the system, as well as the factors that contribute to it, with additional consideration paid to the different target - or impact focus - for each.

The exact definitions for these depend on context, and for the purposes of the Delivery Action Plan we are using micro to reflect the individual; meso to reflect groups and organisations; and macro to reflect the wider health and care ecosystem, including systems, policy and structure. For the Action Plan to be successful it is important that there is impactful positive and sustainable action across all three levels.

Table 1 – Delivery Action Plan Priorities

Priorities	Meaning
1: Creative Health and the individual (micro)	Utilising Creative Health approaches to improve people’s health and wellbeing.
2: Creative Health and community (meso)	In collaboration with partners in the culture, arts, heritage, health, and social care systems, to build and support creative health across East Sussex localities and communities^{^[1]}.
3: Creative Health, Systems, Networks and Partnerships (macro)	Work with the ICS and wider cross sector partners to embed and champion creative health across a wide range of service offers and settings, backed up with robust approaches to Research and Evaluation.

We recognise that there are many examples of good practice in the field of Creative Health, alongside existing gaps in the knowledge base; therefore, there is a need to develop new and robust approaches to both operational works and research and evaluation, to gauge the impact, appropriateness, and sustainability of the works that are delivered under the Creative Health Agenda. We will in this way, seek to understand the economic, social and health impacts, as well as cost/benefit analysis of these works; in this way, we are proud to be contributing to the ever-expanding evidence base (please see appendix 3).

We will incorporate the Life course[1]approach into the Creative Health Agenda to ensure that we are understanding and supporting the needs of people from pre-conception to end of life care.

Life Course Stage	Outline
Starting well	From pre-conception through to birth, and on into childhood, adolescence, and then into transition to adulthood - including Children and Young People with SEND (see glossary)
Living Well	From transition to adulthood, 18 to 25 depending on status and needs (see SEND above), and broadly throughout working age and into older ages.
Ageing Well	From retirement and into older age.
Dying Well	Death can occur throughout any stage of the life course (from stillbirth to child death, and on into adulthood and older age ranges). Central to this is the support for end-of-life care, a “good death”, and care for the bereaved.

Creative Health has a wide range of applicable approaches and inputs that vary across the life course; we will represent these, as well as the breadth and complexity of the creative, cultural, heritage, artistic, health and social care services offers and inputs, that can support our communities in East Sussex.

If we can successfully support the potential of Creative Health to contribute to a preventative and sustainable approach to health improvement, utilising the power of creative cultural artistic and heritage offers to help us explore, understand, and give meaning to lives, we will have delivered an innovative, and essential contribution to making East Sussex a Creative Health County.

We hope the Creative Health agenda will contribute to long-term improvements in Healthy Life Expectancy and Quality of Life for the communities we serve, and support the system partners in both statutory, voluntary and community sectors delivering health and care offers and the Creative, Cultural and Heritage industries across East Sussex.

Context

Creative Healthier Lives – Arts in Public Health sits within the wider health and wellbeing ecosystem across East Sussex. The Delivery Action Plan will align with NHS and wider health and care system strategic documents and priorities:

· Healthy lives, healthy people: East Sussex Health and Wellbeing Board Strategy

· Sussex Integrated Care Strategy: Improving Lives Together

· East Sussex Joint Strategic Needs Assessment (JSNA)

· Adult Social Care Strategy | East Sussex County Council

· East Sussex Cultural Strategy

What do we mean by arts and creativity?

Arts

The arts are conceptually difficult to define. The All Party-Parliamentary Group for Arts, Health, and Wellbeing (APPGAHW) used a definition of arts including ‘the visual and performing arts, crafts, dance, film, literature, music and singing…gardening…and the culinary arts’[2].

The National Centre for Creative Health defines Creative Health as 'creating the conditions and opportunities for arts, creativity and culture to be embedded in the health of the public’.

For the Strategic Plan we have been guided by the literature[3] and the Faculty of Public Health, Arts and Health Special Interest Group[4], to adopt a broad definition of the arts:

· Performing arts: activities in the genre of music, sound art, dance, theatre, singing, film, etc.

· Visual arts, design, and craft: activities in the genre of animation, craft, drawing, fashion, interior design, painting, photography, public art, sculpture, textiles, etc.

· Literature: writing, reading, attending literary festivals etc.

· Culture and Heritage: going to museums, galleries, art exhibitions, concerts, the theatre, community events, cultural festivals, and fairs etc.

· Online, digital, and electronic arts: digital art, electronic art, filmmaking, graphics etc.

The arts are a process of discovery and creative effort[5]; in short, they encompass both high level professional productions, exhibitions and events and ‘everyday creativity’¹taking place both within the home and within the community as individual or group endeavours, and as publicly funded activities. This also includes the places art engagement takes place, such as concert halls, galleries, libraries, theatres, and museums, as well as health and social care environments, community settings, and homes.

Arts, including culture, are commonly split into two areas of activity:

- Those that are essentially receptive, involving an artistic or creative offer that has been created or curated by a practitioner and is now presented for experience or consumption by an arguably passive audience[2].

- Those that are essentially participatory, requiring active engagement with creative processes and involvement in the arts[6]from all involved.

Creativity

Arts Council Englanddefine creativity as “the process through which people apply their knowledge, skill, and intuition to imagine, conceive, express or make something that wasn’t there before.”[7]Art and creativity are often used interchangeably and there is an obvious and enduring link between them, with the “Arts” often defined as the product of a process of creative act, effort, inspiration, or discovery. The precise role of creativity in the “Arts” in any given form, however, from fine art to drama dance and literature, is not universally static, varying significantly across time and cultures. Creativity goes beyond the formal constraints of particular artistic practice and can be found in every aspect of people’s lives. Everyone can be creative, although not everyone has access to the same opportunities to engage with the arts and creativity.

Kaufman and Beghetto’s[8] Four-C model of creativity usefully demonstrates how context impacts creativity.

The Four-C model of creativity

Mini-C	Personal	Explorative behaviour that is individually inventive and meaningful.
Little–C	Everyday	Everyday creativity, the ordinary daily actions humans engage in to create new ways of doing things.
Pro-C	Expert	A level of expert creativity not classed as exceptional.
Big-C	Genius	Creative genius.

Table 2 Source: The Four C model of Creativity Adapted from Kaufman & Beghetto, 2009

Within this plan we are seeking to embrace all aspects of this model with greatest emphasis on Mini-C and Little-C.

A note on Culture and Heritage

In this paper we are including culture and heritage within our use of the terms arts and creativity. This is in line with the research of Professor Chatterjee[3] at University College London, who specifically assessed the positive impact of museum spaces; a key culture and heritage domain, on the physical and mental health wellbeing of participants[4]. We hope through this approach to widen the Creative Health offer to as broad a range of settings and opportunities as we can. Given the wealth of heritage and cultural opportunities in East Sussex we want to ensure that we are maximising their positive impacts on the health and wellbeing of all those involved as practitioners, and participants, as visitors to - and curators of - cultural and heritage spaces.

Evidence of the benefits of arts and creativity

There is growing evidence that arts and creative activity can lead to improved health and wellbeing; evidence suggests that getting involved in creative activities throughout the Life course in communities reduces loneliness, supports physical and mental wellbeing, and helps to strengthen social ties[9]. Creative interventions have been associated with improvements in wellbeing and social wellbeing[10]^,[11],[12], slower declines in cognition^{^[13]}, reduced levels of isolation and loneliness ^{^[14]} and lower mortality rates^{^[15]}.

Arts specifically as therapy have been used for over a century^{^[16]},yet it is only in recent years that systematic and controlled studies have examined the therapeutic effects and benefits of the arts and healing^{^[17]}. The role of the creative endeavours as a contributor to health and wellbeing outcomes and their use as a public health resource is beginning to be more widely understood^{^[18]}.

The increase in interest in the Creative Health agenda and increasing volume in research - although varying in quality and approach - over the last two decades¹²shows that the Creative Health opportunities can contribute to the promotion of good health[19]. This includes the areas of carer resilience, the prevention or, or support and amelioration of a range of mental and physical conditions, and treatment or management of acute and chronic conditions [20] and end of life care or bereavement:

Figure 1: how the arts support prevention, promotion, management and treatment

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Fig 2 Source: Adapted from Fancourt et al, 2020

On a broader basis, across the “Life course” from preconception to end of life care, the arts have been shown to support child social development and wellbeing as well as cognitive function in older age. Furthermore, positive impacts across a range of developmental stages, and the management and treatment of many specific conditions, have also been observed; as set out in the Figure below.

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Figure 3: Specific impacts of the arts on health and wellbeing

Source: Fancourt and Finn, 2019

A 2021 systematic review of the evidence on arts and creativity in later life [21] shows that participation in group arts and creativity interventions helps to support the physical, mental, and social aspects of ageing. Additional research suggests that participatory art-based activity, performed weekly over several months, may improve both mental and physical health in older people in the community, including improved wellbeing and quality of life, a decrease in frailty, and increased feelings of autonomy and control[22]^,[23].

Artistic and cultural engagement can have a range of positive impacts on health and wellbeing, including a reduction of reliance on medication use (or enhanced compliance with treatment places and medication regimes) and Primary Care (GP visits; moderate symptoms in chronic health conditions, including diabetes, dementia, stroke and respiratory disease; decrease mortality rates; reduce pain and fatigue; and increase healthy behaviours.[24] The arts can therefore be considered as a social determinant of health, which public health can consider within its prevention approach to improving quality of life and reducing the gap in healthy life expectancy for the population of East Sussex (please see appendix 4).

Inequalities – accessing the arts.

Regardless of socio-economic or demographic backgrounds, recent evidence[25] has shown that adults who participate in arts and cultural activities:

· Are more likely to have better cognitive reserve in later life.

· Are less likely to develop dementia.

· Have lower levels of frailty and chronic pain in older adulthood and experience less loneliness and depression, and better wellbeing.

· Live longer.

Nonetheless, access to the arts is not equal; only 10.3% of adults (n=38,069) in the UK have regular patterns of participation in the arts such as singing, playing an instrument, taking part in a drama group, painting, drawing, or writing stories or poems. Only 18% of adults are frequently engaged in cultural activities, such as going to book clubs, exhibitions, plays, live music events, museums, historical places, or archaeological sites[26].

Evidence indicates that the most vulnerable groups are 20% less likely to participate in creative activity in the UK than the least deprived, and that these activities increase subjective wellbeing[27]. There are significant variations in engagement according to gender, ethnicity, disability, age, socioeconomic group, and geographical location [28];for example, those in higher socio-economic groups are more likely to engage in sport, arts, museums, galleries and heritage[29] than those in lower socio-economic groups²¹^{,[30],[31],[32]}.By contrast, those from minority ethnic groups have been found to be well represented in attendance at public libraries and in arts activities geared towards mental health protection[33].

However, there is evidence to suggest this ‘participation gap’ may be an oversimplification and people from lower socio-economic groups do engage and benefit from the arts, although they are more likely to experience barriers to engaging with the arts such as cost, health, and travel. There is an overreliance on a notion of art and creativity linked to Big-C and Pro-C, with limited account taken for mini–C and little-C activities[34].

There is potential to use access to the arts through health routes for those experiencing poor health, to overcome inequalities and provide improvements in health and wellbeing to those experiencing disadvantage, especially if activities are delivered appropriately. However, within this approach there is also a need to acknowledge risks of using access to health-giving arts to disproportionately benefit those with higher socio-economic status, cultural capital, higher education, better access to - and familiarity with - “the Arts” or “Creativity” attainment, all of which has the potential to worsen health inequalities.

Target groups

Within Creative Healthier Lives – Arts in Public Health we are focusing on the health and wellbeing of specific population groups. These groups are linked to the NHS Core20Plus5 criteria which includes the most deprived 20% of the English population and five target population groups; maternity; severe mental illness (SMI); chronic respiratory disease; early cancer diagnosis; and hypertension case finding (see Appendix 1).

Within East Sussex, 14% of the population fall within the ‘Core 20%’, with higher concentrations in some areas; Hastings has the highest concentration, 43%, followed by Eastbourne, 20%. Our focus will be on Hastings given the level of identified need. Alongside this we will also target other areas and communities disproportionately and negatively impacted by the pandemic, including older people and children and young people, given our system priorities and the evidence indicating that these are areas where arts, creativity and culture can have a positive effect.

Social prescribing

Social prescribing is a means of enabling health professionals to refer people to local, non-clinical services. It is informed by the recognition that people’s health and wellbeing are determined by a range of factors (social, economic, and environmental), and aims to meet these needs in a holistic way whilst supporting people to take greater control of their lives. There is growing evidence demonstrating positive health and wellbeing outcomes linked to social prescribing, including improvements in quality of life, wellbeing and levels of depression and anxiety[35]^,[36].

Social prescribing has been embraced across wider health and care policy; it is considered a key component of Universal Personalised Care and was incorporated into the NHS long-term plan (2019) model of personalised care. Within this context and the focus on community-centred approaches to health, social prescribing has a key role to play in supporting the strategic priorities of this plan, enabling the embedding of arts and creativity into place and system approaches to improve and sustain the health and wellbeing of people across East Sussex.

Arts and social determinants of health

What do we mean by social determinants of health?

Many factors that affect our health and well-being are not medical, but rather social, cultural, political, psychological, or economic. A person’s chance of enjoying good health and a longer life is influenced by a range of interacting social, economic and environmental conditions in which people are born, grow, live, work, and age. These conditions are the determinants of health, and include individual lifestyle factors, community influences, living and working conditions, and more general social circumstances that influence our health[37].

The role of arts in social determinants of health

Recognition of the social determinants of health is now consistent across UK health policy documents; and across the UK, arts-based strategies are increasingly being integrated into systems to address the social determinants of health¹. A recent WHO Health report provided extensive evidence on how engagement with the arts can help to address social determinants of health, such as by developing social cohesion, reducing loneliness and social isolation, developing skills (including speech and language acquisition in children), building capacity, promoting social inclusion, and building individual and group identity.¹²

Research has suggested a direct association between those who engage in two hours of arts engagement per week and significantly better wellbeing, compared to those who engage in less than two hours a week[38]. This aligns to the idea of an ‘arts dose’ as a measure for creative activity and positive health and wellbeing impacts flowing from creativity.However, the evidence shows relatively low engagement with publicly funded arts amongst people living with economic and social disadvantage[39]^,¹; there is a need to improve access and engagement to support people to live healthier, happier lives.

Labonte[40] sets out the ways that risk conditions, psycho-social risks and behavioural risk factors interconnect to impact wellbeing and health. Population level actions at all stages are important to provide scalable and sustainable impact. Within this position paper and our strategic plan, we are framing arts and creativity as a protective factor for psycho-social risks and to provide effective intervention to support health and wellbeing.

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Figure 4: Framing Arts and creativity as a protective factor for Health and Wellbeing Source: Adapted from Labonte,1993.

Developing the Delivery Action plan

Creative Healthier Lives - Arts in Public Health the action capturing the range of ambitions and programme strands for the county will be led and developed by Public Health East Sussex, informed by works to date and discussions across a wide range of county, regional and national partners. The plan will support the East Sussex ambition to become a Creative Health County. It will ensure East Sussex continues to champion, develop, and invest in the artistic and cultural experiences that enrich the lives of residents. The plan builds on the intentions of this position paper and sets out a commitment to harnessing the health and wellbeing benefits of arts and creativity for everyone in East Sussex. The action plan will address key areas where arts and creativity can help mitigate against the ill effects of social health determinants, seeking to align with NHS England priorities including Core20plus5, and support the population health focus of the Sussex Health and Care Integrated Care System (ICS).

The development and implementation of the action plan is taking place during a period of permacrisis; defined as: “an extended period of instability and insecurity, especially one resulting from a series of catastrophic events [41]

It is noted and evidenced that arts and creativity can play an important role in supporting people during this period and provide tools and opportunities to support people’s health and wellbeing, despite the challenging context.

Focus areas.

To develop our strategic plan commitment to using the arts to address inequalities and improve the health and wellbeing of East Sussex residents, we have identified six areas which will help East Sussex become a Creative Health County:

1. Leadership and partnership

East Sussex Public Health will provide strategic leadership, whilst working with partners to develop leadership, co-production and collaboration across the county,in support of the creative health agenda, including within local government, health, voluntary, community and social enterprise (VCSE), and cultural sectors.

2. Knowledge

East Sussex Public Health will disseminate and support sustainable access to information about creative health, including the evidence base, best practice, evaluation methods and local activity.

3. Evidence

East Sussex Public Health will monitor the contribution of creative health activity across the county and against key local strategies, including the development of a Community of Practice (a Creative Health Support Collaborative) to share evidence and best practice.

4. Commissioning

East Sussex Public Health will create the conditions for continued investment in co-produced creative health programmes and interventions with a focus on target groups (as identified above).

5. Workforce development

East Sussex Public Health will identify, promote, and facilitate networking and professional development for all those engaged in creative health across the county.

6. Communication

East Sussex Public Health will promote the work taking place and disseminate best practice and findings to support ongoing interest and engagement with creative health across the county.

Engagement

We want to work together with organisations and individuals across East Sussex to engage more, listen, learn, and work intentionally, to enable participation from those who are seldom heard, alongside others across the county.

We will work with partners to develop targets and deliverables that allow us to hold each other to account and to see progress is made in meaningful and measurable ways. As part of this engagement work, we will collaborate with a wide range of arts and creative partners, including established providers and grassroots organisations, to ensure we are reflecting the diversity of need[5] and interest across the county.

Underpinning our engagement work to date were two social learning events; these events included representation from a range of stakeholders, including Public Health, Arts organisations, and community representatives. These events took place between December 2022 and February 2023 and sought to facilitate collaboration, shared ownership, and a commitment to developing East Sussex as a Creative Health County with participants. Building upon these social learning events we will be reaching out to service users via community groups, to understand more about their perspective on creativity and the arts, the impact of the activities, and what we need to consider as the plan develops.

Outcomes and Aspirations:

To achieve success, we are aware of the need to take a long-term approach to the Action Plan; within this we have the following priorities, outcomes, and aspirations:

Priority

Outcomes

Aspirations

1: Creative Health and the individual

• Increased awareness of creativity and the arts to manage individual health & wellbeing.

• Improved access to, and uptake of, the arts especially in coastal deprivation areas and those disproportionately impacted by the pandemic (e.g., older people, younger people).

• Increased engagement in individually meaningful activity and everyday creativity.

• Creative health opportunities are available and accessible to East Sussex residents, no matter who they are or where they live.

• Improved health and wellbeing of target communities, supporting their ability to cope in the context of the permacrisis, with reference to the post-pandemic context.

• Improved access to creative health interventions for those in coastal communities disproportionately affected by the pandemic.

• East Sussex residents encouraged to take part in a minimum of 2 hours per week of creative activity.

• Creative health activities promoted and commissioned across the county.

• Increase in research activity and contributions to the evidence base for creative health with a focus on how creative health can mitigate inequalities and provide detailed insights at a county level.

• East Sussex becomes a Creative Health County – providing everyone in East Sussex with the opportunity to engage in arts and creativity to support their health and wellbeing.

2: Creative Health and community

• Establish a community of practice to support & sustain creative health across East Sussex.

• Support the development of creative groups to build community and engage local communities in creative health.

• Establish a ‘snapshot’ of existing creative health initiatives across East Sussex.

3: Creative Health, Systems, Networks and Partnerships

• Establish a data set using quantitative and qualitative methods to understand creative intervention impact and broader impacts on health and wellbeing.

• Work closely with system and place partners to embed creativity and the arts into health improvement, healthcare, regeneration, and other relevant policy.

• Work with partners including Sussex Health and Care Integrated Care System (ICS) and National Centre for Creative Health to embed creativity at system.

• Build academic partnerships to further the evidence base and best practice for arts and creativity.

• In conjunction with arts and culture sector partners and communities, establish a collective ambition for what ‘good’ looks like in terms of wellbeing outcomes.

Governance

We will establish a working group to support the delivery and accountability of the Delivery Action Plan. This group will consist of colleagues from Public Health, Academia, NHS Sussex ICB, Persons with Lived Experience, and the Cultural Sector. The position paper and Delivery Action Plan will be reviewed and accountable to Public Health Senior Management Team (SMT) and the Adult Social Care and Health DMT, with reporting delivered through the Public Health Board, Culture East Sussex Board, ESCC Corporate Management Team and the Health and Wellbeing Board, as appropriate.

Conclusion

A justified response to any proposition is to challenge whether or not it will make any tangible difference to the people that the proposition seeks to serve, the , “So What?” that we need to address if we are serious about our plans.

We know that the health, social and civic challenges faced by the county we serve are considerable. With the ongoing need to promote inclusion and tackle the impacts of inequality, economic, social and health system issues and calls upon statutory and voluntary and community sector service offers seemingly higher every day we must do everything we can to simultaneously support our communities and prevent the exacerbation of impacts they experience as a result of the social determinants of health.

We need to do all we can to maximise the impact of the resources available to us and support the health and wellbeing, and cohesion and connectivity of the communities we serve.

These communities need a way to share their experiences and opportunities to move, share, connect, learn and create with others.

We know that sometimes simple opportunities can have positive, profound and lifelong impacts on individuals and through them shape and support families, communities and the county as a whole.

It is clear that creative health opportunities are effective in promoting lasting and sustainable health improvement and health protection across the life course, and that these opportunities can be of low cost and high impact.

With the wealth of creative assets, opportunities and expertise across East Sussex and building upon the works of ESCC, NHS and Creative sector partners there are many opportunities to harness the health improvement potential of creativity to add a much needed and potentially very powerful tool to the public health offer.

The potential of Creative Health to contribute to the vibrancy and resilience and health and wellbeing of our populations is clear. We ask therefore that stakeholders join us in developing the Creative Health Programme further, endorse the strategic direction and recognise the considerable health gains to be had in supporting the Creative Health agenda.

Appendix 2: Proposed Development Plan

Timeline: November 2022 – September 2023

Evidence review

A review looking at the impact of creativity on health and wellbeing, including what's been done, for who, best practice and effectiveness. This would include national (and potentially international) evidence around the impact of creative interventions on mental health and wellbeing for people of all ages. This would also look at best practice/guidance, and potentially project evaluation methods.

Scoping what is happening locally already

A scoping exercise to see what creative interventions already exist across the county. Subsequent discussion of phases 1 and 2 should identify where the gaps are, what works for who, and who could be specifically targeted with creative interventions. Use of East Sussex Community Information Service (ESCIS)[6] database and local authority commissioned creative programmesto build and develop the local activity picture.

Local data collation

Collation of local data to describe the mental health and wellbeing epidemiology, social prescribing activity, and comparative data. We are reviewing options including using the local community survey, the health-related behaviour survey and national wellbeing surveys.

Social Learning

Two social learning events have been held with stakeholders to identify needs and assets; the events scheduled for December 2022 and February 2023 featured an assortment of different stakeholders from the wider cultural, heritage and artistic agendas across East Sussex and helped us access a comprehensive range and depth of insight, knowledge and understanding. The events acted as a springboard to help refine the thinking underpinning this paper and set the foundations for the Strategic Plan that follows on from it. Future social learning events will be supported by engagement with the wider arts, culture and community sector across East Sussex to enable a wide representation of views, including service users, and develop interest and commitment to the plan and creative health across East Sussex. This has taken the form of a “supportive” offer for the Culture, Arts, Heritage and Creativity networks, systems, and practitioners.

The East Sussex Creative Health Support Collaborativesoft launched in June 2023 and will commence a series of events, webinars, gatherings, and opportunities from September 2023.

Implementation

The aim is for the strategic plan to act as a roadmap to enable the implementation of activity and initiatives, utilising arts and creativity to support health and wellbeing across East Sussex. It will be a ‘living document’ reflecting the developments and growth of arts and creativity across the county over time.

Appendix 3: PESTLE analysis of arts and creativity

Political	· Growing awareness, interest, and political context for the use of the arts and creativity to support health and wellbeing e.g., APPG Arts Health and Wellbeing, Arts Council England (ACE) Let’s Create strategy, UCL Creative Health MASc, WHO scoping review of the role of the arts in improving health and wellbeing, RSPH Arts, Health, and Wellbeing Special Interest Group. · NHS Long Term Plan commitment to giving people control over their health and more personalised care including social prescribing and a focus on connecting with local groups and support services. · Integrated Care Systems (ICS), commitment to tackling health inequalities and population health. · Local initiatives and actions which support the role arts can play in East Sussex and provide opportunities e.g., Eastbourne as an Arts Council England Levelling Up for Culture Place[7], Culture East Sussex. · Permacrisis context creates a sense of ‘what next’ for people and potential negative impact on people’s wellbeing, in this context there are opportunities for arts and creativity.
Economic	· ‘Cost of Living’ crisis means those hardest hit are those with the poorest outcomes who may also be least likely to access arts and creativity opportunities. · Autumn statement 2022 (17^th November 2022) – spending cuts and increases in tax will have an impact on individuals and organisations. · Limited sustainable, ongoing funding opportunities for arts interventions to support creativity. · Need for research and evidence to demonstrate impact and cost benefit. · Reliance of voluntary and community sector to deliver interventions, many of which experience funding and resource challenges. · Need to consider sustainability as part of project delivery.
Social	· Some attitudes to ‘arts’ and ‘creativity’ both from users and those making decisions can impact involvement, uptake and advocacy. · Perception of elitism in relation to arts can be significant for some target groups. · Increased demand for services. · Impact of the pandemic and cost of living crisis can impact engagement e.g., reluctance to attend public events or costs associated with taking part. · Opportunity to identify marginalised groups and work within existing provision to support engagement. · East Sussex has an old and ageing population, with 26% of residents over 65. · East Sussex has 22 LSOAs in the most deprived 10% nationally. · Opportunity to look at what’s happening across the county and review/ develop innovative approaches.
Technological	· Technology provides new opportunities for engagement and service delivery, especially around digital creativity. · Skills development. · Potential of digital exclusion based on skills, access and availability, digital poverty as a barrier to access. · Digital and information literacy requirements of initiatives and how that impacts access. · Social media engagement and opportunities to promote creativity and health.
Legal	· GDPR - data gathering and sharing · Safeguarding · Health and Safety · National Living Wage
Environmental	· Pros and cons associated with partnership delivery e.g., wider access vs. management challenges. · Location of interventions – may be more accessible to certain groups. · Climate change and environmental impact of delivery. · Opportunities linked to corporate social responsibilities (CSR) e.g., volunteering, community engagement. · Responsibilities to communities where initiatives occur e.g., impact on existing projects.

Appendix 4 Creative Health Indicators

The Public Health Outcomes Framework[42] outlines the government’s vision for public health, with two overarching outcomes:

1. Increased healthy life expectancy.

2. Reduced differences in life expectancy and healthy life expectancy between communities.

As a measurement of how well we’re doing, in relation to achieving these outcomes, a set of supporting indicators was devised. These indicators are split into four domains.

· Wider determinants

· Health improvement

· Health protection

· Healthcare and premature mortality

Nine of these indicators are listed below; these indicators have been chosen, in relation to the Arts in Public Health Strategic Plan, due to the accompanying evidence base that demonstrates the impact that arts and creativity can have on these public health outcomes. A summary of the evidence base is provided in the table:

Indicator	Domain	Evidence
Reduction in the attainment gap	Wider determinants PHOF Indicator- B02	Since 2019, the disadvantage gap index has increased from 2.91 to 3.23 in 2022 (the highest level since 2012)[43]. This suggests that the disruption to learning, due to COVID-19, has had a greater impact on disadvantaged pupils. Studies (qualitative, quantitative and some RCTs), involving music interventions, suggest engagement with the arts and creativity may improve educational attainment¹⁸. It’s also suggested that early childhood engagement in arts activities can predict academic performance¹².
A reduction in 16–17-year-olds not in education, employment, or training (NEET) or whose activity is not known.	Wider determinants PHOF Indicator-B05	Approximately 10.5% of 16–24-year-olds in England were not in education, employment, or training (NEET) in 2021[44]. Encouraging young people who are NEET to get involved in the arts and creative activities can help to develop their social skills, confidence, and self-esteem. This may result in them moving into education, employment, or training[45].
Pupil absence, Persons, 5-15 years	Wider determinants PHOF Indicator-B03	According to the most recent national statistics, 1.6 million pupils were persistently absent from school (missing 10% or more of their possible sessions) during the 2021/22 term[46]. Several studies have suggested that pupil participation in music programmes can reduce truancy and increase school attendance[47]^,[48].
The percentage of adults who feel less lonely (lonely often / always or some of the time, Persons, 16+ years)	Wider determinants PHOF Indicator-B19	According to the 2020/21 Community Life Survey, approximately 3 million people in England said they felt lonely, “often” or “always”[49]. There is strong evidence to suggest that engagement with the arts and creativity can improve aspects of social cohesion including reducing the feeling of loneliness¹⁸. These interventions have proved particularly successful amongst those living in rural or disadvantaged areas[50]^,[51],[52]and in people with dementia[53]^,[54].
Self-reported wellbeing - people with a low satisfaction score	Health Improvement PHOF Indicator-C28a	According to the Office for National Statistics (ONS), approximately 5% of the population of England have a low satisfaction score in relation to their self-reported wellbeing[55]. A report that synthesised the findings from over 3,500 studies relating to the role of arts and creativity in the prevention, management and treatment of ill-health and health promotion, suggested that there was strong evidence relating to the use of the arts to improve wellbeing in adults and that this evidence can be trusted to guide policy development. The evidence relating to children and young people is also promising¹⁸. An example of an intervention that was reported to improve self-reported wellbeing was tai-chi for older adults[56].
Frailty & MSK indicators	Health improvement PHOF Indicator-C27	Frailty in older age increases the risk of falls, fractures, disability, and premature death[57]. Arts and creativity engagement may reduce the risk of frailty in older age¹². Studies demonstrating this have focused on dance as an art form. However, other studies have demonstrated that engagement in music sessions, within inpatient settings, is associated with a decreased risk of falls[58]^,[59] and attending the theatre, concerts, museums, galleries, and the cinema within the community can slow the rate of frailty progression[60].
GP time and repeat visits	Health improvement PHOF Indicator-N/A	It is estimated around 20% of patients consult their GP for social issues[61]. Social prescribing (including the prescription of arts and creativity-related activities) has been shown to reduce the number of GP visits made by recipients[62].
Depression and self-reported happiness	Health improvement PHOF Indicator-C28c Depression- QOF presence and incidence (18+ years)	Approximately 1 in 6 (17%) adults experienced some form of depression in the summer of 2021, this is an increase of 7% in comparison to pre-pandemic levels[63]. Engagement with the arts and creativity has been shown to both prevent the onset of depression[64] and reduce depressive symptoms in those with the illness [65]. Positive effects can be physical (increased muscle strength and neurochemical effects), cognitive (stimulation of memory), social (increased social connectedness), personal (self-esteem) and cultural (creative expression) 58.
Anxiety (self-reported)	Health improvement PHOF Indicator-C28d	Despite improvements in the last year, average ratings for anxiety across the UK are still greater than they were before the start of the COVID-19 pandemic[66]. There is a wealth of evidence demonstrating the benefits that creativity and arts engagement and participation has on anxiety across all age groups (children, adults, and older people). Studies have also been conducted in people with chronic conditions, such as cancer[67]^{,[68],[69],[70]} and coronary heart disease[71]^,[72], those with non-psychotic mental health disorders[73]^{,[74],[75],[76],[77]} and in marginalised groups including migrants and refugees[78], prison populations[79] and the homeless⁴. All have demonstrated that arts and creativity-related interventions can reduce anxiety in participants.
Isolation and social networks	Wider Determinants PHOF Indicator- B18a, B18b	There is strong evidence to suggest that engagement in the arts and creativity can both reduce isolation¹⁹^,¹³ and act as a protective factor particularly for groups at a higher risk of isolation such as individuals with a neurological disease[80],[81],[82],[83]. Participation in group singing and music activities was found to enhanced wellbeing, development of new skills, positive relationships, a sense of belonging and increased social networks in older people[84].
Self-esteem	N/A	Increased self-esteem is one of the most frequently reported outcomes of arts and creativity engagement interventions. There is robust evidence demonstrating impact across the life course (children¹³, adolescents¹⁹, adults¹³ and older people[85]) and in higher risk groups including those experiencing mental ill-health[86],[87], stroke patients[88], adult prisoners[89] and young offenders[90].
Sense of life purpose	Health Improvement PHOF Indicator – C28b	A study commissioned by the Arts Council found that using public libraries had a positive impact on wellbeing (higher life satisfaction, higher happiness, and higher sense of purpose in life) as well as finding library users more likely to report good general health[91]. A review of the literature on creative arts and healing showed that, music has been evidenced to enhance mood and sense of purpose[92].

References

[1] Communities refers to groups or cohorts of people with knowledge/lived experience of creativity or practice of cultural, heritage, or artistic practice.

[2][2] This is an area of contention in cultural practice as it is difficult to define the precise boundaries between passive consumption of creative products, active engagement and attention and participatory involvement. The fluidity in roles and nature of audience and performer, creator and consumer, audience and collaborator, bystander and participant is essentially unresolvable.

[6] ESCIS is a database of community information and events developed and managed by the Library and Information Service of East Sussex County Council, in association with Brighton and Hove Library Service. It is free for everyone to use.

[7] DCMS and Arts Council England identified 109 Levelling Up for Culture Places across England (outside of London) that will be the focus of additional engagement and investment.

[1][1] See HM Gov 2019 Health matters: Prevention - a life course approach - GOV.UK (www.gov.uk)

[2] All-Party Parliamentary Group on Arts, Health and Wellbeing (2017) Creative Health: The Arts for Health and Wellbeing. Available at: Creative Health: The Arts for Health and Wellbeing.

[3] Davies,C.R. et al. (2012) Defining arts engagement for population-based health research: Art forms, activities and level of engagement, Arts & Health, 4:3, 203-216, DOI: 10.1080/17533015.2012.656201

[4] Faculty of Public Health Arts and Health Special Interest Group (undated) What do we mean by arts and health? Available at: Arts and Health Special Interest Group (fph.org.uk)

[5] Williams, R. (1989). Culture is Ordinary [1958]. In Resources of Hope: Culture, Democracy, Socialism. London: Verso, 3–14, cited by All-Party Parliamentary Group on Arts, Health and Wellbeing (2017) Creative Health: The Arts for Health and Wellbeing.

^{^[6]} Fancourt D, Aughterson H, Finn S, Walker E, & Steptoe A. (2021) How leisure activities affect health: a narrative review and multi-level theoretical framework of mechanisms of action. The Lancet Psychiatry, 8(4), 329 – 339. doi.org/10.1016/S2215-0366(20)30384-9

[7] Arts Council England (2021) Let’s Create, Strategy 2020 – 2030. Available at: Our strategy 2020-2030 | Arts Council England

[8] Kaufman, J. C., & Beghetto, R. A. (2009). Beyond Big and Little: The Four C Model of Creativity. Review of General Psychology, 13(1), 1–12. https://doi.org/10.1037/a0013688

[9] Arts Council England (2020) Let’s Create, Strategy 2020 – 2030, Outcomes. Available at: Outcomes | Arts Council England

[10] Grossi E, Tavano Blessi G, & Sacco PL (2019). Magic Moments: Determinants of Stress Relief and Subjective Wellbeing from Visiting a Cultural Heritage Site. Culture, medicine and psychiatry, 43(1), 4-24. doi.org/10.1007/s11013-018-9593-8

[11] Wang S, Mak HW, & Fancourt D. (2020) Arts, mental distress, mental health functioning & life satisfaction: fixed-effects analyses of a nationally-representative panel study. BMC Public Health 20, 208. doi.org/10.1186/s12889-019-8109-y

[12] Power A, & Smyth K. (2016) Heritage, health and place: The legacies of local community-based heritage conservation on social wellbeing. Health & Place, 39, 160-167. doi.org/10.1016/j.healthplace.2016.04.005

^{^[13]} Chatterjee HJ, & Noble G. (2013) Museums, health and wellbeing. Farnham, UK; Burlington USA: Ashgate Publishing Ltd.

[14] Fancourt & Finn (2019) HEALTH EVIDENCE NETWORK SYNTHESIS REPORT 67 - What is the evidence on the role of the arts in improving health and well-being? A scoping review for the World Health Organisation. Available at: https://www.who.int/europe/publications/i/item/9789289054553

^{^[15]} Fancourt D,& Steptoe A. (2019) The art of life and death: 14 year follow-up analyses of associations between arts engagement and mortality in the English longitudinal study of ageing. BMJ. doi.org/10.1136/bmj.l6377

^{^[16]} Graham-Pole J. (2000) Illness and the Art of Creative Self-Expression. Oakland, CA: New Harbinger Publications.

[17] Staricoff, R (2004) Arts in health: a review of the medical literature. London: Arts Council England. Available at: Arts in health: A review of the medical literature | Repository for Arts and Health Resources (artshealthresources.org.uk)

[18] Clift, S (2012) Creative arts as a public health resource: moving from practice based research to evidence based practice. Perspectives in Public Health, 132 (3), 120-127. doi.org/10.1177/1757913912442269

[19] Mak, Coulter & Fancourt (2021) Associations between community cultural engagement and life satisfaction, mental distress and mental health functioning using data from the UK Household Longitudinal Study (UKHLS): are associations moderated by area deprivation? BMJ Open, 11(9), e045512. doi.org/10.1136/bmjopen-2020-045512

[20] Fancourt, Warran & Aughterson (2020) Evidence Summary for Policy The role of arts in improving health & wellbeing Report to the Department for Digital, Culture, Media & Sport April 2020. Available at: DCMS_report_April_2020_finalx__1_.pdf (publishing.service.gov.uk)

[21] McQuade, L & O’Sullivan, R (2021) Arts and Creativity in Later Life: Implications for Health and Wellbeing in Older Adults. Executive Summary. Institute of Public Health. Available at: Arts-and-creativity-executive-summary-Final.pdf (publichealth.ie)

[22] Beauchet, O., Cooper-Brown, L.A., Hayashi, y. et al. (2022) Improving the mental and physical health of older community-dwellers with a museum participatory art-based activity: results of a multicentre randomized controlled trial. Aging Clin Exp Res 34, 1645-1654. DOI: 10.1007/s40520-022-02139-3

[23] Creech, A., Hallam, S., Varvarigou, et al. (2013). Active music making: a route to enhanced subjective well-being among older people. Perspectives in public health, 133(1), 36–43. https://doi.org/10.1177/1757913912466950

[24] Johnson, H (2020) Arts and Culture in a ‘new normal’. The Psychologist. Available at: Arts and culture in a ‘new normal’ | BPS

[25] Fancourt D, Bone JK, Bu F, Mak HW, Bradbury A. The Impact of Arts and Cultural Engagement on Population Health: Findings from Major Cohort Studies in the UK and USA 2017 – 2022. London: UCL; 2023 March.

[26] World Health Organization. Regional Office for Europe, Mak HW, Coulter R, Fancourt D. Patterns of social inequality in arts and cultural participation: findings from a nationally representative sample of adults living in the United Kingdom of Great Britain and Northern Ireland. Public Health Panorama. 2020;6(1):55–68.

[27] Calouste Gulbenkian Foundation UK Branch. (2016). Participatory Performing Arts: Summarising our approach. London: Calouste Gulbenkian Foundation UK Branch

[28] NHS (2019) Breaking Down Barriers to Healthcare. Available at: https://www.england.nhs.uk/publication/breaking-down-barriers-to-better-health-and-care/

[29] DCMS (2017) Taking Part focus on: Diversity Trends, 2005/06 to 2015/16. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/610859/Diversity_focus_report.pdf

[30] Brook O. (2016) Spatial equity and cultural participation: how access influences attendance at museums and galleries in London. Cultural Trends, 25:1, 21-34. DOI: 10.1080/09548963.2015.1134098

[31] Mak HW, Coulter R, & Fancourt D. Is area deprivation associated with differential engagement in arts, culture and heritage? Evidence from three nationally-representative samples. n.d 2020

[32] Mak HW, Coulter R & Fancourt D. (2020) Patterns of social inequality in arts and cultural participation: Findings from a nationally representative sample of adults living in the United Kingdom of Great Britain and Northern Ireland https://apps.who.int/iris/bitstream/handle/10665/331566/php-6-1-55-68-eng.pdf

[33] DCMS (2020) Libraries – Taking Part Survey 2019/20. Available at: Libraries - Taking Part Survey 2019/20 - GOV.UK (www.gov.uk)

[34]Johnson, HJ & Monney, N (2021) Using the Arts to Support the Arts: A Creative, Community-University Partnership Approach to Building Arts Inclusivity in Economically Deprived Communities. Forum Qualitative Sozialforschung / Forum: Qualitative Social Research, 22(3). https://doi.org/10.17169/fqs-22.3.3650

[35] Kings Fund (2020) What is social prescribing? Available at: What is social prescribing? | The King's Fund (kingsfund.org.uk)

[36] OHID (2022) Social prescribing: applying All Our Health. Available at: Social prescribing: applying All Our Health - GOV.UK (www.gov.uk)

[37] Dahlgren & Whitehead (1991) Policies and strategies to promote social equity in health Background document to WHO – Strategy paper for Europe. Available at: Policies and strategies to promote social equity in health (core.ac.uk)

[38] Davies, Knuiman & Rosenberg (2016) The art of being mentally healthy: a study to quantify the relationship between recreational arts engagement and mental wellbeing in the general population. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4702355/

[39] University of Warwick (2015) Enriching Britain:Culture, Creativity and Growth. The 2015 Report by the Warwick Commission of the Future of Cultural Value. Available at: warwick_commission_final_report.pdf

[40] Labonte, R (1993) Health promotion and empowerment practice frameworks. In PHE (2017) Reducing health inequalities: system, scale and sustainability. Reducing health inequalities: system, scale and sustainability (publishing.service.gov.uk)

[41] Collins English Dictionary (2022) ‘Permacrisis’. Available at: Permacrisis definition and meaning | Collins English Dictionary (collinsdictionary.com)

[42] Office for Health Improvement & Disparities, Public Health Outcomes Framework. Available at: Public Health Outcomes Framework - OHID (phe.org.uk)

[43] GOV.UK (2022) Key stage 2 attainment, Academic Year 2021/22. Available at: Key stage 2 attainment, Academic Year 2021/22 – Explore education statistics – GOV.UK (explore-education-statistics.service.gov.uk)

[44] GOV.UK (2021) NEET age 16-24, Calendar Year 2021. Available at: NEET age 16 to 24, Calendar Year 2021 – Explore education statistics – GOV.UK (explore-education-statistics.service.gov.uk)

[45] LGA (2021) Education to Employment – Supporting Youth Participation. Available at: Education to Employment - Supporting Youth Participation | Local Government Association

[46] GOV.UK (2022) Pupil absence in schools in England: autumn and spring terms. Available at: Pupil absence in schools in England: autumn and spring terms, Autumn and Spring Term 2021/22 – Explore education statistics – GOV.UK (explore-education-statistics.service.gov.uk)

[47] Cain M, Lakhani A, Istvandity L. (2016) Short and long term outcomes for culturally and linguistically diverse (cald) and at-risk communities in participatory music programs: a systematic review. Arts Health;8(2):105–24. doi: https://doi.org/10.1080/17533015.2015.1027934.

[48] Heyning L. (2010) The enhancement of musical and other learning for both teachers and students through a weekly choir session. Australian Journal of Music Education, 1. Available at: https://epubs.scu.edu.au/educ_pubs/1070

[49] GOV.UK (2021) Community Life Survey 2020/21- Wellbeing and Loneliness. Available at: Community Life Survey 2020/21 - Wellbeing and Loneliness - GOV.UK (www.gov.uk)

[50] MacLeod A, Skinner MW, Wilkinson F, Reid H. Connecting socially isolated older rural adults with older volunteers through expressive arts. Can J Aging. 2016;35(1):14–27. doi: 10.1017/S071498081500063X

[51] Murrock CJ, Graor CH. Depression, social isolation, and the lived experience of dancing in disadvantaged adults. Arch Psychiatr Nurs. 2016;30(1):27–34. doi: 10.1016/j.apnu.2015.10.010.

[52] Pearce R, Lillyman S. Reducing social isolation in a rural community through participation in creative arts projects. Nurs Older People. 2015;27(10):33–8. doi: 10.7748/nop.27.10.33.s22.

[53] Dowlen R, Keady J, Milligan C, Swarbrick C, Ponsillo N, Geddes L et al. The personal benefits of musicking for people living with dementia: a thematic synthesis of the qualitative literature. Arts Health. 2018;10(3):197–212. doi: 10.1080/13607863.2018.1433634.

[54] Ho RTH, Fong TCT, Chan WC, Kwan JSK, Chiu PKC, Yau JCY et al. Psychophysiological effects of dance movement therapy and physical exercise on older adults with mild dementia: a randomized controlled trial. J Gerontol B Psychol Sci Soc Sci. 2018:1–11 (Epub ahead of print). doi: 10.1093/geronb/gby145.

[55] Office for Health Improvement & Disparities Public health profiles. Available at: Public health profiles - OHID (phe.org.uk)

[56] Greenspan AI, Wolf SO, Kelley ME, O'Grady M. Tai chi and perceived health status in older adults who are transitionally frail: a randomized controlled trial. Phys Ther 2007;87

[57] Kojima G, Liljas AEM, Iliffe S. Frailty syndrome: implications and challenges for health care policy. Risk Manag Healthc Policy. 2019 Feb 14;12:23-30. doi: 10.2147/RMHP.S168750. PMID: 30858741; PMCID: PMC6385767.

[58] Chabot J, Beauchet O, Fung S, Peretz I. Decreased risk of falls in patients attending music sessions on an acute geriatric ward: results from a retrospective cohort study. BMC Complement Altern Med. 2019;19(1):76. doi: 10.1186/s12906-019-2484-x.

[59] Rogers N, Fancourt D. Cultural engagement is a risk-reducing factor for frailty incidence and progression in non-frail adults. J Gerontol B Psychol Sci Soc Sci. 2019;8. doi: 10.1093/geronb/gbz004.

[60] Fancourt D, Steptoe A. Physical and psychosocial factors in the prevention of chronic pain in older age. J Pain. 2018;19(12):1385–91. doi: 10.1016/j.jpain.2018.06.001.

[61] Husk et al. (2019) Social Prescribing: where is the evidence?. Br J Gen Pract, 69(678), 6-7. https://doi.org/10.3399%2Fbjgp19X700325

[62] Thomson, L. J., Camic, P. & Chatterjee, H. (2015). Social Prescribing: A review of community referral schemes. London: University College London.

[63] Office for National Statistics (2021) Coronavirus and depression in adults, Great Britain: July to August 2021. Available at: Coronavirus and depression in adults, Great Britain - Office for National Statistics (ons.gov.uk)

[64] Kim J. Effects of community-based group music therapy for children exposed to ongoing child maltreatment and poverty in South Korea: a block randomized controlled trial. Arts Psychother. 2017;54:69–77. doi: 10.1016/j.aip.2017.01.001.

[65] Stickley, Wright and Slade (2018) The art of recovery: outcomes from participatory arts activities for people using mental health services. Journal of mental health

[66] Office for National Statistics (2021) Personal well-being in the UK: April 2021 to March 2022. Available at: Personal well-being in the UK - Office for National Statistics (ons.gov.uk)

[67] Hirsch S, Meckes D. Treatment of the whole person: incorporating emergent perspectives in collaborative medicine, empowerment, and music therapy. J Psychosoc Oncol 2000;18(2)

[68] Haun M, Mainous R, Looney S. Effect of music on anxiety of women awaiting breast biopsy. Behav Med 2001

[69] Weber S, Nuessler V, Wilmanns W. A pilot study on the influence of receptive music listening on cancer patients receiving chemotherapy. Int J Crit Care 1997;8

[70] Morrison P, Nishimoto PW, Kim JB, Medina-Dupaix C, Bantum EO. Perceived Impact of Participation in a One-Time Expressive Arts Workshop. Mil Med. 2019 May 1;184(5-6)

[71] Collins R, Hunt A, Quinn C, Martyr A, Pentecost C, Clare L. Methods and approaches for enhancing communication with people with moderate-to-severe dementia that can facilitate their inclusion in research and service evaluation: Findings from the IDEAL programme. Dementia. February 2022

[72] White JM. Effects of relaxing music on cardiac autonomic balance and anxiety after acute myocardial infarction. Am J Crit Care 1999;8

[73] Stickley, Wright and Slade (2018) The art of recovery: outcomes from participatory arts activities for people using mental health services. Journal of mental health

[74] Uttley et al (2015) Systematic review and economic modelling of the clinical effectiveness and cost-effectiveness of art therapy among people with non-psychotic mental health disorders Health Technology Assessment, No. 19.18

[75] Lawson J, Reynolds F, Bryant W, Wilson L. 'It's like having a day of freedom, a day off from being ill': exploring the experiences of people living with mental health problems who attend a community-based arts project, using interpretative phenomenological analysis. J Health Psychol. 2014 Jun;19(6)

[76] Margrove KL, Heydinrych K, Secker J. Waiting list-controlled evaluation of a participatory arts course for people experiencing mental health problems. Perspectives in Public Health. 2013;133(1):28-35.

[77] Martin, L. et al (2018) Creative arts interventions for stress management and prevention – a systematic review. Journal of Behavioural Sciences https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5836011/

[78] Nilay Ugurlu, Leyla Akca & Ceren Acarturk (2016) An art therapy intervention for symptoms of post-traumatic stress, depression and anxiety among Syrian refugee children, Vulnerable Children and Youth Studies, 11:2, 89-102

[79] National Audit Office (2017) Mental Health in Prisons. Available at: www.nao.org.uk/report/mental-health-in-prisons

[80] Ali, K., Gammidge, T., & Waller, D. (2014). Fight like a ferret: a novel approach of using art therapy to reduce anxiety in stroke patients undergoing hospital rehabilitation. Medical humanities, 40(1), 56–60. https://doi.org/10.1136/medhum-2013-010448

[81] Morris, J. H., Kelly, C., Toma, M., et al. (2014). Feasibility study of the effects of art as a creative engagement intervention during stroke rehabilitation on improvement of psychosocial outcomes: study protocol for a single blind randomized controlled trial: the ACES study. Trials, 15, 380. https://doi.org/10.1186/1745-6215-15-380

[82] Hannemann B. T. (2006). Creativity with dementia patients. Can creativity and art stimulate dementia patients positively?. Gerontology, 52(1), 59–65. https://doi.org/10.1159/000089827

[83] Ozdemir, L., & Akdemir, N. (2009). Effects of multisensory stimulation on cognition, depression and anxiety levels of mildly-affected Alzheimer's patients. Journal of the neurological sciences, 283(1-2), 211–213. https://doi.org/10.1016/j.jns.2009.02.367

[84] What Works Wellbeing (2016) Music, singing and wellbeing in healthy adults. Available at: wellbeing-singing-music-briefing-nov20162.pdf (whatworkswellbeing.org)

[85] McQuade L. and O’Sullivan R. (2021): Arts and Creativity in Later Life: Implications for Health and Wellbeing in Older Adults. Executive Summary. Institute of Public Health. Available at: Arts-and-creativity-executive-summary-Final.pdf (publichealth.ie)

[86] Parr H. (2006). Arts and social capital. Mental health today (Brighton, England), 23–25.

[87] Kagan C, Sixsmith J, Siddiquee A, Bol S, Lawthom R, Kilroy A. Community Psychology Meets Participatory Arts: Well-Being and Creativity. Havana, Cuba: HOMINIS, International Conference; 2005

[88] Kongkasuwan, R., Voraakhom, K., Pisolayabutra, P., et al. (2016). Creative art therapy to enhance rehabilitation for stroke patients: a randomized controlled trial. Clinical rehabilitation, 30(10), 1016–1023. https://doi.org/10.1177/0269215515607072

[89] Arts Council England (2018) Arts and culture in health and wellbeing and in the criminal justice system: a summary of the evidence. Available at: https://www.artscouncil.org.uk/sites/default/files/download-file/Arts%20and%20Culture%20in%20Health%20and%20Wellbeing%20and%20in%20the%20Criminal%20Justice%20system-%20a%20summary%20of%20evidence.pdf

[90] Frogett and Ortega Breton (2020) Building Resilience and Overcoming Adversity through Dance & Drama (BROAD) 2019 Research and Evaluation Report. Available at: http://artsevidence.org.uk/media/uploads/PRU%202020%20BROAD%202019%20Report.pdf

[91] Fujiwara, D, Lawton, R & Mourato, S (2015) The health and wellbeing benefits of public libraries. Available at: The health and wellbeing benefits of public libraries.pdf (artscouncil.org.uk)

[92] Daykin, N., Mansfield, L., Meads, C et al. (2018). What works for wellbeing? A systematic review of wellbeing outcomes for music and singing in adults. Perspectives in public health, 138(1), 39–46. https://doi.org/10.1177/1757913917740391