A GUEST BLOG BY DR FRANCES WILLIAMS
This guest post by Dr Frances Williams argues that the field of Arts in Health needs safe spaces and new platforms for critical reflection and democratic decision making, particularly when faced with a seemingly rising tide of privatisation of public services.
Dr Frances Williams completed her Phd on the topic of arts, health and devolution at Manchester Metropolitan University in 2019. She lives and works between North Wales and South London.
WE NEED TO TALK ABOUT PRIVATISATION
Last month saw the launch of a new course in ‘Creative Health’, due to start at University College London, later this year. Taking the name of the All Party Parliamentary Group’s report of 2017, it was billed as auspicious as it would ‘create a new generation of socially engaged scholars and practitioners’ able to ‘meet the needs of a changing health, social care and voluntary third sector’.
In the Q&A at the launch, one prospective student asked panellists what they thought about the ‘downside and danger’ of arts on ‘social prescribing driving the privatisation of services’. An awkward silence met this ‘good question’. While the pressing need for investment in the third sector was underlined, no call was made to restrain the influence of corporations within the NHS. This is despite mounting public concern – inflamed by the government’s response to the pandemic – that the NHS must be kept publicly owned and free at the point of delivery. Many might ask, why not?
Perhaps the panellists here were taking their cue from the Creative Health report itself, where blame for lack of progress was laid implicitly at the feet of the NHS rather than than multi-national corporations. ’The culture of healthcare can tend too much towards the technical-industrial and bureaucratic’ (APPGAHW, 2017: 5). APPG chairman, Lord Howarth, describes the NHS as ‘bureaucratic in character’, emphasising the alternate need for a ‘health-creating society’ above expanding sickness services (Howarth, 2017).
Such a growth in demand, prompting a parallel rise in supply, would undoubtedly be undesirable. But given the current pandemic, might this criticism now be extended on equal terms to corporate interests too? Have they not been found to be just as costly and bureaucratic, if not considerably more so? The NHS has proved remarkably efficient in delivering the vaccine roll-out when set alongside the failed venture of ‘Test and Trace’ outsourced to private companies such as Serco by way of Baroness Dido Harding (friend of the Health Minister, Matt Hancock, recently found to be on the wrong side of the law).
Of course, the Creative Health report never aimed to speak truth to power, but rather nestle its recommendations amongst government aims (under Teresa May’s leadership at that time who described health inequality as a ‘burning injustice’.) As such, it stands an exemplar of shrewd realpolitik. But can such diplomacy, backed-up by the type of evidence provided, stand in place for collective discussion amongst workers within the field as to what ‘building back better’ might involve?
Inequalities exacerbated by the pandemic throw this question into sharp relief as the field has historically been built on certain understandings of how social conditions give rise to good health. The ‘social determinants of health’ (Marmot & Wilkinson, 1999) constitute the conditions in which people are born, grow, work, live and age. Governments use good housing and good education to promote good health outcomes. But ’culture’ was late in being recognised as an area able to promote individual and collective health.
As part of my PhD research (Williams, 2019), I looked at how the field of ‘Arts in health’ emerged in the late 1990s and chart its evolution as a political movement. It has always been aligned with Tony Blair’s ‘third way’ which promoted private capital alongside public investment in relation to the NHS as proposed in The New NHS, Modern, Dependable (1997). Heath Secretary Alan Milburn set out the new terrain:
This is about redefining what we mean by the National Health Service. Changing it from a centrally run monopoly provider to a system where different health care providers – public, private, voluntary and not-for-profit – work to a common ethos, common standards and a common system of inspection…This is the modern definition of the NHS (Milburn, 2002).
Blair’s premiership marked an opportunity for change at a time when Michale Marmot’s groundbreaking research first exposed the human cost of Margaret Thatcher’s monetarist policies in the 1980s. Hardship was more keenly felt in regions in Scotland, Wales and the North of England where heavy industries once thrived. At the seminal ‘Windsor conferences’ leading up to the millennium, arts in healthcare emerged in the form of a ‘national’ entity for the first time (though this was a misnomer, to an extent, as it never included Scotland or Wales, now devolved). The Windsor report optimistically chimed that ’elevating the arts, health and wellbeing into a pivotal role across the spectrum of health care’ might represent ‘the real third way for health’ (Philipp et al, 1998: 6). The first ever ‘National Network for Arts and Health’ (NNAH) was put in place in 2000 and with that also, the first research centre for Arts in Health too, based at Durham University.
The drive towards embedding arts in health policy at highest level of government appeared to transcend party political difference in this decade. Andrew Mawson’s pioneering heath centre in Bromley-by-Bow, for example, was described as ‘a bridgehead between New Conservatism and New Labour’ (Froggett et al, 2001).This new type of institution pioneered social prescription and also went on to become the model for the roll out of ‘Health Living Centres’ in 1999. Mawson was outspoken in his condemnation of the public sector approach which he castigated as ‘liberal ideology’. He was determined that his health centre would not be:
…another tacky, run down public sector building, but a centre of community and entrepreneurship defined by innovative design, a welcoming environment and quality furnishings, with hard work, enterprise and creativity at its heart (Mawson, 2008: 78)
While the tastefulness of the furnishings might not have been in question, they left much room for ambiguity as to what the venue revealed about its level of public accountability. One visiting Secretary of State visiting Bromley-by-Bow asked ‘where is the NHS sign?’ such was the camouflaged environment surrounding him. In the decades that followed, variegated public-private institutions such as Bromley-by-Bow, were acknowledged as those which had ‘discarded’ embedded welfare state provision ‘in favour of privately capitalised and mixed economy models of cultural and social organisation’ (Philips, 2011: 36). Such processes were mirrored within The Arts sector more broadly, whose own public institutions reorientated their funding streams at the behest of Arts Council England, away from public ‘subsidy’ and in favour of the cultivation of private ‘investment’.
Off the hook
When policies of austerity were introduced in the UK, key figures sounded alarms. As the state was ‘shrunk’, ‘our capability to think and plan on a large scale has been delegated to corporations… as though the process itself was not initiated by vested interests which too rarely consider health impacts’ (Parkinson & White, 2013). For some, then as now, this rejection of the ‘big’ welfare state was seen as the healthy pursuit of creative solutions for a system ‘broken beyond repair’ (Cottom, 2019). But for others, alarming levels of social and economic neglect resulted in the move away from national state provision to more regional footprints (granted needy status as ‘creative places’). Disparities of resource, unevenly distributed, led to the ‘abandonment of areas of deprivation by both the market and the state’ one researcher claimed at this time (Friedli, 2012: 9 my italics).
Researcher Lynne Friedli pointed to a ‘fatal weakness’ in public health leadership to ‘question the balance of power between public services, communities and corporate interests’ (Friedli, 2012: 10). With critical attention solely trained on ‘the operation of the Welfare state as opposed to the operation of the market’, the state was too easily ‘blamed’ for social hardship while ‘unregulated free market capitalism’ was left ‘off the hook’ (Friedli, 2012: 8). She identifies how ‘ideological support’ is tacitly lent to the latter over the former through unquestioned faith in the market which can divert attention from ‘questions of economic power and privilege and their relationship to the distribution of health’ (Friedli, 2012: 3).
This bias exists in more recent, hybrid institutions now established over the country, not just in Bromley-by-Bow. The Life Rooms in Liverpool, for example, places itself ‘at the heart’ of the local community offering a mix ‘of learning, recovery, health and wellbeing’. It provides ‘one roof’ under which many private, local-authority owned and voluntary social care organisations co-mingle. Yet staff here have observed how the signage has proven ‘too corporate’ for some local residents who are ’deterred’ from coming in’ as a result (Harrison et al, 2017: 19). While the blurring of such distinctions might offer opportunity to find and fill ‘gaps between services’, such ambiguities prove confusing for publics and can disguise different motives, responsibilities and accountabilities.
These are same muddy waters Alison Pollock points to in her comments on the latest NHS reforms for health and social care outlined by the government this month. ‘No control is proposed over the composition of these (provider) collaboratives,’ she notes. ‘They could and presumably will consist of private as well as public providers, e.g., of mental health services, residential and nursing care, acute hospital care and pathology services.’ Such as move would risk ‘giving private companies influence over the allocation of NHS funding’. Pollock quotes Dr Graham Winyard on this point: ‘They are there to make money from the NHS’. And so, she concludes, they ‘should not be admitted as members. Yet the document is silent on this point’ (Pollock, 2021: 6).
The distinction between private and public has now become a line to exploit rather than carefully drawn. Mixed ‘collaborative’ partnerships have been enabled by recent NHS restructuring which has seen this dividing line breached by the very same actors intent on ‘radical’ reform. The Director of the NHS Vanguard programme for example, Samantha Jones, became Chief Executive of UK branch of the US corporation Centene only months after leaving her NHS job. We are now at the point, in post-Brexit pandemic-hit Britain, where there US multi-nationals are buying-up GP services across areas of the country, a move largely opposed by the general public but made welcome by NHS such managers, such as Smith, intent on ‘integration’.
Those campaigning to keep the NHS public want to give these US companies less, not more control. Yet their power will be enhanced by de-regulation as the checks of ‘common ethos, standards and system of inspection’ set by Milburn will be dispensed with by Hancock. Those in Arts in Health risk becoming complicit in the cultivation of creative ‘innovation’ on terms whereby the public sector socialises risk, while financial rewards are privatised (Mazzocato, 2011). As such, the organisational models developed under the Arts in Health banner demand fresh scrutiny and contextualisation beyond the usual terms of ‘evaluation’. They urgently need to be placed within their historical, political and economic contexts too.
The final irony, then, is that a recent report on social prescribing by those working in the third sector describes it as having as potential to ‘exacerbate inequality’ in a ‘range of ways’ (Cole et al, 2020). As the Chair of the Royal College of General Practitioners in Wales made the point: ‘It is disproportionately more likely that the prescribed activity will be available in a more affluent community’. Meanwhile, speaking on Radio Four in January, Baroness Cavendish, called for a more ‘bullish’ approach to social prescribing as doctors are too shy of ‘telling people how to live their lives’. This goes directly against Michael Marmot’s insistence on the ‘shift of power’ necessary to enable us to gain a ‘sense of control’ over our lives (Marmot, 2011: 28).
Will such inversions of meaning be highlighted in the forthcoming talk on the ability of social prescribing to reduce inequalities at UCL? Claims could look cosmetic if there is no space for outlining the hidden agendas at play by parties working in collaboration including those that constitute Arts in Health. Artists comprise one ‘hidden cost’, unfairly burdened with responsibilities of care thrown-up by a rigged public infrastructure. The labour of artists constitutes an ‘invisible subsidy’ (Belfiore, 2021: 14). While nurses under current pay schemes, are reduced to using food banks, becoming the objects of charity.
Invisibility, silence, along with undeclared bias then, could lead to the tragic development of ‘creative ill-health’. Yet how would we know to recognise such a perversion if it came into being? Or, indeed, if it already has? There’s a need to create safe spaces and develop new platforms for critical reflection within the field of Arts in Health in order to have open, more democratic discussions around its future. These can’t only occur behind closed doors between Lords and Baronesses useful as that may be in our current ’chumocracy’.
No doubt it is easier to write about these issues working outside of institutions that rely on government funding. This is certainly the case when diktat is fast replacing any ‘arms length’ principle in The Arts. There is a ‘climate of fear’ developing that prohibits open discussion of histories of injustice, one underlined by threats to withdraw public funding. Shockingly, even exhausted healthcare workers are being made subject to attack (from anti-vaxers and the far right, alike).
Under populist governments, silence may seem the safe, indeed, the only option. But in losing the ability to articulate our own restraint, binds are reinforced. Students studying ‘creative health’ deserve fuller, franker, more nuanced answers to their question if their future roles – working in a field dedicated to social good – are to be secured. As Lord Adebowle warned rather ominously at the launch of The National Centre for Creative Health, ‘the future is created as much by what we don’t discuss as what we do’.
All Party Parliamentary Group on Arts Health and Wellbeing (2017). Creative health: the arts for health and wellbeing. http:// www.artshealthandwellbeing.org.uk/APPG-inquiry/Publications/ Creative_Health_Inquiry_Report_2017_-_Second_Edition.pdf
Belfiore, E. (2021) Who cares? At what price? The hidden costs of socially engaged arts labour and the moral failure of cultural policy. European Journal of Cultural Studies.1–18.
Burns, H. (2015) Make the NHS a well-being service not sickness service. The New Scientist. https://www.newscientist.com/article/dn27197-make-the-nhs-a-well-being-service-not-sickness-service/#ixzz6nNn5J5EM
Cole et al, (2020) Rolling Out Social Prescribing : understanding the experience of the voluntary, community and social enterprise sector. National Voices.
Cottom, H. (2018) Radical Help: How we can remake the relationships between us and revolutionise the welfare state. Virago, Little Brown, London.
Friedli, L. (2012) ‘What we’ve tried, hasn’t worked’: the politics of assets based public health , Critical Public Health, DOI:10.1080/09581596.2012.748882
Froggett et al, (2001) Bromley-by-Bow Centre research and evaluation project: integrated practice – focus on older people. University of Lancashire.
Harrison et al, (2017) An evaluation of the Mersey Care Professional Advice Area. Liverpool John Moores University.http://allcatsrgrey.org.uk/wp/download/management/human_resources/An-evaluation-of-the-Mersey-Care-PAA-service-final-1701171.pdf?platform=hootsuite
Howarth, A. (2017) Dancing to a Different Tune: The Contribution of Arts to Health. Haygarth Lecture, University of Chester. https://www.chester.ac.uk/node/41127
Marmot, M., Wilkinson, R., (1999) Social Determinants of Health. Oxford UniversityPress, New York.
Marmot, M. (2010) Fair Society, Healthy Lives. The Marmot Review. University College London. www.ucl.ac.uk/marmotreview
Mawson, A. (2008) The Social Entrepreneur: Making Communities Work. Harper Collins. London.
Mazzocato, (2013) The Entrepreneurial State: Debunking Public vs. Private Sector Myths. Anthem Press.
Milburn, A. (2002) Speech to the Commonwealth Fund International Symposium. http://www.ukpol.co.uk/alan-milburn-2002-speech-to-the-commonwealth-fund-international-symposium-on-health-policy/
Parkinson, C & White, M. (2013) Inequalities, the arts and public health: Towards an international conversation. Arts Health. 2013 Aug 12; 5(3): 177–189.
Philips, A. (2011) Too Careful: Contemporary Art’s Public Making. In: Andrea Phillips and Markus Miessen, eds. Caring Culture: Art, Architecture and the Politics of Public Health. Berlin/Amsterdam: Sternberg Press/SKOR, pp. 35-56. ISBN 978-1-9341-5-71-9.
Philipp et al, (1998) Beyond The Millenium. A summary of the proceedings of the first Windsor Conference. The Nuffield Trust.
Pollock et al, (2021) ‘Integrating care: Next steps to building strong and effective integrated care systems across England’ Response by Newcastle University.
Williams, F. (2019) ‘In a creative healthy place? Situating Arts and Health within the discourse of ‘the devolution revolution’. Doctoral thesis (PhD) Manchester Metropolitan University.