In this case study, community artist and project manager Johan Skre reflects on how he has facilitated the engagement of older people experiencing social isolation and chronic conditions.

What projects have you been working on?

POBL Project

In 2019 POBL, a social housing association,  celebrated the people who shaped the way in which the National Waterfront Museum in Swansea evolved and showed how the museum plays an important role as community space. More than 150 individuals, groups, volunteers and staff took part in this project, all involved with the museum in some way. The result is an exhibition with over 120 portraits and 80 minutes of video interviews that give us an insight into who these people are, what they do and how the National Waterfront Museum connects them all. The exhibition was commissioned by Amgueddfa Cymru / National Museum Wales. It opened April 13th 2019 and was on display until September 29th 2019.

Celebrating the diversity and inclusivity of Swansea as it marks its 50th year as a city.

HARP Sprint

This project took place mainly from May to August 2020. It was organised by YLab, funded by Arts Council of Wales. We looked at how the arts can support people living through lockdown. As part of a team of 3, I contributed to the development of Rengarific, an inclusive online arts activity aimed at engaging veterans and others who might be particularly difficult to reach with an artistic activity. We had 3 groups with 15 people in total; 10 veterans (aged 45-70) from Pembrokeshire and 5 people from a brain trauma unit in Cardiff. The groups were led by experienced Swansea arts in health practitioner Lee Aspland.

Participants created works of art in their own time, using art forms of their choosing, and at the weekly meetups they discussed each other’s works and why they had made them. The groups ran for 6 weeks and culminated in 3 exhibitions. The response from participants was overwhelmingly positive.

In our health board’s social prescribing work we continued using Rengarific as an online activity for people who did not want to meet with others or leave their house. Everyone who participated were experiencing loneliness and low self esteem, with two cases of mourning a loved one as well. 10 people took part in 2 groups in the second lockdown of 2021. Lee Aspland facilitated these groups until he had to leave for health reasons. One lady, Melanie, said the art and conversations about her work helped her express things she hadn’t been able to with words, which allowed her to move on and process her grief. Ann said that art was an incredible way to connect to people, and that when doing art it all comes out, even things she had never talked about to anyone before.

Dance to Health

In 2021 SBUHB signed a service level agreement with Aesop, a charity that collaborated with SBUHB as a health partner to develop Dance to Health, a proven falls prevention activity. The funding was part of HARBWR’s budget and came from NHS charitable funds. Dance to Health uses falls prevention theory from Physiotherapy to create a programme of dance activities delivered by specially trained, qualified dance artists. The groups are mainly for people aged 65 and up, and at risk of falling or injuring themselves in the home, but is also open to younger participants with mobility issues. Compliance is very high compared to the traditional prescribed exercises, and the social aspect of the groups is an added bonus that should not be underestimated. Each group needs funding before it can start, usually from the local primary care cluster, as part of their falls prevention strategy. We now have 12 groups running across our health board, with more than 70 referrals since they started in March-April. Each group has a capacity of 20. Eleri D’Arcy who is leading SBUHB’s strategic falls prevention work, is very supportive of Dance to Health and we expect these groups to flourish and fill up within a year.

Do you see your projects as social prescribing activities?

With the POBL project I worked with socially prescribed groups and since 2020 I have worked with Arts on Prescription, which forms part of the social prescribing offering in Swansea Bay. Our current project HARBWR has referral partnerships with the eight social prescribers working for the health board, but also de facto social prescribers like the councils’ Local Area Coordination teams, OTs and several other community workers. When I started developing our referral routes in 2020, I expected all referrals to come from the social prescribers. But due to capacity issues and the nature of the patients that were referred to them, I quickly realised that I needed to broaden our horizons to make sure we could get referrals that were suitable, where we could make a real impact. This has worked really well, but the downside with many referral pathways is that it is more challenging to measure our impact and our interventions are not being added to patients’ NHS journals.

Recruitment – why do participants take part in social prescribing activities?

When referring people to HARBWR, referrers specify one or more reasons they have referred someone.The categories are a mix of feedback from referrers (what they think is most prominent) and some specialised activities (falls prevention and pulmonary rehab). The categories are: Anxiety, Depression, Low confidence, Isolation / Loneliness, Pain management, Falls prevention, and/or Long COVID / Pulmonary rehab.  The one box that is always ticked is isolation/loneliness. The second most ticked is low self esteem. So I think our activities are popular because we offer a positive way for people to get better. Our activities are fun, social and not as “scary” or intrusive as traditional clinical treatment. Patient compliance is a challenge in occupational therapy, falls prevention and pulmonary rehab; and this is significantly better with activities such as Dance to Health and the wellbeing choir. Talking about and receiving treatment for mental health problems and trauma can be a big hurdle for some, but exploring and expressing these issues through arts activities can be a gentle way to make progress. We also give participants something to look forward to and something they get better at. In Dance to Health this is emphasised with regular tests to show their progress, and over 90% of participants improve their physical abilities.

Patient compliance is a challenge in occupational therapy, falls prevention and pulmonary rehab; and this is significantly better with activities such as Dance to Health and the wellbeing choir. Talking about and receiving treatment for mental health problems and trauma can be a big hurdle for some, but exploring and expressing these issues through arts activities can be a gentle way to make progress.

Our facilitators are mostly chosen based on relevant experience, as there are no agreed requirements or qualifications for delivering Arts in Health activities (except Dance to Health, which requires a dance degree and special training). It is however essential that facilitators have experience with vulnerable people and leading groups, as well as undefinable people skills that lets them connect with a broad range of people and show a measure of empathy. In addition to the time it takes to deliver sessions, facilitators are paid some hours to communicate with participants and keep them engaged between sessions. For example, Lee Aspland, a visual artist and photographer in is 50s,  has been working with vulnerable people for the health board since 2008, and has had to shield during COVID for health reasons. So he connected with older participants in particular during Rengarific sessions, as he had shared experience with them. I am currently recruiting 4 new facilitators to expand what we do, and in addition to experience I am looking at their artistic practice and how they got into Arts in Health. This is to ensure breadth in artistic modalities, but also to look at how the artists’ experience can magnify their impact. For example, I have been asked to suggest some activities for a pilot programme looking to support people waiting for assessment or treatment for stomach cancer. As it happens I have interviewed a ceramic artist who started an Arts in Health degree after her son was diagnosed with leukaemia, and she found ways of processing that horror through her art. This experience has inspired her to do an Arts and Health degree in Cardiff, so that she can help others with similar experiences.

What were the outcomes on participants?

It is proven that engaging in creative activities and the arts is beneficial to people’s health. With HARBWR we are just starting a proper evaluation now, in collaboration with the Wales School for Social Prescribing Research and USW, so there is little empirical evidence as of yet. With Dance to Health it will take several months before participants start to see physical improvement. But the feedback from all activities has been very positive, with participants reporting that the activities they go to give them something to look forward to, and that the art they make helps them express things they haven’t been able to say or reflect on before. Research on loneliness tells us that, although difficult to measure, we are making a big impact on people’s everyday lives, but also their future health, by helping them out of isolation and loneliness.

How do you engage older people who experience social isolation?

What do you do to meet participants’ engagement needs?

This is our biggest challenge. Since I am the only member of staff, and I work 15 hours per week, I haven’t got the capacity to follow people up and engage with them about their art, what they would like to do next and so on. Our older service users need more than just an email with dates for workshops, a lot of them need to chat and interact with a human being and there is no time for that with present arrangements. We have seen quite a few people drop out after a few sessions, and I think we could do a lot more with this and showcasing our participants’ work on social media etc. I have started the process of recruiting someone to help with admin and engagement 1 day per week.

What is important to you in terms of values?

To promote the use of arts and creative activities in our health board, but ultimately my main goal is to contribute in ways that are unique to the arts so that we make the biggest possible impact on the health of our population and our health system. It’s not about the art, but how the art can really support people who have been through a lot and lighten the burden on a stretched system. I am also passionate about contributing to a foundation for arts in health training or qualifications for artists, to make it a more viable career path for artists.

What takes a lot of time but is really important?

Building and improving relationships with referrers is key to receiving high quality referrals, which in turn have better results from prescribed activities. For our older participants the social aspect of an activity really makes all the difference, as well as the setting. We organise our activities in the community, like church halls or community centres, which is less intimidating than a hospital or surgery. Regular human contact seems to help greatly in keeping older people engaged, which is why we need more human resources for this work.