Arts & Health: Economics and the dangers of Randomised Control Trials

Posted in Arts & Health, News by chrisfremantle on September 15, 2014

Couple of really interesting presentations and discussions at the ESRC funded Arts, Health & Wellbeing Research Network meeting in London. Unfortunately this was the last event in the series, but I’m sure that a longer term programme will emerge, especially when it was noted that there have been some 200 participants of which approximately 50 have been Phd students.

The first interesting area was a presentation by David McDaid on health economics and how that field interacts with research and decision making. We know that decisions about healthcare are made on the basis of efficacy and cost, but McDaid unpacked some of the basics for us. He highlighted that when looking at the economics of any decision about healthcare we need to understand:

  • the cost of inaction;
  • the cost of action (and here he pointed out that understanding project or programme costs is very difficult and arts organisations can be quite opaque about their costs. Costs also need to include in-kind costs absorbed by partners.);
  • The cost effectiveness of the action in comparison to other potential actions;
  • levers for maximising value (ie how to maximise the money spent by working on uptake and participation).

In terms of the cost of inaction he highlighted three areas to consider:

  • Cost of every visit to the GP (which in the figures he showed was about £45 per appointment);
  • The higher cost of attending Accident and Emergency;
  • The even higher cost of hospitalisation.
  • In parallel with this are the informal care costs (ie how much is the family bearing factored at hours times the minimum wage), and the out of pocket costs for the individual for treatments or lost earnings.

Some really interesting challenges emerged in response to McDaid’s framing of the economics through the example of ‘arts on prescription vs. individual therapy sessions.’ Firstly, why these are presented as alternatives when in many cases they might be complimentary? Secondly why reduced contact is presumed to be good when there are circumstances where greater contact with healthcare workers is the good outcome. To which David responded, “These are all good points, but the model of decision-making in healthcare economics is simplistic.”

On the back of McDaid’s presentation were two evaluated project case studies, one using reading with people with chronic pain, and the other using arts on prescription for people with depression and anxiety. Both were really significant, but looking at them through the lens McDaid had provided, you’d note:

  • the need to focus on efficiency of delivery, maximise participation, understand operational finances and share models;
  • be prepared to scale up from projects to programmes.

The afternoon presentations focused on the perceived weaknesses of two Randomised Control Trials recently published. Without trying to rehearse the details, some interesting points emerged which suggest that using Randomised Control Trial (the gold standard for evidence in healthcare decision-making) to prove the value of arts interventions is not something to be undertaken lightly.

Arts interventions need to be understood as “complex interventions” as defined by the Medical Research Council and interestingly this means that any “complex intervention” should,

  • Start with a theory;
  • define which ingredient(s) essential;
  • include process analysis.

In terms of theory, healthcare is looking for the ‘theory of change’ that the study is going to test, but that ‘theory of change’ requires the practitioners (not just the researchers) to be very clear about their practice, and to deliver that practice in a consistent way in relation to the theory. (This clearly links to the ongoing development of a qualification in participatory practice by the ArtWorks programme in Scotland, jointly funded by the Paul Hamlyn Foundation and Creative Scotland.)

Perhaps one of the characteristics of any theory of change in the arts is the fundamentally voluntary nature of participation in that change. It’s one of the problems pointed out with Randomised Control Trials – people get selected to participate in the arts randomly. This is slightly problematic, particularly when you’re asking someone to engage in creative activity or even singing.

The point about defining essential ingredients is important – process-based work is often about context, empowerment and empathy as well as specific activity, but it’s extremely difficult to study more than one factor.

Finally the process analysis is important, on one level because that might a way to balance the attempt to define the essential ingredient, but also because timing and pattern are important in experiential work, e.g. participants are often interviewed for the baseline and then interviewed at the end of the programme, precisely the point where they might be feeling a sense of loss of an activity that had been enjoyed. Even a Randomised Control Trial is subject to such factors: not only what questions are you asking, but when are you asking them.

There was reference made to another Randomised Control Trial focused on singing, to be published imminently, which was ‘successful.’ It will be interesting to understand how this was constructed.  But going back to McDaid’s point, scale may be critical because at least one really good, well evaluated, project was unable to engage with the Clinical Commissioning process simply because it’s too small (and most arts & health organisations are small even in the cultural sector, let alone in relation to healthcare).

The understanding of “complex interventions” in the medical literature bears further scrutiny and some references were suggested including Marchal (2013) (and Yin (2009) on “systematic case theory”).

Theo Stickley started the morning by offering an imagined scenario around the trajectory from the materialist understanding of healthcare that characterised the 20th Century through a transition to an holistic understanding of healthcare that could characterise the 21st Century.  Whilst it’s important that the practitioners delivering arts in healthcare are well trained and professional, that they can articulate clearly their theory of change, as well as the economics of their interventions, the belief that the Randomised Control Trial is the way to prove the value might genuinely jeopardise what makes the arts distinctive from other interventions. We must become more articulate about the characteristics and values of our artforms and forms of intervention to ensure that they have equal status with the economics and the criteria imposed by the methods of research.

Only one speaker said, “and the art produced in this project was good too. We were proud of it.”

The Scot who burned down the White House

Posted in Uncategorized by chrisfremantle on September 4, 2014

Originally posted on adcochrane:

Burning of the White House by British forces, 1814

Burning of the White House by British forces, 1814

The Scots have had had a remarkable impact on American history. Less well-known is the Scot who burned down the White House and inadvertently helped inspire the American national anthem,  a “mad, romantic, money-getting” Cochrane.

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What art have I seen? Louise Hopkins

Posted in Exhibitions by chrisfremantle on September 3, 2014

Linlithgow Burgh Halls – great space and a nice chance to see a range of Hopkins’ reworking of everyday objects such as maps and fabrics.

Whose space is it anyway?

Posted in Arts & Health, News, Sited work by chrisfremantle on September 1, 2014
Maria McCavana and Bill Breckenridge, Waiting Room, CAMHS Gorbals, 2013.  Photo Alan McAteer (with permission)

Maria McCavana and Bill Breckenridge, Waiting Room, CAMHS Gorbals, 2013. Photo Alan McAteer (with permission)

You can’t easily go and see the work that Maria McCavana and Bill Breckenridge did for the Child and Adolescent Mental Health Service (CAMHS) unit in the Gorbals. It’s not that we might not particularly want to visit a CAMHS unit. It’s not that it isn’t public space (of course it’s not a gallery, not that sort of public space). It’s real public space, public service space (NHS space) where people sit and wait whilst their children and young people attend sessions with clinical psychologists and therapists. You really can’t just wander in and have a look at the art.

This is a problem for arts and health projects. The public places in which they are often to be found aren’t public in the same way as a park or a street or even the atrium of a big hospital.

But these spaces matter. And it’s all the more important that as a professional community we are able to see what colleagues and peers are doing, hear how it works and learn from these projects.

Maria McCavana, artist, and Dr Lindsey MacLeod, Clinical Psychologist specialising in child and adolescent mental health, shared the process and results of the work in the CAMHS unit in the Gorbals and also previously at the Knightswood Centre (now demolished and therefore even less accessible). They talked about their interests and motivations as well as the lessons learnt.

This event was part of UZ Arts’ programme for the Fringe (for background on UZ see the end of the piece).  Maria participated in UZ Arts’ residency programme in Sri Lanka this year, and UZ are interested in how the lessons can be transferred to artists in Sri Lanka for the benefit of the patients, families and carers. Creative Therapies, the Glasgow based art (in the broad sense) therapies organisation, provided organisational support and structure and the project was funded by the Yorkhill Children’s Foundation.

The brief for the project was focused on the users of the space, the clients, having an influence on the design of the space, actually to give them a sense of ownership. Lindsey said, “We asked young people to make their mark on the building.” The brief also asked that, “the space should be interesting, but not too interesting (ie not overwhelm the kids on the spectrum or over stimulate the children with ADHD).”

It was refreshing to hear the concerns from the perspective of the clinician:

That colleagues and teams are busy (and a project such as improving a waiting area is on top of an already full workload). Service delivery on a day to day basis is the priority.

That as a clinician, maybe more so in mental health services, you need to be very confident to entrust your patients/clients into the hands of someone outside the NHS.

That if it wasn’t some of the clinicians’ “cup of tea,” did that really matter? This led onto a really interesting discussion around evaluation.

Of course we assume that evaluation is important. But what exactly are we evaluating?

Is the space improved? Yes the space is improved, but it would have been improved with fresh paint, new carpets and new furniture. What did the ‘art’ do? Actually the art made it more specific, more interesting. The waiting room is now a nicer, more comfortable waiting room, but its also now an interesting waiting room rather than a generic one. It’s got funny bookshelves where each book fits into its own slot.

Maria McCavana and Bill Breckenridge, Waiting Room, CAMHS Gorbals, 2013.  Photo Bill Breckenridge (with permission)

Maria McCavana and Bill Breckenridge, Waiting Room, CAMHS Gorbals, 2013. Photo Bill Breckenridge (with permission)

It’s got an amazing sculptural bush of individual letters sticking out in all directions (top image). The signage has been sorted out to reduce visual clutter.

Maria McCavana and Bill Breckenridge, Waiting Room, CAMHS Gorbals, 2013.  Photo Bill Breckenridge (with permission)

Maria McCavana and Bill Breckenridge, Waiting Room, CAMHS Gorbals, 2013. Photo Bill Breckenridge (with permission)

But let’s be clear, you wouldn’t reproduce exactly this scheme in all the CAMHS waiting rooms across Glasgow. It’s not designed to be literally reproducible. It’s designed to be distinctive. The approach used is definitely reproducible.

Who benefits and how? The brief was drawn up through consultation with staff and users. McCavana and Breckenridge proposed a residency-based approach working with nominated patients/clients of this CAMHS unit. They did a series of workshops over an extended period. McCavana and Breckenridge designed the workshop process and all the activities, and there is a clear development from the workshops to the installed project. If I’d been involved in the workshops, I’d recognise my contribution in the space.

Like many artists interested in participatory and co-creative work, McCavana is articulate about the need to change power relations, to give voice to those who don’t normally have a voice. We’re not talking about art therapy – that’s something different. Grant Kester, one of the key writers on participation and collaboration says,

“In the most successful collaborative projects we encounter instead a pragmatic openness to site and situation, a willingness to engage with specific cultures and communities in a creative and improvisational manner … , a concern with non-hierarchical and participatory processes, and a critical and self-reflexive relationship to practice itself. Another important component is the desire to cultivate and enhance forms of solidarity… .” (The One and The Many: Contemporary Collaborative Art in a Global Context, Duke University Press, 2011, p125)

The discussion following the presentation raised some other issues, including the important role of the ‘host’ in doing this sort of residency based work. This is something that the Artist Placement Group highlighted in the late 60s but continues to be an issue. If an artist is going to work in a context, especially one where there is an existing community, it is essential that someone in that community acts as a host, doing those things a host does. This includes doing the introductions but also discretely making sure that the artist doesn’t step on toes. It means making sure that the artist is included in community activities where appropriate, but also protecting the artist from internal niggles and ongoing wrangles. A member of the audience pointed out that when this works well the host becomes a co-creator of the process.

The other subject that was raised from the floor focused on the extent to which these sorts of projects involving artists in healthcare buildings are actually patching up bad architecture. There was some feeling in the room that this was the case. Of course the specific projects that had been presented were work done in older buildings, but…

What is distinctive is the participatory and co-creative process that artists are using. Although some of the younger architecture practices also do this, the larger more established ones, particularly doing public sector work, are not. Nor would it be easy for them to, given that they are embedded in the supply chain, usually employed by the main contractor, not even the client.

What is also distinctive is the blurring of art, design and architecture. This project could have been done by a young design or interior architecture studio. It’s not the art specifically that makes this distinctive, rather it’s the turn to participation and co-creativity.

There were other good points made from the floor which I haven’t covered here, but the overriding one is that we need more presentations like this, and more time for the ensuing discussions.



UZ Arts is an international arts charity based in Glasgow. We create our own work and collaborate with artists and producers who wish to work across art forms and across borders creating work outside conventional arts venues – often in public space.

We commission artists and support the development of their work through residencies, hothouses and collaborating as their producers or co-producers. In the last 3 years we have commissioned over 60 artists in 8 countries but with more than 50% of the work being made in Scotland.

Much of the work we make or support is sited . That is to say site specific – made for a particular place or site located – made for a particular type of location.
Some of the artists we work with engage with the public either as a source of inspiration or as collaborators in the delivery of their work

What art have I seen? Jupiter Artland

Posted in Exhibitions by chrisfremantle on August 31, 2014


Jupiter Artland – very much appreciated Jessica Harrison’s gruesome reworkings of found ceramic
mantlepiece ornaments using epoxy and nail varnish. You walk into the upper exhibition space and see what you take to be a suite of traditional ceramic figurines and it takes a moment to realise that they have been Tarantinoed. Someone else referenced the Chapman Bros.

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What art have I seen? Matisse and Information

Posted in Exhibitions by chrisfremantle on August 23, 2014

Matisse Drawing with Scissors, the complete lithographic series from Verve magazine, and also the Information show that forms part of Generation.  Both at Paisley Museum and Art Gallery.  Didn’t get to the Tate for the Matisse show – is this a substitute?

The historical part of Information is revealing and the documentation is interesting.  The best of the new crop is the piece with the coat check tickets.

What art have I seen? Mark Neville

Posted in Exhibitions by chrisfremantle on August 19, 2014

There is a sequence of film in black and white with no sound where we simply, through the use of a camera mounted on the side of a vehicle moving through a settlement, see what the soldiers see – kids making finger guns to shoot at them, a woman smiling, men studiously ignoring the passing vehicle. We see lots and lots of stands selling vegetables (even in b&w the eggplants stand out shiny and dark). Some people are caught really close up as they pull their scooters over to let the vehicles pass. The normality of the scene is constantly challenged by the shadow of the 50 cal machine gun mounted on the top of the vehicle tracking over everything.
The artist and photographer Mark Neville spent time in Helmand Province, Afghanistan, with 16 Air Assault Brigade in a project organised by firstsite in Colchester and the Imperial War Museum. This exhibition at the Imperial War Museum comprises large format photographs and films he made whilst there.
Mark uses a very high speed film camera, usually used for documenting science experiments, which means that even from a moving vehicle the image is really clear.
The still photographs also exhibited involved taking a large format camera and flash unit normally used in fashion shoots out on patrol (I can’t quite imagine how this worked, but I believe it knowing Mark’s commitment to his process). Kids, a man slaughtering a goat, nothing that looks like a patrol in a war zone (a soldier carrying a case of Irn bru) except what you see in peoples’ eyes – suspicion and uncertainty.

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What art have I seen? Carl Andre

Posted in Uncategorized by chrisfremantle on August 15, 2014

Dan Flavin Institute. Photo Chris Fremantle

Currently at the Dan Flavin Institute in Bridgehampton you can see an exhibition of cards and letters that Carl Andre sent to Sol LeWitt (press release here).
It’s pretty clear that they must have shared a sense of humour as well as an aesthetic.
There is on sequence of instructions for painting landscape (a card divided into a grid of six boxes -three by two – in each box is the name of one colour paired with the names of one of six other colours. Down the side of the card is written the word foliage). Following the instructions should lead to works which might remind you of works by Joseph Albers.
There’s another set of 16 cards each, in sequence, with three lines of the biography of Spinoza pasted onto them. 
There’s a set with different materials’ polar curves (something to do with algebra), again cut out of a University textbook. image
This pretty much demonstrates a number of LeWitt’s Sentences on Conceptual Art such as “Irrational thoughts should be followed absolutely and logically.” Sorry not to be here for part 2 in the winter featuring Andre’s poetry.

What art have I seen? Robert Motherwell

Posted in Exhibitions by chrisfremantle on August 13, 2014

Robert Motherwell the East Hampton Years 1944-1952 at the Guild Hall in Easthampton.
Selection of works starting at the point when Motherwell was still caught between Surrealism and Cubism. Some of the works are truly beautiful, and in places you catch glimpses of realism – a shadow under a shelf – you’re not sure if its you’re imagination. Sad they razed his house in 1985 (bad decade).

What art have I seen? New Parrish

Posted in Uncategorized by chrisfremantle on August 9, 2014

The new Parrish Art Museum just outside Southampton, designed by Herzog and de Meuron (of Tate Modern fame), is at once a challenging and also quite subtle piece of architecture. It aspires to sit in the landscape like the epitome of an agricultural building: larger maybe, more overtly using the materials of agricultural architecture such as sterling board and exposed concrete.  It’s very different from the quiet neoclassicism of the old Parrish. Sitting on a basically rectangular plot next to Route 27, the relationship to landscape dodges the otherwise generic retail architecture that prevails along every highway in the US. On the other hand the relationship of the car parks, oak trees and swales at the back of the building is good, and the quality of wildflower meadow also successfully differentiates this space from commercial, municipal and domestic lawns.  Fritz Haeg and the Harrisons would be pleased to see this, and perhaps it will slowly change the wider landscape.
Inside the overhanging roof creates a quality of light recogniseable from the best architecture in places with such strong summer sun.
The spaces suit Maya Lin and Denis Oppenheim, both with works installed this summer. Maya Lin’s explorations of aspects of landscape at different scales are compelling, whilst Oppenheim’s proposals for splash buildings are fun and funky, but keep your attention.
The building doesn’t seem to serve traditional painting quite so well. It is perhaps too austere for William Merritt Chase’s works on show. 
It’s quite an achievement for a small town (albeit with access to considerable wealth) to have produced a space which will be considered alongside the best small art museums in the world. But with great wealth comes great responsibility and it would be interesting to hear how this institution engages with all those who are excluded. It looks like it might have good environmental credentials, but it needs good social ones beyond the conventional work with schools – where’s the residency with the hispanic migrant working community that services the domestic and gardening needs of the Hamptons, or works with isolated older people in the winter?


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