Cost-effectiveness, evidencing value for money & funding models Roundtable
In the latest roundtable of the Creative Health Review, we investigated the economics of creative health. We discussed funding and commissioning models that could help to embed creative health into health and social care systems in a sustainable way. We also looked at the cost-effectiveness of creative health interventions, and how this can be measured and articulated to policy-makers, including how we might capture the wider value that creative health can offer to individuals, communities and society over the long-term.
A brilliant range of speakers lent us their expertise to help us think through these issues. If you missed the session, you can watch it back here.
Funding in the creative health sector
The first half of the session focused on financing, funding and commissioning creative health. Director of the Culture, Health and Wellbeing Alliance (CHWA), the national membership organisation for creative health, Victoria Hume, set the scene for the conversation by summarising initial results from the annual UK Creative Health Survey which provided some insights into how the sector is funded and where the money comes from. The survey finds that around one-third of respondents provide creative health work on a freelance basis, which can be precarious and generates relatively low levels of income. The availability of sustainable funding is a priority for the sector, with 40% of respondents citing this as the thing that would help most in their work. During the pandemic, trusting relationships were established between the VCSE, local authorities and healthcare sectors to meet an immediate need, and this allowed funding to flow more freely. Victoria made the case for this level of trust to continue as we face current healthcare challenges;
“…trust in the evolving body of evidence that already exists, and investing in the expertise that is already in the sector, and that means the sustained core and infrastructure costs, to build a workforce that is able to meet the new demand and help turn that expertise into leadership.”
Commissioning creative health
The establishment of Integrated Care Systems (ICSs), which bring together organisations including the VCSE sector across a local footprint to commission for health and wellbeing, should help to facilitate the commissioning of creative health. Gloucestershire ICS is an example of a healthcare system leading the way in creative health commissioning. One of NCCH’s ICS Hubs, Gloucestershire has a long history of creative health provision, and the ICS has committed to cultural commissioning as part of its healthy communities provision. Deputy CEO and Director of Strategy and Transformation at Gloucestershire Integrated Care Board, Ellen Rule, introduced their approach. Using examples such as arts activities to support children and young people’s mental health and signing activities to support people with chronic lung conditions and long-covid, Ellen described how creative health is applied across a continuum of need, from supporting universal wellbeing in the community, to the application of creative approaches as a non-medical intervention for a diagnosed medical need.
Gloucestershire has collected what it believes to be the largest creative health dataset in the world, recording referral information and consistent outcomes from all providers. These outcomes reflect what is meaningful to participants and their families, as well as health-related outcomes. This has allowed Gloucestershire to build a case within the system for creative health as an effective approach to improving health. As a result, some creative health programmes have been able to move from a short-term pump-priming funding model, intended to demonstrate effectiveness, to routine, recurrent funding models that provide greater security and sustainability for providers.
Creative health providers in Gloucestershire have also been innovative in their approach to tackling challenges around resourcing and sustainability. The Gloucestershire Creative Health Consortium is made up of five organisations providing a range of creative health programmes for diverse target populations. Cath Wilkins, CEO of Artlift, a founder member of the consortium, described how this way of working has advantages for consortium members and adds value. For example, members have been able to partner on pilot projects, cooperate to reduce duplication and wastage in the system, share expertise, and have found efficiencies across systems and procedures. Acting as a consortium, they can provide a coordinated offer to external partners such as the NHS and local university. The consortium model also allows the organisations to look at progression pathways across the programmes offered – for example, someone who has benefited from Artlift’s mental health programme can be more easily referred to an employment and skills service offered by Artshape. Working collaboratively increases access to different funding sources, and initiatives can be more easily scaled up.
Helen Sharp, Director of Ideas Alliance proposed developing this model still further into an alliance commissioning model. Using this approach, commissioners retain influence over providers, but, in contrast to the usual one-to-one commissioner-provider model, providers work in collaboration rather than in competition, which allows them to share risk, resources and gains. In alliance commissioning, providers and commissioners develop a shared set of aims, principles and outcomes and have greater flexibility to try new and innovative approaches.
Helen also highlighted some key features of commissioning that are directly relevant for creative health. It is important that systems are commissioning for the right outcomes, by which we mean outcomes that are important to people. This means that target outcomes should be coproduced by people with lived experience. In work by the Ideas Alliance, outcomes that are important to people relate to overall wellbeing and often include a sense of belonging and community, relationships and connection, a sense of purpose, autonomy and control, being active, having opportunities to learn and the ability to give back – all areas where creative health can be impactful. People with lived experience are therefore an important resource in the (re)design and delivery of services and commissioning for coproduction is essential. Commissioning for learning, with pump-priming to facilitate the testing of new ideas, is also important.
Helen suggests that for creative health, with Gloucestershire as a case in point;
“…we know it works, we now have that evidence, and it is a case of really using that to build confidence and do something quite formal now in terms of commissioning.”
Demonstrating the value of the arts to the healthcare sector
Finally in this section, Tim Joss, CEO and founder of Aesop (Arts Enterprise with a Social Purpose), described his organisation’s pathway to a sustainable funding model, and what they have learnt about how arts organisations can make the case for their value, particularly with respect to articulating this to the health sector. Aesop identified key questions - What are the NHS requirements to adopt innovation? Does ‘health pull’ compromise artistic freedom and integrity? How does the NHS pull in innovation? Using the exemplar programme Dance to Health, a national dance-based falls prevention programme for older people, Aesop addressed these questions, evidencing health outcomes required by the NHS and surveying arts facilitators who were happy with the approach. The programme was then able to leverage funding from Innovate UK to scale up. In the current healthcare climate, Tim identified several drivers which he believes will encourage the uptake of arts-based approaches in the healthcare sector and he envisions ‘a future where arts solutions for society’s problems are valued and available for all’.
Cost-effectiveness and evidencing value for money
In the second half of the session we turned our focus to how we measure and demonstrate that creative health is cost-effective and offers value for money. In doing so, we also raised important issues around what we mean by ‘value’ and how we articulate some of the wider long-term or societal impacts that creative health can have beyond the completion of a specific intervention.
Senior Health Economist at Kings College London (KCL), Dr Andy Healey, who is involved in the economic analysis of the SHAPER (Scaling-up Health Arts Programmes: Implementation and Effectiveness Research) programme at KCL, provided an overview of some of the methods we might use in assessing cost-effectiveness in a creative health programme. All types of economic evaluation provide a framework through which we can bring different types of evidence together and apply monetary values which allow us to analyse and compare the costs and consequences of an intervention or programme. Which method we use will depend on the audience. In healthcare contexts, the National Institute for Healthcare Excellence (NICE), which makes decisions around which new healthcare technologies should be adopted, prefers cost-effectiveness analysis. Using this method, the impact of an intervention on life expectancy and quality of life is measured and expressed as a QALY (Quality-adjusted Life Year). If the cost per QALY is under the current threshold of £20,000 then the intervention can be considered to offer value for money. However, this approach does not take into account wider social value, and the impact on other stakeholders outside of the healthcare system. Social Return on Investment, which applies a monetary value to benefits identified by a broad range of stakeholders, is a technique that can be used to reflect this wider value.
Andy noted that it may not always be appropriate or desirable to apply monetary values to all outcomes. Cost-Consequence Analysis is another method of economic evaluation which may be useful in creative health. Using this approach costs are calculated, and outcomes expressed either quantitatively or qualitatively and decision-makers are left to decide whether the benefit is worth the investment.
Capturing and measuring value and what matters to people
“We need research that is carried out over 5-10 years to capture a much fuller impact of what is achieved by approaches such as creative health, and have time for these range of outcomes to mature to then understand what the full economic value is. The research needs to include outcomes that are meaningful to a person as well as what matters to policymakers and clinicians.”
Our second speaker in this section, Dr Marie Polley, Co-Founder of Meaningful Measures and Co-lead of the International Evidence Collaborative at NASP, has spent many years researching and developing tools to measure the outcomes that most matter to people. In addition to physical and mental health, people value spiritual outcomes such as finding meaning and purpose in life, and having a sense of control over their own wellbeing, incorporating the social determinants of health. However, these outcomes often come below health outcomes in decision-making. The things people value in their care, such as kindness, compassion and peer support can also be used to inform better service design.
Marie notes that in her experience of evaluating social prescribing, data is often captured at the end of an intervention, and the longer-term benefits are therefore missing from the analysis. Whilst some outcomes may be almost immediate, (for example a reduction in loneliness through participating in group-based activities), outcomes related to things like skills training or debt advice may take longer to manifest. Some interventions may also have a ripple effect within families or communities.
Finally, Marie asserted that a coherent approach and shared language was necessary across stakeholders to demonstrate the economic value of creative health.
“We need more agreement at a high level between key government departments, policymakers and funders around what economic evidence is required for them to accept that creative health approaches do deserve equal recognition, in many cases, to medical approaches.”
Demonstrating the value of creative health to Government
Our final speaker, Dr Daniel Fujiwara, CEO of Simetrica-Jacobs and visiting fellow at the London School of Economics has extensive experience of analysing social value, including valuation of the wellbeing impacts of arts and cultural participation.
Daniel explained the measures of cost-effectiveness and value that are accepted by HM Treasury (as outlined in the Green Book which provides guidance on how to appraise and evaluate policies, projects and programmes). Cost-Benefit Analysis, where both the costs and impacts are expressed in terms of monetary value are particularly important. Using case studies, Daniel showed how his research has helped to demonstrate economic value to policymakers, particularly the Department of Digital, Culture Media and Sport (DCMS). For example, research with Arts Council England and the British Museum, looked at improvements in happiness when people were engaging in particular activities. Arts, culture and creative activities scored particularly highly. Similar techniques were applied to measure impact of engagement with arts and culture on life satisfaction and wellbeing. Converting this impact to monetary value, the study was able to estimate that engagement in the arts has a value of £1084 per year per person. This sort of data can then be useful for decision-makers such as DCMS when analysing the impact of arts or cultural initiative, or to justify investment.
Our panel discussion acknowledged that economic analysis was complicated, could be daunting, and requires expertise. Given the limited resources available to providers within the sector, there were concerns about who could fund and carry out this work. However, Daniel warned that other sectors have developed consistent approaches for measuring value which allow them to justify public funding, and the arts and cultural sector must not be left behind. Work by DCMS is underway to develop standardised metrics for attributing value to arts and cultural interventions, and it is important that the impact on health and the wider social determinants of health is reflected in this.
The session highlighted the complexities of demonstrating the economics of creative health, and we are very grateful to our speakers for their insights into how to push this forward. There are opportunities to build on existing datasets and frameworks to help demonstrate the economic value of creative health in a way that is consistent with existing Government guidance. At the same time, we must continue to research the long-term and wider cross-sectoral social impacts and incorporate outcome measures which reflect what matters most to people, in order to fully capture the value of creative health work.
At a health system level, commissioning of creative health in Gloucestershire has incorporated co-produced, person-centred outcome measures into performance management. The provider consortium model, supported by the system, has allowed programmes to scale where necessary and provide data in a consistent way, allowing for comparison with other interventions and building further trust in the approach within the system. The evidence of success in Gloucestershire can now be used to help develop sustainable commissioning models for creative health across other ICSs. This will help to alleviate some of the financial pressures and precarity experienced by creative health providers, and provide the flexibility and resource necessary for the sector to further develop in terms of professional development, infrastructure and leadership.
We look forward to continuing this conversation with our Creative Health Review Commissioners.
Roundtable Agenda & Biographies: https://ncch.org.uk/uploads/NCCH-Cost-effectiveness-Evidencing-Value-for-Money-and-Funding-Models-Roundtable-Agenda.pdf
Our next roundtable and final roundtable of the Review will take place on May 16th 10am-12 noon on the theme of Leadership and Strategy - Embedding Creative Health in Integrated Care Systems. Register for this session here.