1 Section 1: Programme Structure and Artistic Interventions

External Evaluation Report 2020Marion Friend MBE, Gráinne Hope, Charlotte Wells

Edited by Conni Rosewarne

2 Contents

ContentsIntroduction 4

Context 6

RoyalBrompton&HarefieldNHSFoundationTrust 6

RoseWard&PaediatricIntensiveCareUnit 6

Foulis,Rowan&FirTreeWardsandtheTransitiontoAdultServices 6

rb&hArts 6

VocalBeats 7

StaffandRolesWithintheProgramme 8

TimelineofVocalBeats 9

Methodologies 11

Section 1: Programme Structure and Artistic Interventions 13

ContractualAgreements 14

ProfessionalDevelopment 15

MusiciansinHealthcareMentoring Programme 16

YouthVoice 17

MusicalProgression 19

TheProfileofVocalBeats 20

Section 2: The Artists’ Perspective 21

ProfessionalMusiciansinHealthcareandTheirRole 22

Relationships 24

ArtistSupport 25

Section 3: Clinical Perspective 26

WhyAnalysethisInterventionfromaClinicalPerspective? 27

HowMighttheInterventionWork? 27

ReviewofClinicians’ExperiencesofSingingProjectsWithinHealthcare 29

DynamicPhysicalityofSingingSessions 30

PracticalFocusonBreath 30

3 Contents

Non-threateningtotheMedicalParadigm 30

ScientificEvidence 31

CollaborationWork 31

Conclusion with Recommendations for rb&hArts and Other ‘Music in Hospitals’ Programmes 33

SummaryofRecommendationsfromtheThreeSectionsofthisEvaluation 35

Additional Information Resources 37

Further Reading 37

Bibliography 38

Arts: 39

Clinical: 39

ACKNOWLEDGEMENTS 41

APPENDIX: Description of Conditions 43

CysticFibrosis 44

Bronchiectasis 44

Asthma 44

PrimaryCiliaryDyskinesia 44

Post-CardiothoracicSurgery 45

Front cover photograph © Elam Forrester

Vocal Beats logo by Bethinn Evans

Report design by Gem Davis

4

IntroductionConni Rosewarne, rb&hArts Music Programme Manager

Whenconsideringourparticipatorymusic-makingprojectVocalBeats,itisfascinatingtoreflectonitsdevelopmentoverthepast5yearsandwhathasbeenpossibleinthattime.Priortotheintroductionofthisinitiative,whilerb&hArtswasdeliveringadynamicprogrammeforadultpatients,activitiesspecificallyforyoungpeoplewerelimited–andgrowingevidencebothexternallyandinternallysuggestedthatweweremissingacrucialopportunity.Theprogrammestartedwithasinglemusiciansinginglullabiesoneafternoonaweekandhasgrownorganicallythroughcollaborationacrossartistic,organisationalandclinicalareas;itisnowdeliveringtwoafternoonsofmusicactivityperweekwithsinging,beatboxingandukuleleonoffer.Inadditiontothis,1-to-1vocalcoachingsessionsarenowofferedtoyoungpeoplegoingthroughtheoften-challengingtransitionphasetoadultservicesoncysticfibrosisandtransplantwards,alongwithaYouTubechannelco-producedbyYouthAmbassadorsandonlinemusic-makingcoursesinthewakeoftheCovid-19pandemic.Thishasallbeengreatlysupportedbyfantasticpartnershipsandadvocacywithinthetrust,includingthepaediatricplayteam,andrespiratoryphysiotherapistswhobridgeaccesstopatientsandprovideadeeperunderstandingoftheirexperiencesandneeds.InthepastyearwedevelopedakeypartnershipwithTheRoyalMarsdenNHSFoundationTrust,deliveringmusicsessionstoyoungcancerpatients,and havebeenshortlistedfortwoprestigiousawards.

5 Introduction

Gettingtothisstagehasnotbeenwithoutitschallenges.ThoughwehavebeenincrediblyluckytobesupportedbyYouthMusic,CoopBuildingConnectionsFund,TheBromptonFountainandBBCChildreninNeed,sustainablelong-termfundingcontinuestobeaconcerninthecurrentclimate.Intermsofprogrammedelivery,findingtheprofessionalmusiciansrequired–withexceptionalpersonalandmusicalskillsincludingadiverseandadaptablerepertoire–fortheever-changingcontextsofhospitalwardscanbetrickytomaintainonaweeklybasis.Inadditiontothis,wehavehadtoovercomeseveralbarriersinordertoreacholderyoungpeopleonadultwards,particularlythosewithcysticfibrosis–suchisthenatureofworkingwithintheparameterssetbyaneeds-ledpractice.Allinall,theprojectrequiresrobustinfrastructurelestitbecomestoodelicateabalancetomanage.Thishasbeencompoundedinrecentmonthswithservicesunabletocontinueonhospitalwardsthrough-outthepandemic,meaningmusicianshavehadtoquicklyadapttoonlinedeliverytoserveyoungpatientsconsidered‘extremelyvulnerable’andrequiredtoshield,withlimitedsocialopportunitiesoraccesstoeducationalservices.

Theseachievementsandchallengesareexploredinthisreportbymeansofthreedistinctvoiceswhichrepresentartsorganisations,artists’workinglivesandclinicalperspectives,witheachwell-respectedandhighlyregardedintheirrespectivefields.ThisoverarchingevaluationbringstogetherthreereportsbyMarionFriendMBE,GráinneHopeandCharlotteWellstopresentanexternalexpertbird’s-eyeviewoftheprogramme,via

independentreviewandanalysisfromtriangulatedperspectives.Thisevaluationapproachreflectsthechallengethatartistsfaceinembodyingacomplexinterdisciplinaryroleandpracticeinhealthcareandseekstodemonstratehowtheseinterdependenciescancometogethertorunaneffectiveprogramme.WehopethattherecommendationsthatarisefromappraisingthepracticeofVocalBeatsinthisway,givenattheendofthisreport,canofferpracticalsolutionstoissuesoftenmetinmusicinhealthcare,whilstalsoidentifyingspecificimprovementstostrengthentheVocalBeatsprogrammeforthelongterm.WhilstthisreportwasconceivedpriortotheuncharteredterritoryofCovid-19,itstillprovidesacrucialdialogueonhowmusicinhospitalscanbestserveyoungpatientswhichispertinentaswebegintobroachatentativereintroductiontoward-basedworkinthecomingmonths.

Likewise,wehopeotherNHSTrustsandacutesettingswillbeinspiredtoshareinourjourneyandgainadeeperunderstandingofwhatcanbepossiblewhendevelopingthistypeofworkforpatients.Weaimtoadvocateforasocialmodelofhealth,applauding‘softeroutcomes’thatcanhaveahugeimpactonapatient’sjourneythroughthehealthcaresystem.

Finally,thisreportcelebratesthemassiveachievementsmadebyourmusiciansandeveryonewhohastakenpartinVocalBeatssinceitsinceptionin2015.WelookforwardtothenextfiveyearsofVocalBeatsandwillbereportingthedevelopmentoftheprogrammeinanotherexternalevaluationin2025.

6 Context

ContextRoyal Brompton & Harefield NHS Foundation TrustRoyalBrompton&HarefieldNHSFoundationTrustistheUK’slargestspecialistcentreforthetreatmentofheartandlungdisease.Workingfromtwosites–RoyalBromptonHospitalinChelsea,London,andHarefieldHospitalnearUxbridge–theTrustisinternationallyrenownedfortheexpertiseofitsstaff,highstandardofcareandresearchsuccess.ExpertsattheTrustprovidesomeofthemostcomplexsurgeryandsophisticatedtreatmentsavailableanywhereintheworld,topatientsfromall agegroupswhohaveheartandlungconditions.

Rose Ward & Paediatric Intensive Care UnitThepaediatricdepartment,RoseWard,isanationalheartandlungreferralcentreforchildren,offeringafullrangeofdiagnosticandsurgicalinterventionsforpatientsfromprenatalto16yearsold.Hospitalisedchildrenfaceamyriadofcomplexchallengeswhichcanbefurtheraffectedbyprolongedand/orrecurrentstaysinahospital.

TheTrust’sPlayServicesupportspatientsandtheirfamiliesduringtheirstay.Itaimstoensurethateveryyoungpersonhasthebestpossiblehospitalexperienceandispreparedfortheirclinicalintervention,offeringarangeoffunandsocialactivitiesintheplayroomandatthebedside.Inaddition,theChelseaCommunityHospitalSchoolprovidesNationalCurriculumeducationforallyoungpeopleattheTrust.

Foulis, Rowan & Fir Tree Wards and the Transition to Adult ServicesFoulisWardislocatedatRoyalBromptonHospitalinChelsea,andspecialisesincareforcystic

fibrosis.TheTransplantUnit(RowanandFirTreeWards)isbasedatHarefieldHospital,oneofsevencardiothoracictransplantcentresacrosstheUK.Careattheunitincludesassessmentfortransplantationofpatientsonthewaitinglist,aswellasassessmentfollowingtransplantationforreadmissionsandforpatientswhoarefittedwitha leftventricularassistdevice(LVAD).

Atallthreewardscarebeginsfromage16,withthetransitionforpatientsfrompaediatricservicescarefullymanagedbyinterdisciplinaryteams.Thistransitioncanbechallengingforyoungpatientsandtheirfamilies,especiallyastheymayhavebeencaredforbythesamepaediatricteamformanyyears.Researchhasshownthattransitionprocessescanhaveadverseeffectsonyoungpeople’smentalhealthandwellbeingiftheappropriatelevelofcareandsupportisnotoffered,andthetrusthasdevelopedspecialisttransitionpathwaystoensurethiscanbedoneascomfortablyaspossible.

rb&hArtsrb&hArtsisdeliveredthroughRoyalBrompton& HarefieldHospitalsCharitywith3.6(FTE)staffmembers.Itischaritablyfundedtobringthebenefitsoftheartstosupportinpatientsandoutpatientsandthelocalcommunitiessurroundingeachhospital.Theartsprogrammeaimstoincreaselevelsofwellbeing,enhancethepatientexperienceandimprovethehealthcareestatethroughthearts.Itbeganin2002,andinatypicalyearnoworganisesmorethan500interventionsacrossarts,music,andparticipatoryarts,workingwith30artistsandrecordingover6,500participants.Thecorecreativeprogrammeincludes3weeklySingingforBreathingworkshopsforolderpeoplelivingwithchronicobstructivepulmonarydisease(COPD);

7 Context

2 MusiciansinResidenceproviding6hoursoflivemusicforadultsperweek;temporaryexhibitions;and‘crafternoons’whichoffer10hoursofparticipatoryartsandcraftsworkshopspermonth.

Vocal BeatsVocalBeatsisahospital-ward-basedmusicprojectforchildrenandyoungpeopleaged0-25yearsoldatRoyalBrompton&HarefieldNHSFoundationTrust.Theweeklyprogrammeincludes:

• Twoafternoonsessionsofsinging,ukuleleandbeatboxingforchildrenaged0-16yearsonRoseWardandthePaediatricIntensiveCareUnit(PICU);

• Oneeveningsessionofvocalcoachingforyoungadultinpatientswithcysticfibrosis(CF)onFoulisWard;

• Oneafternoonsessionofvocalcoachingforyoungadultinpatientsawaitingorrecoveringfromcardiothoracictransplant.

Thesesessionsrangefromperformancesforbabiesandtoddlersto1-to-1teachingsessionsforteenagers.Eachsessionistailoredtotheneedsofthepatient:whethertohelpwithrelaxation,offeranexperience,ordistractfromdiscomfort,withactivedynamicsingingorbeatboxingsessions.Performance-basedsessionsforyoungerchildrenaretailoredtoincludethechildren’sfavouritesongs,aswellastoencourageeyecontactandparticipationbymeansofactionsorclapping,movementanddancing.Thesingingandbeatboxingsessionsareindividuallytailoredtoeachchild,andalongsidethemainsingingorbeatboxteachingactivitytheyincludeanactivewarm-upforbodyandvoice,posturalawarenessandrealignment,diaphragmaticbreathingawarenessandpractice,andvocalexercises.

Theprojectcurrentlydeliversover900hoursofparticipatorymusicperyear.Itaimstoincreaselevelsofmentalwellbeingbyfacilitatingaccesstohigh-qualitymusic-makingopportunitiesforyoungpeopleandtheirfamilies,whilstalsodevelopingmusicskillsandenhancingthepatientexperience.

Figure 1 Heather McClelland leading instrumental group

sessions © Nik Read

8 Context

Staff Member Job Title Role description

Karen Taylor

InterimPatient&Public EngagementProgrammeManager& ArtsLead

StrategicleadforArtsattheTrust.FormerlyHeadofArts.

Karen Janody InterimHeadofArtsOverseesandmanagesrb&hArtsprogrammedeliveryandfundraising.

Conni RosewarneMusicProgrammeManager,formally ProjectCoordinator

ProjectmanagementofVocalBeatsandMusiciansinHealthcareMentoringProgramme.Leadforevaluation.

Heather McClellandLeadMusicianinResidence

Overseeingward-basedmusicactivitieswithcriticalinput.Deliveringsingingandukulelesessionsforpatientsaged0-16onRoseWardand1-to-1vocalcoachingforcysticfibrosispatientsaged17-25.

Stac Dowdeswell MusicianinResidenceMaternitycoverforsingingandukulelesessionsforpatientsaged0-16.Nowdelivering1-to-1vocalcoachingfortransplantpatientsaged17-25.

Bellatrix BeatboxerinResidenceDeliveringbeatboxperformanceandfacilitationfor patientsaged0-16.

MC Zani BeatboxerinResidenceDeliveringbeatboxperformanceandfacilitationfor patientsaged0-16.

Staff and Roles Within the Programme

9 Context

Timeline of Vocal BeatsAneedforlivemusicinpaediatricwardswasidentifiedfollowingthepublicationoftheBi-Annual Children and Young People’s Survey(CareQualityCommission,2016),whichhighlightedthatyounginpatientsfelttheydidnothaveenoughcreativeactivitiesoropportunitiesforengagementwhilestayinginhospital.Simultaneously,agrowingbodyofevidenceindicatedsignificantbenefitsfromaccesstolivemusicinhealthcareforyoungpatients–particularlywithregardto mentalandphysicalwellbeing,relaxation,anddistraction.

2015ThankstoinitialfundingfromhospitalcharityTheBromptonFountain,HeatherMcClellandwasrecruitedintopostasMusicianinResidencedeliveringbedsidesingingandukulelelessonsoneafternoonaweekonRoseWard.Thisworkwassuccessful,mostnotablywithyoungerpatientsandtheirfamilies,howevertherewasademonstrablegapinengagementwithteenageboys.McClellanddevelopedgoodrelationshipswithclinicalstaffinthisinitialstage,includingphysiotherapistCharlotteWellswhohadpreviouslysupportedandadvocatedformusiciansonSingingforLungHealthprojects.TogetherMcClellandandWellsbegandiscussingandsharingresourcesforwaysthatvocalexercisescouldpotentiallysupporthealthoutcomesinrespiratorypatients,particularlythosewithCF.ThebookThis is a Voice (Kayesetal.,2016)becameapivotaltext,inspiringtheideaofusingbeatboxingasawaytoaddresstheidentifiedgapinengagementwhilstalsopromotingfurtherlunghealth.ArelationshipwiththeUKUkuleleKidsClubwasalsodeveloped,anditbegantosupplyukulelesforyoungpeopletokeepafterdischargefromhospital.

2016rb&hArtssuccessfullyappliedtotheYouthMusiccharityforFundAsupporttoexpandtheprojecttotwodaysaweek,forprovisionledbyMcClellandandwithprofessionalbeatboxersonbothdays.

10 Context

2017YouthMusicandTheBromptonFountaincontinuedtofundVocalBeats,withrb&hArtssuccessfullyapplyingtoBBCChildreninNeedtocreateapart-timeProjectAssistantposttosupporteffectiveevaluationoftheproject.rb&hArtshostedtheannualNationalAllianceofMusiciansinHealthcare(NAMIH)conferenceatRoyalBromptonHospital,organisedbyOPUSMusicCIC.

2018YouthMusicincreasedfundingtotheproject.ThissupportedtheexpansionofprovisiontoincludeyoungadultswithCFtransitioningfrompaediatrictoadultcareandyoungadulttransplantpatients,aswellasgoingtowardsthedevelopmentandstart-upoftherb&hArtsMusiciansinHealthcareMentoringProgramme.Menteeswererecruitedwithamusician-ledinductionday.VocalBeatsmusiciansdeliveredpresentationsatSoundConnectionsEarlyYearsandNAMIHconferences.Ashared-practicedaywasheldbyrb&hArts,hostingmusicians,Singing for Lung Healthpractitioners,musictherapistsandrespiratoryphysiotherapistsforachancetoshareknowledgeanddevelopnetworksacrosstheUK.

2019 5menteescompletedthementoringprogrammeandpublishedreflectiveessaysontheYouthMusicNetwork.CharlotteWellsledtrainingsessionsfor VocalBeatsmusiciansinrespiratoryhealth.rb&hArtssuccessfullyappliedto YouthMusicFundBtobegindeliveringadditionalmusicsessionsforyoungcancerpatientsaged0-25atTheRoyalMarsdenNHSFoundationTrust,commencinginSeptember.VocalBeatswasregisteredasaserviceevaluationatRoyalBrompton&HarefieldNHSFoundationTrusttoformaliseevaluation,gatheringpublishableevidencetobeconcludedin2021.TheprojectwasshortlistedfortheYouthMusicSocialActionAwardandtheRoyalSocietyof PublicHealth’sArtsinHealthAward.

11 Methodologies

MethodologiesThisreportismadeupofstandaloneassessmentsbythreeexternalevaluatorswithdifferentspecialisms.Thisapproachseekstocreateamulti-facetedoverviewoftheprojectfromkeyperspectivesthatareseparatebutinterlinked,tohighlighttheproject’ssuccessesandpotentialsandtoprovidelearningsforbothrb&hArtsandforthewider‘musicinhospitals’sector.ThecommissioningbriefforthereportwasinformedbytheYouthMusicDo, Review, Improve2017qualityframework,whichisatoolthatmusicpractitionersandorganisationscanusetosupportplanning,reflectionandevaluation.

Allthreeevaluatorsappliedqualitativemethodstogeneratethinking,feedbackandrecommendationsforthefutureoftheVocalBeatsprojectaswellasforother‘musicinhospitals’programmesthatmaybelookingtoreplicatesimilarmodelsofpractice.ThereviewlooksatpracticedeliveredatRoyalBrompton&HarefieldNHSFoundationTrustonly,anddoesnotincludesessionsbeingdeliveredatRoyalMarsdenNHSFoundationTrustasthesearestillintheirinfancy.

MarionFriendMBEhasheldseniorpositionsinprestigiousinternationalculturalorganisationsforovertwenty-fiveyears,includingDirectorofJuniorTrinityatTrinityLabanConservatoireofMusicandDance,andpostsatWigmoreHall,BBCTelevisionMusicandArts,andthePhilharmoniaOrchestra.Marionnowworksasacoach,mentor,facilitatorandconsultant.HerreviewexaminesVocalBeats’organisationalstructureandcapacityforprogression,focussingonlearninganddevelopmentoutcomesforparticipantsandmusicleaders.

Friend’smethodologyincludes:

• Individualface-to-faceinterviewswiththeteamoffourprofessionalmusiciansandwithonementeeparticipatingintheMusiciansinHealthcareMentoringProgramme

• In-personandtelephoneinterviewswithConniRosewarne,ProjectCo-ordinator

• TelephoneinterviewswithJenniferRaven,DeputyDirectorSoundConnectionsandwithCarolineMooreArtsManager,GreatOrmondStreetHospital

• ObservationoffoursessionsinRoseWardandFoulisWard,RoyalBromptonHospital

• AttendanceatRowanWardHarefieldHospital

• Informalconversationswithpatients,parentsandcarersduringobservations(permissionstatusgranted)

• Deskandpodcastresearch

• Drawingonrelevantexperienceincludingattendanceand1-to-1coachingatSoundConnectionsEarlyYears/ArtsHealthandWellbeingConferenceFebruary2018

Gráinne HopeisaprofessionalcellistandthefounderandArtisticDirectorofKids’Classics,whichdeliversamusicprogrammeinIreland’schildren’shospitals.ShewaschosentorepresentIrelandtobecomeatrainerofMusiciansinHealthcareSettingsaspartofapioneeringEuropeanprogrammeledbyMusiqueetSanté(France).Her evaluationofVocalBeatsisfromanartistpeer reviewperspective.

12 Methodologies

Gráinne’ssectionofthereviewappliesaqualitativeapproachtothemethodology,whichincludesinformalinterviewsandafocusgroupwiththreeVocalBeatsmusicians,aswellasobservedvisitsinHarefieldHospitalandonRoseWardatRoyalBromptonHospital.

Topicguidesfortheinterviewandfocusgroupsweredevelopedfromresearch,personalexperiencedevelopingprogrammepartnerships,managingandtrainingprofessionalmusiciansworkinginhealthcaresettings,andwithreferencetotheEngaged Passions, Searches for Quality in Community ContextspublicationbyrespectedresearcherandwriterPeterRenshaw.Questionswerekeptopen-endedtoallowparticipantstooffermoredetails,personalinsightsandknowledge.

Charlotte WellsisaHighlyspecialistrespiratoryphysiotherapistwithoverfifteenyears’experiencespecialisinginrespiratoryservicesincludingcysticfibrosis,bronchiectasis,emphysema,primaryciliarydyskinesiaandasthma,aswellasworkingwithinsleepandventilationteams.Sheiscurrentlyinpostasaspecialistpaediatricrespiratoryphysiotherapistworkingwithinatertiaryservicemanagingchildrenwithdifficult-to-controlasthmaandexercise-inducedlaryngealobstruction(e-ILO)atRoyalBromptonHospital.

CharlottehasjustcompletedherNIHRMastersinClinicalResearch.Priortobeingappointedforthisreport,CharlottecontributedtotheVocalBeatsprogrammebyeducatingmusiciansonrespiratoryconditionsandworkingwiththemtodevelopvocalfacilitationtechniquesthatcomplementrespiratoryphysiotherapy.Shehasauniqueperspectiveintermsofpaediatricrespiratoryconditionsandtheaccompanyingclinicalandsocialcontexts,whichmakesherinputtothistriangulatedevaluationinvaluable.

Charlotte’ssectionreviewspublishedliteraturetobetterunderstandhowmusic,singingandbeatboxingcouldbebeneficialforcardio-respiratoryhealth;sheofferscommentaryonclinicians’experiencesofhospital-basedsingingprogrammes(Singing for Lung Health);andexploresthepotentialbenefitsofcollaborativesessionsbetweenVocalBeatsandthephysiotherapyteam.

Thedatafromallthreereportsisincorporatedin an overallconclusionwithdiscussionofinterlinkingthemesattheendofthisdocument.Thisisaccompaniedbyasetofrecommendationstobeusedbyrb&hArtsandotherprofessionalindividualsandorganisationsdeliveringmusicin healthcareprogrammes.

13

Section 1: Programme Structure and Artistic InterventionsMarion Friend MBE

TheweeklymusicalactivitywithintheVocalBeatsprogramme isdevelopmental,asmanypatientsreturnregularlyforspecialisttreatmentandsomearethereon a longer-termbasis.

Theprogramme’ssuccessispredicatedonasmallteamofhugelydedicatedprofessionalmusicians.Excellentrelationshipshavebeenbuilt;themusicianshaveidentifiedpotentialandsupportedparticipantsindevelopingtheirmusicianship,oftenwithgratifyingoutcomes.

Throughdemonstrablyproductiveandmutuallysupportiveworkingrelationshipswithclinicians,theplayteamsandrb&hArtsmanagement,themusicianshavefoundtheirplaceatthe‘heart’ofthehospital.Anunderstandinghasdeveloped;theyhaveassimilatedintothecultureofanacuteclinicalenvironmentandareconstantlylearninghowtheirmusicalinterventionscandovetail,interlinkandenhancethepatients’emotionalandphysicaldevelopmentandprogression.

14 Section 1: Programme Structure and Artistic Interventions

There’s a constant dialogue between performers, play team and clinicians. It’s very holistic. It’s integrated and you get to know everyone well and build relationships, for example with Charlotte Wells, physiotherapist. So music isn’t separate from the overall experience. The hospital has a close relationship with the arts, and music’s presence is natural. Feedback from the team is welcome and ideas are nurtured.Heather McClelland

TheVocalBeatsprogrammedemandsskilledcommitmentandconvictionfromthesmallcohortofprofessionalmusiciansinvolved,allofwhomhaveactivelivesasperformersintheUKandoverseas.Sensibly,thepolicyistohaveonesingerandonebeatboxerineachsession,whichmeansthatcontinuitycanbemaintainedevenifoneperformerhastoputinadeputyonoccasion.Thatsaid,itcanbechallengingtofindasuitabledeputywiththeskills,experienceandsensitivityforthespecialisthospitalenvironmentatRoyal

Brompton&Harefield.Onesolutionhasbeentheintroductionof theMusiciansinHealthcareMentoringProgrammedeliveredbyrb&hArtsandSoundConnections,asdiscussedlater.

Managementofthewide-rangingandinnovativeartsprogrammeatRoyalBrompton&HarefieldNHSFoundationTrustisundertakenbyasmallteamledbyKarenJanody,HeadofArts,withstrategicoverviewfromKarenTaylor,Patient&PublicEngagementProgrammeManager&ArtsLead,previouslyHeadofArtslaunchingVocalBeatsin2015.Theteamishugelycommittedbutatcapacitygiventhestrategic,fundraisingandoperationalfunctionsrequiredtorunitsrangeofactivitiesencompassingvisualart,craft,commissions,exhibitionsandthepioneeringSinging for Breathingweeklyworkshopsforadultswhicharenowcelebratingtheirtenthanniversary.

ThemainregularpointofcontactfortheprofessionalmusiciansontheVocalBeatsprogrammeistherb&hArtsProjectCo-ordinator.Thisjobtitlemaynotadequatelycommunicateto thoseoutsidethedepartmenttheextentoftheresponsibilitiesinthisrole(sinceupdatedto‘MusicProgrammeManager’).TheyincludeactingasanintermediarybetweenthemusiciansandRoyalBrompton&HarefieldNHSFoundationTrust;communicatingtothewiderstaffcommunity;supportingtheunderstandingoftheworkanditsroleinthetrust;andundertakingresearchandevaluationinliaisonwiththemusicians.RecentevaluationworkincludesthecomprehensiveVocal Beats Year 2 End of Year report 2018-19,andtheProjectCo-ordinatoriscurrentlyinvolvedina serviceevaluationfortheprogrammewhichwill continueuntil2021.

Contractual AgreementsThefourprofessionalmusicianswhodelivertheVocalBeatsprogrammeareemployedonafreelancesessionbasis,withtimefor

Figure 2 Singing sessions with families in the Royal Brompton

Hospital play room © Elam Forrester

15 Section 1: Programme Structure and Artistic Interventions15

preparation,evaluationandreflectionfactoredintothefee.Given thenatureoftheworkandtheunpredictabilityofinteractionswithpatients,thereisverylimitedtimeattheendofasessionforthemusicianstoevaluate,debriefandsharereflections,andthereisoftennosuitablequietspaceinwhichtodoso.Iftheprogrammeistocontinueevolvingandaimingforbestprofessionalpractice,theremaybearequirementtoformalisetheseelements.Thestatusofthefreelancecontractscouldbereviewedtobecomepart-timesalariedroles–particularlyfortheleadmusician,ifappropriate.Notwithstandingtheincreasedfundraisingchallengethiswouldentail,suchamovecouldconsolidatethestatusof VocalBeatsandenablefurtherdevelopmentof theprogrammeasanationalandinternationalrolemodel,byincorporatingresearchandintegrated practice.

Professional DevelopmentContinuingProfessionalDevelopment(CPD)isvaluedandencouragedatRoyalBrompton&HarefieldNHSFoundationTrust,andtheprojectteamandcoreteamofmusicianshavehadaccesstoarangeofopportunities.However,thecomplexityoftheworkmeansthatthereisacontinualimpetustodevelopknowledgeexchange,trainingandnetworks;thisisdiscussedfurtherinPart2ofthisreport.

InternaltotheVocalBeatsprogramme,therangeofexpertise,skillsandknowledgeintheteamgivesrisetoongoingopportunitiestolearnfromoneanother.ThecommitmentofphysiotherapistsandotherclinicianshasbeencrucialtotheimpactfuldevelopmentofVocalBeats.Thereiscurrentlyacademicresearchbeingconductedintothesynergiesbetweentheartsandthehealthcaresectors(Intersectoral action: the arts, health and wellbeing, Synergy between sectors: the arts as a tool to improve health and well-being, strengthening the link between health and the

arts,WorldHealthOrganisation,Sept2019)andit isupliftingtoobservethisbeingputintopracticewiththeinter-disciplinaryknowledgeexchangethattakesplacebetweenthecliniciansandthemusicians.Inparticular,physiotherapistCharlotteWellshasobservedthemusiciansatworkandcontributedtotheirtrainingandknowledgewiththeaimofdevelopingagreaterunderstandingoftheclinicalaspectsofrespiratoryconditions.TheSinging and Beatboxing condition information sheet peer-to-peerdocumentthatsheproduceddescribestheclinicalconditionsandtheirsymptomsindetail,andsuggestswaysthatsingingandbeatboxingtechniquescanimpactonpatientwelfare.

Asasalariedemployee,ProjectCo-ordinatorConniRosewarneisabletoaccesslocalKensingtonandChelseaCounciltrainingopportunities,evaluation

Section 1: Programme Structure and Artistic Interventions

External training programmes completed by various Vocal Beats musicians include:

• OPUSMusic(opusmusic.org)

• SnapeMaltings:MOTMusiciansworkinginchallengingsettings(snapemaltings.co.uk/music/residencies/mot)

• VocalProcess(vocalprocess.co.uk)

• LEAPTalentDevelopmentProgramme(serious.org.uk)

• PulseArts(pulsearts.co.uk)

Within Royal Brompton & Harefield NHS Foundation Trust the musicians have access to:

• Adesignatedandevaluatedinductionprogramme

• Sharedreflectionsessions

• Supervision

• OpportunitiesforsharinggoodpracticeandsectorknowledgewithphysiotherapistCharlotteWells

16 Section 1: Programme Structure and Artistic Interventions

andsocialmediatrainingforcharities,andstatutorytrainingwithinBrompton&HarefieldTrustincludingsafeguarding,palliativecare,equalityanddiversity,andhumanrights.ShewasalsosupportedtoattendanartsandhealthresearchintensiveprogrammeledbyDaisyFancourtatSnapeMaltingsearlierin2019.

Knowledgeexchangeandprofessionaldialogueareconsideredmandatoryinthespecialistareaofartsinhealthcare,whichisarelativelynewfieldparticularlyforparticipatoryartsprogrammesinhospitals.Thereisongoingresearchintothebenefitsandimpactofthework,anditsinterfacewitharangeofclinicalandcreativedisciplines.rb&hArtscontributestothisresearchandisamemberofvaluablespecialistandwiderartsnetworksincludingLondonArtsandHealthForum,NationalAllianceofMusiciansinHealthcare,CulturalandWellbeingAllianceandNHSNationalPerformanceAdvisoryGroup(NPAG).Notwithstandingthatrb&hArtsisasectorleader,thepossibilityfortheverysmallteamtoattendmeetingsandconferencescanbelimited,owingto capacityaswellasaccesstofunding.

Musicians in Healthcare Mentoring ProgrammeTheMusiciansinHealthcareMentoringProgrammewaslaunchedin2018andisdeliveredbyrb&hArtsinpartnershipwithSoundConnectionsandsupportedbyYouthMusic.Therewerefiveearly-careermusiciansontheprogramme2018/19,andasecondcohorthasbeenselectedfromJanuary2020.AsimilarinnovativemusicmentoringprojectwasrecentlycompletedatAlderHeyChildren’sNHSFoundationTrustincollaborationwithLiveMusicNow https://alderhey.nhs.uk/services/arts-for-health,alsofundedbyYouthMusic.

Theobjectivesforrb&hArtsaretoofferthemusiciansprofessionaldevelopmentopportunitiesbygivingtheminsightsintoclinicalsettingswith

thebenefitsofshadowingand1-to-1mentoring.SoundConnectionsisinvolvedwiththeinductionprocessandoffersindividualdevelopmentneedsanalysis(DNA)toeachmenteeattheend oftheprogramme,helpingtoidentifyfurtherprofessional objectives.

Theextractsbelowaretakenfrominterviewsandreflectiveessays,ofwhichthelatterarearequirementoftheprogramme.Thesequotesillustratethequalityoftherecruitmentandtheinsightsthatthementeesgainedfrombeingimmersedintherb&hArtsenvironment.

Everyone is engaged with the same aims on the wards. You learn to create a space and build your sensitivity to situations. I appreciate music a lot more now. Nicola Tagoe, mentee

NicolahasundertakentrainingwithPulseArts,andthismentorshiphasinspiredhertoexpandherportfoliowithworkinEarlyYearssettings.ShehasrecentlybeensuccessfulinreceivingaDeveloping your Creative PracticeArtsCouncilEnglandaward.

17 Section 1: Programme Structure and Artistic Interventions

Heather [McClelland] had so many different techniques that she used to work with to keep the young people engaged and not feeling embarrassed; she was always encouraging and let them make the final decisions. She also checked in with them constantly to make sure that they were ok with what was happening. After reflecting on Heather’s practice, I identified several points that will be really important in my own practice:

• Identifying the end goal and working out with small steps what we can do to get there

• Believing in yourself and your ability, in order to hold the space so that you can check everyone understands and that whatever the outcome that is ok

• It’s ok to make mistakes; learn from them and carry on

• Being confident enough so that they trust you and go with what you are trying to do

Sasha Mattock, mentee, extract from reflective essay

Over the course of the programme my confidence increased as I became more used to the ward. And it was incredibly rewarding work.  But it calls for a high degree of resilience.  I was extremely impressed with the musicians’ ability to enable musical sessions that delivered

positive experiences for all the patients.  And again having the benefit of an experienced mentor to discuss the issues with was very helpful.  This allowed us to work through the emotions that came up during the sessions and reflect on how the music would have benefited the patients. Sara Fawcett, mentee, extract from reflective essay

Youth VoiceThestrategyforthehighlydistinctiveVocalBeatsprogrammehasbeentocreateacurrentandcontemporaryofferingthatappealstoyoungpeople.Thereareseveralestablishedprogrammesforparticipatoryartsaimedatchildrenandyoungpeopleinhospitalthatsharetheseaims,andeachhasitsownidentitydependingoncircumstances,clinicalspecialismsandsettings.TwoexemplaryprogrammesinLondonareatGreatOrmondStreetHospital(https://www.gosh.nhs.uk/wards-and-departments/departments/gosh-arts)andBethlemandMaudsleyHospitalSchool(https://bethlem-maudsleyschool.org.uk),whereCityofLondonSinfonia(https://cityoflondonsinfonia.co.uk/wellbeing/wellbeing-projects)iscurrentlyundertakingathree-yearresidency.

TheintroductionofbeatboxingtotheVocalBeatsprogrammetwoyearsagohasbeenparticularlysuccessful,becauseaswellasbeingfunandentertaining,itprovidesphysicalexerciseforrespiratorypatients;itcanalsointerestboyswho mayinitiallybereluctanttosing.

18 Section 1: Programme Structure and Artistic Interventions

Manyoftheyoungpatientswhoneedtoreturnto RoyalBromptonHospitalonaregularbasisaregivenukulelestotakehomeandareencouragedto continuetheirmusicalactivityandlearning.Theyarealsogivenresourcesasappropriate,includingrecordingsoftheirfavouritesongsandworksheetswith‘beatboxinghomework’.

‘Mum don’t forget to pack my ukulele’Themotherofa14-year-oldpatientrelatedtheimportanceofherdaughterknowingthattheteamofmusicianswouldbewaitingtomakemusictogetheronherreturntohospital.

Patients are given choice – there is nothing fixed or rigid. Trust builds up and the patients absorb the experience from afar even when they’re not inpatients Stac Dowdeswell

Young people feel heard – it’s not ‘teachery’ though learning is taking place. It allows freedom – it’s the young person’s sessionConni Rosewarne

Figure 3 Bellatrix leading beatboxing sessions © Elam Forrester

19 Section 1: Programme Structure and Artistic Interventions

Musical ProgressionItisevidentfromobservingseveralsessionsonthewardsandtalkingtotheteamofmusiciansthatthepatients’musicalprogressionisapriority,eventhoughcontinuityisinevitablyfragmented.However,considerationcouldbegiventosettinguppilotnetworkssupportingmotivatedpatientstocreateindividualpathwaysorlearningplans,inordertosustaintheirmusicalactivitybetweenhospitalvisits,intheirownlocality.Withthepermissionofpatientsandtheirfamilies/carers,therecouldbeliaisonbetweendesignatedVocalBeatscoremusiciansandwithschoolorcollegemusicdepartmentsornon-formalnetworkstosupportmusicalprogression,similartospecialistcliniciansinhospitalsbeingincontactwithGPs.Giventheintroductionofsocialprescribingopportunitiestheremightbepossibilitiesforthisprovisiontobesourcedandfunded.TheinitiativewouldseemtimelygiventherecentlaunchoftheNationalAcademyofSocialPrescribingpartnershipwithArtsCouncilEnglandandNHSEngland(https://www.gov.uk/government/news/social-prescribing-new-national-academy-set-up).

Inmanycasesmusicalpotentialhasbeendiscovered,unleashedandnurtured,anditseemsvitaltomaintainanddevelopthispotentialforthebenefitofpatients’skills,wellbeing,creativityandself-esteem.ThereisperhapsaninevitableironyinthefactthatmanyyoungpatientsareonlyaccessingmusicprovisionwhentheyreturntoRoyalBromptonHospitalforregularclinicalstays.

TherecentintroductionoftheVocal Beats Youth Ambassador programmeforthoseaged17-25willenableyoungpeopletoaccessfurtherresourcesonlineandtocreateamusicalnetwork;thisisanimaginativepeer-to-peerstrandwithpatientsworkingalongsidetheteamofprofessionalmusiciansandafilm-makertoaddresstheisolationthattheymayexperiencegiventhatmanyareunabletomakemusictogetherinperson.

As the initiativetakesshapeitcouldbeaprioritytoextendmusicalnetworksandshareinspirationwithexternalpeergrouporganisationssuchastheaward-winningBeatbox AcademyatBatterseaArtsCentre(bac.org.uk).

rb&hArtsrecognisesthebenefitsofintroducingArtsAwardsaccreditationtotheprogramme.ThoughitwashopedthattheVocalBeatsambassadorscouldundertakethis,ithassofarnotbeenfeasiblegiventhelogisticsandintermittentcontactwiththeyoungpeopleinvolved.Thereisimpetustomoveforwardhowever,andtoexploreitforthefuture,asaccreditationcanprovideausefulstructureifimplementedsensitivelyinpartnershipwiththepatients.Inaddition,individuallearningplansasreferredtoearliercouldbeintroducedandcreatedjointlybypatientsandprofessionalmusicians.‘Individual’planscouldalsoincorporate‘buddy’plansforensembleworkandforrecordingcompositionsandperformancesonlineorinperson.

Giventhatmostpatientsaregiventheopportunitytoplaytheukuleleonthewards,somemaywishtoexploreaccreditationbytakinganexam;thereisnorequirementtoreadnotatedmusic(http://rgt.org/exams/ukulele-exams.php).

Figure 4 Vocal Beats Youth Ambassadors; Mia, Skye, Eleanor

and Bethinn © Alex Hyndman

20 Section 1: Programme Structure and Artistic Interventions

Considerationcouldbegivento:

• Developinga360°pilotpathwayschemeforpatientstocontinuetheirmusicalactivityintheirownlocalitybetweenhospitalstays

• ResearchinghowthenewNationalAcademyforSocialPrescribingcouldbenefittheVocalBeatsprogramme

• SupportingVocalBeatsAmbassadorsindevelopingwiderpeernetworks

• ResearchingarangeofaccreditationmodelsthatmayberelevanttoVocalBeatsparticipants

The Profile of Vocal BeatsTheVocalBeatsprogrammewithitsyouth-ledethoshasreceivedrecognitionintheformofseveralawardnominationsincluding:

• FinalistinSocietyofPublicHealthAwardsArtsinHealthcategory(www.rsph.org.uk)

• VocalBeatsYouthAmbassadorsProgrammewasshortlistedforYouthMusicSocialActionAwards(https://www.youthmusic.org.uk/awards)

• KarenTaylorrb&hArtsLeadwasawardedaRoyalBrompton&HarefieldHospitalsStaffChampionAwardinrecognitionofherworkontheVocalBeatsprogramme

HeatherMcClellandwasinvitedtojoinaSingingonPrescription‘creativethink-tank’atSnapeMaltingsrecently,alongsideleadingpractitioners,researchers,policy-makersandclinicians.Thisisavaluableopportunityforknowledgeexchangewithinabroad‘musicinhealthcare’forumandforraisingtheprofileofVocalBeats.Furthermore–notwithstandingtheconstraintsoftimeandfunding–theprogrammeisnowonthecuspoffurtherexcitinginitiativessoitmaybeanopportunemomenttosharegoodpracticemoreextensivelywithawiderrangeofstakeholders;thesecouldincludeprofessionalandamateurmusicensembleswithwhomthereisanartisticsynergy;commercialandcorporateorganisations;andarangeoftrustsandfoundationswhomaywishtobecomemorefamiliarwiththeprogramme.

21

Section 2: The Artists’ Perspective Gráinne Hope

OneofthekeyaimsofthissectionofthereportistoreviewtheartisticqualityoutcomesinVocalBeats.Thisinvolvedinterviewingtheartistsonthesubjectoftheirlivedexperienceasprofessionalmusiciansworkinginhealthcareandhowthiscorrelatestoand/orimpactstheirprofessionalroleoutsidethehealthcaresetting.

22 Section 2: The Artists’ Perspective

Severalthemesforconsiderationemergedfromthedatacollectedthroughthediscussionsandobservations,withrelatedsub-themes:

• TheProfessionalMusicianinHealthcare:

• Roleofamusicianinhospital/artisticoutcomes

• Competencies/appropriateskillset

• Challengesasanartistworkinginthesetting

• Relationshipsof:

• Musiciansandstaff

• Musiciansandpatients

• Themusiciansasateam

• ArtistSupport:

• Reflection

• Journaling

• ‘MusicinHealthcare’training

Definingorcreatingaframeworkformeasurementofqualityoutcomesintheartsisrecognisedasachallengingtask,andissomethingthathasalwaysbeenopentodebate.Nonetheless,thereseemstobeanunderstandingsharedbymanyartsorganisationsthatoutcomesarespecifictoeachprogrammeandcontext,andshouldbeunderpinnedbyhowtheworkengageswithitsaudience.

InhisSupporting Excellence in the ArtsreviewcommissionedbytheDepartmentofCulture,MediaandSport,BrianMcMasterwrote:

For something to be excellent it has to be relevant, and for it to be relevant it has to be continually reinterpreted and refined for and by its audience.Whenlookingatartisticoutcomesseveralimportantconsiderationscometomind,ofthe

musical,personalandprofessionalcompetenciesof themusiciansfacilitatingthemusicalengagement,whoarecentraltothesuccessand qualityofanyprogramme.

Professional Musicians in Healthcare and Their RoleThemusiciansengagedintheVocalBeatsprogrammeweredrawntotheroleformanydifferentreasons.SomebecameinvolvedbyrespondingtoanopencallbythehospitalforanArtistinResidence,anotherwasinvitedtocoveramaternitypost,andseveralofthemusicianshadbeenprofessionalcolleaguespriortostartingin this role.

Whenaskedwhatmotivationsdrewthemtothisrole,thetwomainreasonsthatemergedwere:aloveofmusicandworkingwithchildren.Onemusicianadded‘itmadesense’(therole).

Whenthediscussionturnedtowhatkeepsthemworkinginthisroleonemusiciancommented,

…it’s really fun and it’s like a real privilege. It is intense and it’s not for everyone, there are big challenges, but – it is also like, it does gives you a sense of purpose

Figure 5 Baby with kalimba © Elam Forrester

23 Section 2: The Artists’ Perspective

ItisworthnotingthattheprofessionalmusiciansfacilitatingtheVocalBeatsprogrammeareallhighlyskilledprofessionalsinger/songwritersandchampionbeatboxers,andtheyallhavealotofexperienceworkingwithmusicandchildrenineducationandcommunitycontextsthatpredatestheirinvolvementinVocalBeats.

Duringthefocusgrouptherewassomeinterestingdiscussionaroundtheadditionalskillsandcompetenciesthemusiciansfeltwerenecessaryforahospitalmusicianrole;theseincludedtheneedforflexibility,adaptability,communication,theabilitytothinkunderpressure,tobesensitivetoandgenerouswithlettingthemusicbepatient-led,andtheneedtobeemotionallyintelligent.

Theyagreedthatitcanbechallengingwhen,withsomepatientswhoyouseeregularlyandformrelationshipswith,somethinghappenstothem–thatitcanbehardto‘block it out’.

Inboththeinterviewsandthefocusgroup,theartistsengagedwithexploringtheirdifferentrolesasprofessionalmusiciansandasprofessionalmusiciansinhealthcare,andtheimpactthateachrolehasontheother.Onemusiciancommentedthattheamountofcollaborationandimprovisingrequiredinthehospitalsettingmeantthattheirlevelofmusicianshiphadgoneup,andtheyhadalsobecomemorevocallyfit.Anothermusicianobservedthattheyhavenowbecomemoreacutelyawareofsituationsoutsidethehospitalsetting,andarebetteratreadingaroom(audience)asadirectresultoftheirroleasamusicianinhospital.Anotherimpactsharedbythemusicianswasthattheyarenowmoreawareofwhatpeoplearegoingthroughandthatthissometimescomesthroughintheirsong-writing.

Onemusiciancommentedthatitisveryeasyforthemnottoholdthetworolesinequalregard,butthatitremainsnonethelessimportantforthemasfacilitatorstorememberthattheyare

alsoperformingartists:whiletherolescanfeedintoeachother,itisimportanttomakespaceforeach one.

Themusiciansrevealedanumberofpersonalandprofessionalchallengestheyfaceintheirrole,includinginfindingbalancebetweenbeinganartistandtheirpracticeinthehospital.Onemusiciansaidthattheyfeltthatbeinganartistinahospitalinvolvedareallyfinedance:peoplelovetohearthemperformandhearabouttheirprofessionalmusiclivesoutsidethatsetting.Anothermusiciansharedthatitcanalsobeachallengemusically,assomeonewillalwaysaskyoutoplaysomethingthatyoudonotknow,andallmusiciansacknowledgethatyoucanneverbepreparedforeverysituation.Therewasaconsensusaroundtheparticularchallengeforamusiciantokeepevolvingandaddingtotheirrepertoirewithworkthatisrelevanttotheyoungpatients.

Whenthemusicianswereaskedhowtheymeasurethesuccessofamusicalengagementonesaid,‘everyone is so different, a success for one person is so different to another person’;anothermusiciannotedtheimportanceof‘recognising this context is very specific’andalso‘what’s already there’.The samemusicianaddedacommentwhichillustratesthatprogressionandsuccesslookdifferentin‘in-the-moment’contexts:

We are very lucky that little tiny things that might not be considered like a successful session in an

Figure 6 Music-making app ThumbJam on iPad © Nik Read

24 Section 2: The Artists’ Perspective

education establishment, like someone smiling or a baby tapping their foot, that’s an incredibly successful session in a subtle wayThemusiciansnotedthatthetrainingtheyhadreceivedtoimprovetheirunderstandingofcysticfibrosisandthephysicalcomponentsofbreathing,alongsidewritingartsobservationshadhelpedthemtorecognisewhatasuccessmightlooklikein thiscontext.Onemusicianwentontosay,

You have to develop a language to understand that [observation]

RelationshipsTheVocalBeatsmusicianshavedevelopedstrongrelationshipswiththeplayteamonRoseWard.Thereisahandoverfromtheplayteambeforethemusiciansheadoutaroundtheward,andaplayspecialistsometimesaccompaniesthemifthereis a complexcase,tomakeintroductionsifneeded.

Duringobservationofmusiciansontheirmusicvisits,itwascleartheywereverycomfortablenavigatingthehospitalsettingandfindingopportunitiestostartamusicalengagementor conversationaboutinstrumentswithpatientsand families.

Onemusiciancommentedthattheyfeltthenursesrecognisethevalueofwhattheyaredoingandwouldsometimesaskthemusicianstocontinuewhilethenursescarryoutasmallprocedure.

Laterindiscussions,thepotentialtoconsiderimplementingafurtherpastoralsupportfordesignatedstaffhandoversinalladultwardswheretheprogrammetakesplace-butdoesnotbenefitfromthepresenceofthepaediatricplayteam-emerged.Itwasfeltthatidentifyinganindividualor teamwhowouldbeabletofullybriefthemusiciansoneachyoungpersonwouldenablethemusicianstobettertailorthesessiontomeetthe

patients’individualneeds.Thiswouldbeespeciallyvaluableinmorechallengingcircumstancesonadultwardsandwouldcertainlyhelpaidtheimpactof themusicalsession.

Oneinterestingtopicthatcameupduringthefocusgroupandinterviewsconcernedtheextentofinformationaboutapatientthatmusiciansneedtofacilitateasession.Theyagreedthatabalancewasneeded;onemusiciancommentedthattheywouldforgohavinganyknowledgeaboutapatient’sbackground,andwouldratherjustgotothatpatienttoofferthechoiceandopportunitytoengageornot engage.

Anotherexpandedfurtheronthis,talkingabouttheimportanceofofferingyoungpatientsthechoicetotakepartinamusicsession

I can offer them a choice, and I have learnt quite recently that that is a humongous part of why I think what we do is so important – because they don’t get to choose that many things [in hospital] …and for them to say yes …I love that you can say no to me as well, I want to offer you something you can say no to, but also you can say yes, and if you choose to participate then it’s a little bit of normality I think, and a little bit of escapism, and giving that to someone is just magic … it’s a real privilege to be able to do that, I feel very lucky. Whenonemusicianwasinvitedtosharewhatdrewthemtothisrole,theycommentedthat,‘I think as humans what we all crave is connection’.They went on:

For some reason beatboxing really does that. It is always being seen

25 Section 2: The Artists’ Perspective

as a party trick, as a novelty; it’s more than that, it’s an art form and it is a language and it transcends everything. It transcends culture, style, age, sex, it’s just expression. And anyone can do it … it doesn’t matter about whether you’re the best or not. It’s whatever sound you make, every sound is a good sound, it doesn’t matter: it can be a whistle, a click, a word, but every sound is a form of their expression... It gives everyone a blank slate to start onTheVocalBeatsprogrammewasbeingdeliveredbyanindividualmusicianwhenitfirstcommenced;ithasnowgrowntobeaprogrammethatsupportsmusicbeingdeliveredindividuallyandinpairs.Theparticipatingmusicians’previousprofessionalrelationshipsandfriendshipsthatexistedbeforeworkingwiththeVocalBeatsprogrammehavecertainlyhelpedthembecomea solidmusicalandsupportiveteam.Asonemusiciancommented,‘it’sajoytocollaboratewithotherexceptional musicians’.

Artist SupportArecentresearchreportbyvisualartistNicolaNaismithentitledArtists Practising Wellfocusesonsupportforartistsandrecognisestherolethattheartist,manager,funder,commissionerandpolicymakershaveinsupportingthewellbeingofartists,andalsolooksatthefactthatthiswellbeingisessentialforthemtobeabletoproduce quality work.

Allthemusiciansinterviewedacknowledgedandwereverygratefulforthesupporttheycurrentlyreceivefromrb&hArtsandtheopportunitiesforcontinuedtrainingandsupervisionthattheyare offered.

Themusiciansfeltthattheircurrentinvolvementinprogrammedocumentationhashelpedcreatemoreawarenessoftheirrole,andthattheartsobservationstheydohavehelpedthemtoobservemoredetailsofthemusic’simpactduringeveryvisit.Theyacknowledgedthatwhiletheevaluationprocessescouldattimesseemcomplicated,theywerealwaysevolving.Nonetheless,acommonunderstandingamongtheteamwouldbebeneficialtothewaytheyapproachthedocumentationandthepotentialinturntogatherdeeperandricher data.

Themusiciansrecognisedtheneedtoreflectindividuallyandalsowiththeirteampartner.Onemusiciannotedthat‘on your own it’s quite lonely, so good to reflect [as a team]’.

Journalingisamorerecentadditiontothemusicians’practiceintheVocalBeatsprogramme.Themusiciansacknowledgedthatithasbeenveryhelpfulasaformofreflectionandinsupportingtheirwritingofcasestudies,butalsohighlightedthatitcanbesomewhatcomplicatedtofigureouttheevaluationprocess.Theyfeltitwasimportantforthemtomoreclearlyunderstandwhattheyaredocumentingandthedifferentformsofdocumentation(e.g.forthepurposesofdata,feedbackortheirownreflections).

NoneoftheVocalBeatsmusicianshadanyspecific‘musicinhealthcare’trainingpriortostartingtherolewithVocalBeats,althoughtwohadobservedanothermusicianintheteambeforecommencing.OneofthemusicianshasundertakensometrainingwithOpusMusicsincetheybeganwithVocalBeatsandallreceivedahospitalinduction.

AlltheVocalBeatsmusicianshavetakenpartinCPDtrainingrelatingtorespiratorydiseasesandtheyconfirmedthishashelpedthemunderstandmoreofthephysicalandmedicalchallengesofpatientstheymeet,andhasalsohelpedtoinformthemusicactivitiesthattheyfacilitateduringmusicalengagements.

26 Section 3: Clinical Perspective

Section 3: Clinical PerspectiveCharlotte Wells

Thissectionbrieflyreviewsthepublishedliteraturetobetterunderstandhowmusic,singingandbeatboxingcouldbebeneficialforcardio-respiratoryhealth;itreviewsclinicians’experiencesofhospital-basedsingingprogrammes(Singing for Lung Health);andexploresthepotentialbenefitsofcollaborativesessionsbetweenVocalBeatsandalliedhealthcareprofessionalteams.

27

Why Analyse this Intervention from a Clinical Perspective?Fromaclinicalperspectivemusicprovisionisseenasanalternative‘intervention’whichactsasanadjuncttotheotherpharmacologicalandnon-pharmacologicaltreatments.Itaimstopositivelyimpactonachildoryoungperson’sexperienceduringtheirhospitalstayandtosupporttheeffortsoftheclinicalteam.Itisalsohopedthatthesesessionswitheachpatientwillhaveanimpactbeyondtheirstayandignitethepossibilityofexploringmusicandallitshealthandwellbeingbenefitsathomeandinthecommunity.ThisideaissupportedbyGoldenberg’s(2018)literaturereviewwhichlookedatthecurrentbodyofevidenceconcerningtheeffectofsinginglessonsforrespiratoryhealth,andwhichincludedallexperimentalresearchdesigns.Sheidentified17studiesthatinvolvesinginginterventionsinchronicobstructivepulmonarydisease(COPD),asthma,cysticfibrosis,Parkinson’s,cancerandquadriplegia.Goldberg’sfindingsidentifiedimprovementsinphysicalfunctioning,qualityoflife,mood,breathingcontrolandtrendstowardsimprovedrespiratoryfunctionandrespiratorymusclestrength,withreductionsinperceivedsenseofbreathlessness,fearandmentalpain.Thissuggeststhereisaneedtofurtherexplorethepotentialbenefitsofvocalmusic-makinginrespiratoryhealthcaresettings.

How Might the Intervention Work?Forchildrenandyoungpeoplewithcardio-respiratoryconditions,therespiratorymusclesplayanimportantroleinmaintaininglunghealth.Airwayclearance,breathingcontrol,respiratorymusclestrengththroughexerciseandbreathingpatterns:thesearecommonthemesinhealthmanagementforpeoplewithavarietyofheartandlungconditions.Thestrengthofthemusclesinvolvedinbreathingisimportantandcanaffectmanyoutcomesforchildrenstayingonthewards

at RoyalBrompton&HarefieldNHSFoundationTrust,including,forexample:

• howquicklychildrensuccessfullycomeoffventilatorsupportaftersurgery

• howeffectivelychildrencancleartheirchestofexcesssputum

• howablechildrenaretoexerciseeffectivelywithoutseverebreathlessness(Enright,2004;Reid,2008;Chang,2006;andWiddicombe,2006).

Studieshaveshownthatsingingrequiresregulationofairflowandencouragestheuseofagreaterlungcapacity(Collyer,2009,Sundberg,1987).Encouragingalargertidalvolumethroughbetterlowerthoracicbreathingmimicshowsomeairwayclearancetechniqueswithinphysiotherapyinterventionswork.Theactivecycleofbreathingtechniques(ACBT)developedbyPryorandWebberdescribehowthelargertidalvolumesattainedinthistechniquearethoughttohelprecruitoropenareasinthelungswheresputumhasblockedanairway,helpingtomobiliseandclearthesecretions.Goldenberg(2018)suggeststhattheshearingforcesandoscillatingpressuresgeneratedinthelungsduringsingingcouldhelpmobilisesecretions,

Figure 7 Active Cycle of Breathing Techniques (ACBT)

developed by Pryor and Webber

Section 3: Clinical Perspective

28 Section 3: Clinical Perspective

hydratetheairwaysurfaceliquidandreducetheviscoelasticpropertiesofthesputum,makingiteasiertoclear.Onthisbasis,wesuggestthatbothexerciseandsingingsessionscouldactinasimilarwayasanadjuncttoairwayclearanceforrespiratorypatients,mobilisingsecretionsandtherebymakingiteasiertoclearsputum.Benefitsof singingincludethatitdoesnotrequireanydevices,patientscandoitontheirown,andtheelementoffunandenjoymenthelpsreducetreatmentburden(Raskin,2009).

Bothphysiotherapytechniquesandsingingtechniquesfocusontheimportanceofposture,diaphragmaticbreathingandbreathcontrol.Althoughvarioustechniquesexist,theonemostcommonlyusedinbothphysiotherapyandsinginginvolvesdescentofthediaphragmoninspiration,leadingtothelateralmovementofthelowerribsina‘buckethandle’motionwhichtogetherpushtheabdominalwalloutwardsjustbelowthexiphisternum;followedbyeitherpassiverelaxationonexpirationinnormalrestingbreathing;or,duringairwayclearancesuchasAutogenicDrainage(AgostiniandKnowles,2007),ForcedExpiratoryTechniques(FETs)inACBTandinsingingsessions,thecontractionofabdominalmusclestocontrolan‘activeexpiration’thatpushestheabdominalviscerabackupagainsttherelaxingdiaphragm.Withinphysiotherapybreathingcontrolsessions,pursed-lipbreathingiscommonlytaughtasamethodthatcreatesresistancetotheexhalationinordertomaintainsomepositiveexpiratorypressure,therebyreducingthepossibilityofairwayclosure.Thiscanhelpbreathcontrolonactivityandexercise.Goldenberg(2018)suggeststhat,‘the lengthened airway, positive expiratory pressures and long sustained phrases required in singing can theoretically inhibit the collapse of airways’inasimilarwaytopursedlipbreathing.Bothcanhelpreducethesensationofbreathlessness,empowerpatientswiththeabilitytocontroltheirbreath

whilstmoving,andreducetheriskofover-breathingordisorderedbreathingpatterns.

Bothphysiotherapyandsingingsessionsencourageposturalrealignmenttoachievenormalspinalcurvature,engagementofcorestabilisingmusclesandpelvicfloor,aswellasrelaxationaroundtheneckandshoulders.Inthecontextofphysiotherapyinterventionsthisistoachievebetterairwayclearancetechniques,amoreeffectivecough,improvethebreathingpatternandreducestressincontinence;insinging,ontheotherhand,itisforthepurposesofbetterbreathcontroltoachievelongersustainedphrasesandbettercoordinationbetweenmuscles.Althoughthepurposesbehindtheuseoftheinterventioninphysiotherapyandsingingaredifferent,theoutcomeisthesame,andbothinterventionscanimprovepostureandstrengthencoremuscles,whichwillinthelongtermbenefitthepatientandreducetheirriskofinjury,long-termbackpain,andstressincontinencecausedbychroniccoughingduetothechild’srespiratoryconditionandrepeatedchestinfections.

Figure 8 Singing for Breathing warm up for vocal sessions using

fricatives and pursed-lip breathing exercises © Elam Forrester

29 Section 3: Clinical Perspective

Throughre-establishingdiaphragmaticbreathingandgoodposturalalignment,bothphysiotherapyandsinginginterventionsalsofocusonre-establishinga‘normal’or‘good’breathingpattern.Bythiswemeanchangingclavicularorapicalbreathingtodiaphragmaticbreathing,establishingagoodrhythmandflowtothebreathingpatterntoenabletheparticipanttoeitherexercisewithoutthediscomfortofexcessivebreathlessnessor,in singingpractice,toachievelongerphrasesandbetterbreathcontrol.ThestudiesinsingingforlunghealthbyLordetal.(2010)foundthatbetterbreathingpatternsandcontrolwereseenafterthesixweeksofsingingsessions.Thisishugelyimportantasdysfunctionalbreathinghasbeenfoundtobeasignificantcauseofbreathlessnesssymptoms,anxietyandmorbidityinpatientswithrespiratoryconditions(Veidaletal.,2017).Treatingdysfunctionalbreathingandre-establishinga‘normal’breathingpatterncanhelpreducerelianceonrelieverinhalers,andhospitaladmissionsaswellasimprovesymptomsforchildren(BarkerandEverard,2014).

Musicandsingingsessionsareoftenindividuallytailoredatthebedside,whichmakesmeasuringtheintervention,doseandoutcomefraughtwithchallenges.Whatisthe‘right’outcomethatwillcaptureachildoryoungperson’sexperience?Perkinsetal.(2018)encounteredthisissuewhentheywereunabletodemonstratethebeneficialimpactofasinglemusicsessiononpaininchildrenpost-surgery.Theyhighlightedtheneedtocreatea toolthatisabletoexploretheobservableimpactofmusiconchildren’semotionsandbehaviours.

Review of Clinicians’ Experiences of Singing Projects Within HealthcareOneoftheleadingprojectsatrb&hArtsandinthewidersectorisSinging for Breathing(orSinging for Lung Health),whichprovidesweeklysingingclassesforolderadultslivingwithCOPD.This

programmehasbeenenormouslyinfluentialinitsapproachandsuccesses,providinginspirationforcriticalthinkingandbuildingtheevidenceforVocalBeatsfromahealthperspective.ToreviewtheimpactSinging for Breathinghashadonbothparticipantsandclinicians,VictoriaHumeconductedaseriesofinterviewsonits10-yearanniversarybothwithpeoplewhohadparticipatedinaSinging for BreathinggroupandclinicianswhoworkedwithinRoyalBrompton&HarefieldNHSFoundationTrust.Thisworkledtothecompositionof‘TheSingingHospital’anditsperformanceattheRoyalCollegeofPhysiciansCatch Your Breath exhibition.Victoriahaskindlyallowedmetoreadandanalysethoseinterviewscriptsfromtheclinicians’experiencesofthissingingprojectwithinRoyalBromptonHospital;theseincludetheleadconsultantandaresearchphysiotherapistwhowereinvolvedintheprojectfromitsinception,anddoctorswhohaveworkedwithsingingprojectssinceithasbeenestablished.Overalltheprojectwasdescribedasahugelyjoyfulexperience,whichsuccessfullysupportedabilityandreducedthesocialisolationsooftenseenwithprogressiverespiratoryconditions.Themeswhichemergedfromacrossallthreeinterviewswere:

• Dynamicphysicalityofthesessions

• Practicalfocusonbreath

• Non-threateningtoamedicalparadigm

• Scientificevidence

Figure 9 Singing for Breathing perform 'The Singing Hospital' at

Royal College of Physicians, 2019 © Elam Forester

30 Section 3: Clinical Perspective

Dynamic Physicality of Singing SessionsEachpersoninterviewedcommentedearlyonthatthesurprisingthingthatwasmostnotableaboutaclass-basedsingingsessioninrespiratoryhealthwasthephysicalityofit;theactivityandenergylevelsweremuchhigherthanexpectedfromsucha class.

I saw that there was more to it than a sing-song quite quickly, just from the warm-ups that she was doing. Thewarm-upsandvocalexerciseswereactiveandapplicabletothephysiotherapyclassesforexercise-basedrehabilitation:

I was nearly immediately taking things on: how can I use this in PR [pulmonary rehabilitation]?

Practical Focus on BreathThroughouttheinterviewtranscriptstherewasconsiderationofhowbreathcontrolwasattendedtointhesessions,inawaythatwasverydifferentfromtraditionalbreathlessnessmanagement:

Well I think it’s a very deliberate physical activity. You have to hold yourself in a particular way, you have to control your breathing. And… you know, the output of that is very obvious: if you’re singing effectively or not.Thebenefitsandapplicationsofthisformofbreathingcontrolandfocusonbreathpatternwereconsideredbyboththephysiotherapistandconsultant.Theideathatitisimportanttoprepareyourbodytobreatheforsinging,justasforexercise,andthepotentialapplicationofthisconceptintothelivesoftheparticipantscouldbewhatenablesbetterfunction.

…there are likely to be many psychological benefits… but I think having an activity that is also physical in people who have a physical impairment, who are breathless and have detrained, become physically deconditioned because of their breathlessness. Singing for Breathingclasseswereseenasahugelypositivegroupactivitythatfocusedonabilityratherthanrespiratorydifficulties.

Breathlessness is something that people have in their heads. It’s a sensation. So it’s made up of the physical inputs that are coming back from the breathing, combined with what the person thinks their breathing is going to be like and what they’re expecting, so you start with people who expect to be breathless, they expect to be limited, they expect to be distressed, they’re fearful of breathing and breathlessness; so techniques that can overcome that, which may be something that you do as a different behaviour around breathlessness, may well be helpful.

Non-threatening to the Medical ParadigmThesuccessofanartsprogrammewithinahealthcareorhospitalsettingoftenrequiressupportfromleadorinfluentialconsultants,withwhomtheoverallresponsibilityforpatients’healthlies.Itisthereforeinescapablethattheremayneedtobesupportandendorsementfromconsultantsforanartsprojecttogainafootholdwithinthehospital

31 Section 3: Clinical Perspective

setting.Weareencouraged,then,thattheleadconsultantwhowasfundamentalintheSinging for Breathingresearchprojectscommentswithinthehospitalnotes:

It’s not challenging any kind of medical paradigm for me, it just seems like a perfectly normal, sensible thing, which you know is either useful or not for some or loads of people, and you know I think will take its place as a useful activity and something that we can recommend.Furthermore,anothercliniciandescribesitas;

…personalised medicine, you know? In the same way that we’re personalising things based upon people’s genetics and genomics, we should be personalising them on their human experience of culture and family – these are all just as much integral to creating personalised medicine…

Scientific EvidenceAllthreeinterviewsaddanoteofcautionaboutourcurrentknowledgelevelconcerningthetheoryandimpactofsinginginterventions.Theyalldescribethegoodlevelofqualitativeevidenceand experimentalevidence,butaswehavealreadyhighlighted,thereisaneedforrandomisedcontrolledtrialsbeforethistypeofinterventionwouldbewidelyacceptedasanadjuncttomedical care.

Thinking about it from a scientific point of view, there are going to be some things about it which are going to be true or not true so in terms of advocating for it, I think it’s important not to run ahead of the evidence.

Collaboration WorkCollaborativeworkingbetweensingingteachersandphysiotherapistshasbeenrecordedbeforeinliteratureandwithinthishospitaltrust.Lordetal.(2010and2012)documenteditintheirsingingstudyintervention;andbeginningwitha 30-minutesessionwithaseniorphysiotherapyonbreathingcontrol,thenaturalevolutionoftheVocalBeatsteamwassupportedbythepaediatricphysiotherapists.Havingahealthcareprofessionalwithinthewardandteamyouareworkingoncanbehelpfulforfacilitatingacceptanceofthesingersintothewardenvironment,tointegratepractices,tolearnanddevelopknowledgeofthehealth/diseaseconditionswithwhichthesingersareworkingandtohelpthemidentifywhatsuccessmightlooklikewithinasingingsession.Giventhatsingingandphysiotherapyareworkingtowardssomecommonaims,itisnaturalthatthisallianceoftenexists.

Figure 10 1-to-1 Vocal coaching session © Nik Read

32

Followingworkandsharedsessionsbetweenphysiotherapistandsingers,someformalteachingsessionswerearrangedforthewholeVocalBeatsteam.Fourhalf-daysessionswerearranged.Sessiononewasonthepathophysiology,medicalmanagement,andphysiotherapyaimsforeachcardio-respiratoryconditiontheymayencounteratRoyalBromptonandHarefield.Sessiontwoaddressednon-pharmacologicaltherapeuticaimsandtheorycommontophysiotherapyandsinginginterventionsforcardiorespiratoryhealth,Sessionthreefocusedontheoreticaldevelopmentofsinginginterventionsandsessionstailoredtoeachcardiorespiratorycondition.Sessionfourwasapracticalsessionsplitbetweenward-basedobservationoftailoringsessionsanddevelopingreflectivepractice.TheaimofthesessionswastoempowertheVocalBeatsteamtocreatepersonalisedsessionstakingintoconsiderationthechild’shealthconditionyetstillmaintaintheartisticelementoftheirwork.Developingthesingersunderstandingofbothhealthconditionsandthephysiologybehindhealthcareinterventionsenabledthemtobetterunderstandandrecognisewhatimprovementsparticipantsweremakingandhowsignificanttheycanbetotheiroverallhealth.Thistypeofeducation–whichwouldalwaysberecommendedforanysingingintervention,whetheritbeSinging for Lung Healthoralocalhospitalproject–iswhatsetstheprogrammeapartfromacommunitychoir:itgivesthesingerstheabilitytocreateatargetedtherapeuticinterventionbywayofanartisticoutlet.Ensuringregularreflectivepracticeisessentialforthesingerstolearnhowtoidentifywhat‘success’mightlooklikeintheclinicalareatheyareworkingin,tobetterunderstandtheirownpracticeandmaintaintheirownhealthandwellbeing.Reflectivepracticecanbedoneasanindividualbutbetterguidedwithasupervisororasateamandallowsmusicianstoprocesswhattheyhavenoticedwithinsessions,findingsignificanceinthingspossiblyoverlookedinthemoment.

It canallowincreasedawarenessofpatternsandresponsesleadingintimetoabetterunderstandingofbreathandsinging.

Goldenberg(2018)concludesherliteraturereviewbysaying:

The singing teacher who teaches a patient with respiratory disease should seek out information about the particular disease to understand the nuances of a student’s needs and, if possible, collaborate with the appropriate medical care team. Further studies of the impact singing has on respiratory disease and health are warranted.Itwasalsonotedinthe‘TheSingingHospital’interviews,inrelationtohowSinging for Breathing leadersneedappropriatetrainingpriortotakingon agroup:

We’re treating people’s voice, right? And there’s a whole profession – speech and language therapists – they should really be involved in this work as much as possible, because there’s a bit of evidence to suggest that if we improve dysphonia then we improve the amount of obstruction in their lungs. [But for] undiagnosed voice problems, singing incorrectly damages the voice [and] risks harm. Different leaders with different levels of expertise … need to pick out really, really technical aspects of delivery.

Section 3: Clinical Perspective

33 Conclusion

Conclusion with Recommendations for rb&hArts and Other ‘Music in Hospitals’ Programmes

34 Conclusion

AttheheartoftheVocalBeatsprogrammeliesa corebeliefinthevalueofsupporting,developingandenhancingthepatientexperiencethroughcreativemusic-makingandlearning.Thefollowingorganisationsformthefoundationwithoutwhichrb&hArtswouldnotbeabletodeliverthiswork:

• RoyalBrompton&HarefieldNHSFoundationTrust

• RoyalBrompton&HarefieldHospitalsCharity

• TheBromptonFountain

AbeliefintheefficacyoftheVocalBeatsprogrammeappearstopermeatetheethosofhospitallifeinthewardsateverylevel,engenderingknowledgeexchange,collaborationandsupport.ThisisevidencedbythequalityoftheworkwhichhasbeenrecognisedexternallyandparticularlyinthevitalfinancialsupportgivenbyYouthMusicandotherfunders.

Thoughthisreportreviewstheprogrammefromthreedistinctprofessionalperspectives,thereareoverlapsworthnoting.EachcontributorrecognisesthededicationofthemusiciansandthehighstandardstheyespouseineveryaspectoftheirworkatRoyalBrompton&HarefieldHospital.There isalsoaconsensusregardingtheimportanceofongoingdialoguebetweentheVocalBeatsteamandtheclinicalteam,intermsofsharingtheirspecialistknowledgeforthebenefitoftheyoung patients.

Themusiciansareconstantlydevelopingtheirpracticeinhospitalsettingsandasindividualleadingperformersandsongwriterswithhigh-profilecareers,anditisevidentthattheyconsiderbothaspectsaspriorities.Operationallythiscanbechallenging,notonlyintermsofdiaryclashes,butalsorisk-takingasartists,inpursuitoftheirgoalforpatient-ledmusicalinterventionsbasedoncollaboration,improvisation,and,fromthis,innovation.However,italsovalidatesthemand

bringsabroadstimulatingpresencetotheirworkon thewards.

In2015therewasoneMusicianinResidenceinRoseWard,andnowtherearefourmusicianswhooffersinging,beatboxingandukuleleonaweeklybasis,andalsoworkwithyoungadultsontheRoyalBromptonandHarefieldsites.Thissuccessstoryhasevolvedaccordingtoparticipantneedandbyseeingthepotentialtogrowtheprogrammeasitembedsinhospitallife,therebyenhancinganddeepeningthepatientexperience.Theadditionof1-to-1musicsessionsforyoungadultsin2018isanexampleoftheteam’scareandawarenessinaddressingthesocialisolationexperiencedbymanypatientswithcysticfibrosis.

AstheCreative PeoplechapterofEveryone can develop and express creativity throughout their life (Let’sCreate,ArtsCouncilEnglandStrategy2020-2030)states:

Children and young people talk passionately about the pleasure they get from creative activities (many of which they undertake in their own time, and often online) and how they use them to express themselves and develop their skills and confidence. They also talk about the important role that creative activities can play in helping them deal with anxiety, stress and social isolation.TheVocalBeatsprogrammeembracestheseaspirationsbyofferingpatientschoiceandtheopportunitytodeveloptheirmusic-making,buildingtheirskillstorealisetheirpotential.FormanypatientsthehospitalsettingatRoyalBromptonandHarefieldmaybetheonlyplacewheretheycandothis,andthereportrecommendsbuildingpartnershipsexternallytoextendtheopportunitiesandsharepractice.

35 Conclusion

Theareasofresearchandrobustevaluationinthisspecialistclinicalcontextarealsohighlightedinthereport.Itisrecommendedthattheseshouldbefurtherdevelopedinordertosharelearningacrossawiderhealthcareforumandtoprovideevidenceforsecuringfundinganddevelopingnewpartnershipsacrosssectors.OfparticularimportanceisaninvestigationintotheimpactandeffectofthemostcommonsingingorbeatboxingtechniquesusedwithintheVocalBeatsteam,sothatwemightbeabletobetterunderstandandunpicktheefficacyofthesetechniquesforchildrenwithheartandlungconditions.Analysisshouldfocusonsingingandbeatboxingtechniquesfromaphysiologicalandvocalcoachingperspective.Oncewehavedeepenedourknowledgeandevidenceforwhyandhowthesesingingtechniquesmightworkandthebenefitstheymayoffer,wecanthenmorewidelyrecommendtheiruseinavarietyofsettings.

rb&hArtsiswellplacedtobeattheforefrontofcurrentthinkingregardingpersonalisedmedicineandsocialprescribingintheworktheyundertakewithpatients,incollaborationwithclinicians.

Whilstrecognisingissuesregardingcapacityandfundraisingimperatives,itishopedthattheVocalBeatsprogrammewillgrowinprofileandgainfurtherrecognition;thoughthiswillinturnbenefitRoyalBrompton&HarefieldNHSFoundationTrust,itwillprimarilybenefittheyoungpatientswhoeveryoneagreesarethetoppriority.

Summary of Recommendations from the Three Sections of this Evaluation:

• Standardiseevaluationprocessesfortheteamofmusicianstogainacommonunderstandingandtoenablethegatheringofdeeperandricherdata.Themusicianswouldalsowelcomeclarificationofthetypesofdocumentationrequired.

• Furtherintegratethepracticesofthemusiciansandthehealthcareprofessionalstoidentifywhatsuccesswithinacreativemusicsessionmightlooklike.

• Amendthestatusofthefreelancemusicians’contractstopart-timesalariedroles,particularlyfortheleadmusician–ifappropriate,andsubjecttofunding.

• Continuetoexpandmusicians’knowledgebyattendingCPDopportunities,namelyworkshops,conferencesand/orexchangeprogrammesorcollaborationswithotherleadingprogrammesnationallyandinternationally.

• WithreferencetotheMusiciansinHealthcareMentoringProgramme:

• Developastandardisedapproachtomentor-menteerelationships

• Considerwhetherthementorswouldbenefitfromtailoredmentorshiptraining

• Identifyandclarifytheroleofthementeesduringsessions

• Facilitatetheobservationandreviewofmenteesinsomecapacity,creatingandleadinganinterventionwhereappropriate

• Invitesomeofthe‘alumni’menteesbacktoworkinsessionswiththeVocalBeatsmusicianswiththeaim

Figure 11 Participant playing the kalimba © Nik Read

36 Conclusion

ofbecomingdeputymusiciansinthefuture

• Considertheintroductionofanapprenticescheme

• Createanonlineforumorfurthermeetingopportunitiesformenteesduringthecourseoftheprogramme

• Developa360°pilotpathwayschemeforpatientstocontinuemusicalactivityintheirownlocalitybetweenhospitalstays.

• Considertheintroductionof‘individual’learningplansthatalsoincorporate‘buddy’plansforensembleworkandcompositiononlineorinperson.

• ResearchhowthenewNationalAcademyforSocialPrescribingcouldbenefittheVocalBeatsprogramme.

• SupportVocalBeatsAmbassadorsindevelopingwiderpeernetworksandorganisations.

• ResearcharangeofaccreditationmodelsthatmayberelevanttoVocalBeatsparticipants.

• Shareevidenceandgoodpracticemoreextensivelywithawiderrangeofstakeholders;thesecouldincludeprofessionalandamateurmusicensembleswithwhomthereisanartisticsynergy;commercialandcorporateorganisations;andarangeoftrustsandfoundationswhomaywishtobecomemorefamiliarwiththeprogramme.

• Furtherexplorethepotentialbenefitsofvocalmusic-makinginrespiratoryhealthcaresettingsthroughformalisedresearch.

• Seekopportunitiesforfurtherclinicalstaffbuy-in;bypresentingtophysiotherapyteams,forexample.

• Createatooltoexploretheobservableimpactofmusiconchildren’semotionsandbehaviours.

• Embedstructuredreflectivepracticeintothemusician’sworktodevelopexperientiallearningandself-supervision.

37 Conclusion

Additional Information ResourcesCysticFibrosisTrust(https://www.cysticfibrosis.org.uk/what-is-cystic-fibrosis)

StandardsofCareandGoodClinicalPracticeforthePhysiotherapyManagementofCysticFibrosis(https://www.cysticfibrosis.org.uk/the-work-we-do/resources-for-cf-professionals/consensus-documents)BritishLungFoundation(https://www.blf.org.uk)

AsthmaUK(https://www.asthma.org.uk)

PrimaryCiliaryDyskinesia(https://www.blf.org.uk/support-for-you/primary-ciliary-dyskinesia-pcd)

BritishHeartFoundation(https://www.bhf.org.uk)

Further ReadingIrons,J.Y.,Petocz,P.,Kenny,D.T.,Chang,A.B.(2019)‘Singingasanadjuncttherapyforchildrenandadultswithcysticfibrosis’,Cochrane Database of Systematic Reviews,issue7.Availablefrom:DOI:10.1002/14651858.CD008036.pub5.

Irons,J.Y.,Kenny,D.T.,Chang,A.B.(2010)‘Singingforchildrenandadultswithbronchiectasis’,Cochrane Database of Systematic Reviews,issue2.Availablefrom:DOI:10.1002/14651858.CD007729.pub2.

Lewis,A.,Cave,P.,Stem,M.,Welch,C.,Taylor,K.,Russell,J.,Doyle,A.M.,Russell,A-M.,McKee,H.,Clift,S.,Bott,J.andHopkinson,N.(2016)‘Singingforlunghealth–asystematicreviewoftheliteratureandconsensusstatement’,npj Primary Care Respiratory Medicine,issue26.Availablefrom:DOI:10.1038/npjpcrm.2016.80

38

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Goldenberg,R.B.(2018)‘SingingLessonsforRespiratoryHealth:ALiteratureReview’,Journal of Voice,32(1),pp.85-94

Lord,V.M.,Cave,P.,Hume,V.J.,etal.(2010)‘Singingteachingasatherapyforchronicrespiratorydisease–arandomisedcontrolledtrialandqualitativeevaluation’,BMC Pulmonary Medicine,10.Availablefrom:DOI:10.1186/1471-2466-10-41.

Lord,V.M.,Hume,V.J.,Kelly,J.L.,etal.(2012)‘Singingclassesforchronicobstructivepulmonarydisease:arandomizedcontrolledtrial’,BMC Pulmonary Medicine,12:69.Availablefrom:DOI:10.1186/1471-2466-12-69.

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41 ACKNOWLEDGEMENTS

ACKNOWLEDGEMENTS

42 ACKNOWLEDGEMENTS

AlderHeyChildren’sNHSFoundationTrust(www.alderhey.nhs.uk/services/arts-for-health)

ArtsCouncilEngland(www.artscouncil.org.uk)

BatterseaArtsCentre(www.bac.org.uk)

BBCChildreninNeed(www.bbcchildreninneed.co.uk)

BethlemandMaudsleyHospitalSchool(www.bethlem-maudsleyschool.org.uk)

TheBromptonFountain(www.thebromptonfountain.org.uk)

CarolineMoore,ParticipatoryArtsManager,GOSHArts

CityofLondonSinfonia(www.cityoflondonsinfonia.co.uk/wellbeing/wellbeing-projects)

Culture,HealthandWellbeingAlliance(www.culturehealthandwellbeing.org.uk)

Foulis,RowanandFirTreeWards

GOSHArts(www.gosh.nhs.uk/wards-and-departments/departments/gosh-arts)

InstituteofPsychiatry,PsychologyandNeuroscience(IoPPN–www.kcl.ac.uk/ioppn)

JenniferRaven,DeputyDirectorSoundConnections(www.sound-connections.org.uk)

LEAPTalentDevelopmentProgramme(www.serious.org.uk)

LiveMusicNow(https://www.livemusicnow.org.uk)

LondonArtsandHealthForum(http://www.lahf.org.uk)

MusiciansinHealthcareMentoringProgrammeParticipants:NicolaTagoe,SaraFawcett,SashaMattock,LilaBhattacherjee,andAidenMaier

NationalAllianceofMusiciansinHealthcare(http://www.namih.org)

NHSNationalPerformanceAdvisoryGroup(NPAG–www.npag.org.uk)

OPUSMusic(https://opusmusic.org)

Parentsandcarersofpatients

PatientsofRose,Foulis,RowanandFirTreeWards

PulseArts(www.pulsearts.co.uk)

RoseWardclinicalstaffincludingwardsistersandPlayServices

RoyalBrompton&HarefieldHospitalsCharity(www.rbhcharity.org)

RoyalBrompton&HarefieldNHSFoundationTrust(www.rbht.nhs.uk)

SnapeMaltings:MOTMusiciansworkinginchallengingsettings(www.snapemaltings.co.uk/music/residencies/mot)

SocietyofPublicHealthAwardsArtsinHealthcategory(www.rsph.org.uk)

TheRoyalMarsdenCancerCharity (www.royalmarsden.org)

TheRoyalMarsdenNHSFoundationTrust (www.royalmarsden.nhs.uk)

Theteamatrb&hArts:KarenTaylor,ConniRosewarne,KarenJanody

TheVocalBeatsMusicians:HeatherMcClelland,StacDowdeswell,Bellatrix,MCZani

UkuleleKidsClubUK(https://uk.theukc.org)

VictoriaHumewhoverykindlygrantedususeofherinterviewtranscriptsfromresearchfor‘TheSingingHospital’.

VocalProcess(www.vocalprocess.co.uk)

YouthMusic(www.youthmusic.org.uk)

YouthMusicSocialActionAwardsponsoredbyHalLeonard(https://www.youthmusic.org.uk/awards)

43

APPENDIX: Description of Conditions

44 APPENDIX

ListedbelowaredetailsofthemainheartandlungconditionsthatthechildrenandyoungadultswhoareinpatientsatRoyalBrompton&HarefieldHospitalsmayhave.ThesedetailsareprovidedtogivecontexttotheVocalBeatsworkandthepeopletheymaybeworkingwith.

Cystic FibrosisCysticfibrosis(CF)isageneticallyinheritedlife-limitingconditionthataffectsallthemajororgansofthebody,suchasthelungs,pancreas,bowel,liverandkidneys.Inbrief,itoccursbecauseanalteredcysticfibrosistransmembraneregulator(CFTR)genecausesthecellsinthebodytohaveanimbalanceofsodiumandpotassium,whichleadstomembranesbecomingdehydratedandsticky.Thickmucusbuildsupeverywhereinthebodybutparticularlyinthelungsanddigestivesystem:theairwaysproducethickmucuswhichishardtoclearandmakespeoplewithCFmoresusceptibletolunginfections.Repeatedinfectionsintheairwaysleadtoirreversibledamage(Ironsetal.,2019).ThemanagementofCFcaninvolveacomplexdailytreatmentprogrammethatusuallyincludesairwayclearancetechniques,physicalexercise,pancreaticenzymesandothermedications,aswellashospitaladmissions.Suchanintensivetreatmentregimenmayhaveanegativepsychosocialimpactonchildrenandadolescents(Glasscoe,2008),particularlyadolescents(D’Auria,2000).PreviousstudieshavefoundthatindividualswithCFmayhavepoorqualityoflife(QoL)(Quittner,2008).

BronchiectasisBronchiectasisisdiagnosedthroughidentificationof‘irreversibledilationofperipheralairways’onaCTscan.Thesedamagedairwayscauseover-productionofmucus,however,thesamedamagemeanstheairwaysareunabletoclearthesesecretions,whichleadstoanongoingcycleofinfectionandfurtherlungdamage.Theseexacerbationsfrequentlyrequirehospitalisation

fortreatment.Themanagementofbronchiectasisinvolvesmaintainingrespiratoryhealth,clearingtheairwaysandphysicalexercisetomaintainphysicalfunction.

AsthmaAsthmaaffectstheairwaysinthelungsofchildren,youngpeopleandadults,andcanchangeoverthecourseofalifetime.Typicalsymptomsofasthmamayincludebreathlessness,difficultybreathing,tightairways,coughingandwheezing;thesesymptomscanbepersistentorintermittent,andmaychangeasachildgrowsup(GINA,2018).Theaimofasthmamanagementistominimisesymptoms,exacerbationsandhospitaladmissions;tofindtheminimumdoseofeffectivemedicationtoavoidadverseeffects;tomaintain‘normal’pulmonaryfunction;andtoenableachildtoparticipatefullyinphysicalactivity(GINA,2018).Asthmamanagementusesinhalersandmedicationstotreatinflammationandinfectionintheairways,aswellasnon-pharmacologicalinterventionswhichmayincludepsychologytohelpwithanxietyandadherencetomedications,andphysiotherapytohelpwithexercise,airwayclearance,symptomdifferentiation,breathcontrolandbreathingpatternretraining(Veidaletal.,2017).

Primary Ciliary DyskinesiaPrimaryciliarydyskinesia(PCD)isarareinheriteddiseasethataffectscilia,whicharetiny,hair-likestructuresthatlinetheairways.Ciliamoveinunisoninwave-likemotions,carryingmucustowardthemouthtobeswallowed,coughedorsneezedoutofthebody.Themucuscontainsinhaleddust,

45 APPENDIX

bacteria,andothersmallparticles.Iftheciliaarenotworkingwell,bacteriawillremainintheairways,whichcancausebreathingproblems,cyclesofinfection,andotherdisorders.PCDmainlyaffectsthesinuses,ears,andlungs.SomepeoplewhohavePCDhavebreathingproblemsfromthemomentofbirth.ThemanagementofPCDinvolvesairwayclearancetechniques,sinusrinsing,maintaininglunghealthandphysicalfitness.Treatmentofinfectionsfrequentlyrequireshospitalisation.

Post-Cardiothoracic SurgeryAwiderangeofcardiacandthoracicsurgeriesareperformedatRoyalBromptonHospital&HarefieldHospital.Theseincludemeasuresfromcorrectionofcongenitalmalformationoftheheart,tolungtransplants.Oncesurgeryiscompleted,recoverycantakefromaslittleas5daysuptoseveralmonthsbeforereturningtofullfunctionanddischargehome.Differentsurgeriesrequirevaryingincisionsites,whichcanmeanthechild’schestmay

havebeenopenedviathesternumorribs.Aftersurgerychildrenspendtimeontheintensivecareunitwhichcanbenoisyandfrighteningforthem;theyoftenneedtohaveintravenousmedication,chestdrainsandlinesinandontheirbodies.Theymayneedtoundergopainfulprocedures;althoughmovingaroundaftersurgerymayalsobepainful,itisanimportantstepforensuringthechild’srecovery.Afteralungtransplanttimeinisolationmayalsoberequireddependingoneachpatient’simmunesystemandtheirbody’sacceptanceoftheneworgan.Nervescanbecutorbruisedduringsurgery,andthiscanalterthepatients’abilityto‘feel’theirbreathing.Oncerecoveredandmovedtohighdependencyunitsandthegeneralward,fewerlines,drips,drainsandmedicationareneededandthechildrenarefreertomoveandplay.Dependingonthesurgeryandincisionsite,childrenwillbegivenadviceonwhattheycanandcan’tdountilfullyhealedoverthenext6weeksto3monthsathome.

46

rb&hArts would like to give special thanks to Marion Friend MBE, Gráinne Hope and Charlotte Wells for all their work and support to create this brilliant report, along with Youth Music, without whom this would not be possible.