The Ethical Dimensions of ‘Cost’ and ‘Benefit’: Reconsidering economic value in arts and mental health research

Added on Friday, April 2nd, 2021

stars ICC Head of Research Kerry Wilson shares her presentation at the recent UKRI MARCH Mental Health Network seminar on Ethical Dilemmas in Arts and Mental Health practice and research.


This interdisciplinary online seminar was hosted by the UK MARCH Network’s Special Interest Group in Ethics and Evaluation in Arts and Health, and in collaboration with the ATTUNE Consortium, on 29th March 2021. With presentations from an inspiring group of practitioners, including those with lived experience, and researchers from the field, we explored a range of ethical dilemmas in research and practice under the themes of Consent, Confidentiality and Power; Redefining Concepts of Care through the Arts; and Risk and Responsibility for Adverse Effects. The event concluded with a panel discussion on Future Directions in Ethics, Arts and Mental Health: research and practice. Enormous thanks to colleagues Dr Lindsay Smith, Dr Andrew McWilliams and Grace Gelder for bringing the event together and all fellow presenters for such a rich and pertinent discussion.

I was delighted to have the opportunity to share my own experiences of research in the field with this growing community of interest, including how a recent focus on professional ethics has encouraged a reappraisal of earlier research at the ICC on the economic value and cost benefit of cultural interventions in mental health care. Reflecting on the strategic drivers and political motivations behind such research, I made the case for a more values-based approach to research and evaluation in arts and mental health. This includes a more careful consideration of the role of the academy and independent researchers in supporting the sector to build its evidence base, and more significantly in mediating structural narratives of ‘cost’ effectiveness, ‘value’ for money, and in encouraging more realistic interpretations and representations of investment in arts and mental health.

Setting a research agenda at the ICC

As a cultural policy research institute, launched in 2010 as a collaboration between LJMU and the University of Liverpool, the ICC is a legacy initiative of the city’s successful tenure as European Capital of Culture in 2008. Driven by a narrative of culture-led regeneration, the most significant and regularly cited indicators of success for the Liverpool 08 project relate to the economic boost it brought to the city, including for example in relation to visitor spend and the tourist economy. The ICC was established to build upon a substantive evaluation of Liverpool 08 conducted by both partner institutions, and to consider more holistically the value and impact of arts and culture within urban development strategies and wider public policy agendas, including health and social care.

Within this remit, there was a specific mandate from local stakeholders to focus on the economic value and cost benefit of arts and culture as an alternative to clinical interventions and mainstream public services, particularly within the context of community mental health and wellbeing. At the same time, and to give you a flavour of the political climate in the city, David Cameron launched his Big Society agenda here as one of four pilot ‘vanguard’ regions. This was soon publicly reneged by the former city Mayor, after the loss of more than £100m of Area Based Grants to Liverpool had put many community-based organisations at risk, the very organisations required to support the Big Society agenda of communities doing more for themselves.

As austerity measures began to take effect in the city from 2010, the political narrative on cultural value was shifting, in some quarters, from arts and culture as key assets in urban regeneration and lifestyle economics, to emphasising their social value as cost-effective – or rather cheaper – alternatives to rapidly shrinking public infrastructures. This included for example, as part of the launch of the institute, public speculation on how £1 spent on a reading group might ultimately save up to £30,000 in non-prescribed anti-depressants. This was described by a colleague as ‘blokes in a pub, back-of-a-beer-mat hypothesising’, which is perhaps not the best way to launch an academic research institute. It was inspired however by genuine personal belief from our individual stakeholders, based on lived experience, in the value of arts and culture and its capacity to make a difference in mental health.

So how do we evidence the economic value of arts and culture?

We had a clear mandate therefore but with one fundamental flaw in the plan. We had a very small team of academics to begin with, seconded to help develop the institute from within both partner institutions. The team did not include a cultural economist, a health economist, or an economist of any description… So, we needed to take a few steps back before we could move forward, and this included a review of economic value and impact research in arts and cultural sectors, in collaboration with our partners at Mersey Care NHS Trust.

It was important for us to think about how we could potentially measure cross-sector economic value and impact, so in this context, economic value generated for health and social care sectors by arts and culture. Our research partners at the time were interested in communicating the ‘added value’ and advantages of collaboration between the two sectors. Not surprisingly, the review showed that relevant methods were mostly used to consider creative and cultural sector(s) as single units of economic activity in purely fiscal terms (direct turnover; Gross Value Added; contribution to GDP). As such, social return on investment (SROI) emerged as the most appropriate approach for considering the types of outcomes and subsequent cost-benefit that we were interested in exploring.

Using social return on investment at the ICC

Through this groundwork, we were able to persuade our host institutions to fund an additional Research Fellow post and subsequently recruit an accredited SROI analysist to act on the recommendations made in the review. Examples of how we have since used the approach, led by ICC Research Fellow Gayle Whelan, include evaluations of a dementia awareness programme led by National Museums Liverpool with a range of national partners, and of an ‘arts on prescription’ programme based in St Helens. Reflecting on our experience of using the method, there are certain pros and cons:

Pros: We know that the method is valued by our arts and cultural partners as they think it ‘speaks to commissioners’, and we know in the case of NML’s work for example that it has helped to secure additional funding and contributed to the longevity of the programme. The fact that it involves multiple stakeholder engagement in this context, for example in a consultative capacity in identifying social outcomes, is considered useful and effective. This process also illustrates the value of qualitative data in identifying and communicating those outcomes, something that is often undervalued and campaigned for in arts and health research.

Cons: There are limitations with any research method, and in the case of SROI these include scepticism on the reliability of social outcomes, given that there are no control measures in place. The accuracy of financial proxy measures used to calculate return on investment is also sometimes questioned (these are usually drawn from a database of previous social value research). Most importantly, SROI is not a comparable method as it is so context-specific and subjective to each programme evaluated. We might be able to say for example in other economic value research that the live music sector has a higher direct turnover than theatres and other performing arts, but we can’t use SROI ratios to say that one intervention has more social value and is therefore ‘better’ than another.        

Empirical research on practice in the field

Alongside evaluation work, the institute has also provided a platform and space to explore the practice of cross-sector cultural work, which is essential if we are to truly understand the intricacies and relationships between policy, professional practice and impact of the sector. Most recently, this has included my study of professional ethics in the culture, health and wellbeing field, focused specifically on museums working in health and social care settings and prison library services. This was conducted as part of a Leadership Fellowship funded by the Arts and Humanities Research Council.

The premise of this study was to consider the efficacy of museum and library sectors’ own codes of ethics when working in non-conventional professional environments, and it showed a number of ethical challenges in the field. To begin with, there are incredibly complex collaborative structures that include a range of organisations within and across public, private and charitable sectors, each bringing their own ethical codes, regulations and standards of working. Within these communities of practice, volunteers play a substantive role in making these programmes happen as unpaid members of the collaborative workforce and therefore with no ethical allegiance or obligation to any particular profession.

Practically speaking, there was considerable evidence of work assimilation across professional boundaries for cultural workers, especially in the prison system where librarians assume various responsibilities of a prison officer. This can lead to conflicts between own core professional values and local system regulations and procedures, for example with regards to access to information and censorship of reading materials.  Overall, the sheer intensity of this work and the emotional labour involved, particularly when working with vulnerable groups, results in the emergence of care as an abiding principle and practice, including self-care and team support strategies, and access to professional support services when required.

As such, sector codes of practice become largely irrelevant on a day-to-day basis, with cultural work more intuitively informed by factors including personally held moral values; political ideology and orientation; other/prior professional training and development; faith and religious beliefs; and life-course social and cultural experiences. As the research progressed, virtue ethics became a useful, alternative theoretical lens, due to its focus on shared moral qualities and key virtues amongst different practitioners.

Re-evaluating narratives of economic value

Over the years and mostly inspired by my Fellowship research, I’ve been thinking about how we re-enact our own ethical values as academics, particularly with regards to how we represent and support arts and cultural sectors as ‘independent’ researchers. The assumption is that independent, academic evaluation research partners occupy a ‘critical distance’ from the programme, enabling an objective appraisal of its outcomes. In reality, to truly understand ‘what works’ needs a more embedded, empirical and ethnographic approach in order to capture what is involved at the input and activity stage of any programme. This inevitably leads to certain subjectivities, both in delivering an honest appraisal of the work under consideration and in balancing our own emerging care for this work and our research partners.

There is a responsibility within this to reframe narratives of cost-effectiveness, which the AHRC Instrumental Values study shows. With reference to the sheer scale of voluntary work and assimilation of other roles and responsibilities in the field, of course affective cultural work in mental health care is a cheaper alternative to clinical interventions when much of it is unpaid and involves doing the work of other professionals. Whether it is ethical to present it as such is another matter. The truth is that third sector organisations need just as much infrastructural support as any other and it is vital to acknowledge the various forms of investment that people delivering culture, health and wellbeing projects make in their work. We can of course hypothesise on the likely financial savings and economic value of more community-based, preventative public health strategies and interventions. In reality and in practice, for every £1 spent on a reading group, people give infinite amounts of their own time, energy, commitment, care and emotional resilience.

With this, comes issues of replication and scalability in project-based interventions. Where ‘best practice’ exists, it is often underpinned by years of cultural workers going ‘above and beyond’ in developing and sustaining cross-sector partnerships. The limited scope of short-term, project-based interventions is matched by persistent structural inequalities in who gets to access and benefit from more mainstream cultural assets and services. Overall, as researchers in the field, our role is not to misrepresent, oversell or indeed underplay the important and vital role of arts and culture in mental health, but to perhaps exercise more rhetorical caution in how we evidence and advocate its impact.

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