Can a Dutch model of care at home be adapted to the UK?

In 2006 four nurses in the small Netherlands town of Almelo realised that years of ‘reform’ had undermined their relationships with patients. The very vocational commitment that had brought them into the profession in the first place was compromised. The four nurses decided enough was enough and Jos de Blok and his three colleagues had a better idea, to set up their own social enterprise, Buurtzorg, to look after older people in their homes, in the way their ethics and craft demanded.

Nine years later they have more than 9,000 colleagues and Buurtzorg, looks after more than half of the Dutch people needing care at home and as been named the country’s best employer year on year, and is not only a magnet for any Dutch nurse that wants to do a better job but also a role model for the rest of the sector.

Yet Buurtzorg has also cut costs to such an extent that an independent evaluation said if every other Dutch provider worked the same way millions more euros would be saved.

That’s because — and here’s the revolutionary bit — all this has been accomplished through nurses managing themselves in 800 small neighbourhood teams that engage more effectively with other local services, voluntary carers and patients themselves.

And we mean ‘’managing themselves”. Buurtzorg has many leaders but no managers. The self-organised teams are supported instead by peripatetic coaches and an IT system designed around care-giving and collaboration.

Otherwise, the whole national operation is run from a small back office that looks after billing and co-ordinates information and learning across the teams — 40 HQ staff for 9,000 in the field.

In 2015 more and more health and social care commissioners and providers in England are talking about how the Buurtzorg model can be adapted to the UK context, because co-ordinated compassionate care demands it.

The two professions that can best support the growing number of people needing support to enable them to live independent, safe and meaningful lives at home are community nurses and home care workers. However both these professions face a growing crisis.

Many nurses, in England and elsewhere, have responded to the same pressures by giving up and leaving the profession, turnover is at an all time high and the number of district nurses has almost halved, from 12,620 in 2003 to 6,656 in 2013, a 47% drop in a decade. Meanwhile home care work  is underpaid and undervalued with staff turnover at over 30% per annum and huge recruitment difficulties. 

A revolution in England is underway, but it faces formidable obstacles. The Dutch health insurance system enables social enterprises to introduce innovative approaches more easily than our system does, and although the self-management model certainly can produce savings it does involve upfront investment and transition costs.

But the groundswell for radical change is growing among health and social care professionals in England, and the NHS England Five Year Forward View has earmarked several ‘vanguard’ initiatives to plot the way ahead.

In addition, community nursing leaders in Guys and St Thomas’s NHS FT are collaborating with their local authorities and communities in co-producing new neighbourhood services, including scoping the possibility of a Buurtzorg-type experiment.

Jos de Blok founder of Buurtzorg will be leading a workshop there, in support of an initiative by our social enterprise consultancy, Public World, to take inspiration from his experience and support the care revolution here.

Jos is also speaking at an event in London July 16th organised by Public World Consulting, the Royal college of Nursing and the UK Homecare Association for leaders in health and social care. There may be a few tickets left.

Some people have said to us, “it’s a great idea, but it won’t work in England.” If those four nurses in Almelo had taken that attitude tens of thousands of Dutch lives would not have been transformed as they have been. If they can do it, so can we!

James Archer and Tamsin Fulton - Public World Consulting

Greater Manchester – the Temperature’s Rising!

Heather Davison, Education and Development Director at the Royal Society for Public Health, takes a trip to Greater Manchester and leaves feeling inspired about the great work they are doing in the community to improve the public's health and wellbeing. 

I left London to travel to the North West region last week, where it was a few degrees colder with even a flurry of snow,  but the hot topic at all my meetings was "Devo Manc". The run up to the full handing over of the health and care budget is truly on its way with 2016 just around the corner.  Everyone I met from the wonderful Kate Ardern, Director of Public Health at Wigan Council, and Vicky Bannister Director at Wigan and Leigh Homes to Ed Moss Development Director at Young Advisers, are so full of positive energy and the art of the possible, that you cannot help but feel the future direction of the public’s health and wellbeing is in good hands.   

My visit to the Greater Manchester Fire and Rescue Service (GMFRS) also gained my vote of confidence.  I had the privilege of meeting Andy Boswell, Adrian Peake and Ian Plummer from the Community Risk Intervention Team. The team has been created as part of a collaborative pilot between GMFRS, North West Ambulance Service and Greater Manchester Police to help drive further reductions in risk to the most vulnerable communities across Greater Manchester through a wider approach to prevention activities. The project has the potential to save the public purse £3.2milliion per year as a consequence of increased independence and reduction of demand.  In addition to substantive economic saving there is the social value aspect that this type of integrated working brings. The team members I met were so enthusiastic and committed to their roles which take them into the heart of the community. And it's crystal  clear their skills and ongoing training and  the backing of the joined up services ‘trusted brand status’  can play an important part in the further integration of health and social care provision across Greater Manchester.  

It was cold but sunny with blue skies when I left the GMFRS headquarters in Salford for my final meeting before heading South. The weather was energizing as only sunshine on a cold day can be.  It matched for me the feel of the place and the tremendous energy and enthusiasm everyone I had met during my stay has for their organizations, communities and for Greater Manchester itself - it's your time and we are proud to be part of your future.

West Midlands Fire Service; the wider public health workforce

Kiran Kenth, Wider Public Health Workforce Development Manager, Royal Society for Public Health & Public Health England;

Could the West Midlands Fire Service be the next major public health workforce?, I definitely think so!  They are on a mission to improve lives to save lives through; Prevention, Protection and Response.

I was asked to represent RSPH at the West Midlands Fire Service Health Inequalities Conference on 18^th November and what an inspirational and motivating experience this was. I was honoured to be in the company of Professor Sir Michael Marmot, the Chief Fire Officer for West Midlands Fire Service, Phil Loach and Director of Service Delivery, Gary Taylor.  I was truly inspired by the high level of organisational leadership, commitment and positive energy to engage with improving the public’s health and wellbeing agenda and the shear dedication to contribute to the reduction of health inequalities through the organisational adoption of the Marmot 6 objectives.

The West Midlands Fire Service  is a large, relatively untapped public health resource with potential the to impact on virtually every important issue affecting health and wellbeing.  They have a key role in terms of “prevention” and risk reduction strategy, targeted at vulnerable communities shown to be at highest risk of deprivation and ill health.

What I learned yesterday was invaluable.  The devotion and diligence of the West Midlands Fire Service  as much as their  commitment and persistence in tackling “the root causes of the causes” was truly inspiring.  The Chief Fire Officer, Phil Loach launched the West Midlands Fire Service Report; “Marmot; The way forward” and spoke about the vision and the strategic priorities of the West Midlands Fire Service and how this is now centred on prevention and wellbeing.

WMFS have developed a major prevention and health improvement programme; “making health everybody’s business” and yet still remain fully committed to providing the highest standard of emergency incident cover, including the delivery of a risk based 5 minute attendance to incidents where life and property are at risk. Their mantra is “Prevention, Protection, Response” where prevention and protection remain their highest priority with emergency response being the first line of defence.

Phil Loach described his workforce as “a high performing, flexible workforce, able to cope with  innovation and change and who are encouraged to be the very best they can be and do whatever it takes in pursuit of excellence”.

I am sure that many people still have the traditional view of a fire service as the red fire brigade and putting out fires.  But I can honestly say, this is simply not the case anymore.  I was completely taken away by the wide range of programmes that have been designed  by WMFS to tackle issues such as:

·         Dysfunctional neighbours

·         Anti social behaviour

·         Disability

·         Preventable ill health and early death

·         Empowering people to improve wellbeing in communities that traditionally suffer poor health outcomes

·         Engaging directly with households and neighbourhoods

·         Helping people of all ages, cultures and backgrounds to achieve sustainable behaviour change

·         Healthy neighbourhoods and improvements in community resilience

·         Improving life chances and equality of opportunity

There are 1322 FTE fire fighters across the West Midlands; 58 technical support officers ; 61 fire safety officers and 38 fire stations in the region. This is equivalent to at least a million contacts with the public, across the west midlands.  That is a significant number of opportunities to make an impact on public health and harness the untapped resource across a wider workforce.

The new West Midlands Fire Service delivery model that they describe as a “modern day fire and rescue service”, brings 21^st century vision and a depth of understanding to health improvement and self-recognition of the contribution the fire service have to play in this agenda.  As I discovered, when I met with Gary Taylor, 10% of a fire fighters time is spent attending an emergency call out to a fire.  The rest of the time is committed to protection and prevention and by adopting  the prevention methodology, West Midlands Fire Service have seen a 40% reduction in fires across the midlands region. A very proud achievement.

Hearing some  fire fighters talk about their own experiences and sharing case studies really enlightened me with regards to the capability, capacity and reach such a workforce has and the contributon they make to improving health and saving lives.   The access and level of engagement Fire Officers have to vulnerable people is far greater and meaningful than what a health care professional or even a social worker might have.  They engage and find the most vulnerable people with their proactive outreach approach and have proactively demonstrated how they can improve the lives of people  living with dementia, older people with physical impairments, troubled young people with youth offending history; re housed people living in poor housing conditions and turning around the lives of young people with low aspirations.

Given the opportunity to hear the impact made by fire fighters and vulnerable people officers, it  was no surprise to hear the wide ranging day to day responsibilities of the workforce, engaging those communities at highest risk.  Such examples include:

• Proactive Engagement and outreach with the most vulnerable;  homeless , NEETs, mental health, troubled families, older people, domestic violence
•  Educational programmes working with children in schools an childrens centres
• Aurora Boot camps for young people looking for chances of employment, mentoring schemes designed to support young people in experiencing significant life difficulties
• Young Fire Fighters Association
•  Alcohol & Drug awareness community sessions
• Safe Haven residential schemes – outdoor activities
• Interactive schemes alerting young people to the dangers of gun and knife crime
• Using Vulnerable People Officers to work directly with groups such as the frail elderly
•  Supporting 1:1 home safety checks
• Home visits by fire fighters trained in MECC and social determinants Most of the fire fighters are using ‘making every contact count’ to have tailored conversations about improving health and wellbeing and supporting individuals to make lifestyle behaviour changes.  For example, using the home safety visit to have a conversation about issues such as stopping smoking, being more active, winter warmth,fuel poverty etc
• Links and partnership working with other agencies supporting mutli agency case management to the most vulnerable and at risk communities
• Keyr role in child and adult safeguarding.

Many people think the NHS, public health and social care system is unsustainable without radical transformation. The ageing population, increase in lifestyle-related poor health and financial forecasts mean it has never been more urgent to shift our focus to prevention. We need to take every opportunity to create the environment, information and support to help people and communities change their behaviour and to enjoy better health and wellbeing. The West Midlands Fire Service have clearly demonstrated how they can contribute in a big way to this system-wide transformation.

They are a workforce out in the public domain being active and vigilant and improving the conditions by which people live  and face on a day to day basis.   By engaging at the level they do (doing what intakes i.e climbing thorough windows to get to isolated people and not giving up on them)  they are not only providing the education and support to enable the public to make healthy informed choices but improving the quality of people’s lives.

So what needs to happen to make the most of the fire service’ potential to enhance public health delivery:

·         It is time to review the future role and funding allocation of the fire service and its highly regarded operational staff.

·       We need to promote the Fire Service as a wider public health workforce and disseminate the good practice and innovation in prevention and contribution they make to the public’s health and wellbeing. Public health commissioners need to consider  whether the Fire service should be part of commissioning plans for the future

·         There is a need for more research to be publish  on the evidence base of the potential impact of the fire service on public health.

West Midlands Fire Service is an exemplary model of a wider workforce.  I commend them on their effort, successes and achievements to date. They are a workforce which needs to be recognised, acknowledge and celebrated by the public health system and I know that RSPH are privileged to have Chief Fire Officer on the Board. 

Exciting times ahead and RSPH look forward to building the relationship with West Midlands Fire Service.

Making Mental Health “Visible”

By Gina Mohajer

This week, a gentleman on the radio said, “if you break your leg, you can’t walk. If you have a mental health problem, you can’t see it”. I thought this aptly summarised the problems we have with mental health in society and why, more than ever, we need to raise awareness and bring mental health to the forefront of government health policy.

Today, Friday 10^th October, is Mental Health Day and the theme is “Living with Schizophrenia”. It is estimated that around 26 million people worldwide suffer from schizophrenia. However, despite this being a treatable disorder, a staggering 50 percent of sufferers are not receiving the treatment they need, 90 percent of whom live in the developed world. Considering the huge advances in medicine and technology, the amount of money invested in the healthcare system, and our understanding of the detriments of poor mental health – this statistic is shocking and highlights that a great deal more needs to be done.

Today’s awareness raising is to ensure that those living with schizophrenia are no longer stigmatised or marginalised from society – which can augment their condition – but instead get the best possible care, as early as possible, and receive the support they need to manage their illness and help them on their journey to recovery. For more information about schizophrenia and to download the “Living with Schizophrenia” report click here.

Today is also a great opportunity to highlight the importance of mental health and wellbeing more generally and to ensure that although it may not be as “visible” as a physical condition, it is equally important and needs to be treated as thus. We all have a responsibility as individuals to listen and take care of our body and mind, as employers to create a workplace that is fair and where clear policies exists to prioritise staff wellbeing, as practitioners to ensure that patients receive the correct care and treatment and that the government continues to promote mental wellbeing through national guidelines.

One in four adults in Britain will experience a diagnosable mental health problem in any one year; this is a vast number of people and none of us our immune. However, it is essential that we understand that we can through education, self awareness and empowerment make a fundamental difference to improving and protecting not only our own mental health and wellbeing but also of those around us. Through concerted efforts, we have the ability to bring about real positive changes – a belief at the core of the Royal Society for Public Health.

For more information on mental health and training click here

For more information on mental health in the workplace click here

Happiness at Work

The key to tackling mental health problems?

The equation seems simple; a healthy workforce equates to a happy workforce which results in a more productive and successful organisation. This is good for society and the country’s economy. However in reality the picture is bleak, suggesting that this formulae is neither being understood nor utilised.

Unfortunately, poor mental health is not uncommon in today’s society. In Britain, one in four adults will experience a diagnosable mental health problem in any one year, despite the UK being one of the richest countries in the developed world. Whilst wealth does not necessarily lead to happiness, having a good standard of living, access to free healthcare, can certainly improve a society’s wellbeing. However, not so surprisingly, 80 percent of people with a mental health problem believe that their condition is associated to work related problems. Does this imply that employers do not understand the equation mentioned above? Or are they so intent on achieving their outcomes that they choose to ignore it, not realising that the long term affects of poor mental health can be catastrophic for society. 

With one in six working Britons experiencing a mental health issue at any one time, including depression, anxiety or stress - more needs to be done to address these unsettling statistics.

In the run up to Mental Health Awareness Week (12^th – 18^th May) two significant, and timely, documents have been published; a survey by Depression Alliance revealing that a third of people struggle to cope at work due to stress/exhaustion, and a report entitled “Depression in the Workplace in Europe: new insights from business leaders", which makes the argument that employers need to be more responsible for the wellbeing of their employees and the benefits this has on the country’s economy and society as a whole.

At any one time in Britain one worker in six will be experiencing depression, anxiety or problems relating to stress. Among people who describe their mental health as poor, 80% say this is at least in part a result of problems at work

The report, which was published at the end of April, suggests that mental health problems are the leading cause of disability worldwide, affecting 350 million people. More over, depression disproportionally affects adults of working ages and the financial impact on business and the economy is profound. Recent figures, from the London Schools of Economics and Political Science and King’s College London, shows that the annual cost of depression to European businesses is a staggering £77 billion. This is directly a result of lost productivity.

Presenteeism, as identified in the report, can be as detrimental to the organisation and the individual, as much as absenteeism, if not more. In the UK, it is believed that 1.5 times as much work is lost through presenteeism as absenteeism for mental health conditions. This can be attributed to two reasons; firstly, employees with depression also experience cognitive symptoms (difficulty concentrating, indecisiveness and forgetfulness) up to 94% of the time, hindering their performance in the workplace. Secondly, employees are reluctant to take time off work, even when they need to, due to fear of losing their job or demotion, which could compromise their finances. This therefore fuels their stress and can augment and prolong existing mental health conditions. 

In the UK it is argued that 1.5 times as much work is lost through presenteeism as absenteeism for mental health conditions

Time off work or reduced productivity at work can 

affect finances and push people into debt

Having a mental health problem can impact all aspects of our every day life including our relationships with family, friends and colleagues. The Depression Alliance survey which involved 1,200 people, found that 83 percent affected by a mental health problem at work also experienced isolation or loneliness. However, only half of those feeling depressed or lonely confided in a colleague, yet a large proportion who did, reported to have felt better.

Mental health problems can affect any of us, however, in spite of this, there is a widespread lack of awareness, especially in the workplace, of how to recognise the signs and support people. Colleagues and managers may not know how, or feel confident, in supporting someone with a mental health condition, and moreover may not be aware what, if any, the companies policy is on mental health. The report stated that the majority of workplaces (78% in the UK), do not have a formal mental health policy in place and would most likely benefit from reviewing how they deal with depression. Not surprisingly, many employees are reluctant to inform their managers if they know that they have a problem due to fear of facing prejudice or stigmatisation. This of course can escalate feelings of isolation.

Chief Executive of Depression Alliance, Emer O'Neill says, "Depression is the biggest mental health challenge among working-age people and often leads to considerable loneliness and isolation at work. However, many companies aren't properly equipped to manage employees who suffer from depression so providing support to these individuals in the workplace is essential”.

Who’s responsibility is it anyway?

We are all susceptible to experiencing a mental health problem. Research suggests that around 50 percent of our mental health can be attributed to our genetics and environment, but the remaining can be altered by our activities and steps we take in life to protect our mental health. With such a high percentage of mental health problems related to work (it is where we spend the majority of our adult life) more needs to done to protect the mental health and wellbeing of employees. Employers therefore should create a supportive environment that reduces the taboo around mental health, but also implement strategic health and wellbeing plans with the sole intention of protecting their workforce and providing managers and colleagues with the knowledge and tools to deal with mental health appropriately and effectively.   

The Royal Society for Public Health (RSPH) is a strong advocate of improving the health and mental wellbeing of the population, through the creation of health champions and workplace health and wellbeing champions. Our new national Level 2 Award in Mental Wellbeing qualification, seeks to equip people with practical skills they can incorporate in their every day lives to improve and protect mental health. When people have good mental health, they can lead more fulfilling lives, can solve problems and are more productive.

For more information, on the Mental Wellbeing qualification and how it can be adapted for your organisation, please contact Gina Mohajer gmohajer@rsph.org.uk.

Useful Links:

NHS Choices Helpline

http://www.nhs.uk/Conditions/stress-anxiety-depression/Pages/mental-health-helplines.aspx

Depression in the Workplace: A report featuring new insights from business leaders

http://targetdepressiondotcom.files.wordpress.com/2014/04/target-report_final.pdf

Mental Health Foundation

http://www.mentalhealth.org.uk/

Photo by Sina Bahrami

Improving health and wellbeing through dance

The benefits of physical activity for our health and wellbeing are well documented, described by some as the ‘wonder-drug’.[1] The Government has recommended that we do at least thirty minutes of moderate exercise five times per week.[2] A staggering percentage of the population, however, fall short of this target. According to recent research, 80% of adults surveyed did not achieve the recommended level of physical activity.[3] The level of inactivity amongst children and older people is similarly concerning; research suggests that around 49% of children do not achieve the recommended target for their age group.[4] This figure rises to an overwhelming 92.5% for people over the age of seventy-five.[5]

As a society, we are leading increasingly sedentary lives, with much of our time spent sat down at a desk, in a car or in front of the television. This is a significant contributing factor in the soaring rates of obesity across all age groups, as well as the increasing prevalence of conditions such as type-2 diabetes and cancer[6]. People experience a variety of barriers to physical exercise, such as a lack of local sports facilities, financial constraints, feeling self-conscience or having a lack of enjoyment in sporting activities. It is vital that individuals have access to physical activities that help to overcome some of these barriers; dance may be one such option.

Dance offers an inclusivity rarely found with other forms of physical exercise. The almost endless list of dance styles, from street and hip-hop to ballroom and jazz, can all be easily adapted to suit different age groups, cultural backgrounds or level of ability. The ‘Dance for Lifelong Wellbeing’ project run by the Royal Academy of Dance catered for their older participants, the oldest of whom was 102, by adapting the classes for chair or frame based dancing[7]. Whilst other forms of physical exercise may suffer from high drop-out rates, the level of enjoyment and motivation amongst dancing participants remains high.[8] A survey conducted in 2011 found that amongst young people, dancing is now the second most popular physical activity in the United Kingdom, second only to football.[9]

Dancing can be a highly sociable activity, focusing less on competition and more on the freedom of self-expression and in the case of styles such as Syrtos or Tango, a celebration of cultural heritage.  For these reasons, evidence indicates that participation in dance can be hugely beneficial for mental health and wellbeing, helping to reduce feelings of social isolation, stress, anxiety and depression. Dancing can also increase feelings of confidence and self-esteem and provide a coping strategy for the stresses of daily life.[10]  Youth Dance England emphasises that dance can also be beneficial for the development of social skills in younger people and can be instrumental in encouraging positive attitudes more generally to health and wellbeing, changing views on issues such as drug and alcohol abuse[11].  A study conducted in Sweden, focusing on teenage girls suffering from mental health issues such as stress, found that those who participated in dance classes twice per week reported significant improvements in self-rated health, an effect which lasted for up to a year after the classes ended.[12]

Moreover, there is a wealth of research demonstrating the substantial benefits of dance for physical health. Dance is an enjoyable method of maintaining a healthy weight, thus reducing the risk of largely avoidable conditions such as heart disease and stroke. The movements involved in dancing have also been proven to increase flexibility, balance and co-ordination, which can reduce an individual’s risk of suffering from osteoarthritis and is particularly significant for older people; studies have shown that for older people participation in dance can reduce the risk of suffering a fall[13]. Dancing also offers considerable cognitive benefits, such as improving memory, as it requires the utilisation of several skills at once, such as memorising steps, listening to the rhythm of the music and physical movement. According to one study conducted over a 21 year period, dancing can reduce the risk of developing dementia by approximately 76%.[14] These benefits are the motivation behind programmes such as the English National Ballet’s ‘Dance for Parkinsons’ and ‘Dance for Dementia’ classes and also, the dance classes provided as part of Age UK’s ‘Fit as a Fiddle’ initiative.

Government cuts to funding for the arts is an enduring concern for arts organisations in this country. Since 2010, Arts Council England has seen their grant-in-aid funding cut by around a third[15], resulting in severe cuts for many groups, including those focusing on dance. A growing body of literature, however, demonstrates the hugely positive impact dance could have on avoidable illness, which is currently placing a huge financial burden on the NHS, welfare system and the economy. With the widespread appeal of dance and the wide-ranging benefits it offers, dancing is a vital tool for health improvement initiatives.  

The RSPH has now opened submissions for the Arts and Health Awards 2014. This year the awards will focus on the value of creative arts for older people with long term conditions in the community or within health and social care settings.  More information can be found here.

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References

[1] The Guardian. Physical Activity the Underrated Wonder-Drug. Available online at: http://www.theguardian.com/living-with-cancer-macmillan-partner-zone/physical-activity-the-underrated-wonder-drug (Last accessed 1st April 2014)

[2] NHS Choices. Physical Activity Guidelines for Adults. Available online at: http://www.nhs.uk/Livewell/fitness/Pages/physical-activity-guidelines-for-adults.aspx  (Last accessed 1^st April 2014)

[3] The Independent. 80% of Adults in England ‘don’t exercise enough’. Available online at: http://www.independent.co.uk/life-style/health-and-families/80-of-adults-in-england-dont-exercise-enough-8741988.html (Last accessed 1st April 2014)

[4] British Broadcasting Corporation. Children need more Exercise – especially Girls, Study says. Available online at: http://www.bbc.co.uk/news/health-23778945 (Last accessed 1st April 2014)

[5] BUPA. Keep Dancing...The Health and Wellbeing Benefits on Dance for Older People. London: BUPA, 2011. Available online at: http://www.cpa.org.uk/information/reviews/shall-we-dance-report.pdf (Last accessed 1st April 2014)

[6] British Broadcasting Corporation. Inactivity ‘killing as many as smoking’. Available  online at: http://www.bbc.co.uk/news/uk-wales-politics-18876880 (Last accessed 15th April 2014)

[7] Baber M. Dance and lifelong well being. Available online at: http://www.agewatch.org.uk/fitness/dance-and-lifelong-well-being/  (Last accessed 15^th April 2014)

[8] ibid

[9] Arts Council England. Dance and Health – The Benefits for People of all Ages. London: Arts Council England. Available online  at: http://www.artscouncil.org.uk/media/uploads/documents/publications/phpN0GNFD.pdf (Last accessed 1st April 2014)

[10] Burkhardt J, Rhodes J. Commissioning Dance for Health and Wellbeing – Guidance and Resources for Commissioners. Available online at: http://www.obesitywm.org.uk/resources/Dance_Active_-_Commissioning_Doc_Jan_Burkhardt_V6Final1V3_2.pdf (2012, last accessed 1st April 2014)

[11] Youth Dance England. Dance and Health. Available online at: http://www.yde.org.uk/main.cfm?type=HEALTH (last accessed 15^th April 2014)

[12] Duberg A, Hagberg L, Sunvisson H, Moller M.  Influencing Self-rated Health Among Adolescent Girls With Dance Intervention A Randomized Controlled Trial. Archives of Paediatrics and Adolescent Medicine 2012; 167: 27 - 31

[13] BUPA, 2011.

[14] Ibid.

[15] Financial Times. Arts funding ‘flashpoint’ is local authority spending cuts. Available online  at: http://www.ft.com/cms/s/0/d3983bce-9d7a-11e3-83c5-00144feab7de.html#axzz2yxqOFViJ (Last accessed 15^th April 2014)