ENO BREATHE, ‘The art of medicine and the science of the arts’

Dr Harry Brunjes, United Kingdom
Chairman of the English National Opera

Social Prescribing is an active partnership between community and physician. Its foundation lies in the truism that health is ultimately defined by genetic, social, and environmental factors. Social Prescribing is a discipline that has increased in status in recent years, becoming more widely accepted, and is now in receipt of both Government support and funding. It is an integrated approach, and some view the concept as the sort of professional care that doctors were once able to offer when the pressures were not as great as they are today. There has been a growing understanding of the potential of the arts to promote health, prevent disease, and accelerate rehabilitation from illness.

ENO Breathe is a joint project between English National Opera and Imperial College NHS Trust treating respiratory problems post-Covid with three specific missions. First, to improve the recovery and well-being of the patient. Second, to evaluate and evidence the impact of the work. Finally, to roll out ENO Breathe as a national programme. The project is all part of ENO’s aspiration to be a leading arts provider in social prescribing, working at the cutting-edge intersection of arts and health and utilising the art form of opera for an integrated, holistic recovery programme that supports both body and mind.

ENO is Britain’s only full-time repertory opera company, based in St Martin’s Lane in Covent Garden. ENO presents mainstage opera at its home in the London Coliseum and elsewhere, but the company also does much more. ENO Baylis is English National Opera’s learning and participation programme, offering people of all ages a range of opportunities to engage with opera. The whole concept is rooted in the socially driven work of ENO founder, Lilian Baylis, who believed that opera and the arts can make a positive difference in people’s lives. Therefore (continuing the theme and aspirations of the founder), the modern ENO believes it can both empower and employ social prescribing to transform the lives of people and communities. To plagiarise a dictum, ‘Ask what can opera do for the country and not just what can the country do for opera.’ Lilian Baylis was indeed an early pioneer of social prescribing.

Coronavirus disease (Covid-19) became a global pandemic in 2020, with an unparalleled impact on individual health, the resilience of healthcare systems, and the wide-ranging well-being of sovereign nations. A significant minority of Covid patients report ongoing symptoms beyond one month from symptom onset. The most commonly reported are shortness of breath and fatigue. Other symptoms include headache, cough, joint pain, chest pain, gastrointestinal disturbances, dysphagia, anosmia, anxiety, and depression. Shortness of breath is well documented as a frequent and problematic presentation of long Covid. Clinical abnormalities (on follow-up imaging) are reported as mixed inflammatory and fibrotic. Lung function studies report a predominance of a restrictive pattern and reduced lung diffusing capacity. Covid associated coagulopathy is widely reported but associated with severe disease and venous thromboembolism.

Imperial NHS Trust already employs singing as part of integrated care for people with chronic respiratory issues, often specifically related to smoking and asthma. Imperial considered that ENO Breathe could help with the breathlessness that patients experience when recovering from Covid. The physiological problems with breathing are compounded by psychological complications manifesting as anxiety in shallow, panicky breaths as opposed to deep inhalation.

An integrated six-week pilot of weekly, one-hour sessions involving singing, breathing, and well-being was structured, aimed at enhancing the recovery of patients experiencing symptoms after their initial Covid-19 illness. Patients are referred into the pilot by Imperial NHS Trust. The criteria are that all patients had been hospitalised with Covid and had been discharged to the community but are still experiencing breathlessness after 8-12 weeks, despite normal CT scans. The programme includes remote learning technology to develop an online programme (via Zoom) that is fully accessible to patients who are self-isolated. The sessions are led by an ENO vocal coach and singing specialist. The online participant hub contains a range of digital resources created for ENO Breathe, including breathing techniques, singalong tracks, and bespoke filmed lullabies to listen to and watch for calm and relaxation. Core to the pilot will be posture, physical readiness, and breath awareness. Each session will have a specific theme and targets. Participants move and stretch in a physical warm-up to help them find ‘space to breathe’. They learn exercises they can utilise outside of sessions to regulate breathing in moments of panic and/or breathlessness. Long Covid patients can also experience vocal fatigue along with their breathlessness, and thorough vocal warm-ups are useful in supporting the voice.

ENO Harewood is a programme that provides a full-time training and performance scheme to talented singers at the beginning of their careers. This allows them to continue their technical development within the professional environment of a repertory opera company. Classical singers spend years training to coordinate the complex physiological tasks singing requires. A lot of time is spent learning to distil these into a single sensation; a single thought. ENO Breathe takes this same approach and applies it to working with people recovering from long Covid. Emotional connection and engagement are key. The musical material in the programme elicits an emotional response and is uniquely appropriate for this group, as it is explicitly designed to calm. A love of singing is not a prerequisite for taking part. The aim is that the programme will be of value for both those who enjoy singing and those who feel more ambivalent about it.

Why lullabies? Lullabies are short and memorable and by their very nature are accessible to all. Lullabies stretch back farther than the written word and are rooted in love, tenderness, and caring. They span cultures and continents. Many lullabies have a peaceful, hypnotic quality and tend to sit comfortably within a non-specialist singer’s vocal range, making traditional lullabies ideal for this group and this programme. There are also powerful moments when lullabies appear in operas. Each of the ENO Breathe lullabies has been linked to a partner lullaby from a moment in an opera. These are to watch, listen to, and be immersed in. Singing lullabies builds emotional connections with the other activities and exercises in the programme. Participants leave sessions with a calming song in their heart, and, crucially, this creates a positive emotional connection to a wealth of tools and exercises to help manage their symptoms.

English National Opera values the work of ENO Baylis at the same level as mainstage opera. There is no hierarchy. The same level of attention, resources, and expertise was focused on creating ‘ENO Breathe Lullabies’ with performances recorded especially for participants in the programme. The performances and recordings for these lullabies were made by members of the ENO orchestra, ENO soloists, ENO Harewood artists, and ENO stage & technical over a three-day period.

The pilot scheme is in its final stages, to be followed by an evaluation report. Although the programme is in its early days, the feedback is extremely promising. Many patients have said how transformative the programme is and how much of a lifeline it is. Individual patients’ stories and reflections on the success of the scheme have been rewarding for patients, Imperial, and ENO alike. There is now momentum to move quickly to more London groups. In addition, plans are underway to run an ENO Breathe group for frontline NHS staff who are still suffering from Covid symptoms. A nationwide rollout is in planning for 2021.

Social prescribing encompasses the values of ENO and reinforces the company’s wish not just to provide artistic excellence onstage but also to ensure that opera and the performing arts can provide genuine and sustainable benefit to the community long-term, evidenced by a full evaluation and publication. It is the belief of both English National Opera and Imperial NHS Trust that ENO Breathe is a unique opportunity to provide both support and recovery for the physiological and psychological consequences of long Covid.

References:

1. Younan, Junghans, Harris, Majeed, Gnani; Maximising the impact of social prescribing on population health in the era of COVID – 19, JRSM 2020 Vol 113(10) 377 – 382
2. Brunjes; Ladies and gentlemen, there will now be a long interval – theatre in the covid-19 era, BMJ November 2020
3. Imperial College Healthcare working with English National Opera on singing programme for Covid-19 patients, https://www.imperial.nhs.uk, August 2020
4. Dixon; The Role of Social Prescription, Westminster Insight’s Tackling Loneliness and Social Isolation in Older People Conference, December 2020
5. Pitini, Adamo, Gray, Jani; Resetting priorities in precision medicine: the role of social prescribing, JRSM 2020 Vol 113(8) 310 – 313
6. ENO Breathe with Imperial College Healthcare NHS Trust; https://eno.org/news/eno-breathe-with-imperial-college-healthcare-nhs-trust/, August 2020
7. Pillay, Kondratiuk, George, Park, Onn Min Kon, Lalvani; Literature Review of the long-term health impacts of COVID – 19, Imperial College London, October 2020
8. Dixon, Everington, Lalvani, Brunjes; English National Opera launches ENO Breathe, September 2020

Dr Harry Brunjes (London University and Guy’s Hospital) started Premier Medical from his Harley Street Practice, becoming Chairman of the Premier Medical Group.   RTA (a subsidiary) was sold to BUPA in 2005.  In 2010 Premier Medical was acquired by Capita.  In 2016 Harry reacquired PMG and rebranded as Kuro Health.   WARP Technologies, Medicals Direct and Mobile Doctors were added to the consortium.  Non-Exec positions have included The Good Care Group, Equity Red Star (Lloyd’s Syndicate) and Newmans Clinics. Harry was Governor of Bedford Modern School, Valderrama Golf Club  and Expert Witness Institute.  In 2007 Harry was President of the Sussex Medico-Chirurgical Society.  In 2010 Harry was elected Vice-President of the College of Medicine and is a Fellow of the Royal Society of Medicine.  Harry was Chairman of Lancing College between 2009 – 2019.  Harry has a lifelong interest in music, theatre, opera and piano.

Edited by Richard Kutner, USA