Green social prescribing: challenges and opportunities to implementation in deprived areas

INTRODUCTION

The health and social benefits of exposure to green spaces, such as forests, parks, and community gardens, are increasingly apparent and can improve aspects of both physical and mental health.^1,2 However, research has shown that people of lower socioeconomic position (SEP) are the least likely to spend time on such activities, which is a concern given the wide health inequalities that exist between affluent and deprived areas in the UK, and elsewhere in the world.^2,3

Social prescribing is a policy response to health inequalities in the UK and is being rolled out through community health practitioners or ‘link workers’ in general practice. Green social prescribing (GSP) is a type of prescribing that links patients to nature-based activities.⁴ All countries of the UK provide some form of service for GSP, but the funding, referral process, and nature-based activities available vary nationally and regionally.^5–8

PERCEPTIONS OF GSP IN UK PRIMARY CARE

The UK Government invested over £4 million in a ‘test and change’ GSP initiative across the seven regions of England in 2020 as a response to the rise in mental health problems during the COVID- 19 pandemic.⁷ An assessment of the delivery capacity⁹ and of the perception of GSP among the public and clinicians followed.¹⁰ This included a survey of 4000 members of the general public and 501 clinicians (including 370 GPs). Both link workers and GPs felt that GSP could be beneficial as an addition to a holistic approach, particularly for mental health problems, but they didn’t know enough about GSP and what was available in their locality. Critically, the survey found that only 7% of patients who were suitable for referral to GSP had attended a nature-based activity. Further evaluation demonstrated that when link workers did engage in GSP they mainly referred patients to outdoor sports and exercise activities, rather than the full diversity of nature-based activities.¹⁰ Many of the green activity providers reported being referred patients with very complex health conditions (such as severe mental illness or severe physical disability) that they were not trained nor equipped to deal with, putting them in an unfair position and potentially putting such patients at risk of harm.⁹ There was a perception that GSP was at times being used as a ‘holding system’ for such patients, who were often on a waiting list for specialist NHS care, rather than GSP being integrated into the NHS in a way that enhanced the overall care of the patient. Concerns were also raised about the long-term sustainability of local green activity organisations, which are largely third sector-based, and as such their capacity is often undermined by ‘short- term, competitive and precarious funding model[s]’.⁹

In Scotland, ‘Our Natural Health Service’, a cross-sectoral initiative between NHS Scotland and NatureScot, along with other local organisations, supports GSP across several sites.⁶ From this initiative, prescription referral pathways for GSP have developed and are currently being evaluated.⁴ In Wales, an integrated and person-focused holistic approach to social prescribing and GSP is embedded within the NHS public health policy, and the Welsh Government has committed to making social prescribing, including GSP, a priority.⁵ Pilot studies suggest enthusiasm for GSP among clinicians and patients across the UK,^10,11 and crucially GSP holds potential to reduce or mitigate the effects of health inequalities in patients of lower SEP.² Funding and strong leadership will be essential for the sustainability of these projects along with a whole system-wide approach, including training for providers, generation of a knowledge-base to build awareness of GSP, and information on how to refer and retain those who participate.¹² Some tools have been developed that aim to support clinicians and patients to engage with GSP and improve inclusivity, but there are little data on how and where they are being implemented.^13,14

Although GPs and link workers may generally support the concept of GSP it is not clear if those working in very deprived areas (such as Deep End practices) will have the time and energy to devote to it, given the existence of the inverse care law.¹⁵ The key barriers and facilitators to enabling the workforce and target groups to make use of GSP need to be addressed with consideration for the current working environment, and practical and affordable solutions suggested at individual, practice, and community level. This should also include the availability of green spaces — many urban deprived areas do not have easy access to such spaces,² and trespass laws mean that there is no ‘right to roam’ for 92% of the land in England.¹⁶ A ‘right to roam’ was introduced in Scotland in the Land Reform (Scotland) Act 2003,¹⁷ which gives everyone rights of access over land and inland water throughout Scotland, subject to specific exclusions set out in the Act. The UK Labour party has pledged to adopt a Scottish style right to roam law if they win the next general election.¹⁸

CONCLUSION

Overall, the evidence for GSP is expanding,^1,12,19 but the link between exposure to the natural environment and improved health and wellbeing is mainly based on association rather than evidence of causation. The majority of trials are small and have been conducted outside of the UK.^1,12,20 To date, we know very little about what works for whom and in which circumstance, or what the ‘active ingredients’ of GSP are. Evidence from a report of GSP for people with diagnosed mental health problems suggests several plausible factors that may interact to bring about change but these factors need to be explored further for different populations.¹² More robust evidence to demonstrate clinical and cost effectiveness is also needed, following recommendations on how best to optimise and tailor intervention for GSP in deprived populations in the UK, either from randomised controlled trials or well-conducted natural evaluations with a matched control group.

In summary, GSP as a form of social prescribing has the potential to improve the health and wellbeing of patients who find it appealing and can engage with it. People living in deprived areas who experience the most significant health inequalities may have, in theory, the most to gain from such activities.² However, further research is required to understand and overcome the multiple barriers that may exist to enable people living in deprived areas to make the best use of GSP, in a way that is both integrated into routine care and sustainable.

Provenance

Commissioned; externally peer reviewed.

Competing interests

The authors have declared no competing interests.