The Sustainable Prescription for Mental Health Care: Green Social Prescribing

Mental health and physical health have a strong bidirectional relationship. A bidirectional relationship refers to two entities that influence each other, such as sleep quality and mental health, physical illness and stress, and arguably, nature and nurture.

During the COVID-19 pandemic, many people around the world reported increased feelings of stress and anxiety. These emotions undermine mental health and often lead to tobacco, alcohol, and other substance use as coping mechanisms, with further effects on both mental and physical health. Lockdown and social distancing rules prevented people from leaving their homes and interacting with others, exacerbating feelings of isolation. 

Due to the recent emphasis the COVID-19 pandemic has placed on the importance of nature to mental health, the introduction of social prescribing practices may be beneficial in improving access to green spaces.

Table of contents:

What is social prescribing?

Social prescribing is based on the understanding that there are many determinants of health and illness - such as access to food and shelter, education, employment and social interaction -  and that treatment should include non-pharmaceutical and non-clinical options in addition to medical treatment. Although they can be used by anyone, services provided through social prescriptions benefit people with chronic medical conditions, complex social needs, and individuals seeking support for mental health or feelings of alienation. The NHS aims to have at least 900,000 people referred to social prescribing services by 2023-2024 as part of the transition to Universal Personalised Care.

Green social prescribing refers to the prescription of activities involving nature. These activities may include but are not limited to: outdoor physical activities such as cycling or walking,  gardening or food growing projects, and meditation in green and blue spaces.  

green social prescribing project

Benefits of social prescribing for mental health

For decades, the ‘biopsychosocial approach for assessment, diagnosis and treatment’ has been the main approach for psychiatrists in clinical practice. Social prescribing represents the ‘social’ domain of this approach, and some of its effects on mental health are outlined as follows:

Improve mental and physical health outcomes:

There is a range of literature that supports social prescribing, highlighting its beneficial outcomes through improvement in emotional, mental wellbeing and quality of life (Bragg, 2017). Increased engagement with nature has shown to promote mental wellbeing e.g. green walking programmes have shown to improve negative mood, manage physical conditions, and improve self-esteem. In addition, the promotion of physical activity associated with these green spaces can help support patients in their weight management, promoting prevention and reducing progression to long-term health conditions such as diabetes, hypertension and chronic kidney disease (Improving Access to Greenspace, 2020). 

Social prescribing in accompaniment to medical treatments can also promote medication optimisation. NICE guidelines support the need to reduce inappropriate antidepressant prescriptions for those with mild to moderate depression (NICE, 2004). A study found that 60% of GPs would prescribe antidepressants less frequently if alternative options were available (Mental Health Foundation, 2005). Hence, using the biopsychosocial approach with the addition of social prescribing can improve the effectiveness of overall treatment and, with fewer antidepressant prescriptions, reduce the carbon burden of pharmaceuticals in the NHS.

Reduce health inequalities

The burden of mental illness lies disproportionately on people who are socially marginalised, including those of the Black, Asian and minority background, LGBT community and of a lower socio-economic background (Mental Health Foundation, 2021). Poor mental health also undermines one’s ability to gain and hold employment, obtain quality housing, and escape poverty (Dayson, 2016). In more socio-economically deprived communities, greater tree density around homes reduced antidepressant prescription significantly, emphasising the need for improving access to nature through urban planning (Taylor, 2015). This could also reduce the waiting list in accessing counselling and psychological services, allowing patients to receive more timely care (Mental Health Foundation, 2005). Improving access to green spaces in England alone could save the NHS £2.1 billion a year (Nature England, 2009).

Empowerment:

Offering a broader range of treatment options can encourage patients to take control of the management of their condition (Hassan, 2020). Social prescribing activities such as life skills workshops improve self-confidence, increasing employability, reducing a major social determinant of mental health inequalities i.e. employment, and social integration (Allen, 2014). Access to activities such as group therapy can help promote social connections with others. The aspect of peer support and providing a safe space for those who had similar experiences in these sessions can help provide patients with a sense of belonging to the community reducing symptoms of stress, anxiety and fatigue (Hassan, 2020).

green walking

NHS England Social prescribing program

NHS England has integrated care systems where organizations collaborate to provide services such as social prescriptions personalized to the patient within the infrastructure of primary care. An integrated care system (ICS) refers to the collaboration between organisations to boost population health and improve access to resources for different groups within the population. ICS are components of the NHS Long Term plan, which strives to provide the best possible care for people in early life, with major health problems, and for the aging population, in an effort to reduce disease, improve life expectancy and quality of life. The NHS Long term plan contributes to the goal of Universal Personalised Care, whereby patients will have more agency and choice over their healthcare options. 

The need for a more green social prescribing program in society cannot be undermined. In July 2020, a £4 million investment was made in green prescribing for a cross government project. This two year project tests how to effectively utilize green social prescribing in communities to:

  • reduce health inequalities
  • decrease demand on the health and social care system
  • improve mental health outcomes
  • developing best practices in making more resilient and accessible green social activities.

The following integrated care systems and sustainability transformation partnerships have been chosen as test sites for this pilot program.

South Yorkshire and Bassetlaw Integrated Care System

The South Yorkshire and Bassetlaw Integrated Care System serves Barnsley, Bassetlaw, Doncaster, Rotherham, and Sheffield. In these areas, the suicide rate is higher than for the rest of England. For this reason, it is hoped that the benefits of social prescribing will work to improve mental health status leading to a reduction in the suicide rate by at least 10% in these areas.  The Wild at Heart initiative is a community-based program created by the Sheffield and Rotherham Wildlife Trust to promote mental and physical wellbeing. It allows people of all ages to connect with nature and with one another through nature walks, outdoor arts & crafts, gardening and education on nature preservation.  

Nottingham and Nottinghamshire Integrated Care System

This Nottingham and Nottinghamshire Integrated Care System explores the use of exercise in fresh air and the time it takes people to notice and enjoy nature to improve people’s health and wellbeing. Thereby making this green prescription a part of everyday life. The social prescribing program here is a whole system, all age approach targeting communities disproportionately affected by the COVID-19 pandemic. With the partnership with Framework and the Canal & River Trust among other local organizations, Nottingham City’s social green prescribing will center around developing a green network, investing in the community and voluntary sector, building Nottingham CIty’s assets, focusing on inequalities, and building sustainability.

Greater Manchester Health & Social Care Partnership 

Five green social prescribing projects were selected by Greater Manchester Health and Social Care Partnership to be run by the voluntary sector:

  1. Sow the City: Collaborating with 7 community gardens, this project explores how food growing can improve access to nutritious food, improve wellbeing and improve social connectedness.  
  2. Petrus: Catering to communities with housing needs, this project will explore green prescribing endeavors like outdoor exercise, cycling nature activity and education. This site has a therapeutic community garden that can be accessed by self-referral or by referral from health and support services. community  
  3. Lancashire Wildlife Trust: This green space is involved with ecotherapy projects like Myplace and community projects like My Wild City among others where people can reconnect in nature and be part of its recovery.
  4. Salford CVS: The green social prescribing program of this organization focuses on engaging various communities in activities like growing space development, conversation training and identifying and addressing gaps in therapy, and treatment in natural surroundings. In this way, more access to green and blue projects can be developed to Salford’s residents.
  5. City of Trees: Two projects the City of Trees have undertaken to improve mental health and wellbeing are Dementia-friendly walks and Dementia Naturally Active.

Humber Coast and Vale Health and Care Partnership

This Humber Coast and Vale Health and Care Partnership aims to promote GSP by utilizing existing social prescribing networks, collaborating with partners and following clinical cohort to collate data on individual and community impacts on GSP, developing a Shared Common Outcomes Framework across the 6 different locations, employing grant fundings to support GSP projects to develop Voluntary, Community and Social Enterprise (VCSE).  With the collaboration of Social Prescribing Leads, Mental Health Provides and Green Providers, the GSP initiative will be conducted in 3 phases:

  1. Data of what is going on and where, the beneficiaries of GSP, as well as the barriers and enablers of GSP will be collected and examined.
  2. The impact of GSP on individuals and systems will be explored in addition to collection of data from the clinical cohorts.
  3. With an evidence-rich knowledge base, investments for future care delivery can be made.

Surrey Heartlands Health and Care Partnership

The Surrey City Council is asking their residents to mark green spaces that they enjoy visiting on their online map. They are also surveying their residents on which activities make them feel happier and healthier. This test and learn site aims to improve the health and wellbeing of communities most affected by the COVID-19 pandemic, those with mental health conditions or learning disabilities, and persons of minority groups. Some of their preliminary programs include tree planting, walking groups, and food growing initiatives. 

Further updates will follow about Joined Up Care Derbyshire Sustainability and Transformation Partnership, and Bristol, North Somerset and South Gloucestershire Sustainability and Transformation Partnership test sites.

Link workers

Link workers are social care professionals that ‘link’ individuals to the appropriate interventions using their specialized knowledge of different voluntary, statutory, and community-based services that are available to improve health and wellbeing. They listen to the patient’s concerns and enable them to have more control over their lives by helping them develop a plan to facilitate change. Through community involvement, people can learn new skills, develop friendships, and build a strong support system which encourages personal growth. A few of the many services link workers can help access include: 

  • Advice on benefits, welfare, family, and employment services
  • Contact information for community based support groups
  • Cooking classes, dance lessons
  • Information for additional support in understanding and managing medical conditions
  • Nature-based and physical activity groups
  • Mental health services

These services may be implemented in conjunction with medical treatment.  People can be referred to link workers by local agencies and by self-referral; they may have anywhere between 6-12 contacts with a link worker over a three month period, depending on their needs.  

vegetable_garden-3.jpg

Principles of sustainable mental health care 

The Center for Sustainable Healthcare has developed four principles of sustainable healthcare, designed to reduce healthcare resource use whilst simultaneously improving patient care. In order of power and importance, the principles are (see figure 1 below):

  • prevent need for healthcare,
  • promote better patient self-care, 
  • streamline care systems (improve efficiency)
  • prioritise low carbon alternatives 

Green Social Prescribing can be integrated into each of the four principles. Green Social Prescribing is already known to reduce stress and anxiety [see previous section], preventing certain health conditions from worsening - fulfilling principle 1. 

Often green social prescribing projects want people to continue to use the space they have become comfortable with, (e.g. Argyle Community Trust Project, Plymouth); this encourages patients to begin to manage their own healthcare and wellbeing, fulfilling principle 2. 

Green social prescribing also reduces pressure on the NHS, and takes advantage of an already present, low carbon resource, meeting both principle 3 and 4. Though a single element of sustainable mental health care, it’s clear why green social prescribing is effective as a sustainable option.

Sustainability has been introduced to mental health care in many ways. CSH Fellow Dr Daniel Maughan has previously talked about the inclusion of patient preference when discussing treatment (Maughan, 2014). Pharmaceuticals represent the largest component of the NHS carbon footprint and often the evidence-based drug dose is much less than the prescribed amount; including patient preference is known to reduce resource use, so combining this with larger intervals and decreased dosages could cut carbon levels substantially. This fulfils the CSH principles as declining health is still prevented but the patient is encouraged to play a more active role whilst the service is being streamlined (principle 1, 2 and 3).  Another element of sustainable mental health care is ‘E-mental health’, which takes advantage of the internet and technology to enhance mental health services and has already shown promising results in Canada (Las, 2019). This demonstrates all four principles by allowing patients to have a greater role in their healthcare but in a way that has lower environmental impact. 

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Figure 1. The diagram shows examples that can influence each of the secondary drivers (CSH principles). These have a further impact on reducing the use of health services and carbon emission in order to reduce our carbon usage without having a detrimental impact on health.

Green social prescribing examples

Many successful Green Social Prescribing examples exist, with notable projects including:

Green Walking

Aimed to improve access to green spaces, green walking has proven to be hugely beneficial for adult psychiatric inpatients. The project, piloted by eight Mental Health Trusts (2019), encourages patients to immerse themselves in green spaces as part of a walking group, allowing development of connections with nature, learning to cherish it and strengthening social connections – amongst both patients and staff.  The project is also relatively inexpensive; to find out more, including how to set up a walking group, visit the green walking in mental health recovery project page.

Workplace Wellbeing and Green Space

Work-related stress is a critical issue in the NHS, causing more than four in ten staff to report feeling unwell in 2019. Research by CSH found that providing access to green spaces at work can help reduce this, with staff reporting benefits of feeling calm and re-energised. For staff who regularly spend time in their workplace green spaces, significantly higher levels of wellbeing were reported. Following on from this, CSH is working with Natural Academy to provide outdoor wellbeing sessions for health staff at five NHS sites and training so select staff can lead the sessions. 

The Thriving Communities Funded Projects 

The National Academy for Social Prescribing, in collaboration with the Arts Council England, Historic England and Natural England, NHS England and Improvement, Sport England, the Money and Pensions Service, and NHS Charities Together, is funding 37 projects to extend social prescribing to over 10,000 more people. Successful projects were announced in March 2021 with Green Social Prescribing at the forefront; examples include:

  • Nature Buddies, Dorset plans to deliver 30 nature-inspired activities to 150 community groups, as well as co-producing a training curriculum for 100 link workers and a toolbox for similar initiatives.
  • Argyle Community Trust, Plymouth aims to increase independent use of Central Park for individual wellbeing by engaging 400 people through activity-based sessions such as tree planting and mindful nature walks provided by Green Minds.
  • Green Happy Café, Northampton a wellbeing hub To promote green social prescribing to 3000 people; the programme includes green routes and park activities.

Learn more

To learn more about green social prescribing and other ways in which green spaces can enhance mental health wellbeing and encourage sustainability in mental healthcare, please see:

 

Authors

Shiwei Ooi, University of Leeds MBChB Year 5

Hira Ahmed, Trinity College Dublin Dental Science Year 4

Adeolu Orogade, Economic Self-sufficiency Specialist

Becky Gee, University of Exeter BSc Biological Sciences Year 3