New prescription: A walk in the park

As countries seek to recover from Covid’s aftermath, a unique health plan pioneered in New Zealand in the late 1990s is being emulated in Britain and elsewhere: green social prescribing (GSP), which links patients with nature and communities

By Prasun Sonwalkar

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Published: Thu 24 Mar 2022, 11:06 PM

Goss Moor in Cornwall is one of the many vast, sylvan spaces in England that have long inspired poets and artists; but over the last few weeks, it provided more evidence of how the magic of nature works on people, their health and their sense of wellbeing.

A herd of 26 wild Dartmoor and Shetland ponies was the focus of a unique free activity where attendees of various age groups tried to find the ponies using a tracking app.

The ponies are zeroed in on via a GPS tracking system, a location is sent to those involved, and a meeting place on the moors is then decided before reaching the ponies by following the easiest walking route.

Four such events were held between December and March, and the feedback has been overwhelmingly positive, with attendees feeling ‘informed, healthier, happier’.

The activity was part of green social prescribing (GSP) — an idea that supports people to engage in nature-based activities, such as walking, jogging, cycling, community gardening, food-growing projects, tree planting, dementia walks, local parkruns, care farming, community gardening, conservation volunteering, green gyms, and arts and cultural activities outdoors.

Connecting with nature has been proven to improve health and wellbeing, particularly for those living urban lives with little engagement with nature. Research shows that more people connected with nature during the pandemic while living largely isolated lives or working from home, discovering attendant health and wellbeing benefits. As bedrooms became offices, gardens — and the areas within walking distance of home — became wildlife-watching spots and gyms.

Janine Sargent, the visitor warden for charity Natural England, who ran the Goss Moor events, says: “Green social prescribing events like this are wonderful for connecting people with nature, which is great for mental health and wellbeing. Goss Moor can be a very wild and windy place with tricky terrain, but our guests have had a great time during these walks, with free pasties being offered to participants to keep everyone sustained and fuelled.”

The idea of ‘social prescribing’ is an established health intervention, where doctors, nurses and healthcare professionals refer people to local services for support, rather than prescribing some medical treatment in the traditional way. But ‘green social prescribing’ was introduced in New Zealand in 1998, when people needing support were prescribed engagement with nature, with health workers linking them with green groups, projects and activities.

Nearly 80 per cent of doctors in New Zealand have, at some stage, prescribed exercise rather than medication, and 71 per cent of the patients who followed a green prescription say that they have noticed long-term positive changes. Research shows that green prescribing is among the most cost-effective strategies for encouraging greater physical activity and healthier behaviour generally. Patients taking part in green prescribing in New Zealand are more likely to meet physical activity guidelines.

Besides New Zealand and Britain, more countries are considering adopting the idea of GSP, which also connects with several wider aims related to global health, climate change, land use and environment protection, outlined by bodies such as the World Health Organisation and the United Nations’ sustainable development goals.

The ‘green’ healing touches

In Britain, there is a growing belief that the National Health Service (NHS) needs to be complemented by a natural health service, with nature playing a big part. Several patient-centric green initiatives in hospitals have been running for some years, such as the Jennie Lee Garden in King’s College Hospital, and the Bethlem Royal Hospital in London. Experts say green and blue social prescribing often take shape under the same banner, but there is a distinction between the two. The difference simply is the environment people are subscribed to: a green environment means forests, parks and gardens, whereas a blue environment means lakes, rivers, creeks and so forth. Both types of environment have been found to offer benefits to health and wellbeing.

GSP practitioners have reported a range of positive anonymised feedback from people referred to them, such as: “It’s done me the world of good. I’d say it’s saved me”; “You won’t believe this: I was on 17 tablets’ prescription, every morning, 17, plus 18 in the evening. That’s quite a lot…. when I went with the Enhanced Team they reduced my tablets, and that was better”; “That’s how I can describe it; it’s like having a comfort blanket. That’s how I feel about coming here and doing [this] — you’re getting a little comfort blanket, but you’re putting smiles on other people’s faces too”; “I feel so proud and honoured to be part and parcel of it, and making new friends, and getting to know people. It’s just — you can’t put it into words. It’s just unbelievable”’ and so on.

Researchers at Leeds Beckett University say that prescribing contact with nature for people who have low levels of mental health is excellent value for money: for every £1 invested in specialised health or social needs projects which connect people to nature and cost more to run, there is a £6.88 social return. Their study, based on three years’ research, found that people participating in outdoor nature conservation activities felt significantly better, both emotionally and physically; they needed, for example, fewer visits to GPs or felt more able to get back to work.

Researcher Anne-Marie Bagnall says: “Our analysis of the impacts on people taking part in Wildlife Trusts’ nature conservation activities shows an excellent social return on investment for people with all levels of wellbeing. We can therefore say with confidence that, based on evidence from independent research, these programmes can be effective in both maintaining good wellbeing and tackling poor wellbeing arising from social issues such as loneliness, inactivity and poor mental health. The significant return on investment of conservation activities in nature means that they should be encouraged as part of psychological wellbeing interventions.”

Amir Khan, a general practitioner (GP) and health ambassador for charity Wildlife Trusts, adds: “There is a clear need to invest in nature-based services so that more people can benefit. If more people could access nature programmes, I believe that we would see a knock-on effect in our GP surgeries, with fewer people attending for help with preventable or social problems arising from being cut off from others, not getting active or having a purpose.”

Preserve and protect

In Britain, a £5.5 million cross-government project is underway, aimed at preventing and tackling mental ill health through green social prescribing, with targets to be delivered by April 2023. It aims to test how to embed green social prescribing into communities in order to improve mental health outcomes, reduce health inequalities, reduce demand on the health and social care system, and develop best practices in making green social activities more resilient and accessible. Seven ‘test and learn’ sites have been selected, with thousands of people expected to benefit in urban, rural and coastal places in areas such as south Yorkshire, Nottingham, Surrey, Bristol, Derbyshire and Greater Manchester. The focus is on communities hardest hit by Covid, including those living in deprived areas, people with mental health conditions and non-white minority communities.

Says George Eustice, environment secretary: “The impacts of this pandemic will be felt deeply for many years, but the experience has also led people to appreciate the difference that nature makes to our lives in a new way. There is an increased awareness of the link between our own health, and that of the planet. Studies across the spectrum, from health to financial risk, remind us that it is in our best interests to look after nature. We know that a connection with nature contributes to well-being, and improved mental health. When we destroy nature, we undermine our very foundations. Every country faces a choice as they map out their recovery — store up problems by sticking with the status quo, or get back on our feet by building back better and greener.”

A key partner in the GSP project is Natural England, a public body with a budget of nearly £200 million responsible for ensuring that England’s vast natural environment is protected and improved. Marian Spain, its chief executive, says: “Natural England’s evidence has made clear that nature is good for our health. For many years, we’ve been working closely with our health professional colleagues to make sure we can create a healthy society, which is even more important as part of a green recovery to help everybody cope with the long-term impacts of the restrictions on day-to-day life necessitated by the coronavirus. I’m delighted that Natural England has been able to shape this innovative partnership to consolidate green social prescribing as a core part of the government’s wider ambitions for health care and health prevention within the NHS. A much-needed increase in the use of green social prescribing services will improve the nation’s mental health, reduce demand on our health system and — crucially — reduce the stark inequalities in access to nature, which have been bought into sharp focus during the pandemic.”

The parkrun ballpark

One of the most successful social prescribing projects is ‘parkrun’, a grassroots health initiative that began in Bushy Park in London in 2004, and is now a global phenomenon, with the unique 5km running/walking weekly event taking place in mostly parks and other green locations across 23 countries; nearly 7 million people around the world are registered and, in normal times, 350,000 people walk, jog, run and volunteer at their local community event every weekend. Hailed as a major health booster, the free-to-enter event held every Saturday morning has produced so many success stories that the NHS prescribes ‘parkrun’ to patients to overcome physical and mental health challenges. Almost every town and park across Britain has a group, some with thousands of members, who join and encourage others in a positive, welcoming and inclusive experience where there is no time limit and no one finishes last.

In 2018, the Royal College of General Practitioners and parkrun UK launched the ‘parkrun practice initiative’ to promote the prescribing of physical activity through participation in local events. More than 500 GP practices in the UK have registered to become a ‘parkrun practice’.

The idea is that general practices will link with their local parkrun to promote the benefits of physical activity, not just to their patients but also to GPs and practice teams. Says Simon Tobin, a GP: “I’ve ‘prescribed’ parkrun to more than 100 of my patients in the past two years with some amazing successes. It started off as an informal thing, wondering with a patient whether they might be interested in giving it a go, but it is now something that I actively promote. I used to think that inspirational stories were rare and unique, but as time has gone on, I’ve realised just how common the tales are. It’s actually the commonness and not the unusualness that’s astonishing. I’ve seen the wonderful power of how parkrun can transform lives and I am convinced that it’s the best sort of medicine I can prescribe.”

There is much excitement among health professionals about GSP, but a change of attitude in treating patients is needed. Experts believe that though GPs are in the frontline of social and green prescribing, many know little or nothing about it, with habitual treatments ingrained both in doctors and patients. Also, many patients expect to leave the doctor’s clinic with a prescription for medication to fix health issues, but getting patients to accept a directive to go for a walk or bike ride instead will need a programme of education for both prescriber and patient. It is also easier to pop a pill than go on a long walk or jog, so the issue of patients complying with the treatment to deal with health issues also needs attention.

For GSP to be a success, it has to be part of a systemic approach that incorporates nature-based interventions and nature-based thinking in urban infrastructure and service provision. The experts say the prescribing process also needs to be made easy, for doctors, social care professionals and patients; more widely, it needs to be seen as one part of a holistic health-promotion strategy based on a planetary health perspective.

Prasun Sonwalkar is a journalist based in London

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