There is significant research interest into how nature, natural environments, and associated activities might benefit health; particularly mental health. Clearly, this has become more important over the last year or so. Announced in July 2020, and running for the next two years, is a £5.8m investment by the Department for Environment, Food and Rural Affairs, Department of Health and Social Care, Natural England, NHS England, Public Health England, the Ministry of Housing, Communities and Local Government, Sport England and the National Academy for Social Prescribing (NASP). ‘Green social prescribing’ (GSP), the formal linking of individuals through a healthcare provider and link worker to nature-based activities for health, is being rolled out across England and makes up a significant portion of activities undertaken through social prescriptions.
This funding will enable seven test and learn sites across the country to better connect people to the natural environment, and to activities run by organisations in the community. Kerryn is part of a consortium commissioned to evaluate this roll out, led by the School of Health and Related Research (ScHARR) at the University of Sheffield, along with colleagues from Sheffield Hallam University, the University of Plymouth, and the European Centre for Environment and Human Health. Tom is completing an evaluation of a Sport England funded project The Flourish in Nature Project (led by EDP Drug and Alcohol Services) supporting those in drug and alcohol recovery to be more active and connected to natural environments, with the aim of developing volunteers to support others in their recovery journey. Whilst this is not strictly a part of GSP, it provides valuable insight into the possible barriers and challenges of focussing services on specific populations. Together, we want to understand the processes, outcomes and value-for-money of these approaches, and improve understanding of what works, for whom, in what circumstances and why.
A key element of this work feeds into a broader discussion around the ‘use’ of community assets in social prescribing. There are opportunities and challenges when delivering social prescribing through community activities, both of which are increased by the rapid rise of numbers accessing services. A benefit might be organisations attracting a greater number of attendees but given that even large organisations often have maximum groups sizes, these risk becoming overwhelmed, with long waiting lists and access made challenging to long-standing members. Particularly relevant for smaller groups is the attendance by those experiencing acute mental health difficulties, alcohol and substance use issues, physical mobility impairments and long-term conditions. Groups are often unprepared or untrained to work with these challenges and in such cases, there must be a robust process to redirect or provide assistance to staff and volunteers. Social prescribing commissioners must consider the sustainability of delivery organisations in terms of the number, type and severity of symptoms of those being referred.
Also of concern is the inherently challenging nature of sustainability for Voluntary, Community & Social Enterprise (VCSE) groups. Services and activities are routinely attached to finite pots of money over a fixed period, after which the service simply ceases to be. They are often heavily impacted by economic fluctuation and changes in political agendas and policy. If they are to function effectively as the key end point for green social prescribing, more robust structures and procedures for supporting their sustainability and longevity should be made available (such as project planning, writing grant applications, project management, as well as financial support).
In addition to this, GSP also needs to pro-actively consider the impact and possible exacerbation of health inequalities, which are multi-faceted and complex. By their very nature, GSP activities often take place in rural locations, to where access is limited. They can present financial, structural, and psycho-social barriers – more prevalent among more disadvantaged or complex groups – to the groups who stand to benefit the most. Additional (financial) resource for the VCSE is needed to overcome these barriers and increase the capacity of smaller VCSE groups. A simple referral of somebody with complex needs or at considerable disadvantage is unlikely to translate into sustainable attendance and benefit without additional infrastructure.
Fundamentally, community assets are at the very core of the green social prescribing offer, and their existence, sustainability, funding structures and accessibility are important enabling and constraining factors. We’d argue that the sector should not be considered a ‘resource’ to be used by the health service, but a key collaborator in building healthier communities. If the community ‘resources’ are not supported to become financially viable and sustainable, then they risk becoming fleeting and unreliable, challenging the implementation and success of GSP. Given their importance, it is concerning that the push from NHS England to use the VCSE has apparently come without the necessary work to assess demand, capacity, impact, and sustainability. New health-service models must not seek to re-invent or duplicate good practice by failing to understand local communities, or ignore and smother VCSEs through rapid increases in number and type of referral, without linked funding and support.
About the authors
Dr Kerryn Husk and Dr Tom Thompson are Senior Research Fellows at PenARC and the University of Plymouth Peninsula School of Medicine (Faculty of Health), respectively. They are involved in research into how access to, and activities in, natural environments can have a positive impact on health and wellbeing.