By Amy Booth
Over the last few decades, the provision of health care worldwide has been driven by a culture of over-diagnosing, over-investigating, and over-treating. Despite a growing acceptance that many health conditions are socially and environmentally driven (for example, by socio-economic status), medication remains the norm. Treatment options that do not include “pills” are often perceived of in lesser terms by patients and healthcare providers alike.
In recent years, this culture has started to be questioned. A 2021 government-commissioned review estimated that 10% of medications issued to patients in primary care are overprescribed, and that 6.5% of hospital admissions stem from adverse effects of medication. Both contribute to unnecessary costs for patients and the government.
Moreover, medication is harmful to the environment. Indeed, recent research found that 20% of the National Health Service’s (NHS’s) carbon footprint comes from medicines and chemicals. Also, the leakage of pharmaceutical waste into the environment contributes to myriad health concerns, including anti-microbial resistance. Therefore, the overuse of medication is a social, economic, and planetary health concern. In recognition of this, less traditional ways of managing patients’ complex bio-psycho-social health are gaining traction. One such solution to reducing the systemic and cultural reliance on medication is so-called ‘green social prescribing’ (GSP)—the ‘practice of supporting people in engaging in nature-based interventions and activities to improve their mental health’.
It is well known that exposure to the natural world promotes physical and emotional health. Exposure to nature and biodiversity alters physiological and psychological states, including normalising blood pressure, heart rate and glucose, increasing attention, and stimulating immune function. When combined with physical activity and social interactions, this is believed to incur various health benefits, including decreased cardiovascular disease, diabetes, obesity, allergies, and some mental illnesses. The increasing appreciation of nature’s health benefits opens a world of possibilities for its use as a powerful and inexpensive public health intervention, whilst concurrently benefiting economic and planetary health.
The NHS is currently rolling out a £4-million investment into a two-year pilot of GSP. The scheme aims to improve mental health outcomes, reduce health inequalities, and reduce demand on health systems. In the wake of the COVID-19 pandemic, treatment options—like GSP—that can potentially reduce some of the burden on health systems in a fairly inexpensive and effortless manner are becoming increasingly important. GSP will also aid in addressing concerns that COVID-19 lockdowns, and the inability of people to access green spaces and social activities, contributed to mental illness.
Under this scheme, patients can be referred to a “link worker”, who is employed in a non-clinical role to listen and support individuals. Link workers assess patients and prescribe appropriate nature-based interventions, such as local walking, gardening, or “green exercise” (exercise undertaken in a natural environment). These can replace, or act supplementary to, prescribed medications.
At the surface level, GSP appears to be a comprehensive and low-cost solution to overprescribing, whilst tackling ill health and reducing the demand on healthcare services. The NHS is also advocating for GSP as a way of addressing the social determinants of health which result in health inequalities. Research has shown that participation in GSP schemes such as parkrun (a free weekly 5km outdoor social race that takes place globally) resulted in the greatest improvement in activity and wellbeing from participants in socio-economically deprived areas of the UK. However, the role of GSP in reducing health inequalities is far from guaranteed.
Individuals from more socio-economically deprived communities simultaneously have higher incidence of mental and physical health conditions and reduced access to green space, as compared to people in more advantaged communities. Interviews with patients who had been prescribed social interventions, such as gardening, gym, and social group meetings, identified that individuals who had high socio-economic capital had the autonomy to engage in social prescribing activities. Conversely, patients from lower socio-economic statuses were more likely to concentrate on the immediateness of their social situation than engage in health-enhancing practices like GSP. Indeed, GSP requires a patient to invest in individual lifestyle changes which contradicts the idea that it can aid in combating wider systematic inequalities.
Barriers also impact the implementation of GSP, with link workers highlighting ill health, bad weather, time commitments, poor mobility, and transport constraints as key issues for the success of the schemes. As with any treatment, GSP is reliant on patients adhering to their prescribed intervention, as well as both patient and health professional buy-in to its efficacy. Moreover, GSP is often requires community goodwill to host, for example, “green cafés” (outdoor cafés) or outdoor arts events, but this is not always provided or feasible due to financial and community resource constraints. This does not mean that GSP should be removed from the healthcare agenda, but more work is required to identify specific community needs and support access to green spaces and services. Collaborations between health professionals, link workers, local councils, policymakers, community members, and patients will be vital to successfully implement these interventions.
While GSP may not be the miracle solution to health inequalities, there is something to be said for its role in reducing the environmental impact of health care. There is a growing body of research on the carbon footprint of medication and hospital admissions. Health promotion and disease prevention treatment options like GSP have the potential to reduce the need to prescribe medication and admit patients, and are therefore being explored as low-carbon alternatives in the NHS’s Net Zero pathway. GSP also promotes the maintenance of green spaces and local biodiversity. There is still work to be done on quantifying this environmental benefit, but it does seem a worthwhile sustainability tool.
There is undoubtedly a place for GSP in the health professional’s toolbox as green alternatives are being sought across all industries. There are clear health benefits of being in nature and engaging in social situations. Combined with the social and environmental benefits of reducing medical prescriptions and promoting green spaces, it almost seems like GSP might just be the future of health. But care must be taken to ensure that GSP does not exacerbate existing health inequalities or replace the prescription of necessary medication. It cannot become a blanket treatment option for particular conditions, but must be prescribed with proper deliberation of all the bio-psycho-social elements at play. Ultimately, the social, economic, and environmental advantages of GSP are welcome, but, as it stands, will not be the entirety of the future of health care.