Best practice in commissioning green prescriptions
The Ecosystems Knowledge Network ran a thought-provoking one-day training course covering the design and implementation of green-prescribing. The course trainer was Exeter University based Dr Dan Bloomfield who has worked extensively on-nature based solutions to local health priorities. The course allowed for the discussion of the origins of nature-based interventions; the evidence, data, and outcomes from previous schemes; models of commissioning; and how we can build partnerships to reach our goal of more widespread green prescribing. It was also very interesting to discuss the issues, challenges, and benefits of green prescribing with other attendees, many of whom already had their projects underway.
Green or nature-based prescribing is not a new idea, it was around a long-time before evidence-based medical care became the norm, when patients would be sent to the country or the seaside to recover from a multitude of ailments. Green prescribing is a form of social prescribing, whereby patients are referred to a range of non-clinical interventions that may be designed and developed in conjunction with the service users themselves. Social prescribing recognises that health is determined by a range of social, economic, and environmental factors and therefore approaches people’s health needs in holistic way as well as enabling people to take better control of their own health. The green prescribing of today focuses on both the primary prevention of disease and as an adjunctive treatment for many common health conditions. The nature-based therapies that can be offered are diverse, ranging from care farming and horticultural therapy to green exercise groups and surfing therapy.
Dr Bloomfield discussed his current project, A Dose of Nature1 in Cornwall, run in conjunction with Cornwall County Council. As part of this project he identified that there were a number of ‘nature-on-referral’ services already running across Cornwall but there is a need for a coordinated central-referral system and central funding. To highlight the potential benefits of nature-based intervention in Cornwall, 8 nature-on-referral pilot projects were run across 7 sites between 2014 and 2016. Across the pilot projects, 64 patients were referred and 48 patients completed a programme lasting 10-12 weeks. Results were overwhelmingly positive with an increase in 69% in self-reported wellbeing, two new self-organised support groups created, and 3 patients expected to reduce prescribed medications. In order for a nature based referral service in Cornwall to become sustainable and easy to access for patients and health professionals Dr Bloomfield has launched a consultation document for all key partners to have an input into the final business plan.
In a world of budget limitations, green prescribing has to evolve into an evidence-based practice that stands up to the rigours of commissioning processes. The question here is whether the current evidence is robust enough to support further investment. The short answer is yes. Nature on-referral and access to green space has been shown in published and peer-reviewed evidence to reduce obesity2, reduce cardiovascular mortality3, improve self-esteem and mood4, and reduce the symptoms of depression5. However, as highlighted by a recent report from The University of York6, there is a significant lack of systematic reviews in the literature which fully evaluate the effectiveness of social prescribing. Whilst this was disheartening to some, it is important to note this useful criticism as it highlights the gaps in the research base which need to be plugged in order for the funding of large scale randomised control trials in the future.
A recent report from DEFRA7 looking into the evidence linking natural environments and human health concluded that: “Rather than waiting until the evidence base is significantly more extensive, there appears to be a case for developing more integrated policy and practice across the health and natural environment spheres, with a strong emphasis on learning and evaluation to improve understanding of the most effective approaches and assess impacts.” They go on to suggest that these policies will have benefits to both health and wellbeing as well as the to the natural environment. This report is very promising for the future of social prescribing as a government department is stating that there is a causal relationship between nature and health and that essentially we should make a leap of faith and further commit to social prescribing without requiring a more substantial evidence base.
The course also allowed us the opportunity to discuss case-studies of places where social prescribing programmes are well established. For instance, Bromley-by-Bow in Tower Hamlets where horticultural therapy has been pioneered in a healthcare centre and Rotherham where a CCG funded model connects people with long-term health conditions to a wide range of voluntary organisations and community groups.
As a medical student hoping to go into general practice in the future this training course provided me with a great insight into how social prescribing models can be introduced both in individual GP practices as well as on a regional level. It is clear that the enthusiasm for these projects is abundant but the current barriers of high-quality evidence are potentially holding back the funding. However, DEFRA’s show of support for social prescribing will hopefully be a key tool in securing support from CCGs and health funders. If funding is not forthcoming then other options such as crowdfunding may be viable for sustaining green prescribing projects. Finally, to ensure the success of green prescribing in the future it is vital that we use sharing networks to learn from each other in order to build a sustainable model of social prescribing.