Last reviewed 3 May 2023

This year Mental Health Awareness Week (MHAW) is taking place from 15 to 21 May and is focusing on the theme of “Anxiety”. Online advice is available on how to manage anxiety, with tips such as spending more time in nature, as well as offering ideas such as focusing on breathing and mindfulness, exercise and keeping a diary. In this feature, Christine Grey looks at government policy on prescribing nature for mental health, and whether the NHS can realistically hope to develop effective Green Social Prescribing (GSP) for all patients who can benefit from it, especially when specialist mental health services are in crisis.

MHAW and nature

As well as increasing people's understanding of anxiety, the aim of the awareness week is to keep up pressure for change, “making sure that improving mental health is a key priority for the Government and society as a whole”. Primary care organisations can get involved by publishing suggested social media posts and graphics to spread the word about anxiety.

Social media direct people to the Mental Health Foundation’s website which contains advice on, among other issues, connecting with Nature. There is a beautifully illustrated Thriving With Nature guide this year, offering simple suggestions for seasonal activities for everyone to engage with nature throughout the year. Television presenter and outdoor campaigner Julia Bradbury writes passionately in the Foreword, “I believe it’s vital for all of us to spend time re-connecting with nature for our mental health and wellbeing.”

The guide provides many links to further information and other organisations, including the charity MIND, whose website leads people to the benefits of “ecotherapy”, a nature based therapy that is already available via social prescribing in Surrey. This project includes activities that focus on working in nature, experiencing nature, or spending time with others in nature, and includes local “walking for health” schemes, community gardening, conservation volunteering, green gyms or open water swimming. It has gone so well that “the aim over the next few years is to see it available on the NHS”.

MIND runs ecotherapy self-referral programmes but the website also advises: “Ask your GP; they might be able to refer you to a local programme. This is sometimes called 'social prescribing' or 'green prescribing’”. So there is potential for a surge in such requests over the next few weeks if the campaign does its job.

If we are to prescribe these green interventions, MHAW’s “key priority for the Government and society as a whole” must surely also be to preserve, enhance and improve access to the green corners of our country; a huge cross-governmental mission that needs system wide change, long-term funding, a framework to ensure green space meets the needs of local communities.

Government policy on green spaces and GSP

While there are exciting nationwide moves towards acknowledging the benefits nature can have for people’s mental health, evidence supporting GSP is also emerging in reviews such as a Nature-based Outdoor Activities for Mental and Physical Health, published in Science Direct journal.

The PHE Strategic Plan for 2020–25 gives a commitment to enable healthier, more equitable and sustainable communities, and the NHS Long Term Plan commits to significantly expanding the number of social prescribing link workers in primary care to enable GPs and other health and care practitioners to refer people to workers who can help to ascertain the things that matter to them; for some this will be GSP.

Natural England has played a key role in helping to shape a wide, cross-Governmental £5.77 million GSP Project, which ran until March 2023 and consolidated GSP as a core part of the Government’s wider ambitions for health care and health prevention within the NHS. It tested how to embed GSP into communities in order to:

  • improve mental health outcomes

  • reduce health inequalities

  • reduce demand on the health and social care system

  • develop best practice making green social activities more resilient and accessible.

Seven pilots in communities hardest hit by Covid-19 were taken forward across England in 2020. Funded by a £200 million Shared Outcomes Fund, they were able to explore what’s needed to scale up GSP at a local level in the hope that, if successful, it could be rolled out across the country.

GSP helps tackle health inequalities

Natural England found that people living in areas of high deprivation, who have low income, a low level of education or were not working, older people, minority ethnic groups and those with a long-term illness or condition were the least likely to get out in nature. These are also the people who feel the negative effects of health inequalities.

This year, the final report on the NHS’s capacity to deliver GSP in England, and guide wider national roll out, also threw up concerns that people with wider issues causing them ill health, such as housing and finances, were less likely to engage in green activities. This comes despite the fact that GSP is steadily gaining respect within the NHS as a way of addressing wider social determinants of people’s health. Social prescribing link workers are able to develop relationships with a range of voluntary and community organisations and other statutory services, such as Job Centres, and can make timely referrals for individuals who need other support systems beyond the NHS.

A positive role for GSP

This recent Government’s assessment didn’t intend to laud the benefits of GSP in individual pilot areas but rather aimed to answer its question: “do we have the capacity for a national rollout?” Individuals who have been passionately advocating for the use of nature for mental health may be disappointed by its apparently negative findings. They will, though, be encouraged by the suggestion that projects and networks have been powered by “individuals who see the value in nature connection and nature-based activities and have the time, energy and skills to link up initiatives and create a critical mass for GSP”, and that resources and wider system support should be made more available to them in their efforts.

However, it is undoubtedly disappointing that link workers and green providers have felt overwhelmed with inappropriate prescribing of people whose health problems are “too severe to be suitable” for the services; saddening that there was a “worrying pattern of link workers and green activity providers receiving patients with complex health conditions that they are not equipped to work with”; frustrating that provision is still “patchy” with variation in the types of activities offered and availability of accessible green space; and worrying that there is a “danger it instead acts as a holding system for service users who require more specialised support”.

However, individual GSP pilots have highlighted the benefits of being able to offer a responsive and personalised “holding system” as an alternative when nothing else is on offer. With the current crisis in mental health services this may prove to be a life-saver for some; and with complex mental health issues there remains an unmet need for solutions beyond the medical.

Myplace, an eco-therapy partnership between Lancashire and South Cumbria NHS Foundation Trust and Lancashire Wildlife Trust, named the best “Mental Health Innovation of the Year” at the Health Service Journal Awards 2021, aims to improve mental health in young people and adults by giving them the opportunity to connect with nature, learn new skills and build up resilience. Their activities reduce anxiety, stress and many low level mental health conditions whilst improving physical fitness, health and wellbeing. The scheme reaches out to unemployed or economically inactive people over 25 but there were no restrictions on those under 25 years old who wanted to take part.

An independent review of Myplace found that “all of the young people in the scheme had struggled to find the mental health support they needed”. When asked about Children’s Mental Health Services (CAMHS) specifically, young people expressed problems when moving to adult services. One young person said, with access, “most of the time you are too sick or not sick enough. If you happen to fit in the tiny space in the middle, you have to wait 13 months for treatment and not get sicker or better during those 13 months.” Another said “This is not supposed to be a damning indictment of CAMHS…but this does reinforce how important it is for projects like Myplace to exist.”

At Myplace, young people said “they help in a different way, it’s a mindful place”; “We’re not judged. At CAMHS it’s like a medical thing - you are ill. Here you’re treated like a person.” They liked getting outside and having the structure, “which helps people who are anxious”, but also working at their own pace. The results of the review stated agreement that there should be, among other actions, briefings to GPs “so they know about it and can refer people there instead of CAMHS”.

Conclusion

As the Myplace review concluded, “helping people to engage with nature is a long term and cost-effective solution to complex issues, something the NHS concurs with”. However, both Myplace teams and the NHS also agree that referral pathways could be improved and that there is still “work to be done in getting the message across to all referral partners”.

Important recommendations in the Government’s capacity report also addressed improving awareness in the health sector of GSP and the levels of need that it can benefit. Although the conclusion is that “more work needs to be done”, the hope is that the GSP programme will retain cross-Government support, alongside a renewed drive for more specialist services to prevent inappropriate prescribing and a persuasive argument for more effective network collaboration and longer-term funding for the schemes.