Next time you visit your GP expecting to leave with a prescription for meds, you might be in for a surprise. Instead of the usual printout, you might find yourself clutching a (sometimes literally) green alternative, prescribing an agreed activity outside – a weekly group walk, perhaps, or involvement in a local conservation project. The idea, say advocates, is to shift the focus of prescriptions from illness to wellness, getting more people better and potentially saving the NHS from financial ruin.
So-called “green prescriptions” have long been the norm in New Zealand, as well as in some parts of Australia and the United States, and they’re becoming increasingly popular over here. “Studies on life expectancy show that lack of exercise is now second only to smoking in causing premature deaths,” says Dr Tim Ballard, vice chair of the Royal College of GPs, who adds that mounting evidence points to the health benefits of being out and about in green spaces – less tension, stress and depression; lower blood pressure; improved immune system responses; lower levels of obesity; and milder ADHD symptoms in children, just to name a few. In fact, simply spending more time outside – instead of staring at a TV screen or computer monitor, for instance – equates to an overall increase in physical activity. “So while, unlike in New Zealand, there are no plans for a nationalised scheme for green prescriptions, I think GPs will be more likely to link their patients to them in 2016,” he predicts.
The cost saving could be considerable. Natural England found that for every £1 spent on establishing healthy walking schemes, the NHS could save £7.18 in the cost of treating conditions such as heart disease, stroke and diabetes. Meanwhile, a recent Response for Nature report by the RSPB and other charities recommended that by 2018, one per cent of the public-health budget should be invested in the preventative and restorative value of nature to provide cost-effective health solutions.
But surely GPs have long been telling people to “take a hike”, as it were, to improve both their physical and mental health? “Indeed, I recently came across a 150-year-old edition of Dr Roth’s The Prevention and Cure of many Chronic Diseases by Movements, which basically tells people to forget their tablets and get moving,” says Dr Ballard, adding that in more recent years, there can hardly be a GP in the land who hasn’t systematically given advice around getting off the bus a stop early or walking upstairs instead of taking the lift.
There have been more centralised attempts, too, notably the recent NICE-accredited Exercise Referral Scheme. “But just as patients often don’t take the informal advice, evidence also found that after 12 weeks on the scheme, people were virtually back to where they started, and after six months, they were completely back to square one,” says Dr William Bird, strategic health advisor for Natural England, who believes a large part of the problem is that many people simply don’t like gyms. “Then came the Let’s Get Moving scheme and that failed, too, probably because it was too rigid.”
So what’s different now? “The big change – and I’ve been pushing for this a lot – is making exercise fun and sociable, as well as using it as a means to an end,” he explains. “So encouraging someone to go for a walk in a green space, which ends with having a pint in the pub or a cup of tea, makes the activity far more appealing. You’re talking to your mates, you’re out in the countryside and you’re having a good time. It’s all about trying to get exercise to be part of a fun life, not an add-on.”
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Also critical is the outdoors element, he says. “For some reason, it is much easier to keep up a movement or exercise regime when it’s outdoors,” agrees Daphne Miller, a physician in San Francisco who has written out hundreds of prescriptions for outside activity. Maybe it’s because it doesn’t incur the monthly membership bills, figure-hugging clothing and pressure of gyms – or perhaps it’s because of the scenery, fresh air or what Miller terms “the camaraderie of the trail”.
Another key factor for success seems to be partnerships with relevant organisations, thereby taking the pressure off already overstretched GPs. “Liverpool has just invested £1.5m into working with the council to get more people into parks because we know that people who live near them are less obese and less likely to suffer from depression,” says Dr Bird. “In Weymouth, GPs are working with a local RSPB reserve, getting people into things like conservation and birdwatching.”
National Parks are particularly involved in green prescribing, and are in the process of teaming up with local Health and Wellbeing Boards and GP surgeries up and down the country. “In Devon, for example, there’s a green prescription scheme being piloted by Dartmoor National Park Authority, whereby GPs encourage people to get out into Dartmoor, rather than dealing with medical conditions through drug interventions,” says Paul Hamblin, executive director of National Parks England.
Professor John Ashton, of the Faculty of Public Health, says it’s imperative that people from urban areas don’t miss out. “The Lake District, for instance, brands itself as the nation’s playground, but actually the national park is currently predominantly accessed by middle-class people coming from the South East, while a lot of local kids on the west coast of Cumbria don’t go at all. We need to make sure they can cycle in from places like Barrow and Whitehaven to participate.”
He adds that it’s important to draw on what we already know works when it comes to green prescribing. Dr Bird, for example, set up the first green gym – outdoor sessions run by conservation groups – in 1998, to promote physical activity and wellbeing, and the scheme now has hundreds of centres. Meanwhile, many GP surgeries have long been running well-attended walking schemes from their surgeries.
There are barriers, notably that many patients expect more when they go to the doctors. “We know that walking 30 minutes has a more advantageous outcome for people with angina than a coronary stent, but if I told my patients they don’t need the stent, they’d think I was trying to save money or not doing my job,” says Dr Bird, adding that there are patients who are hell bent on popping pills for every ailment. “It’s going to be a major hurdle to get over this idea that the NHS has to be about white coats and stainless steel, but we really do need to get green space on the agenda, and seen as a sexy health benefit.”
Given that there aren’t megabucks to be made out of green prescribing, drug companies may oppose it, too. Meanwhile, some doctors themselves are rolling their eyes, feeling they’ve tried and failed before, or nervous that the patient won’t follow through or that exercise isn’t a safe enough cure, says Dr Bird.
“The difficulty is that GPs and other doctors are trained in the biomedical paradigm,” agrees Dr Ballard. “But if you look at the research around the benefits of being outdoors; the number of hospital admissions there are because of drug complications; and the financial pressures on the NHS, then social prescribing – whether green prescriptions or indeed referrals to befriending schemes for the socially isolated – really has to become more normalised. In fact, I just won a grant to pilot the identifying and referral of people in fuel poverty to have interventions for their cold homes because mounting evidence shows that if you take people who have high contact with the NHS and sort out their homes to be dry and warm, it decreases GP appointments and hospital admissions.”
Orlando Rutter, senior learning and outreach officer for Dartmoor National Park Authority, says GPs seem to be reassured when it’s clear that nobody is suggesting a one-size-fits-all approach. “For one person, the best prescription might be a weekly cultural history walk, whilst for others it might be outdoor counselling. Indeed, we know that some people who wouldn’t sit in a room with a counsellor say they would talk about their problems on a walk. Equally, nobody is suggesting interventions that don’t have an evidence base, which, by the way, we are building on all the time.”
Dr Rob Hicks, who has been giving out green prescriptions for as long as he can remember, says, “The main thing that I find makes the advice around getting outdoors hit home is writing it down. Patients want to leave the surgery with something tangible.”
Perhaps it’s just a matter of time before everyone knows what green prescriptions are. Meanwhile, why wait for yours? Just find a green space and get moving.
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