Green Social Prescribing report - May 2023

Key findings from a 2-year ‘test & learn’ approach to delivering green social prescribing in Surrey Heartlands

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Green Social Prescribing report - May 2023

Executive summary

This report outlines the key findings from a 2-year 'test & learn' approach to delivering green social prescribing in Surrey Heartlands.

The Green Social Prescribing programme set out to understand more about how to address some of the barriers to nature-based interventions for people experiencing mental health or emotional wellbeing needs, and some of the barriers to health and care professionals recommending green approaches to the people they support.

Among the approaches piloted by the programme were community-based projects, primary care-led pathways, digital innovation, diversity and inclusion initiatives, and nature-based training and wellbeing support for health and care staff.

Key findings

Nature and green space play a key role in health creation and the prevention of ill-health
Lack of equity of access to nature and green space is a health inequality
Ongoing barriers to accessing nature and green space for health and wellbeing exist
Nature connectedness is uniquely placed to treat and prevent mental ill-health
A resilient and accessible nature and health sector requires sustainable funding
Stronger connections are needed between community-based nature health providers and the healthcare system
Nature-based workplace wellbeing support for health and care professionals can support a cultural shift towards valuing nature in health
The management of Surrey's land and water should support human health and wellbeing
Cross-sector partnerships and empowered communities are key to delivering sustainable green health and wellbeing provision.

Key recommendations

Develop a nature health strategy for the Surrey Heartlands ICS
Commit to delivering local green health and wellbeing provision as part of the ICS baseline investment in prevention
Support VCFS green providers with long-term sustainable funding
Continue to test and learn from innovative approaches to digital nature
Embed green health and wellbeing provision into health and care pathways as part of everyday professional practice
Incorporate nature connection into workplace wellbeing for health and care staff to reduce sickness rates and improve retention
Align land management and nature recovery strategies with health and wellbeing outcomes for local communities.

Nature and health

A growing body of evidence points to the impact of the natural environment on people's health and wellbeing. Spending time in green or blue spaces, and seeking contact with nature, can have a positive effect on both physical health and emotional wellbeing.

The increase in urbanisation of living environments is changing the relationship people have with nature in terms of reducing the likelihood of exposure (proximity or time spent in nature) or impacting feelings of connection to nature. Families on low incomes or from minority ethnic groups often have the least access to nature. The time children spend in green space or connecting to the natural environment continues to decline.

There are inequalities in the quality of nature available to different groups of people. 'Inequalities in socio-economic status and between people in inner-city, sub-urban, and rural areas intersect with inequalities of experience and access relating to race, disability, age and gender'.

Evidence highlights the benefits of nature to mental health and shows that both contact with nature and connection with nature have a positive impact on health and wellbeing. Living near natural environments is associated with lower stress and faster recovery from mental health issues.

However, it's not just how much time people spend in nature that affects their health and wellbeing but the quality of their connection to nature. 'Nature connection' reflects how people think and feel about nature. People do not need to be in a natural environment to connect to nature, but nature connection is linked to higher mental wellbeing and lower levels of anxiety.

A range of nature therapies may also enhance psychological resilience to mental ill-health. The promotion of wellbeing, social inclusion and mindfulness in nature can help build up an individual's capacity to cope with life stresses and have a prophylactic effect against poor mental health in the future.

There is also evidence of a positive relationship between nature and physical health. Time spent in green space is beneficial for the immune system, physical activity levels, cardiovascular health, the respiratory system, and weight. Adults and communities exposed to local green space show reduced risk of Type II Diabetes and obesity, and increased likelihood of physically active lifestyles. There is some indication of a correlation between contact with nature and more positive perinatal outcomes.

During the Coronavirus pandemic nature, wildlife, and time spent in green and natural spaces became even more important for people's wellbeing. Outdoor spaces played an essential role in allowing people to spend time with friends and loved ones. During Coronavirus restrictions there was a clear correlation between how people used the outdoors and the distance they live from green spaces. The closer people lived to their nearest park, the more likely they were to visit during lockdown.

Emerging evidence points to a correlation between nature connection and pro-environmental behaviours. The Lancet Countdown Report identifies climate change as the most important health threat of the century. Climate change, and the ecological crisis associated with temperature rises, threatens people's ability to thrive and to survive. However, a positive relationship has been found between nature contact, nature connection, and pro-environmental behaviours.

The Lancet urges governments to push for more sustainable healthcare systems and highlights the important role of healthcare staff in changing clinical practice and advocating for wider changes to the delivery of health and wellbeing.

Green interventions for health and wellbeing can deliver a positive return on investment and help to reduce health inequalities. An evidence review commissioned by Natural England found that nature-based initiatives for people with mental health issues gave returns from £2.35 to £10.70 for every £1 invested. A study by The Wildlife Trust found that environments rich in wildlife had a positive impact on mental health and showed a Social Return on Investment (SROI) of between £4.20 and £11.94 for every £1 invested.

The current National Institute for Health and Care Excellence (NICE) guidelines advise against prescribing anti-depressant medication as a first-line treatment for less severe depression. Whilst a range of talking therapies and mindfulness practices are proposed as alternatives to traditional medication, NICE does not explicitly recommend green social prescribing or nature-based interventions.

However, a recent survey commissioned by the Department for Health and Social Care (DHSC) shows that most clinicians see green social prescribing and nature-based health as part of a holistic approach to patient care that can work alongside more traditional interventions, such as medication or talking therapy.

The survey also highlights a link between the personal behaviour of clinicians in relation to spending time in nature and their professional actions. Clinicians who spend time outdoors daily or most days were more likely to be favourable to prescribing nature-based activity.

Most clinicians considered that the inclusion of green social prescribing in NICE guidelines would lend credibility and prompt investment in the infrastructure around it. Building the infrastructure around green social prescribing – a robust social prescribing workforce, easy referral routes into nature-based activity, and clear information on local provision - is critical to embedding and scaling up green approaches to health and wellbeing.

Social Prescribing

Social prescribing is part of the NHS Long-Term Plan and one of the Six Components of Personalised Care. It is one of the 10 High Impact Actions for Primary Care.

Social prescribing is a holistic, person-centred approach to health and the wider determinants of health. It recognises that many things that affect health and wellbeing can't be treated by doctors or medicine alone. Social prescribing connects people to non-medical support, such as social activities, debt, housing, and employment advice, or keeping active.

Social prescribing may begin with a referral from a GP, a hospital, a mental health professional, or social worker to a social prescribing link worker. Link workers (and other community wellbeing workers) listen to what matters to people and help people to live the best lives they can.

Connecting people to physical activity, arts, culture, creativity, and nature can improve health and wellbeing, reduce loneliness, and empower people to self-manage long-term conditions. Social prescribing can address common mental health conditions, including loneliness, stress, mild to moderate depression, and anxiety. Evidence suggests that social prescribing can also save costs and reduce pressure on health services by reducing the need for GP appointments and medical prescriptions.

Green Social Prescribing

In July 2020, Environment Secretary George Eustice announced a £4million investment for a cross-government project aimed at tackling and preventing mental ill-health through green social prescribing.

With additional contributions from NHS England, Sport England, and the National Academy for Social Prescribing, the investment total was £5.77million.

The project set out to test how to embed green social prescribing into communities to:

Improve mental health outcomes
Reduce health inequalities
Reduce demand on the health and social care system
Develop best practice in making green activities more resilient and accessible.

The two-year project was run by multiple partners including:

Department of Health and Social Care
Office for Health Improvement and Disparities
Department for Environment, Food and Rural Affairs
Natural England
NHS England and NHS Improvement
Department for Levelling Up, Housing and Communities
National Academy for Social Prescribing
Sport England.

Seven Integrated Care Systems were selected as 'test & learn' sites for embedding and scaling up green social prescribing:

Humber Coast and Vale Health and Care Partnership
South Yorkshire and Bassetlaw Integrated Care System
Nottingham and Nottinghamshire Integrated Care System
Joined Up Care Derbyshire Integrated Care System
Greater Manchester Health and Social Care Partnership
Bristol, North Somerset, and South Gloucestershire Integrated Care System
Surrey Heartlands Health and Care Partnership

National evaluation

An evaluation of the Green Social Prescribing 'test & learn' sites has been led by an academic collaborative and will be published later in the year. Emerging evidence from an interim report finds that about 7,000 people will have benefited from a green social prescribing referral since the beginning of the programme.

Many more people will have found their way into a nature-based activity because of the wider work that has raised the profile of green interventions to improve health and wellbeing.

At a national level the Green Social Prescribing programme has informed the following:

It is referenced in the current update of the Government's Mental Health and Wellbeing Strategy 10 Year Mental Health and Wellbeing Plan
It is explicitly detailed in the first revision to the 25 year Environmental Improvement Plan
There is a green social prescribing case study in the NHS England Statutory Guidance to Integrated Care Systems: Working in Partnership with People and Communities.

The Green Social Prescribing Toolkit shares case studies and learning from each of the sites, and this will be published by the National Academy for Social Prescribing in the Summer.

Emerging evidence

Consistently strong take up with between 85%-89% of people referred engaging with GSP activities
A proven reduction in anxiety and depression levels
Improvements in quality of life and happiness
50% of people referred live within the top 20% of areas of deprivation (IMD).
Engagement of people from minority ethnic groups reflects or exceeds percentage of people from ethnic minority backgrounds in the local populations
A total additional investment of £1.5million has been raised collectively across the programme to supplement national funding.

The Surrey Heartlands 'Test and Learn' site for Green Social Prescribing

Green social prescribing in Surrey Heartlands was delivered through a partnership between Surrey County Council, Surrey Heartlands NHS, social prescribing, the voluntary, community, faith, and social enterprise sector, and environment organisations.

Recognising that a lack of equity of access to nature and green space is a health inequality, the main aim of the programme was to test innovative approaches to delivering nature-based health and wellbeing activities to priority groups. These groups included:

People with identified mental health needs .
People with Learning Disabilities.
People who are physically disabled.
People with Dementia and their carers.
People from minority ethnic backgrounds.
People living in key neighbourhoods.

The programme also set out to engage health and care professionals with the evidence for the benefits of nature connection and access to green space for people's health and wellbeing.

The strategic alignment of green approaches to health and wellbeing with other policy developments within health, environment, and communities was also a key driver of the programme.

Headlines

400+ participants engaged in GSP activities
320 members of Surrey's Green Health & Wellbeing Network
£85K+ of funding to VCFS organisations
30+ delivery partners
120 healthcare professionals engaged in nature-based wellbeing or training
£250K of match funding
£5K+ of social value delivered through the GSP programme
4 GSP films produced
16 VR headsets purchased, and 4 360-degree nature films produced
75 participants in the First Step Green Volunteering programme
8 City and Guilds qualifications awarded to young people volunteering on a GSP project.

Three core principles informed the delivery of the Green Social Prescribing programme in Surrey Heartlands:

Innovation

The Green Social Prescribing programme set out to 'test and learn' from different approaches to delivering nature-based wellbeing activities to different groups of people. These approaches addressed specifically inequalities of experience of access to nature and green space.

Collaboration

The programme was led by an innovative partnership between Environment, Communities & Prevention, and health. It worked in partnership with a range of cross-sector organisations to deliver green social prescribing and green health innovation. Its projects were co-designed with people with lived experience.

Integration

The Green Social Prescribing programme created alignment between nature-based health and the strategic priorities of the Surrey Heartlands Health and Care Partnership around mental health, prevention, and sustainability. It targeted health inequalities associated with lack of access to nature and green space, so no-one is left behind.

Cross-sector partnerships

The Green Social Prescribing programme has worked with a range of partners and stakeholders to deliver its test and learn approach to nature-based health and wellbeing provision. The programme was led by a cross-sector partnership between Environment and Communities & Prevention at Surrey County Council and Surrey Heartlands ICB.

A partnership between health and environment underpinned the programme's aim to support stronger links between Surrey's nature and the need to tackle health inequalities and create healthier, more resilient, communities. The Surrey Heartlands bid was informed by two workshops with over 90 participants from across health, environment, district and borough councils, green infrastructure organisations, and the VCFS.

The Green Health and Wellbeing Network, which evolved from these bid-development workshops, has grown to over 320 members who represent sectors from across Surrey Heartlands. Quarterly green health and wellbeing events have strengthened connections between network members, and monthly newsletters have created a space to share nature-based health and wellbeing updates. The Future NHS Collaboration Platform for Green Health and Wellbeing provides a shared online workspace for professionals with an interest in this field of healthcare.

Delivery of green social prescribing was supported by the VCFS, green infrastructure organisations (including the RHS, the National Trust, and Natural England), district and borough councils, and some health providers (including the Surrey and Borders Partnership NHS Foundation Trust and Primary Care). The co-production of the programme's core nature-based health and wellbeing provision was supported by the Surrey Coalition of Disabled People and a panel of lived experience experts.

Additional funding was secured through a range of sources. SABP NHS Foundation Trust provided match funding for a garden project on its St Ebbas site, with additional support from St Kilda Trust. Surrey County Council Environment funded Nature in VR through Interreg Europe and it funded the development of First Step Volunteering. Dose of Nature was supported by Adult Social Care's Contain Outbreak Management Fund. The Surrey Training Hub has contributed £40,000 to nature-based wellbeing for Primary Care staff. In-kind support was provided by local businesses through Surrey County Council's Social Value Marketplace.

The strategic context

The core aims of the Surrey Heartlands Green Social Prescribing programme – to use nature-based interventions to address mental ill-health, to tackle health inequalities through greater equity of access to nature and green space, and to encourage broader diversity and inclusion within the environment sector – are aligned to Surrey County Council's priorities to enable a greener future, empower communities, tackle health inequalities, and grow a sustainable economy.

The programme also contributes to the Health and Wellbeing Strategy (priority two: 'supporting people's mental health and emotional wellbeing by preventing mental ill-health and promoting emotional wellbeing') and supports the ambitions of the Health and Care Partnership to focus on prevention, to deliver care differently, to work with communities to drive local change, and to develop a workforce with the necessary culture and skills to deliver the healthcare of the future.

Green social prescribing supports with the personalisation of healthcare and the programme is accountable to the Surrey Heartlands Personalised Care Steering Group. The Green Social Prescribing programme has also contributed to Surrey Heartlands' Culture, Design, and Development Group in recognition of its collaborative and integrative approach to systems change and innovation.

The Fuller Stocktake Report sets out a vision for Primary Care that gives people more choice about how they access care; provides people with more proactive and personalised care; and outlines an ambitious and joined-up approach to prevention.

Many of the core principles within the Fuller Stocktake Report are reflected in the aims and ambitions of the Green Social Prescribing programme:

Green social prescribing integrates nature-based interventions and activities into care pathways giving people more choice about their health and wellbeing.
It de-medicalises pathways by introducing the value of nature into creating and maintaining good mental and physical health.
Green social prescribing tackles health inequalities by improving equity of access to green space, and it addresses wider determinants of health such as loneliness and social isolation.
Green social prescribing encourages community partnerships.
It empowers people to practice self-care by providing opportunities for social connection and skill development through which new relationships, purpose and meaning are found.
It supports the NHS workforce with professional development and with nature-based wellbeing initiatives to create a positive working environment.
Green social prescribing reimagines NHS estates as sites of health creation for local people, for patients, for staff, and for the natural environment.

Green social prescribing and nature-based approaches to health and wellbeing are also aligned to the NHS's ambition to be the first net zero healthcare system in the world. To fulfil net zero ambitions each NHS trust and ICS are required to produce, monitor, and report against a 'Green Plan'.

The Surrey Heartlands ICS Green Plan includes a commitment to work collaboratively with partners on areas such as social prescribing and green spaces. Its pledge to focus on biodiversity to improve NHS estates and provide green space to support the health and wellbeing of staff and patients aligns well with the ambitions of the Green Social Prescribing programme.

Improving access for all

Alongside the Green Social Prescribing's aims to address health inequalities, inclusion, and mental health, the programme also set out to encourage increased uptake of nature-based provision and access to green space for the health and wellbeing of all Surrey's residents.

The Green Social Prescribing webpages on Healthy Surrey provide a wealth of information for professionals and the public on the value of nature for health and local opportunities to engage in a range of nature-based activities. Resources include:

Publications and peer-reviewed research on nature and health .
Resources and guides on a range of topics from starting a community garden to dementia awareness and mental health training for green health providers to support a more diverse population.
Local green activities from walking and cycling, or gardening and food growing, to animal and horticultural therapy.
Self-referral options for green social prescribing projects.
Conservation and green volunteering opportunities.

Surrey Information Point was reviewed and updated to incorporate a wide range of green and blue spaces, and nature-based activities, that support people with self-care and a healthy lifestyle.

A Winter Wellness Campaign 31 tips to make the most of Surrey's nature during the winter was shared on Healthy Surrey, Surrey Matters, and social media. It included information on how to connect to nature to improve mood, increase fitness, and reduce the risk of depression.

The Nature Connection Fund

The Nature Connection Fund provided over £85K to voluntary, community, and social enterprise organisations to provide nature-based health and wellbeing provision to local people.

The focus of the fund was innovation and new approaches to supporting people with mental health needs and those from priority groups, including people with learning disabilities and people from minority ethnic backgrounds who are less likely to access the health and wellbeing benefits of nature and green space.

Community engagement and co-design

The design of the Nature Connection Fund was supported by a range of professionals representing people with mental health needs and Green Social Prescribing's other priority groups. The design of the projects was also informed by a summary of community engagement that had asked members from each of the priority groups which nature-based activities they would prefer to access and the barriers they experience in accessing such activities.

Shortlisted applicants were invited to a workshop hosted by the Green Social Prescribing programme and people with lived experience to help co-design projects that would support and be accessible to people with mental health or other support needs. People with lived experience were reimbursed for their time and expertise in helping applicants to shape their projects to address specific needs.

Evaluation

Nature Connection Fund projects were required to provide monitoring data and outcome measures (ONS4 and Nature Connectedness), to DEFRA and an academic consortium for quantitative analysis. A full data analysis will be published in the national evaluation of the seven 'test and learn' sites later in the year.

The projects were also asked to collect photographs, case studies, and participant feedback. Some Nature Connection Fund providers participated in semi-structured qualitative interviews about their experiences of running green health and wellbeing projects for the Green Social Prescribing programme.

Wild Swim Project

The Wild Swim Project delivered two 4-week courses of open water swimming on the river Wey. Each group of 12 people met for an initial session of 2.5 hours followed by 3 further sessions of 1.5 hours. The course was run by 2 qualified outdoor swimming coaches, lifeguards, and outdoor and mental health first aiders. The sessions provided learning about safe wild swimming, as well as an opportunity to meet and bond with a group facing mental health and emotional wellbeing needs.

The participants felt welcomed, safe, and in good care throughout the course. Qualitative feedback highlights the positive impact of the wild swim experience on confidence, motivation, resilience, and mood. Initial data analysis suggests improvements across all outcome measures.

Happiness level 'yesterday' increased on average by 2.8 points
Life satisfaction increased on average by 1.5 points
An average increase of 1.4 points in the level of how 'worthwhile things they do in life' are
Anxiety levels 'yesterday' reduced by 1.9 points.
'Connection with nature' at the end of the course improved by 0.8 points.

"Since starting the wild swimming my mood has improved considerably. The benefits I have experienced have far exceeded my expectations. It's really solidified the benefits of being in nature to my mental health as a method of self care."

"The swimming group has made me think about different ways to deal with my feelings and has inspired me to think of the future. I am encouraged that I will feel better and that it is okay to let people help."

"There are no words to describe how amazing this experience has been. A new hobby which has literally overcome my anxiety and depression."

Include Project

The Include Project delivered 'Stroll and Sign' nature walks to people with Learning Disabilities to increase nature connection, improve communication and encourage social contact.

Include Project During the walks inclusive communication methods like Makaton signing, modified language and an iPad App called Pictello were used to draw people's attention to nature, discuss the surroundings and record a chat book which can be shared with others to describe the walk and what they've seen.

Participants included friends, family and social care staff who were able to learn new signing skills to foster stronger relationships and improve community inclusivity. Improved fitness, communication and independence was observed by the caregiver for one participant who is largely non-verbal.

"It's good exercise. It helps me do my steps. I'm supposed to do 10,000 steps a day, but I don't always manage it. Coming to Stroll & Sign really helps."

"It gives us something to look forward to."

A Day in the Woods

Sorbus Learning delivered their project A Day in the Woods in partnership with Surrey Care Trust's Gateway Allotment project and the Amber Foundation.

The project was targeted at people with low to moderate mental health needs but worked also with people who were experiencing social isolation, illness, addiction, family breakdown and unemployment.

A Day in the Woods provided participants with a range of outcomes from their outdoor learning activities:

A shared outdoor experience of the natural environment as a 'therapy' activity.
Contact with wildlife through nature-based activities.
Transferable 'soft skills' such as team working, work ethic, and communication skills.
New 'hard skills' (coppice and woodland management) for outdoor working.
Improved physical, mental, and emotional well-being.

a day in the woods Trained outdoor learning practitioners provided activities to small groups (6-12
people) that catered for adult education (individual learning), socialisation (group events), recuperation (physical activity) and restoration (mental well-being). These activities all involved engaging with wildlife and the natural environment; nature conservation and woodcraft skills; fire-lighting and shelter making; and rural crafts.

Participants were encouraged to build confidence on the allotment site before taking part in the ancient art of coppicing in nearby woodland, Felland Copse. This enabled participants to develop their outdoor learning skills and safety awareness in a low-risk site before moving on to more challenging activities.

"I really liked learning to use tools and building the new entrance gate. No one's ever showed me that before."

One participant, with a history of severe depression, anxiety, and social isolation, was referred to A Day in the Woods by his social prescribing link worker. He wanted to learn building and horticultural skills, and spend more time outdoors with other people.
He really enjoyed constructing an outdoor learning area and now has a social group he feels confident in.

Mindful Ninja

The Mindful Ninja was funded by the Nature Connection Fund to deliver four 12-week mindfulness in nature courses for teenagers living in Stanwell. The groups were aimed at young people experiencing mental health difficulties or those with neurodiversity.

Located in local green spaces, the Mindful Ninja guided participants through a series of nature-based meditation activities such as rock painting, leaf rubbing, and nature art. The groups also engaged in outdoor activities including nature walks, scavenger hunts and seed planting.

Emily was referred to the Mindful Ninja because of her anxiety, especially in social situations. She found the nature activities and planting sessions really relaxing and started to feel more confident in the group.

She felt safe and unjudged. Emily said that it was nice to be among others that struggled because part of her anxiety and depression was how alone and ashamed she had felt.

Nature Nurtures

Mary Frances Trust's Nature Nurtures programme delivered in-person and online nature workshops and activities for people living with mental health challenges. Funding was also provided to develop allotments at two sites and a Peace Garden at the Epsom Safe Haven.

nature natures The nature workshops were co-designed and held at accessible venues throughout the MFT area. Participants engaged in activities such as building homes for bugs and wildlife, and planting wildflower areas. Themed walks within natural settings encouraged people to connect to nature through photography and collecting objects for art projects.
The online nature sessions were designed for people who found it difficult to leave home due to physical or mental health difficulties. Participants were sent resources in advance to grow or make at home (flower seeds, materials for a bird feeder, notebooks so they could record what they saw and heard in nature). The participants also shared photos online and discussed what they could see.

Some people went on to attend other online groups with MFT and one participant, who had struggled to leave home for a long time, managed to take part in some of the nature walks with the support of the walk leaders and the rest of the group.

The Peace Garden project at the Epsom Safe Haven involved MFT clients and volunteers tidying, replanting, and developing an outdoor space that people now use for relaxation, reflection, and socialisation. There's now a pond, a bug hotel, and a new seating area.

"A big thank you for making such a lovely group. So interesting and uplifting. Sort of boyount somehow. Must keep it with me."

Muslim Women and Girls 'Ecowarriors'

The Muslim Women and Girls 'Ecowarriors' are part of Surrey Minority Ethnic Forum. Initially established as a social group, the members are keen to increase their nature connection and act for the environment. The Nature Connection Fund supported the group to engage in nature connection activities with a range of partner organisations, including the Surrey Wildlife Trust, the Surrey Hills Society, and Surrey County Council's Greener Futures team.

The Ecowarriors engaged with a variety of issues from the ecological importance of heathland habitats, to how to live more sustainably, to the relationship between trees and faith.

In partnership with RHS Wisley the Ecowarriors collated memories, stories, and recipes from the different edible plants they grow at home; how they use them and how these foods, and gardening in general, connects with their personal heritage. The results can be seen at Wisley in an interactive display, 'Dishing up a World of Flavour'.

In the glasshouse at Wisley Gardens is the hand-sewn sea-themed panels created by the Ecowarriors and shared with Wisley as part of the annual 'House Plant Take-Over' event.

All the Ecowarriors reported that working on the nature connection projects had improved their wellbeing. They also reported reductions in loneliness and isolation, improved confidence and empowerment, and an increase in pro-environmental behaviours.

"Seeing everyone so enthusiastic about joining in made me want to get involved."

"The women in this group are like flowers in a garden."

"My whole week's oxygen I get from one session."

Forest Bathing Plus

The Forest Bathing Institute delivered a Forest Bathing Plus programme to support people with physical, emotional, and mental wellbeing. Forest Bathing is the ancient Japanese practice of Shinrin Yoku: the slow exploration of nature through the senses. It means 'spending quality time under the canopy of trees in a forest for health and wellbeing purposes'.

A recent report commissioned by the Forestry Commission, Scottish Forestry, and the Welsh Government, is the first time the health and wellbeing benefits of the UK's woodlands have been quantified. For England, woodlands save £141 million costs associated with mental health illnesses, including visits to GPs, drug prescriptions, inpatient care, social services, and the number of workdays lost due to mental health issues. The figures are based on evidence of the reduced incidence of depression and anxiety resulting from regular visits to woodlands.

Outcomes data from forest bathing sessions hosted by the Forest Bathing Institute and funded largely by the Surrey Hills National Landscape have been analysed by the University of Derby. Participants were referred into the sessions by Community Connections, Woking Mind, Catalyst, Shifa Network, Halow, GPs, and GPiMHS.

42% reduction in anxiety (Poms)
34% increase in nature connection
25% increase in social connection
34% improvement in mobility
9% improvement in self care
8% improvement in usual activities
18% improvement in pain
37% improvement in anxiety/depression
21% improvement in health.

The Forest Bathing Institute worked in partnership with Catalyst, Big Leaf, and Amber to provide a pilot 6-week course of forest bathing for people with moderate mental health needs, young asylum seekers and those experiencing, or at risk of, homelessness. A total of 28 participants took part whose ages ranged from 18 years old to 75 years old. A member of staff from each partner organisation also attended the sessions.

University College London (UCL) is leading an evaluation of outcome measures for the pilot. Pre- and post-course UCL Wellbeing Questionnaires were completed by participants, and post-session interviews were conducted throughout the course. Additional follow up interviews will take place in the summer to give participants a chance to reflect on their forest bathing experience beyond the delivery of the course. A full analysis will be published later in the year.

"Loved the extended tree relaxation today! Great session, resetting my mood and energy."

"I was feeling a massive discomfort on my body. Not anymore."

"I definitely feel better after this session. I feel a bit like when you exercise, and you get a bit of a rush. More positive. Negative thoughts have gone away while I have been doing the activities."

Outcomes data

Do residents feel an increase in nature connectedness after a period of Green Social Prescribing?

Total surveys 336

Increase - 44%
Decrease - 17.7%
No change - 38.3%

Is there a change in the following O.N.S measures after a period of Green Social Prescribing?

Anxiety:

Increase - 19.6%
Decrease - 42.3%
No change - 38.1%

Happiness:

Increase - 75.4%
Decrease - 8.8%
No change - 15.8%

Life satisfaction:

Increase - 75%
Decrease - 5%
No change - 20%

Worthwhile:

Increase - 68.5%
Decrease - 5.4%
No change - 26.2%

Sustainability

Many of the projects delivered through the Nature Connection Fund are being sustained and continue to provide the health and wellbeing benefits of nature connection and green space to a range of people.

The Forest Bathing Institute will be offering 60 one-off forest bathing sessions to social prescribing clients over the summer. It will also be working with the Bridge the Gap Alliance to provide forest bathing to people with complex needs as part of the Changing Futures programme.

Mary Frances Trust was so pleased with the impact of its Nature Nurtures programme that it has committed to continuing a digital nature offer. The Peace Garden at Epsom Safe Haven continues to thrive with support from a team of committed volunteers.

The Muslim women and girls Ecowarriors are involved in a peer research project with Surrey County Council about nature, climate, and faith, which is funded by UKRI and The Young Foundation. Sorbus Outdoor Learning continues to partner with Surrey Care Trust to deliver outdoor skills to support people with their mental health and emotional wellbeing through funding from the National Lottery.

However, most green community health and wellbeing providers are reliant on short-term grant funding that leaves their projects vulnerable. Long-term planning, staffing, and establishing and maintaining relationships with the health system are difficult.

Without sustained investment it is challenging for green health provision to become embedded into the healthcare system or for communities to maintain access to the nature-based activities that play such a valuable part in supporting good mental and physical health.

Primary care pathways

The level of green social prescribing activity in Primary Care is growing. Increasing numbers of primary care patients now have access to nature-based options to support their health and wellbeing and address wider determinants of health such as loneliness and social isolation. Some of this activity has been either supported and promoted by the Green Social Prescribing programme or directly funded.

The health and wellbeing team at Epsom PCN were keen to expand their green social prescribing offer. Funded by the Green Social Prescribing programme and working in partnership with Epsom and Ewell Borough Council, the Community Wellbeing Centre in Longmead, and the project lead for Epsom's Safe Haven Peace Garden, the health and wellbeing team delivered a 6-week in-door gardening pilot to people experiencing low mood, loneliness, or social isolation.

Activities included planting seeds, making bird feeders, and a Gardener's Question Time-style panel session.

The participants enjoyed the opportunity to meet other people and socialise. They are committed to continuing with gardening. There are plans to redevelop a courtyard garden at the Community Wellbeing Centre and to establish a regular gardening group to maintain the space.

The social prescribing link workers at CoCo PCN have run a successful programme of health walks for primary care patients. The guided walks offer an opportunity to socialise whilst exploring local routes that range from easy to intermediate.

Just outside of Surrey Heartlands, within the Frimley Health and Care ICS, Farnham PCN has delivered a very popular series of nature walks for residents of the Sandy Hill area as part of their health inequalities programme.

The Shepperton Village Community Garden has been set up by a team of volunteers led by a local social prescribing link worker, and with funding from the Green Social Prescribing programme, to give people an opportunity to learn gardening skills, create social connections, and grow a variety of plants and vegetables. The garden is supported by the Shepperton Allotment Association.

Shepperton village conservation People are referred into the Community Garden by borough council workers, GPs, and social prescribing link workers. A range of people have become volunteers at the garden including people who were socially isolated, carers, people with mental health needs, and someone with early onset Dementia.

Plans are in place to manage the maintenance of the garden. The Shepperton Village Community Garden will be working in partnership with the Shepperton Village Conservation Group to support the project and promote the opportunity to volunteers.

In collaboration with North Guildford PCN and the National Trust, the Green Social Prescribing programme commissioned Dose of Nature to deliver a new psychologist-led mental health pathway for primary care patients.

A Dose of Nature prescription is a ten-week programme that introduces individuals to the mental health benefits of spending time in nature. It aims to inspire lifestyle changes that will have a significant and lasting impact on mental wellbeing. This is achieved through a combination of education, first-hand experience, and practical and motivational support, led by a trained Dose of Nature Guide.

After a GP referral, patients meet with a Dose of Nature psychologist, who discusses their individual needs and explains more about the programme and the mental health benefits of being in nature. The patients are matched with a trained volunteer, a 'Dose of Nature Guide'.

Over a period of ten weeks, patients meet their Dose of Nature Guide in a natural space once a week and visit nature independently every day. Together they plan where and when they will spend time in natural environments. During their weekly meetings in nature, the Guide demonstrates to the patient a variety of exercises and activities, encouraging them to engage all their senses to gain maximum health benefits from their time in nature.

Alongside one-to-one contact with the Dose of Nature Guide, patients are also given the opportunity to link with other people in receipt of a nature prescription, and to make independent arrangements to meet for walks or to visit natural environments together. Many people find this a highly effective way of ensuring they continue to spend time in nature once the ten-week programme has been completed.

2022 recovery and reliably improved rates (Richmond-upon-Thames hub)

Condition	Recovery rate	Reliably improved rate
Anxiety	75%	96%
Depression	71%	77%

In comparison to most recent NHS CBT recovery rate figures (2020-21):

Depression = 45%
Anxiety = 53%
Recovery = A referral has moved to recovery if they were defined as a clinical case at the start of their treatment and not as a clinical case at the end of their treatment
Reliably Improved = A referral has shown reliable improvement if there is a significant improvement in their condition following a course of treatment.

In Surrey a new hub has been set up at Dapdune Wharf, a site owned by the National Trust, where work will soon begin on a shepard's hut in one of the paddocks to accommodate the Dose of Nature team. Two cohorts of volunteers have been trained so far and 15 patients from North Guildford PCN are currently in receipt of a Dose of Nature prescription.

Working closely with VCSF organisations and other local partners, Dose of Nature will continue to expand their volunteer network to establish an alternative to traditional mental health treatment that complements talking therapies and other primary care pathways.

Digital nature

The Green Social Prescribing programme recognises that lack of access to nature and green space is a health inequality. It was committed, therefore, to piloting innovative and creative ways to delivering the health and wellbeing benefits of nature connection to people who are unable to access green space due to limited mobility or other health issues.

The Royal Society for the Protection of Birds was grant-funded to set up a live stream from a bird feeding station built within their Farnham Heath Nature Reserve.

The RSPB have partnered with two of Surrey's residential care homes for people with dementia.

At the RSPB Farnham Heath reserve trenches were dug and cabling laid to permit a live camera feed from a bird feeding table. The live feed was then live streamed into the communal areas of the two care homes to provide an opportunity for residents, families, and staff, to connect with nature.

Where residents can't access the communal areas of the care home, the RSPB Farnham Heath used their funding to supply tablets so that residents can access the live stream from their rooms.

To bring the live feed to life, RSPB are also planning to run regular volunteer-led sessions in the two care homes to engage residents with what they are seeing on the camera.

The Nature in Virtual Reality pilot was a collaboration between the Green Social Prescribing programme, Environment at Surrey County Council and Interreg Europe. Four 360-degree virtual reality films of Surrey green and blue spaces were produced. These were shared with four priority groups within the Green Social Prescribing programme (dementia, disability, carers, and mental health) using Meta Quest 2 VR headsets.

Virtual Reality pilot Virtual Nature sessions were run in settings the priority groups access regularly, such as community hubs, dementia day centres, and hospitals. During each session users were supported to access one of the four 360-degree films with the aim of increasing feelings of wellbeing and nature connection.

Emerging evidence indicates overall benefits to wellbeing and feelings of nature connectedness. Anecdotally there also appears to be positive effects on quality of sleep, recollection of memories (amongst individuals with dementia) and improved social connection.

Most benefit was found amongst groups of individuals who are often excluded from having access to green space and nature, such as disabled people or people with mobility needs.

Further VR nature pilots are scheduled for cancer patients receiving chemotherapy treatment in East Surrey Hospital and St Luke's Cancer Centre at the Royal Surrey Hospital.

Learning from the pilot will also inform a framework for Surrey that supports the use of emerging technologies in the delivery of health and care.

Green Volunteering and inclusion

The Green Social Prescribing programme acknowledges that under-represented groups are often excluded from mainstream conservation work or green volunteering. Young people, people from minority ethnic backgrounds, and people with mental health needs are less likely to participate in nature-based volunteering activities than other groups.

The First Step Green Volunteering programme addresses this by providing a programme of opportunities to introduce people to green volunteering, with a focus on engagement with under-represented groups.

By increasing diversity and inclusion within Surrey's environment sector, First Step Green Volunteering aims to widen the scope of volunteers supporting local action on the environment, climate change, biodiversity, waste reduction, energy, and flood resilience. Supported volunteering placements also empower people to improve and maintain their health and wellbeing, learn new skills, and contribute to the wider economy.

To inform the delivery of the programme, Surrey Youth Focus, Surrey Minority Ethnic Forum, and Surrey Coalition were commissioned by Surrey County Council to carry out user voice research into barriers and enablers to engagement with green volunteering. Further contextual research was provided by Natural England.

First Step Green Volunteering is an ongoing programme. Taster sessions have been provided by the Downlands Partnership, the Lower Mole Partnership, RHS Wisley, Surrey Hills Society, Zero Carbon Guildford, and Rosamund Community Garden. Sessions have included 'sheep MOTs', habitat management, horticultural volunteering and careers sessions, hedge planting, an eco anxiety workshop, and rainwater harvesting.

So far 75 volunteers have participated in the taster sessions and there has been a positive take up of further volunteering opportunities. 70% of participants who attended RHS Wisley's 'New Shoots' session have subsequently applied to be volunteers. One First Step Green Volunteering participant has applied to the RHS apprenticeship programme.

The Therapy in Nature (TiN) Project is a multi-partner project that aimed to create a natural, green, outdoor space on an NHS estate that can be used as a setting in which to provide therapeutic intervention by Health Care Professional on a one-to-one or group basis.

Surrey and Borders Partnership NHS Foundation Trust (SABP) identified a space on their St Ebbas Hospital site that was perfect for converting into a therapeutic green space. The site is walking distance from multiple mental health and learning disability services that support children, young people, and adults. The site also benefits from an adjacent cricket pavilion which was renovated by SABP in support of the project. The pavilion provides a valuable indoor space right next to the garden.

One of the many aims of the project was to deliver community value both through the development of the space and its legacy. To achieve this, the Green Social Prescribing programme collaborated with the charities Volunteer It Yourself (VIY) and Surrey Choices.

VIY managed the development of the space, including building pergolas, planters, tables, picnic benches, and chairs. VIY recruits vulnerable and/or at-risk local young people (14-24) to volunteer on community build projects. The young people are mentored by professional tradespeople to work toward Entry Level City & Guilds Trade Skills Accreditations. On this project, volunteers gained accreditations in carpentry, health and safety, and painting and decorating.

Surrey Choices' Growth Team is comprised of adults with a range of disabilities and provides an opportunity to gain gardening and horticulture work experience.

The Growth Team (with support from Natural England) provided their expertise to carry out the initial planting of the garden as well as construction of a 'dead hedge' around the perimeter. The team are also providing ongoing regular maintenance of the space.
The CAMHS staff at the St Ebbas site and adult Learning Disability staff will receive training on how to incorporate nature into their practice with a view to developing sustainable nature-based approaches that enhance the delivery of mental health care.

Nature Connection for Professionals

The Green Social Prescribing programme has engaged over 100 health and care professionals with the science of nature and health, and with the benefits of nature connection for their own wellbeing and professional practice.

The Green Social Prescribing programme collaborated with health science academics, clinicians, and green health providers to create the Surrey Heartlands Green Health and Wellbeing Webinar to promote understanding of the value of nature connection and green space to health and wellbeing. The webinar can be accessed through the Surrey Training Hub.

The programme also funded 8 places for healthcare professionals on the University of Exeter Medical School's Nature, Health, and Wellbeing CPD course.

Course participants included four GPs, two social prescribing link workers, one mental health practitioner, and one care home manager.

The CPD course introduced learners to how natural environments can benefit the physical and mental health of people in a variety of ways. It addressed the relationship between nature and health, how the relationship works, why it matters for the environment, public health, and sustainability, as well as how these learnings can be applied in clinical practice.

In a feedback survey course participants were asked for three key things they had learnt. Responses included that the quality, rather than quantity, of nature connection and green space matter to health and wellbeing; that green space can be created in all areas no matter how urban; and that investing in green space can save the NHS money.

These learnings have subsequently been shared with colleagues and applied to supporting social prescribing clients with green health and wellbeing options, exploring sources of funding for local nature projects, and co-designing a community garden in a deprived neighbourhood.

Recognising that nature connection has benefits for the wellbeing of health and care professionals as well as the people they care for, the Green Social Prescribing programme commissioned Wild Gathering (a local CIC) to deliver three NatureWell courses to Surrey Heartlands staff.

Designed by Natural Academy, NatureWell is an experiential course that introduces participants to the University of Derby's '5 Pathways to Nature Connection'. The NatureWell course consists of guided practices and exercises, which participants can incorporate into both their professional and their personal lives. The course provides professionals with techniques to relax, restore and revitalise through the process of nature connection.

NatureWell was delivered to two primary care teams and to CAMHS staff involved in the 'Therapy in Nature' pilot at the St Ebbas site in Epsom. 21 health professionals took part. Each NatureWell course was delivered over three sessions, (one session a week for three consecutive weeks) in a local green space. CoCo PCN met at Holme Farm and the CAMHS team used the garden on the St Ebbas site.

Each session included exercises and practices that resource the participants, building resilience and reducing stress and anxiety, having a positive impact on mental and physical health. The course is rooted in supporting people and nature to recover and flourish together.

After the course participants were also offered a 1:1 telephone or online session to support the integration of the course into their personal and professional lives or, if they had missed a session, to go through that session with them.

At the start of each course participants were invited to fill out an outcome flower, scoring themselves against 8 measures of wellbeing which included self-esteem, mood, motivation, physical health, relationships, community, and connection to nature and the wider world. This was repeated at the end of the course and scores were compared.

In most cases the outcome flower scores increased in all areas after people had participated in the NatureWell course. There were significant increases in self-esteem, motivation, feeling more connected to community, having a greater connection to nature and the wider world.

Following the successful delivery of these courses, the Green Social Prescribing programme has secured funding from the Surrey Training Hub to run further NatureWell courses and to provide up to 32 places for primary care staff on Natural Academy's 'Nature Health Facilitator' programme. Nature Health Facilitators will be trained to deliver NatureWell, supporting the sustainability of this approach and giving more staff the opportunity to learn how to incorporate nature connection into their wellbeing and professional practice.

"Made me realise it's OK to feel the way I'm feeling. It's OK to have time out."

"Made me feel able to reconnect to nature in ways I had not thought of before. Helped me to think in a more positive way and move away from prescriptive thinking to a more open and creative mindset. BIGGEST THANK YOU!"

"I love how the group shared emotion and felt comfortable in this beautiful setting to be congruent with one another."

"It makes you realise the importance of the world and nature around you, and sometimes things are not as bad as they seem when you take a step back."

The Green Social Prescribing programme worked in partnership with Growing Health Together, the Surrey Hills Adventure Company (SHAC), Forestry England, and the Forest Bathing Institute, to host two very popular Nature Connection and Wellbeing Days for Surrey Heartlands healthcare professionals. The events were held at Bucklands Park Lake and Alice Holt Forest. Each day had space for 40 participants and both days were oversubscribed.

Professionals who booked on to the events included GPs, a Consultant Psychiatrist, Mental Health Practitioners, Clinical Pharmacists, Social Prescribing Link Workers, a Consultant in Emergency Medicine, Community Connectors, a Senior Clinical Psychologist, Health and Social Care Commissioners, a Family Support Coordinator, a Police Mental Health Liaison Officer, Physiotherapists, Receptionists, Nurses, a Nursing Associate, a Clinical Lead for Community Nursing, and a Clinical Case Manager for Children and Young People SEND.

Participants spent each day outside in beautiful forest or lakeland surroundings. They gathered under the canopy of trees to listen to health science academics explain the connection between human health and planetary health, and to green health providers speak about the impact of nature on people's physical and mental wellbeing. Local clinicians described how they are supporting communities with health creation through access to nature and green spaces.

To experience for themselves the wellbeing benefits of activity in natural landscapes, participants were invited to try Forest Bathing led by qualified guides from the Forest Bathing Institute at Alice Holt Forest, and woodland yoga, wild swimming, and paddle boarding with the Surrey Hills Adventure Company (SHAC) at Bucklands Park Lake.

In closing reflection sessions participants were asked to record on a postcard their feelings about the day and the time they had spent in natural environments.

The sense of time, and space, and recovery from the pressures of the Covid pandemic were common themes. So too was the feeling of needing a space like the one provided by the Nature Connection and Wellbeing Days on a regular basis.

Participants also reflected on the importance of connecting to nature and the natural environment for the people and patients they support.

"I am feeling blissfully relaxed and inspired by nature and the people attending."

"Having things like this maybe on a more regular basis would certainly help, I think, retain GPs."

"Initially I found it difficult to mentally slow down, until I hugged a tree. The guides were essential to gently prompt me to use my senses. Amazing day."

"Where do I start? Today has been an amazing day of reflection on my last one and a half years. Forest Bathing has given me the time to reflect and move forward."

"I feel re-filled. I really feel re-filled. I work within the NHS, and we spend much of our time pouring ourselves into the lives of the people that we serve. But that's a lot of pouring, and there's that old saying that 'You can't fill a glass with an empty jug'."

"I never expected to be close to a tree and actually sort of well-up a bit because we always hold ourselves together – we're holding ourselves together for other people – so to go to something and just stop and open up, it was a real moment."

"Allow patients to be with themselves but in a way that they can work on their inner thoughts in a place that's so beautiful and calm, and peaceful. It makes so much sense how this would be beneficial to people. Because it's helped me in just a couple of hours. I feel so refreshed."

"It's not just about a pill. We're creatures who are meant to be connected. Why would we spend more time prescribing drugs and not prescribing people and social situations?"

Key learnings

The Surrey Heartlands Green Social Prescribing programme has been a 'test & learn' site for embedding and scaling up green social prescribing. As this report illustrates, the programme has piloted a range of approaches to incorporating nature-based health and wellbeing into the health and care system.

The programme set out to understand more about how to address some of the barriers to nature-based interventions for people experiencing mental health or emotional wellbeing needs, and some of the barriers to health and care professionals recommending green approaches to the people they support.

This report concludes with some of the key learnings from the delivery of the programme. Key learnings are also informed by 11 qualitative interviews with delivery partners and system stakeholders, and feedback from project participants.

People and communities

Nature is uniquely placed to treat and prevent mental ill-health.

The feeling that "nature gives more to those who need more" was a common theme in interviews with green health providers and project participants. It was felt that connecting with nature supports people's resilience and ability to manage anxiety and stress. The project lead for Nature Nurtures at Mary Frances Trust said:

"When everything else around you is quite uncertain, or you're really feeling that things are going to sort of fall apart, to go out in nature, to have the reassurance of the seasons; to have the reassurance that although some things look dead, actually you know some of them will die but some of them will grow again in the Spring. There's always something to make you feel part of a bigger whole."

The perception of nature as non-judgemental was also prevalent. Some professionals, including social prescribing link workers, felt that people found it easier to talk in natural environments. One link worker described how she has moved over to offering 'walk and talk' sessions for her clients following her experience of the NatureWell course:

"More comes out when they're not just sitting facing you, you know, in a busy office."

Gary Evans, the founder and director of the Forest Bathing Institute, described the "nature deficit" experienced by many people living in modern, urban environments and highlighted the need to elevate nature and nature connection so that it becomes part of people's day to day lives.

Connection to nature matters more than just contact with nature.

Many of the health and wellbeing benefits of nature arise from the connection to nature that people make through green social prescribing activities. Spending time outdoors, where nature and the natural environment are just a backdrop to activity, may not have the same benefits. NatureWell participants talked about the "reconnection to nature" that the course created; the opportunity to take time out and really listen, touch, and smell the nature around them.

Equally, the emphasis on the quality of nature connection means that people can be given the opportunity to connect with nature without necessarily being in nature. This has important implications for people who face barriers to accessing green spaces. Mary Frances Trust's Nature Nurtures programme shows that online nature-based activities are a valuable option for people who may feel reluctant to participate in-person.

"You know when you think about online and nature, it feels like it's at odds, but what I think is really good about those is that they're not difficult for people to come to. They just turn the computer on and they're there."

The participants in the online Nature Nurtures sessions developed a connection to nature through sharing photographs, artifacts, and crafts. Crucially, they also formed a connection to each other.

Human connection matters too.

The nature-based activities provided by the Green Social Prescribing programme gave people an opportunity to experience new relationships, a new purpose, and meaningful engagement with their local community.

There is something inherently social about spending time in green space and the opportunity to engage in green activity with other people, and maybe try something new, was a prominent theme in participant feedback.

"You do feel a bit odd when you just go for a walk on your own."

For some people the option to meet initially online eased their concerns about taking part in face-to-face group activities but once engaged, the chance to socialise with others became just as important as the participation in green activities.

"So, people come obviously for the gardening, but they come just as much for the other people, if not more."

Human connection had a ripple effect on one of the Wild Swim Project's cohorts. Taking part in something challenging, like cold-water swimming where people had to rely on each other for encouragement, created a bond between the group. After agreeing to keep in touch via WhatsApp, a core group within the cohort have continued to swim together regularly.

Nature gives people something to care for and makes them feel cared for.

The feeling that people experience nature as 'non-judgemental' was a common theme in interviews with delivery partners. A social prescribing link worker described green social prescribing for her clients as "a hug by nature".

The act of caring for nature through gardening or food growing for example, or even just seed planting at home, was also identified as an important element of the benefits of green activity for health and wellbeing.

"If you're struggling with your own physical and mental wellbeing, to the degree that you can't get out, then having something else to care for, a lot of people have found really helpful."

Ongoing barriers to accessing nature-based activities and green space.

More work is needed to address some of the barriers to accessing the health and wellbeing benefits of connection to nature that people experience. Social prescribing link workers highlighted the cost-of-living crisis as a barrier to more people accessing green social prescribing. Connecting to nature did not feel like a priority for some clients.

Other barriers that people identified were:

The unfamiliarity of spending time in green space.
Poor weather and reluctance to engage in green activities in winter.
Fear of new activities or meeting new people.
Not understanding the value of nature to health and wellbeing.

People from minority ethnic groups face specific barriers to nature and green space. The lead for SMEF's Muslim Women and Girls' Ecowarriors, Shahin Mohamed, observed that some Muslim women had experienced racism in their local parks. Muslim women, she said, can feel very visible because of their head scarfs. They also worry about dogs in public spaces.

"We need dog-free areas for people to be comfortable in with their children. [We also need] women-only areas to be comfortable being there."

On a structural level the issue of transport was prominent. People are excluded from green space and nature-based activities because they can't get there.

"If they're not particularly mobile, then you know if it's more than a 10-minute walk to get to that place, then that's going to be a bit of a barrier."

If people are reliant on public transport, travelling to green spaces may involve long journeys or unaffordable expenses. Projects where free transport is provided, such as Forest Bathing, have been easier for people on low incomes or with access issues to engage with.

"Free transport has been the trick because they get picked up."

The need for more nature-based opportunities close to where people live was also a prominent theme among interviewees. So too was the need for more green provision, particularly in parts of Surrey underserved by green space and opportunities to connect to nature. It was felt that the Green Social Prescribing programme needed time to generate more provision and embed green approaches to health and wellbeing.

"Just at the time that it's running out we're all getting into it. It needs to be given a lot of time."

The health and care system

A resilient nature and health sector needs sustainable funding.

Sustainable funding of the green health and wellbeing sector is required if barriers to accessing the benefits of nature connection and inequalities arising from unequal access to green space are to be addressed. Without adequate and distributed provision social prescribing link workers, health professionals, and other referrers will struggle to recommend a green prescription to the people they support.

A social prescribing link worker said: "We can all see the benefits of green social prescribing. You sometimes feel Runnymede gets a bit left behind. It would be great to have something round here. Just more of it please."

The funding for green health and wellbeing providers needs to incorporate administration, staff management and training costs. Paul Mackenzie, a wild swimming coach said: "We priced it on the time in the water, if you like, and you know we do it because we're keen to make a difference to the people we touch. You know, we've probably spent twice as much time just trying to sort of iron out the whole logistics, the health and safety, the insurance, all the ins and outs and the details. I mean it's a hidden cost."

Resources are also needed to connect the community-based providers of nature activities to the health and care system, to support them to build relationships with health professionals, and establish referral pathways.

"And then you know on top of that you expect us to forge relationships with [priority groups] or have a great working relationship with the health system. The expectation is that you're embedded within this heath system. And you know we don't know who they are. We don't know how to reach them. It's not to say it's necessarily difficult, or too difficult, but you know that it takes some time to do."

Green health and wellbeing providers need to be connected.

The current system of grant funding sometimes leads to a sense of competition between community-based green providers. Some felt, however, that it was important to be able to connect to others providing similar services, without feeling there was any competition, to share learning and experience.

"There's a huge amount of expertise and experience."

Social prescribing link workers too felt they would like more opportunity to work in partnership with other link workers or green providers to maintain projects or coordinate volunteers.

"You can't do everything, and you just kind of feel like you do need a bit of support to get these things going."

The management of land and water should support human health.

Surrey has an abundance of green and blue spaces, but the management of these spaces is not always linked to human health and wellbeing. Some green providers expressed frustration with lack of access to land, or to rivers and lakes, for the purposes of wellbeing activities.

Restrictions on the use of some public and private land, and the expense of visiting some sites, were identified as barriers to a thriving nature and health sector.

"What does society say about the value of nature? You don't have to walk far before you're confronted by Private Keep Out signs."
The issue of pollution in rivers and the expense of visiting some nationally managed sites were prominent themes in qualitative interviews. Some green providers felt that land management strategies should be more clearly focussed on the health and emotional wellbeing of local people.

Health and care professionals need to experience nature connection.

To embed the value of nature into the health and care system, healthcare professionals need to understand the evidence that supports the role of nature in promoting health and wellbeing. More training and further opportunities for healthcare staff to engage with the science of nature and health, and with the impact of nature connection on the people they care for, will support the integration of green health and wellbeing.

The attitude towards nature-based health and wellbeing among GPs, for example, is quite varied. Some have embraced green social prescribing, but others are not aware of it or are unconvinced by it. One social prescribing link worker said:
"It's still very new with the GPs. Some absolutely swear by it, because they've been given an extra tool, and others who don't get it. It's very much down to social prescribers to promote it but we need to be proactive about it. Things in a surgery move so fast and [they] need to keep being reminded."

A prominent theme in interviews with green providers and health professionals though was the need for the health and care workforce to experience the wellbeing benefits of nature and green space for themselves. Gillian Orrow, GP and Director of Growing Health Together, said: "I think it is probably three things. Maybe it's the head, heart, hands. So, they do need the information and the evidence. Otherwise, there's no credibility, but they need to feel it in their heart. This is a good thing and the best way that they can feel that is perhaps through experiencing the benefits themselves. And there's something for me around normalising."

A member of primary care staff who had participated in a NatureWell course said: "You have to do it to really appreciate quite how profound the impact is."

The notion that health professionals needed to be given time to understand the value of nature, and repeatedly be reminded of it, was underpinned by suggestions of developing nature ambassadors, or green health and wellbeing champions, who would promote green health and remind colleagues to connect to nature for their own wellbeing.

Nature and green space are fundamental to health creation and prevention.

Encouraging broader understanding among health professionals and the public about the role of nature and green space in maintaining wellbeing, living a healthy lifestyle, and recovering from mental or physical ill-health, can support healthier people and healthier communities. Investing in green health and wellbeing now is likely to save the health and care system money later. Shahin Mohamed said: "It's a ripple effect… We seem to not want to spend too much initially but we spend a lot more at the end."

Developing a public narrative around nature and health is important for understanding the role of nature in health creation and for addressing health inequalities too. Gillian Orrow said: "I think for me it's really important to develop the public wider narrative that our health isn't actually much about health care, but it's about the conditions in which we live our lives, and nature connection being a fundamental part of that. So that's it for me if we're interested in health equity."

Next steps

The government-funded Green Social Prescribing 'Test & Learn' Site has now ended. The Surrey Heartlands Green Health and Wellbeing programme, however, will continue to grow and evolve into a thriving system-wide partnership. It will seek further funding support to develop accessible and robust green health and wellbeing provision for all people in Surrey.

The Green Health and Wellbeing programme aims to:

Embed the value of nature for health and wellbeing into the Surrey Heartlands health and care system
Support sustainable community-based green health options that are integrated into everyday clinical and non-clinical practice as part of a de-medicalised and personalised care pathway
Contribute to place-based prevention strategies that utilise community assets, including green and blue spaces, and incorporate the health benefits of nature connection into local health inequalities and population health management plans
Utilise innovative approaches to supporting diverse populations with nature-based health and wellbeing, recognising the value of culture, faith and digital
Encourage synergy between environmental policies, sustainability goals for the NHS and the local authority, and the delivery of health outcomes
Create nature connection opportunities for the people who work for Surrey Heartlands ICS to improve wellbeing, manage stress, reduce absenteeism, and support the resilience of the health and care workforce
Explore new business models for the voluntary and community sector to support sustainable green health eco-systems at neighbourhood level underpinned by a clear evidence base and outcomes framework.

Be part of the change

There are lots of ways that you can be part of Surrey's growing green health and wellbeing movement.

You may be interested in finding out more about some of the programme's highlight projects for 2023/24. Or you may like to join the Green Health and Wellbeing Network or the NHS Futures Green Health and Wellbeing Collaboration Platform.

Further information can be found at Green Prescribing - Healthy Surrey.

Sign up on Surrey Says to join the Green Health and Wellbeing Network and keep up-to-date with news about the growing movement.

Join the Green Health and Wellbeing Collaborative Platform by:

Creating an account on www.future.nhs.uk (you don't need to work in the NHS to create an account).
Going to 'My Workspace' > 'Find a Workspace'.
Searching for "Surrey Green Health and Wellbeing" and requesting to join the workspace.

Contact email: gsp@surreycc.gov.uk

Highlights 2023 / 2024

Community Lottery Nature & Climate Fund and Heritage Lottery Fund bids
Natural England's Heathland Connections Research & Development Fund
UKRI The Young Foundation's Community Knowledge Fund
Roll out of Nature Health Facilitator training for Primary Care staff
Green Health Budgets pilot for social prescriptions
Expansion of Dose of Nature and First Step Green Volunteering scheme
VR nature pilots in hospital trusts
NHS estates and community urban greening.

In this section

National evaluation of the preventing and tackling mental ill health through Green Social Prescribing project