Could prescribing nature help close the health gap?

“We just pretend it’s the Med,” laughs one of the group as they head for the water in their swimsuits. There are shudders and squeals of cold as they enter the sea, but they insist the sense of well-being it provides makes it worth pushing through the chill factor.

The rise of wild swimming in Scotland, especially since lockdown – along with the industry that’s sprung up around it, from dry robes to expensive retreats – has been meteoric. But this cold water swimming group is a bit different.

There’s an emphasis on community bonding and having fun – they refer to themselves as the Reservoir Frogs – but there’s also a serious aim of making health and well-being accessible to all.  The Ripple Project is based in Restalrig, Lochend and Craigentinny, some of Edinburgh’s most deprived areas. Here, says the group, there are challenges for many people in getting out into nature. The lack of affordable transport and equipment, combined with the fact that many struggle with limiting physical and mental health conditions, are all factors.

In recent years some claim nature prescribing, in which a doctor or link worker recommends a “dose” of nature-based activity, could be one way to help tackle this health inequality. It’s also known as green prescribing – or blue in the case of outdoor swimming – with the prescribed “course” done as part of a group or individually.

People from the most affluent areas currently live 24 more healthy years than those from the most deprived. Tackling this with the help of nature prescribing is an approach The Ferret has been investigating as part of our year-long solutions journalism project, Mind The Health Gap.

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Three of the swimmers are here “on prescription”, having been referred by their doctor or community link worker (health workers providing social, emotional and practical support and attached to GP practices). They believe nature prescribing should be more widely supported across the country so that more people could benefit.

Scottish nature prescribing was given a springboard in 2017 thanks to a partnership between NHS Shetland and the Royal Society for the Protection of Birds (RSPB). A pilot with five GP practices in Edinburgh and the Lothians followed in November 2020.   Over five months, 350 Edinburgh and Lothian patients were prescribed a dose of nature – either through wild swimming, walking, community gardening or other activities – for 32 different conditions. The majority of prescriptions – 69% – were given to support mental health conditions but 17% were to support physical health conditions and 10% for both. Almost three-quarters of patients said they had benefits, with the majority saying they would continue with the prescribed nature contact.

The Edinburgh initiative included The Ripple’s local St Triduana’s Medical Practice, and its salaried GP Dr Eva Mahler now joins this swimming group one Thursday a month for a dip while offering health advice in a less traditional setting.

“People with chronic conditions and also people living in areas of deprivation can have much higher levels of mental health problems,” she says. “But there’s something so enjoyable about being around nature that makes you feel good. You’re getting daylight and vitamin D, which helps with your diurnal rhythms [the body’s responses to the 24-hour cycle].

“You’re also increasing your aerobic activity, increasing your strength – in this case, doing it with other people and making more social connections. All of those things can be so beneficial for your mental and physical health.”

IRIS Marchand, who is glowing from the cold and grinning from ear-to-ear as she emerges from the water, was referred here by her link worker.

Taking a weekly plunge, as well as taking part in other Ripple activities such as walks in nature, are helping prevent panic attacks and reducing her urge to drink in a way that Alcoholics Anonymous (AA) meetings did not.

Marchand’s mental health had suffered during lockdown when she became increasingly isolated at home. “But this feels like living,” she says after she’s dried off. “Everybody in the world needs green and water and not just being confined in an enclosed space all the time.

“If I could go cold swimming every day, I would,” Marchand adds. “When I’m worried, my shoulders are right up on my ears but after swimming, I can actually drop them down, walk straight and feel normal again.”

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In the water, she says, the horizon seems to open up in front of her, giving her the feeling of space she craves.

Cat Robertson, The Ripple Project’s wellbeing coordinator, says that while these activities may seem simple, the impacts can be profound for a community like the one she works in. “We see people with health issues that have them going to the doctor every two or three weeks,” she explains.  “Health challenges are far less pronounced in areas where you can afford to eat well, have lots of access to green space and fresh air and a sense of hopefulness and purpose. We want people here to have those options too.”

At The Ripple there’s a minibus to take the group to Portobello  – or further-flung locations from Loch Lubanach to Loch Morlich, a small budget for kit as well as safety, and motivation in numbers.

“We encourage people and they tell us it makes their mood better and that they enjoy being challenged,” says Robertson. “Swimming and being outdoors isn’t going to make everything okay when you have real issues, but it really helps promote wellbeing and get people moving in the right direction.”

Her experience of the benefits of free nature-based solutions is backed by another Edinburgh-based partnership between Wester Hailes Medical Practice and Grass Roots Remedies, a workers’ co-operative aiming to make plant medicine accessible and inclusive.  “Historically, herbal medicine was the ‘medicine of the people’  and only the wealthy could pay to see a physician,” explains medical herbalist Ally Hurcikova, who runs a community clinic from the local health centre.

While the prescription of herbal remedies is a distinct practice, there are elements of green, or nature prescribing here too, including growing and foraging for plants and herbs in local outdoor spaces.  “Today of course we are privileged to have free national healthcare, but herbalism is now a private offering with starting prices up to £70-£100 for an appointment.”

Appointments at this clinic are £10 for anyone local, and Wester Hailes Medical Practice makes referrals when doctors feel like a patient might benefit from herbal support.

“It’s truly a radical approach,” Hurcikova says. “In our time running this clinic, we have seen some incredibly transformative stories where people have come through the GP practice, slowly become connected to the support they need and made great leaps in their health.”

While the evidence for nature prescribing is mixed, there are an increasing number of studies that back up the experience of these Edinburgh-based projects.

In July, a Wildlife Trusts report found that targeted green prescribing could save the NHS in England more than £635 million per year, and an evidence review by University College London last year found nature was a “powerful tool” when harnessed by social prescribers to improve health and well-being.

The UK Government is now expanding nature-based social prescribing programmes in England through NHS England, Sports England and the National Academy for Social Prescribing as well as the RSPB and says it is aiming to employ 1000 social prescribing link workers by 2024.

In Scotland, nature prescribing has been a smaller element in NatureScot’s Green Health Partnerships launched in 2018 under the banner of its Natural Health Service initiative in North Ayrshire, Dundee, Highland and North Lanarkshire. The first three areas will continue to be funded next year by partnerships with NatureScot, Scottish Forestry, Public Health Scotland and others while the Lanarkshire project is now funded by the health board.

But GPs from across the country told The Ferret that support for nature prescribing was currently patchy with no coherent national strategy. One GP claimed he had written to his health board to request support for outdoor swimming and walking groups but did not get a reply. Others said that workloads made it difficult to meaningfully engage with the idea of nature prescriptions.

Dr Carey Lunan, chair of the Scottish Deep End Project, which represents GPs working with Scotland’s most deprived communities, says the positive impact that access to nature has on our wellbeing had been “brought into sharp focus” during the Covid-19 pandemic.  “But access is not equal for all,” she adds. “For many of our more socio-economically disadvantaged communities in Scotland, it can be harder to make use of the enormous potential of nature to improve our mental and physical health.

“In densely populated urban environments, access to green space and open water is harder, and transport poverty can mean this can simply feel out of reach.”

Initiatives increasing opportunities for people to benefit from nature-based prescribing were to be welcomed, she claims. But she and others told The Ferret that there must be investment in infrastructure to ensure this was effective.

“We should not underestimate the important role of community link workers in making the connections to initiatives such as these,” she says.  There are fears too that progress made during the pandemic – when people dramatically increased the time they spent in nature due to Covid-19 restrictions – has been lost.

A report released on November 27 by the Office of National Statistics (ONS) estimated that 1.1m fewer people across the UK gained health benefits from spending time in nature in 2022 compared with two years earlier.

It put the value of “lost health benefits” at about £390m and claimed this would be the level of NHS spend needed if it used treatments to achieve equivalent health benefits to those gained from time spent in nature.

“Green space really is our natural health service,” Julie Procter (above), chief executive of Greenspace Scotland says. “But many green health and nature prescribing projects are struggling with short-term funding and budget cuts. This can make GPs and link workers reluctant to prescribe green health activities as they need certainty that the projects will be there to support their patients.

“More investment is needed to expand nature prescribing and to ensure that everyone can enjoy easy access to good quality green spaces.”

Back on Portobello Beach, people are dressed again and ready to go when the skies suddenly open. The group rush off the beach, laughing and euphoric, to take cover. Then they stand, watching the rain, enjoying a moment of stillness.  “I think some people forget how important it is to just let go and observe a tree, the sunshine or the rain,” says Iris Marchand. “To stop over-thinking – even for a moment.”