E101- How Does Nature Help us Heal? (with Prof. Chris Dayson & Dr. Annette Haywood)

What is the effect of nature on our mental health? Today Alex speaks with Prof. Chris Dayson & Dr. Annette Haywood, who have conducted research involving 8000 people, who were given nature-based interventions (such as nature walks, community gardening, tree planting and wild swimming) to help them with their mental health difficulties across seven different sites in the UK.

See below link to an article about their work:
https://www.theguardian.com/environment/article/2024/sep/04/better-than-medication-prescribing-nature-works-project-shows

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Transcript

 Welcome back to the Thinking Mind Podcast, a podcast all about psychiatry, psychology, therapy and related topics. My name is Alex. I'm a consultant psychiatrist. Today we're discussing the question can exposure to nature help us with our mental health problems? To help us discuss this question. I'm joined by Professor Chris Dyson and Doctor Annette Haywood. Professor Dyson joins us from Sheffield Hallam University. He's a professor of voluntary action, health and wellbeing in the centre for Economic and Social Research. Doctor Annette Heywood joins us from the University of Sheffield. She manages the Practice and Research Collaborative in Yorkshire and Humber, which aims to bridge the gap between research and practice linking academic institutions with public health practitioners. Today we're discussing their research project, the National Evaluation of the Preventing and Tackling Mental Ill Health through Green Social Prescribing. And we found our guests today through an article written in The Guardian all about their work, which will link in the description. Today we discuss points such as what is green social prescribing? We discuss more about their research, studying the effect of nature on mental health problems. What are the aims of their research? How they measured people's wellbeing? What do we know about the connection between being outdoors and the impact it can have on our mental health, the financial side of things and how cost effective these interventions are as compared to more conventional therapies like CBT. The limitations of their research and questions for the future, as well as potential barriers to integrating these kinds of services within our health systems and potential barriers to influencing policy makers. As always, thank you very much for listening, and please enjoy today's conversation with Professor Chris Dawson and Doctor Annette Heywood. Thank you so much for coming on the podcast. Thank you for having me. Thanks for having us. A lot of things I want to discuss today. So I mean, first there's the concept of green social prescribing, which not a lot of our listeners will be familiar with. It's a relatively new concept, and I think it's part of the moment we're in in terms of dealing with mental health, that we're starting to realize there's a lot of common sense things that need to be part of everyone's life for us to have good mental health. For example, I recently interviewed someone who prescribes animals for dealing with mental health problems like contact with dogs and other therapeutic animals, and I think this falls under that genre. Like what are these things which are right under our noses that we can and should be using to help us with mental health problems? So, Annette, I'll direct the first question to you. Can you explain a little bit about this concept of green social prescribing? Yes. So green social prescribing has you, as you said, you know, it's about sort of contact connecting people with nature. So it's the practice of supporting people with mental health needs to engage in these nature based activities so they generally you can get a referral from a GP or community mental health team or a social worker, and people can also self-refer into these to these types of these interventions. So what would happen when someone referred themselves in, would that a social prescribing link worker or other professional would direct them and connect them to community groups and agencies for practical and emotional support? So, as you say, there are many different types of activities that people can can access, such as conservation, horticulture, you know, working in in Sheffield, we've got a small zoo, um, a small outdoor farm called Heeley City Farm. And then that's a great way, you know, for people to go down there and work with the animals down there, uh, gardening, for example. Exercise and sports, walking and walking in woods, you know, having, having those sort of walking therapies. And also if you're lucky enough to live near water, you can also be prescribed blue social prescribing, which will be around the sorts of the canals and the river, the river ways, and, I don't know, swimming in the sea if you're lucky enough to live by the coast. So, Chris, how long have these sorts of interventions been around? And then when did you guys get involved in terms of researching them? I mean, I think they've been around forever in many in many ways. We've always had kind of a human being has wanted to engage in activities in groups or on our own in nature. But I guess over time they've become more formalized and kind of like charities and community organizations have formed around them. So I think it's difficult to say when did it begin? But from our perspective, our involvement started in around 2021, I think it was and now wasn't it, when, um, the UK government, um, commissioned its uh, national preventing and tackling mental health ill health through green social prescribing program. And we were appointed by Defra to undertake a national evaluation of what was happening. So they vested their their resources in seven different testing sites around the, around England. And we, we were working in kind of doing in-depth research and evaluation in those sites over two years initially. Um, but we're still still involved now nearly three and a half years on. And can you give us a flavor, Chris, of what the different sites were doing? I mean, they're all doing pretty much the same thing, which I guess was working with their partners in the health system to understand how can they make this work in practice on the ground? How can they make referrals flow more effectively? How can they make sure that there's a really good range of green activities out there in the community? So while a lot of the programs did, was was set up small grant programs so that they could invest in new and additional activities in the community. And then it was really about, I guess, working out what works for for different people in different circumstances and different in different settings. What type of activities were were people interested in, and what were the barriers and enablers to to gain more people involved in in these activities? What were the barriers to define? Chris. Um, I mean, there's, I guess there's, there's some really kind of physical barriers because we're particularly interested in people who might be at most risk of health inequalities. So for a lot of those, those people are living in areas, often inner city areas where the green space might not necessarily be as as attractive and as welcoming as they might want. So for a lot of people in those places, trans transport and accessibility was it was a real issue. And I think that also kind of for people with different types of disabilities and physical impairments, kind of actually being able to access the green spaces where the activities were happening was a was a big barrier. So a lot of the work that the pilots did was figuring out what needs to be done to overcome those, those barriers. And so that might be around helping people realize what green spaces might already be there on their doorstep and encouraging them to access those. But it might also have involved taking them out of the city into, say, in Sheffield or taking them out to the the Peak District, for example, to to do some walking and things like that. Can I also just chip in as well with another barrier? Could have been around, you know, uh, looking at the sort of the availability of kits. So if you're on an allotment and you haven't got wellies or a nice warm jacket, you know, so it was about the cost implications of, of providing, um, the equipment that, you know, that you would, that you would need. Yeah. And I guess for a lot of people, it was really about building their confidence to do to, to get out and do they do these things. And confidence, particularly when you're talking about people with. Low level mental health problems or kind of low well-being and low mood. They they lack a lot of confidence to go and engage in, in social groups. So putting putting additional support into those people to help them access what was already there was it was a big part of it as well. And did you guys get a sense that now it's almost become counterintuitive, even though I said it was common sense earlier? Now, for many people, there's this disconnection, and it's almost become counterintuitive for people to think that something like something as simple as going outside can improve your mental health. Did you guys get that sense? Maybe. Annette, you could tell us, um. What do you mean? Sorry? What do you mean? Like, I guess maybe. Let me let me make this a bit more concrete. I often speak to young people in my work, and I often get the sense of almost incredulity or disbelief or skepticism that something as simple as going outside, going for a walk, working with your hands can improve your mental health. It's almost like we've mythologized. Mental health problems. To the extent that we feel there needs to be some very sophisticated intervention, whether it's a drug or whatever it is, and I need a prescription. Yeah. Or something. I mean, we've got some fantastic quotes from, uh, from our service users. Um, and like, you know, it's sort of getting people out in the fresh air should be more focused. You're connecting with nature. And I think these people, like you say, I think they it it comes as a bit of a surprise to them that, you know, that when they've gone out there and gone into the fresh air and, and into the woods, you know, that they're looking at trees in a different way. Um, so I think I think, yeah, it's sort of it's make I mean, I love being outside in the fresh air. It's to me, it's something that, you know, I just never think about getting on my bike. But yeah, I think it can be something that were people. Yeah, that's what I'm getting at. That element of surprise, actually, that people are surprised that it actually works. I think there's something also about how we've we've kind of engineered all of this stuff out of our daily lives. We spend so much time sat behind computer screens and, and kind of working every hour, every hour that there is that we've forgotten the importance of being out and about and moving in general terms, but also being out about being out in nature. And so we kind of lost lost that routine or we're on our phones while we're walking through a park and we're looking at, you know, we're looking at Twitter or something or X while we're, you know, while we're out walking around a park. And I think this person was saying, you know, connecting with nature, it's the best medicine. Um, it's less of a, it's, it's it's less focused on the quick fix medication. So this person was a lovely quote. And I do like using this, using this particular quote more focused on getting out there, getting in the fresh air. Absolutely. And I definitely want to get to those quotes at the end. Speaking of how things have developed in modernity, funnily enough, I had an article come out in the Guardian yesterday all about the dangers of convenience, that we have all of these conveniences, and there's extremely useful, but for evolutionary reasons, we're very easily seduced by them and we can kind of fall under the spell. And if we're not careful, we can become kind of cocooned in like a world of convenience and become really, really disconnected from reality. And what I found really interesting about putting that article out. Is that is really touched a nerve. And you could see that in the comment section where some people really resonated with it, whereas other people were like, don't take away my conveniences, you know, are you saying we should go back to the Stone age? And obviously that's not what we're saying. What we're saying in this conversation is surely we can figure out a middle ground where we have a lot of the amazing conveniences of modern society, but how do we integrate that a little bit back into nature as well? It's interesting you say that because what are the one of the pilot signs? Actually, they were doing some work around them using VR virtual reality as a way of bringing nature closer to some of those people. In my really struggle, particularly older people with mobility issues who might really struggle to engage, engage in nature. So there's definitely a role, isn't there, for some of those modern technologies in in this, it's about finding what works for different people. Yeah, absolutely. So I guess you guys were primarily in charge of studying these sites to figure out, does it work? Does it help people with their mental health problems? Chris, is that a fair way of summarizing it? Yeah, I think we I think we were interested in does it work? We're also interested in understanding how does it work. So what is it? What is it needs to change within our health systems to enable it to work? Because the evidence base for kind of the impact the nature has on our mental health is really well established. We don't necessarily need to spend lots of time understanding that. But I think what we know less about is what how can we change our health systems and change our behaviors to make this more, more accessible and and more sustainable? So as much as we are interested in yes, measuring does it work? Kind of understanding how it works and making recommendations for the health system about what they needed to do to make it work was a key part of it as well. And and can you walk us through how you organize the research and how you gather the data? Yes. Yeah, yeah. No problem. So we started off, um. What? We were a consortium of 3 or 4 universities, so we've worked together quite a lot, Chris and I. So I work with Sheffield Hallam University. I'm from the University of Sheffield, and then we also got expertise from the University of Exeter and the University of Plymouth. Landed straight in the middle of the lockdown, the first lockdown. So we had to sort of work change a lot of our working processes and work together more, more online like this and sort of so a lot of the data collection etc. interviews were undertaken online. So we looked at quantitative data, which is we had um, we developed a survey and we looked at individual um service user and programme level monitoring data. So we looked at routine data and a survey of providers and, um, NHS linked workers. We then went out and we did some qualitative interviews. So we had um, we did some key stakeholder interviews with um, with a, with a range of people. So we did interviews with over 118 people. Uh, at two time points. And then we had what were we we, we put in what we called embedded researchers. So we had seven sides and three researchers that took on those sites that worked, that worked with those sites, um, to be able to do going to their meetings or, you know, look at some of their documentation and speak to the speak to the test and learn site managers and all the staff there. And then the seven researchers all came together to bring, bring back their findings from those seven sites. So the sorry, the three researchers across the seven sites, we also did an analysis of the program partnership. So this, this this wasn't just Defra that was funding this. It was there was a whole load, a whole whole bunch of um, partners. So we had the Office of Health Improvement and Disparities o had uh, they were Public Health England. We worked with Sport England, Department for Levelling Up, housing, communities, Department of Health and Social Care, NHS England. So it was working across all those partners who not actually a lot of them hadn't worked together before. So we looked at their relationship and how they, they went about um. Working on this on this particular program. And then we also looked at, uh, sites that hadn't been provided with with the Test and Learn site funding. So we called them non test and learned sites. And we did a very little, um, a sort of a small evaluation of those that hadn't had the benefit of the funding. And Chris led on that workshop. And then on top of all that, we did a value for money analysis. So we looked at, um, well-being adjusted life years. And if you wanted to know a bit more about the social return on investment side of it, that's Chris, because Chris was leading on that particular work package. So we all led on particular things that we all pulled together. And then at the end, we did a synthesis of everything, um, and sat together for a long time working out, you know, whether things fitted together and what worked best for each site, but in different circumstances. So we developed a theory of change for each of the sites and then an overarching theory of change. So a logic model around how the how these interventions would work in these, in those particular circumstances. So it was a very complicated, complex project. And we had to boil it down to a few questions. What were the few questions that you answered with this research? Would you say? Yeah, we we sort of look to, um, improve mental health outcomes, reducing health inequalities, looking at reducing demand on health and social care system, and developing best practice in making green social activities more resilient and accessible. Okay, excellent. So, Chris, how are you guys measuring mental health, wellbeing? What sorts of measurements are you using for this? We used established kind of, um, mental health and wellbeing measures that we focused on on one measure in particular, which is the ONS for which is the four measures recommended by the office for National Statistics for Measuring Wellbeing. And the reason why we focused on those is because that's what the NHS England recommends. Social prescribing link work is used to measure outcomes. So we knew that that was that measure was going to be the one that was going to be used most consistently across society. The other advantage of using the ONS for is it enables you to do a type of a value for money analysis called worldviews, which is looking at what the value of additional gains in wellbeing might be. Um, um, as a result of the intervention. So now we're just to look at the, the, the social return on investment or value for money at the same time. And what I noticed reading the Guardian article about your work is, I guess, the ONS for allowed you to compare the well-being of your participants to the average well-being of people in the UK. Is that right? Yeah. So we're able to say we're able to look at how at the start of the programme, how participants compared to the to the national average and then how they compared at the end. And what we found was that at the beginning their well-being was quite, well, quite a long way below the national average. But by the end of the program, most of them would come up to around where the national average average was. So it suggested that there was a very positive kind of initial initial gaining well-being. And we and we knew and that was also statistically significant. So it gave us confidence that there's definitely something, something about these green social prescriptions that was helping people's well-being and the fact that their well-being was lower than the national average when they started, suggested it was reaching those people that they really needed to reach because they weren't reaching people who who already had good wellbeing. They were people whose wellbeing was lower needs. It needed to be improved. So in the research, we specifically targeting people who had low wellbeing, who may have had diagnosed mental health problems, people like that. Yeah. So the the criteria around the programme for the science was quite clear that it should be focused on people who had and it was framed around tackling and preventing in mental ill health. So they're interested in people that may be at risk of developing mental health conditions, but also those who might already have low level mental health conditions and managing them in the community. Okay, okay. And out of curiosity, since you guys have an idea of the national average score, how well are we doing as a national average in terms of well-being? Are you guys able to answer that question? Are we doing good or is there something left to be desired in terms of our well-being? It's interesting that question because even though lots of countries measure their well-being, nobody uses, they don't all use the same measure. So it's really difficult to compare. And there's also some really important kind of like cultural drivers of how we might self-report our own well-being. So I think we need to be really cautious around making making comparisons to other other country. Um, so well-being is measured on a scale of 0 to 10, and the national average is around between 7 and 8. So that suggests that most of the time most of us have fairly good well-being. Obviously, I think there's scope to improve, but I think it's those people that might who might be in the kind of threes, fours and fives. There's a significant number of those, and those are the people I think we should be concerned about. Those are the people that we should be targeting these types of interventions that. And do we have any data? Either of you can answer this if you know about what percentage of people in the UK are in that lower range are at that three, four and five level. We we do, but I haven't got it to hand. But there there's some really useful resources on the office for National Statistics website that lets you kind of interrogate the national wellbeing data. You can look at it by area and you can look at it by bye bye bye bye. Kind of breaking it down by different different categories. Yeah. That sounds like this would be fascinating to look at actually. And now the work and sorry. And the work that we did was also focused on people that were hardest hit by, um, by Covid. Um, also the lower, you know, lower socioeconomic status, uh, younger people and uh, people from minority, um, sorry, ethnic minority populations as well. So we were looking at the, the areas of they were targeted around people with the highest health inequalities. Um, and over what time period did the study take place? So you mentioned earlier in it that you took the measurements at two time points. How far apart were those time points? I think it was it was usually between 3 or 6 months. You wouldn't we didn't want to be too prescriptive because different interventions happen over different time periods. But we want and so the thing that the guidance was around try and take the measure between three months and six months so that we allow sufficient time for any improvements to happen, but so that the the project is are still engaged with the, with the people. Um, I think there is an interesting question about how do we get data over a longer period. So we'd be really interesting to follow up with these individuals after 12 months, 18 months, 24 months. But that wasn't possible within the parameters of our work. But it's definitely an area of for future research, I think. And then in that period in that like 3 to 6 month period, do we know how often people were getting outdoors, how often they were accessing nature? I think it really varied depending on what it was that they were, what they were accessing. So some green social prescribing activities happened once a month, some happened once a week. Some are completely ad hoc. So we had a kind of a big kind of combination of different people engaging in different ways and at different times. Um, and because it was such a broad, a broad program, it was really about people engaging in things that met their needs and their and their circumstances. So there's a real there's a real mix. So there's a mix. So that might be interesting for the future to stratify it more to see. Okay. These are the people who access nature every day versus three times a week versus once a week. There has been some extra research commissioned actually by the NHS as part of this programme, which is looking in much more detail about specific nature based interventions like wild swimming and fishing, and then tracking those individuals over over a longer period to see what the benefits were. So there is additional research coming out. Hopefully that will start to shed a light on how some of those specific activities might work for specific individuals. And I guess, Chris, earlier you were saying we want to figure out how these interventions work, not just whether or not they work and do it. Do we have. Has it has any more lights been shed on that question? Um, yeah, I think we were we were particularly interested in what is it, what is it that can be done at a system level and of a health system level to, to enable and enable these things to work more effectively. And it was really about kind of. Challenges, overcoming challenges around joint kind of building relationships and joining up different systems and different clinical pathways so that the pathway kind of to and from these activities was much more clear on that. And that relies on developing relationships that are kind of a professional individual level between different practitioners, but also between the key organizations in this process. And one of the things that we found was potentially a major stumbling block to, to, to success was the fact that most of these activities are delivered a community level by local community groups, local charities. Some might have 1 or 2 members of the staff, some might be mostly run by volunteers. And those organizations are facing real challenges in terms of their resources. So kind of getting long term, consistent funding to those groups is going to be absolutely vital if we want if we want this to continue. So some of the areas are able to channel that funding to the projects for the last time of the program. But once the once the program closes down, there's still questions about how do we make sure we have sustainably funded green activities in every community in the country? And that's a that's a big a big problem for the for the future. But I think it's is something that speaks really well to the the kind of the new agenda around the future of the NHS. From the Darzi report, which talks about moving more and more treatment into the community, having a focus on prevention. So this work is doing all of the things that the NHS says it needs to do in the future, but we need to make sure that we get the money down to those organisations and volunteers are doing the work if we want it to be successful. Yes, and I guess the goal would be just to make it. I mean, I'm coming at it from the healthcare side, so I've worked in outpatient clinics and hospitals, and I guess what I'm envisioning is a system where there's a there's a clear pathway, you know, I'm talking to someone, I'm talking to a patient in my clinic or even on a hospital ward, and I have a named person that I can refer the patient to. That is part of the system that organizes the activities, that takes them into nature and makes all of that happen. So is that and that's maybe extend me. Is that more or less what you're envisioning a certain level of integration there between health and the social prescribing pathway. Would that would that would be ideal wouldn't it. That would be that would be the sort of ideal scenario. But I think there are so many. Not pitfalls. What's what's barriers for barriers. Yeah. To be able to do that, to have that, you know, like Chris was mentioning, you know, the sustainability of, um, the funding, the ongoing funding, the fact that people leave and, you know, those interventions might not, might not still be accessible or available. Uh, and the variety of different, um, the so many different types of intervention that green social prescribing, you know, can offer. I think there's a there's a real tension, isn't there, between having those really clearly defined pathways from the clinic to the community, but then not not necessarily being too predetermined in what it is that you're offering people. Because one of the key tenets of social prescribing and green social swapping is based basing something on what matters to the individual. So if what that individual was really interested in is going for a walk in the countryside, then it's no good. Only having some kind of horticultural intervention to round to, because that's not what they're interested in. So I think. Creating a pathway from the clinic to a multitude of different green interventions is really, really, really challenging. And then for collisions and link workers to be aware of all of those activities are again is is another challenge. So I think ideally having these really neat system kind of level pathways mapped out and accessible to everybody is ideal. But it's a kind of a major challenge, I think, given the complexity that we're talking about. Funnily enough, this reminds me a lot of the psychotherapy world. So in the psychotherapy where there's many different kinds of psychotherapy, but the ones which are the easiest to standardize and manuals and research when. So cognitive behavioral therapy has dominated in the NHS because it tends to be short manuals, much easier to study than, say, psychoanalysis or humanistic interventions. Even though the research suggests, though the large scale research suggests, that what kind of psychotherapy you do doesn't even matter so much, what really matters is the therapeutic alliance, uh, with the patient. So it feels like it's a similar problem that you guys are facing with this issue. And I wonder in terms of speaking to government and forming policy, is there like a demand for more evidence? Is more evidence the barrier or are there other barriers we could name? I think it's interesting. I think policymakers make evidence a barrier, whereas we think actually the the evidence that being engaged in nature is good for your mental health is irrefutable. So we it the evidence that we really need is evidence that tells us how it works. Yeah, that's not necessarily the type of evidence that governments like to pay for. They like to pay for more kind of effectiveness, efficacy type, type evidence, whereas some more kind of, I guess, policy based kind of understanding of how you make systems work is what paternity is. It is what we is what we really need. But that can sometimes involve some difficult messages for for politicians and policymakers, because it might start telling that they need to think about investing their money in different ways and in different types of of intervention and using different types of evidence to make decisions that they're not used to making. So we're kind of in quite an uncomfortable space for policymakers and takes some real. So you're saying policymakers would have to use their brain, I think. Well, I would say not not maybe not use them, maybe use their heart. I'm just joking that I think I think sometimes it's about having the courage of their convictions and, and recognizing that if everybody involved in this program instinctively believes that the participating in nature is a good thing. So. Yeah. The idea that we if ever if they instinctively know that the idea that we should and that's based on their experience and their knowledge and their personal and their professional knowledge, they should they should be more comfortable in using that to make important policy and spending decisions, rather than falling back on a more limited quantitative evidence base that might fit a medical model of evidence. Yeah, I think we were we were sort of pushed. We're not pushed, but we were we were when we were doing the research, the evaluation, a lot of a lot of it did come back down to numbers, didn't it? You know, like how many is this saving? What does this cost? You know, and the sort of like the qualitative part of it that was really this sort of the rich data with the that they people seem to be less bothered about that side of it, but they want the sort of the hard evidence on, well, how much does that saved us or how much does that cost over that. And sometimes in these, these interventions you can't really show that. And we know that. We know that the human species has developed through storytelling, through telling stories to each other over time and, and over space. And it's stories that really hold sway in our in our imagination and in our mind. And yet we then kind of. We don't trust those stories when it comes to making really key decisions about how we make policy and spend spend our money. It's interesting. Uh, we could we can spend a lot of time talking about that, I think. Yeah. And it's funny that the threshold of evidence for something like nature, where you have to demonstrate not just that it works, but how it works, is so high, because that's not even the case. Always in medicine, where we have interventions where we don't fully understand how they work. Like something like electroconvulsive therapy, which we know works and there's a lot of evidence, but we don't necessarily know how. We have some intuitions, so we have some understandings of how it might work. It's like we have to keep going back and reinventing the wheel to say that it's an effect. They won't sort of accept that it's if it's effective, it's, you know, you have to keep proving that over and over again. Yeah. It's interesting because I think the the policymakers are involved in driving this forward there. They they intuitively kind of believe in the importance of this. And they understand the benefits of this. But it's, uh, it's sometimes there's a perceived other group of policy professionals that need to be convinced with a different type of evidence that we need. So we're we're kind of creating evidence for a group of people that aren't necessarily part of the program, but we see as being really powerful in terms of decision making. Yeah, probably what we don't do enough of in our in our evaluative work is engaging with those people that we think and, and asking them, what is it you actually really need to know, and how can we get the evidence? I'm curious, what if you guys have had much experience dealing with clinicians because I would be in two minds. I can imagine some clinicians, when hearing about this work saying, please make this happen. I would love to have this option for my patients. And at the same time, based on my experience, I can imagine some clinicians being a bit more hard nosed about it and being a bit more skeptical. What's what has your guy's experience of dealing with clinicians been like? Well, my mind, particularly for, you know, for the for the GPS that sort of I'm working with in other work, they're sort of very on board with, with stuff like this. And we're getting some very positive comments from, from the, from the GPS that, you know, at last we've got a study that gives us the confidence to be able to talk to patients about the power of, of nature. Uh, whereas I know that there are more negative. But then that's just individuals, isn't it? I don't know, Chris. What's your. I think there's definitely over time. I've been researching social prescribing for ten plus years. And at the beginning you did come across a lot of clinicians who were quite skeptical and were quite reticent to investing in social prescribing because it meant taking money away from kind of clinical professionals. But I think over time, there's definitely been a progressive shift, and more and more clinicians are coming around to the idea of of social prescribing and as something that is important, particularly in primary care and in and in mental health and flooded places on that. I think when you get into some of the more acute clinical settings, I think where maybe the clinicians and more are still more much kind of attuned to the medical model of evidence. That's where maybe you get you get more resistance. But even there, I think there's more and more clinicians that are that see this as a is an important thing. So I think we're getting there. Yeah. Yeah, I think and I, I brought this up when I talked to the to the researcher who studies animal interventions in psychiatry. We love new options. At least the clinicians I've tended to work with would be, you know, especially at the mild to moderate range. Yes, things can be a bit more different at the acute range. Although even then I think there's room for interventions like these, but especially in the mild to moderate range. We just love to have more options. And also people a lot of people get into psychiatry and mental health care wanting to impact people's quality of lives, and often they feel like they're just managing risk. And it can be very, very demoralizing, actually. So the idea of having interventions which vividly improve the quality of your life, I think would be appealing to a lot of us. Um, can we talk a bit about money? Because money is important, and I know you guys have looked at the financial side of this, so I think Chris is the best person to talk about this. What are the benefits of these kinds of interventions from a financial point of view? So we yeah, we looked at the the value of what kind of of of green space was thriving in the very broadest terms. And we started out by saying, actually, we we don't really know enough about how much this costs and how much does it cost relative to other, other treatments that might be offered to people with mental health? So we did quite a lot of money, quite a lot of work research, mapping the costs of some of the provision that was happening in the seven Tesla loan sites. And then we then we compared that to other treatments for people with mental health conditions already being offered on the NHS. And we found that green social prescribing as an option comes out, really comes out really well in cost terms. And when you compare it to things like, um, talking therapies or other kind of more clinical based mental health intervention in the community, then this is. This is kind of it's a it's a cost efficient way of supporting people. But I think what we'd also say is we shouldn't be thinking about this as an either or. It's not about doing talking therapies for green social prescribing. For many people, they will they're going to need those and they're going to get different things. So what we don't want to get into is a bit of a bidding war between social green social prescribing and and other things. But what we can say is that on a kind of a cost per patient basis, if you like, it stacks up financially, financially. So we shouldn't be worried about this being something that's really expensive. Um, and then what we tried to do was look at what what does this mean in terms of benefits and what we probably what we ideally would have done is looked at what the benefits were to the health system. So is this reducing GP attendances and attendances, admissions into, into mental health services. But we're not in a situation at the moment where the data is there to enable us to do that. Data does not join up along a pathway from from green social prescribing into those services. So we couldn't we couldn't do that. So instead we took this this wellbeing approach, which is all about assigning a monetary value to the wellbeing gains an intervention, um, might lead to. And this is a methodology that is kind of endorsed by the, the Treasury and the Green Book, which talks which is their guidance about how to evaluate projects. They say that the wellbeing approach is particularly, um, beneficial when and appropriate when kind of wellbeing is the goal. One of the key goals of the intervention, and that was the case with being social prescribing. So it felt like a, a um a the right thing to do. And so when we were collecting the right data, set the awareness for to do this. So when we looked at it, we did find that, um, we took a very conservative approach actually, to estimating the benefits, because what we didn't want to do was be accused of over claiming, because there's always a risk that you claim, if you claim you get a benefit of, um, 10 to £15 for every pound invested, people start kind of actually saying this. That's not believable. So we were quite conservative and we looked at some, some really tight parameters, and we estimated that taking all of the kind of the costs into account of delivering the programme, we think the, the benefits in terms of wellbeing was, was around um, two, £2.42, I think it was and it wasn't every pound invested by the government in this work. So we see a really a strong positive return on investment in terms of, in terms of wellbeing. I think where we need to get to is a place where that that wellbeing evidence is, is used more to justify making policy interventions because at the moment they they're still looking to. Okay, that's interesting. It's great that we're getting some wellbeing value for money, but we still need to know how much this is saving the NHS. Um, so could you give me that figure again? So how much wellbeing, how much was wellbeing improved per pound invested by the government. So for every pound invested by the government there was a, there was an it was a return of £2.42 in terms of wellbeing. And that was looking at it over just over a very short period. So if we'd, if we'd looked at over a longer period the value would have been higher. And how do you, uh, derive the, the, the £2.42, i.e. the, the sort of monetary is that the monetary cost of wellbeing by like standard interventions or how do you get that value. So what what it what it draws on national data. Um, which essentially equates what. So we know that people in households with higher income have higher wellbeing. So what it does is it equates a gain in wellbeing to the equivalent gain that you would get in household income. An interesting perspective. So so that's the approach that it uses. It has some has some flaws. It has some critics. But it's it, it's it's a useful way where where the benefits are in and more likely to mean things like wellbeing than on system pressures and on health benefits. It's a it's a neat way of being able to say this, this is this is the benefits of this type of thing. That's really interesting. Yes, it's very similar. It's a very similar principle to the to the quali. But it uses wellbeing as its main as his main measure rather than a measure of health utility. And one thing I wonder was in, in this particular set of, in this particular set of research, was there a distinction made between the effect of being in nature versus the effect of exercise versus the effect of socializing and being with others. Because to my mind, those are all things which independently would improve mental health. But perhaps those are questions more for the future. Difficult. I think it'd be very difficult to measure. There's yeah, there's been a there's a lot of kind of you see a lot of things written about a dose of nature or a dose of their sun. I think what we would argue is that each individual, the combination that makes the difference, is going to be different. So it's really hard to desegregate it and and to then to say, okay, you need to prescribe this much nature and this much social connection, because what works for one individual in one circumstance would be very different to an individual in another. So I think we'd caution against being that reductive in terms of how you how do we go about understanding this? It's also quite dystopian. You know, the idea of like getting prescribe one milligram of nature. So I'm aware of that. So there's something about science which is obviously incredibly useful for understanding the objective world. And yet there's something about science which is so dehumanizing. And perhaps that's how we got in this mess of being so disconnected from nature, the sort of hyper rational, modern world that we've formulated for ourselves. I wonder? What in the past have there been other specific social interventions which you guys have worked with besides nature specifically? And maybe you could tell me some things you've worked with before? Yeah. Uh, we've done we've done a couple together, haven't we, Krista? But one I've, I did Sheffield with a, with a group of colleagues was around um, an evaluation of the British Red Cross community Connectors program. So they would connect people in the community, maybe people who've been bereaved or young parents, sort of young young mothers or young fathers who may have just had a baby and they were feeling very socially isolated. And that was a sort of like I suppose it was like a befriending. But it was it was about sort of connecting, trying to get people to come back into the to connect them to the community so they would be, um, given someone to, to be buddy up with them for, say, six, six weeks to 12 weeks, they would go with them to appointments or they would try and get them involved in something, then go with them for a bit. If they didn't feel that confidence go on their own with the view that that person would then go on their own to those groups, a community group. Some just wanted some friendship. Um, you know, so that was a really that was a really interesting project as well. So that was the British Red Cross Connectors programme. Something else that we're working on at the moment as well is the, um, he's looking at creative health. Yes. I mentioned this to Alex earlier. So we are so, so creative health is all about connecting people to our culture, heritage, opportunities in their in their community. And it's a very similar principle to green social prescribing, but it's about the kind of the culture and heritage of it. Because, again, there's a really, really well established evidence base that says doing these things is good for our health and our mental health. And it's what we need to do is create systems and evidence that that makes it more accessible. So we're we're we're working on that for the next three years as well, using, um, Doncaster as a kind of a testbed for, for this work. And besides mental health problems, do we know anything about the value of either social prescribing or green social prescribing for physical health problems? So for me, things like chronic pain come to mind, for instance. Yeah, physical activity. So aside from the mental health impacts, physical health was also seen to improve. But that was only in one of the pilot sites. So following the um 84% 4%. Physical activity increased to 84% in one pilot site. So a one of the service users in that in that site said it's very rewarding exercise. It gives me a lift every time I go. I feel better every single time I've been and looking forward to the next one. So yeah, improve mental and physical health. Some of my colleagues at Sheffield Hallam, I've been working with, um, a project which is looking at, um, making golf sessions available to people with Parkinson's and Alzheimer's, and there's been some fairly good evidence that actually, you see a reduction in some of the some of the clinical symptoms of those conditions after taking by and these golf sessions. But it also has the added benefit of those, those those patients, their carers get some respite and some time to themselves as well. So there's, there's, there's lots of new and innovative things happening and in evidence emerging all the time. Okay, great. Were there any sort of major limitations to the research that you guys did that you would want to point out anything perhaps you would wish you had done differently, or you might do differently if you do similar research next time. I can mention. We can mention the data, can't we? Chris, I think it was very difficult to get hold of the routine data from, from sites. Um, so we we ended up having to sort of create our own data collection spreadsheet, which took us a long it did really take us quite overbudget. And, you know, it took a lot of time to develop that. So the routine data, you know, if you can improve the routine data, you can improve that, what you actually can get out of that. Def definitely, I think another another thing I think is important to, to realise is that this was focused on seven seven integrated care board areas of England. Um, so the data is only about England. First of all, we haven't studied Scotland, Wales and Northern Ireland. Um, but the other thing, those those seven areas were selected because they were already leading the way in terms of their social prescribing offer and ecosystem. So there'll be other parts of the country that are less well developed and less mature in terms of what they're able to offer people. So I think it's really it's really important to recognise that there's a these seven areas of have this investment. They're already ahead of the game. There's work to be done now to bring those other areas up, up to speed and up to where the, the seven areas of had the investment are. And that's going to take time and that's going to take money. And were there we talked a bit about which individuals were included. Were there any particular individuals excluded for any particular reason, whether it was for having a particularly severe condition or for any other reason? We didn't exclude anyone. It was it would have been something that would have come at the intervention stage. So we were just looking at people who'd we looked at around 8000. That was around 8300 people, uh, who participated. And we've got the data on those 8300 people. I think what some of the sites told us was that sometimes they were getting referred patients who really quite severe and complex needs. And they didn't. It wasn't necessarily appropriate or they weren't ready to be referred on to to green social prescribing activities. So there's the term holding has been used quite a lot for, for these individuals, because the social prescribing system ends up holding onto them to give them support, but it's not really able to to, to refer them on to some of these more creative and, and activities because they're just not ready, they're not confident. And it wouldn't be safe. It wouldn't be safe and it wouldn't be fair to do that. And we saw some of the interviews that we did with the link workers that they were saying that they were they were given people who were really, you know, they they they felt they didn't feel confident, not as in this project and another project that I've been involved in, you know, where the link workers didn't feel confident in, in dealing with these people because they were really, really quite severely ill. Um, and they felt that in a way, they were a bit of a dumping ground for being in where people didn't have anywhere to go. So we'll just refer them into social prescribing. And that wasn't fair on the, on the individual or on the link workers who did feel overwhelmed. And there was a fast there's a high turnover. Wouldn't this Chris with the with the um link workers. Because it's a very demanding role. Mhm. And Annette, could you, uh, give us a flavor of some of those testimonials you mentioned? So some firsthand comments about what people got from these interventions. Yes. Definitely. Yes. So um, so in the uh ONS for uh, we had statistically significant improvements in well-being following nature based activities. So this is about happiness increasing. Um, when I do things with the green activity, it's given me something to focus on. And people will talk to me. And you're not judged. Nobody judges anyone. People just go, and they've all got issues. But we meet up when we chat, not about our health, but we chat about everyday things and what we've been doing. Um, this is typical of tea and a hot chocolate, which is great, and it's bringing us all together. So that's about making people a lot more and a lot happy. This person said. All the bad rubbish that goes through your head or whatever you've got wrong with you, sort of goes out of the window because they talk to you and give you time. So that was around, um, around happiness. Then we had, um, quotes around life satisfaction and life feeling worthwhile. So, um, from therapy, you don't get that feeling of connection with the group. And I think doing the it was a waterways program that they worked on the waterways really appreciated how beneficial it was just connecting with other people. Um, with especially after feeling socially isolated about how, um, being around the right people can boost your mood and confidence. Uh, something to look forward to, something to be hopeful for, um, a test and learn site provider said. We've watched significant changes in adults and children, primarily an increase in confidence and self-belief and willingness to try and have a go. Uh, people were talking about levels of anxiety reduced and depression, um, about having the best night's sleep after the support. Um, they'd be up at 3:00 in the morning. Uh, I can't switch off, but I was totally switched off when I went there. So all those sorts of, like, really positive, um, very rewarding. Gives me a lift every time I go. Those types of, um, quotes were, were scattered around the, around our analysis. And they were they were just in the minority. There's lots more like that. Wonderful. Would you guys, before we sign off, like to add anything else about the future of this area or future questions perhaps you guys want to answer? I think it might be worth you speaking to, uh, Ruth about the work that's ongoing with the with the trial work and also the the ongoing work that Chris and Ruth and the team are doing in the, um, with the evaluation follow up. So for me, I think the big challenge is how how do we how do we embed this in health systems across the country first and foremost? And then how do we do it in a way that's sustainable. That means the groups are often the activities are not scrabbling around for money every year they've got they know they've got some certainty that they can offer these programs and develop them for the longer term. We can crack that, then I think we'll we'll have we'll have done a good job. Something I'd like to tell you guys about if you don't already know. Have you guys heard of the Trieste model? So there is a there is a medium sized city in Italy called Trieste, and it's famous in the mental health world for having a very unusual mental health system, which is fully integrated with social services, such that any patient presenting with a mental health difficulty can very easily access community support, but also opportunities in the in the community like work. And I think activity is similar to green social prescribing as well. And it was for a long time led by a psychiatrist named Roberto Messina, who, you know, looked at this quite closely. And the trusted model, although for political reasons is often under discussed, is visited by mental health providers around the world because of the remarkable results it's achieved in terms of lack of coercion, lack of use of things like the Mental Health Act, lack of the mandatory administration of medications and things like that. Not that they don't happen at all, but the rate is reduced a lot less compared to other medium sized cities. So perhaps something you could learn from looking into Roberto's work is that integration aspect of how do you actually get the mental health systems fully integrated with these kinds of services? That might be something interesting for you guys. There's something interesting now, what's the right scale to do this that isn't there? So we have a habit in the UK of trying to do everything at a national level from the top down. And I think sometimes examples like that show us that the the closer to the ground and the more bottom up we can make these types of interventions, the more likely they are to be successful. Yeah, centralising everything makes it too complicated. Okay, Chris and Annette, thank you so much for joining me today. It's been wonderful to have you on and we look forward to seeing what your work brings us in the future. Thank you. Thank you for having us. Thank you for having us.