NatureScot Research Report 1338 - Valuing the health and well-being benefits of the NHS outdoor estate in Scotland

Year of publication: 2023

Authors: Alison Holt¹, Charles Cowap², Natalie Johnson¹ and Rhiannon Tudor Edwards^3
1Natural Capital Solutions, ²Independent consultant, ³Bangor University

Cite as: Holt, A., Cowap, C., Johnson, N. and Tudor Edwards, R. 2023. Valuing the health and well-being benefits of the NHS outdoor estate in Scotland. NatureScot Research Report 1338.

Keywords

natural capital; health and wellbeing; NHS; outdoor estate; natural capital accounting; tools; ecosystem services

Acknowledgements

The research was commissioned by NatureScot with support from Public Health Scotland. Funding was provided by Scottish Government as part of the programme of work being taken forward to implement the NHS Climate Emergency and Sustainability Strategy 2022-26.

The authors would like to acknowledge and thank Professor Emma McIntosh and Professor Mary Lynch for their contribution on the expert panel. The authors would like to thank Dr Catherine Lawrence for contributing to the final report. The authors would also like to thank Kalpa Pisavadia for production of Figure 5.

The above diagram shows the relationships between the natural capital assets (different greenspace types e.g. garden or woodland); the cultural ecosystem services such as recreation or restorative green health activities (e.g. walking, running, birdwatching), and provisioning and regulating services (e.g. air quality, noise and climate regulation) that give rise to health and well-being benefits (increased mental health and happiness, lowering risk of chronic diseases, including health benefits from reducing pollution, noise, heat and flood hazards). It also outlines the beneficiary groups (patients, visitors, staff and local community users) and emphasises that the health and well-being benefits and the regulating service benefits to these groups will vary depending on the type, spatial location, accessibility, quality and quantity of greenspace, the infrastructure that is provided (e.g. cycle paths, footpaths) and organised activities available (e.g. green gyms or practical conservation). All these elements need to be measured to enable a valuation of the natural capital benefits, i.e., the greenspace characteristics as well as the human use and benefits.

Rapid evidence review

The rapid evidence review was used to find existing metrics that are used to value health and well- being benefits, that would be appropriate for use in the context of the NHS outdoor estate. The focus was placed largely on the cultural services in the review, because there are fewer metrics available at present and it is a fast growing area of research. Regulating services that give rise to health and other benefits are better studied and there are already good metrics available. The searches were limited to research and grey literature published in the English language between 2000-2022. One hundred and sixty-five studies met the inclusion criteria for review. Seventy percent of these papers were focused on quantifying the physical or mental health benefits of activity in a range of greenspaces (e.g. woodland, gardens, parks), and 30% were focused on valuing the benefits from recreational activity, gardening, conservation and ecotherapies.

Overall, the studies quantifying benefits find a positive link between activity in greenspace and an increase in health and well-being, but they are of mixed quality. The largest proportion of the studies focussed on general activities in greenspace, but the second largest on gardens or allotments. The review also demonstrated that there are relatively few studies that have tackled valuing the health and well-being benefits of activities in greenspace. The studies reviewed employ a wide range of valuation methods ranging from the Travel Cost Method (TCM), Contingent Valuation (CVM) and Willingness to Pay (WTP) to QALYs, DALYs and Social Return On Investment (SROI). This suggests that a broad range of valuation methods are applicable. The review has provided some scope for transferring these benefits to the NHS outdoor estate cases, but only in very particular circumstances.

Proposed building blocks framework for evaluation and valuation of health and well-being benefits

Following a meeting with three leading experts in the field of Health Economics we have proposed a “building blocks” framework for the evaluation and valuation of the health and well-being benefits from the NHS outdoor estate. The framework provides a pathway towards a robust assessment of the benefits, ensuring that these benefits are considered fairly alongside other priorities in NHS estate business cases. The framework has been constructed recognising the importance of time-horizons in public health and preventative interventions. Many benefits to physical and mental health and the life-time health opportunity architecture of the population involve costs now and benefits many years in the future. It, therefore, encompasses short term metrics of e.g. greenspace use, as well as methods that will capture the longer term benefits. The framework is also place-based in accordance with guidance in the HM Treasury Green Book, which is linked to the concept of NHS estates as anchor organisations recognising the social, economic and environmental factors that help create good health within local neighbourhoods, playing a key role in addressing health inequalities. The framework supports that the NHS Scotland outdoor estate move from downstream providers of care to upstream preventers of ill-health and disability.

The framework is designed to capture qualitative and quantitative (non-monetary) valuation of the health and well-being benefits so they can be used in decision-making, recognising that it won’t be possible to estimate a monetary value for all of these benefits, and that monetary valuation is only one way of capturing these benefits. It takes a realist valuation approach understanding that socio- economic factors will impact on whether a green health intervention will work. It integrates the natural capital accounting approach and a novel health economics approach to measuring health and well-being benefits from the natural environment (borrowing methods from environmental economics).

The framework is an integrated and modular approach consisting of three steps:

• Step 1 uses a cost consequence framework that captures costs and impacts associated with the outdoor estate activities and interventions. This aligns with guidance from the National Institute for Health and Care Excellence (NICE) for the evaluation of public health interventions which emphasises the appropriateness of cost consequence and cost benefit analysis, taking a wider intersectoral perspective on the identification, measurement and valuation of costs and benefits.
• Step 2 uses a social cost benefit, social return on investment (SROI) framework, centred on the NHS outdoor estate, for evaluating and valuing the benefits associated with it, using the Treasury Green Book as a benchmark.
• Step 3 is concerned with the prioritisation of competing demands at the whole estate level using multi-criteria decision analysis, for the assessment of competing demands on NHS estates.

Practical application of the framework

Data

Greenspace assets: Any approach to valuation will require data on each element (natural capital assets, ecosystem services (cultural, regulating and provisioning) and final benefits) of the conceptual model of the relationships between natural capital assets and health and well-being benefits outlined above. The spatial database of the outdoor greenspace at each of the Health Boards is key to understanding the potential to supply health and well-being benefits. This will aid assessments of quantity, quality and accessibility of these greenspaces and how it influences patient, staff and local community use. This is understanding supply in relation to demand both by physical location, but also considering the social and economic reasons that may make sites accessible and attractive or not. NHS estates will have to be carefully managed for the range of different uses and user groups. A spatial analysis of the greenspaces could inform zoning of the outdoor estate within larger sites. Data on the types of users attracted to the estate greenspaces could be gathered as part of an annual survey of well-being benefits related to greenspace (see below).

Use: Data is required on how the site is being used (e.g. gardening, walking, green gym, outdoor therapeutic interventions, bird watching etc) and by whom. We recommend a survey of use, by different zones at sites throughout the year, and a register of organised health interventions recording the numbers of participants involved in the activity. There are innovative technologies that can help monitor use (e.g. counters on footpaths and cycle paths, sensors on benches, innovative smartphone apps).

Health and well-being benefits: There is a requirement for primary data collection across a range of activities to understand the uses and benefits associated with the NHS greenspace beneficiaries, rather than using existing studies for benefits transfer (the available valuation studies are generally at the wrong scale and too generic for robust benefits transfer to the NHS outdoor estate). However, benefits transfer may be appropriate for specific green health interventions, such as therapeutic gardening, where activities are very similar and take place at a similar scale. Understanding the benefits and their value is, therefore, contingent on gathering data by survey. A well designed annual survey of well-being related to greenspace is recommended. This should also be used to gather important data on the users, such as user type (patient, staff, visitor or local user), gender, ethnicity and socio-economic circumstances. Spotting the gaps in users will enable NHS boards to take appropriate action to establish equality of accessibility.

The health and well-being benefits associated with the provisioning and regulating services can be captured using benefits transfer as in natural capital accounting. A good guide for economic methods is provided in the Defra ENCA ecosystem services data book.

Where to start?

Capturing the value of all the possible health and well-being benefits, across all activities and beneficiaries associated with NHS Scotland’s outdoor estate will be challenging. Consequently, it is sensible to focus initially on using the proposed framework to evaluate situations where there are relatively easy wins, while data is gathered for dealing with the rest. We suggest an initial focus on staff health and well-being (mental and musculoskeletal health), and some specific green health interventions (e.g. gardening and social and green prescribing) in relation to all users.

We also suggest testing out the framework on some pilot NHS Health Board sites and focusing on gathering data as recommended with a focus on different user groups, benefit types and green health interventions (as above) to create learning that can be rolled out across all the Health Boards. This will generate data on benefits transfer that can more easily be applied to other NHS estates.

Conclusions

There is no quick route to valuing the health and well-being benefits of the NHS outdoor estate in a robust way. There may be some quick wins using benefits transfer from other studies for specific organised health activities where there are known numbers of participants, or from very generic recreational activities in specific habitats (such as walking in woodland).

Primary studies using surveys will be necessary to quantify and value health and well-being benefits across a range of NHS outdoor estate activities. The most efficient use of resources would be to prioritise certain activities or user groups and run different projects on pilot NHS Health Board sites. The learning can then be applied to other sites and be used in a future valuation toolkit in the medium to long term.

Summary of recommendations

We recommend the following for a robust evaluation and valuation of the health and well-being benefits from the use of the NHS outdoor estate. They will also help NHS Scotland develop their role as an anchor institution, allowing the outdoor estate to contribute to prevention of illness and address health inequalities:

• Adopt a place-based approach with an awareness of the opportunities being different for urban and rural estate.
• Be aware of time-horizons for valuation and the role of discount rates.
• Employ a shift in thinking about hospitals and their estate as places of acute care to places with a role to play in prevention.
• Begin to gather data and monitor use of the green estate.
• Employ the proposed building blocks framework to valuation.
• An initial focus on benefits to the NHS workforce addressing mental and musculoskeletal health.
• Establish the concept of zoning the green estate for staff, for patients and visitors, for green parking, and for community activities using green estate land.
• Establish demonstration sites with built-in evaluation and the resources required for evaluation with outside links to those familiar with methods evaluation of costs and benefits.
• Deliver evaluations including academic publication in peer-reviewed journals as well as accessible web-based reports and infographics.
• Work collaboratively with experts in the field.

Glossary

Term	Definition
Anchor organisation	An organisation which has an important presence in a place and is tied to a particular place through mission, physical assets and local relationships. Key to this is that the institution is tied to the well-being of the population and influences community health and well-being. Implicit from an NHS perspective is that the NHS has a responsibility to deliver community benefits through the way it operates.
B£ST	Benefits Estimation Tool.
Biodiversity	An abbreviation of ‘Biological diversity’. The variability among living organisms from all sources including, inter alia, terrestrial, marine and other aquatic ecosystems and the ecological complexes of which they are part; this includes diversity within species, between species and of ecosystems.
Boolean operators	Words like “and” and “not” which allow expansion of search parameters.
CBA	Cost-Benefit Analysis.
CCA	Cost-Consequence Analysis.
CEA	Cost-Effectiveness Analysis.
CICES v5.1	Common International Classification for Ecosystem Services.
Cultural services	Non-material benefits that can be obtained from ecosystems, such as physical health and well-being and spiritual enjoyment.
CVM	Contingent Valuation Method.
DALY	Disability Adjusted Life Year.
DCE	Discrete Choice Experiment.
Ecosystem service	The direct and indirect contributions of ecosystems to human well-being and quality of life. There are four categories of ecosystem services: Provisioning, Regulating, and Cultural. The term ‘services’ is usually used to encompass the tangible and intangible benefits that humans obtain from ecosystems, which are sometimes separated into ‘goods’ and ‘services.’
Ecosystem service flow /physical flow	The flow of ecosystem services provided by natural capital e.g. tonnes of carbon sequestered or number of recreational visits.
GIS	Geographical Information Systems.
GI-Val	Green Infrastructure Valuation Toolkit.
Green parking	Semi-paved car parks that provide sustainable drainage, prevent the movement of soil and clogging up of sewer systems. Recycled materials are often used.
Habitat condition	The Biodiversity Metric V.3.1 uses habitat condition as one of the measures of habitat quality. It measures the variation in the quality of patches of the same habitat type against ecological optimum state for that particular habitat.
HALY	Health Adjusted Life Years.
HEAT	Health Economic Assessment Tool.
ICECAP	ICEpop CAPability Measure.
InVEST	Integrated Valuation of Ecosystem Services and Trade-Offs.
Likert scale	A rating scale used in surveys to gauge opinions, values or perceptions. Respondents choose from given options and the responses can then be given a numerical score for numerical analysis. Invented in 1932 by Rensis Likert, America social psychologist (1903-1981).
Local climate regulation	The capacity of habitats / natural capital assets to cool the local environment and cause a reduction in urban heat maxima.
Logic chain	A natural capital logic chain shows the links between natural capital assets (their quantity, quality and location) and the ecosystem services and benefits they provide.
MCDA	Multi-Criteria Decision Analysis.
Monetary flow	The monetary value of the benefits that flow from natural capital assets.
Natural capital	Elements of nature that directly or indirectly produce value or benefits to people, including ecosystems, species, freshwater, land, minerals, the air and oceans, as well as natural processes and functions.
Natural capital accounting	Natural capital accounting is the use of an accounting framework to provide a systematic way to measure and report on the value of the stocks of natural capital and flows of ecosystem service benefits. It documents the natural capital assets, the physical flows of ecosystem services and the monetary flows (or value) of the benefits. It provides a net natural capital value by accounting for liabilities associated with maintaining the natural capital assets. This term is often confused with natural capital assessment, or the monetary valuation of ecosystem service benefits.
Natural capital assessment	Describing or quantifying natural capital assets, the benefits that flow from them and their value. Can include opportunities analysis for restoring or creating new habitat for enhancing the delivering of benefits. Provides natural capital evidence for integration into decision-making to improve natural capital management.
Natural capital assets	A distinctive component or grouping of natural capital components, including e.g. habitats, soils and air.
Natural capital stock	The store of natural capital assets on which humans depend (amount of freshwater, grassland or woodland etc).
NEVO	Environment Valuation Online.
NICE	National Institute for Health and Care Excellence.
Noise attenuation	The capacity of the land to diffuse and absorb noise pollution. Noise can impact health, well-being, productivity and the natural environment.
ORVal	Outdoor Recreation Valuation.
PAMS	Property and Asset Management Strategies.
Present value	Today's value of the benefits you expect to flow from a natural capital asset in the future.
Provisioning services	Characterised by the products obtained from ecosystems such as food, water and timber.
QALY	Quality-Adjusted Life Years.
Qualitative assessment	The descriptive and conceptual findings of non-numerical data.
Quantitative assessment	The collection and analysis of numerical data.
Regulating services	Any benefit obtained from the natural processes and functioning of ecosystems such as flood reduction, water quality, pollination or carbon sequestration.
Sensitivity analysis	A tool to evaluate the impacts of different assumptions and possible outcomes of a valuation.
Spatial data	Data that references a specific geographical area or location.
SROI	Social Return on Investment.
TCM	Travel Cost Method.
VOSL	Value of a Statistical Life.
WELLBY	Well-Being Adjusted Life Year.
WTA	Willingness To Accept.
WTP	Willingness To Pay.

 

Most survey respondents were not at all familiar or merely somewhat familiar with the health and well-being benefits associated with use of the NHS estate in Scotland (133 of 200 respondents, Figure 1a). Most respondents (165/200, 83%) work in the NHS. No volunteers responded. There were small numbers in the remaining categories in the survey (see Figure 1b).

There were 221 responses to the question that asked for the Health Board or Boards on which respondents had based their answers (Figure 1c). NHS Ayrshire and Arran dominated, and along with NHS Tayside accounted for half the responses (110 responses of 221). At the other end of this scale, no responses were received from the Golden Jubilee National Hospital, Healthcare Improvement Scotland, Scottish Ambulance Service and The State Hospital. This may represent an onward distribution bias when considering the results in view of the snowballing approach whereby the survey was initially distributed to all boards.

Table 1 lists the uses, activities and facilities identified by respondents in rank order. Walking and secure bicycle storage were the two most prominent uses according to the number of respondents who identified each, followed by active travel to and from work (itself likely to be by walking or cycling – categories were not mutually exclusive).

Oddly secure bicycle storage was identified by 106 respondents, but cycling itself by only 55 respondents. Uses of a therapeutic nature included:

• Outdoor therapeutic interventions or rehabilitation – recognised by 21% of respondents, and ranked 9th.
• This was followed by Organised Fitness Sessions – 20% of respondents and rank 10th. It is not possible to tell directly from the responses whether the organised fitness sessions were set up with a medical therapeutic intention.

We also sought to distinguish uses by different groups: patients, staff, volunteers, visitors and others. Respondents chose from a shorter list of activities and their responses are presented in Table 2, with uses presented in rank order for each group. Not surprisingly walking is the highest ranked activity on each list, but there is then considerable variation between groups. The value of this information may be in enabling the selection of activities for further development and promotion according to local user priorities.

Table 3 summarises the intensity of use within different NHS functional areas, for example psychiatry, obstetrics, occupational health (a total of 18 higher order divisions of the work of the NHS). The functional areas were based on NHS workforce development groupings with some modification to avoid confusion in the light of steering group feedback. The overwhelming answer for all functional areas was that respondents did not know.

The Stand-Out groups in Table 3 are Health Promotion, Psychiatry, Occupational Health and Primary Care. This is based on the total number of responses in the two highest categories in the Likert scale used for this question. The Likert scale itself is reproduced in Table 3. One respondent stated that every NHS Functional Area made extensive use of the outdoor estate for therapeutic, medical or other service purposes including active use or promotion in treatment pathway plans with active monitoring of outcomes. This is not credible, and this response could be removed for future analysis. Nevertheless, its inclusion does not affect the relative position of the functional areas. Clearly some functional areas will struggle ever to make more than a minimal use of the outdoor estate for therapeutic or medical purposes, and these results may be helpful in supporting the top users to increase their use and share with others, and to encourage the next tier of users as to how they might engage more fruitfully with the NHS outdoor estate.

We were also interested in the involvement of other organisations in health and well-being activities on the estate. Table 4 summarises the results of this section of the survey.

Table 1. Uses, activities and facilities on the NHS outdoor estate: number of respondents.

Answer	Count	Percentage
Walking (SQ002)	157	78.50%
Secure bicycle storage (SQ010)	106	53.00%
Active travel to/from work (SQ019)	75	37.50%
Picnic areas (SQ018)	72	36.00%
Informal recreational gardening (SQ013)	69	34.50%
Cycling (SQ005)	55	27.50%
Running (SQ004)	49	24.50%
Informal social gatherings (SQ036)	43	21.50%
Outdoor therapeutic interventions or rehabilitation (SQ024)	42	21.00%
Organised fitness sessions (SQ009)	40	20.00%
Meetings (SQ025)	39	19.50%
Active travel within estate (SQ020)	38	19.00%
Organised social exercise eg walking or wheeling club (SQ022)	37	18.50%
Nature conservation tasks eg tree planting or hedge laying (SQ026)	37	18.50%
Communal bicycle repair facility (SQ012)	35	17.50%
Visual arts display eg statues (SQ029)	34	17.00%
Artistic creation eg drawing and painting (SQ028)	33	16.50%
Teaching and learning (SQ017)	31	15.50%
Wheeling (SQ003)	30	15.00%
Bicycle hire/loan (SQ011)	29	14.50%
Community Food production (SQ015)	26	13.00%
Informal play (SQ007)	25	12.50%
Birdwatching or other wildlife study (SQ032)	23	11.50%
Formally organised social gatherings (SQ037)	21	10.50%
Outdoor exercise equipment eg green gym (SQ021)	20	10.00%
Corporate volunteering eg awayday activity (SQ033)	15	7.50%
Equipped play areas (SQ006)	14	7.00%
Changing rooms or facilities for sports or other strenuous activity (SQ008)	14	7.00%
Others, please specify below (SQ038)	14	7.00%
Care for animals inc beekeeping (SQ016)	11	5.50%
Foraging eg for mushrooms or wood (SQ027)	11	5.50%
Performing arts rehearsal or performance (SQ030)	11	5.50%
Organised sport (SQ034)	9	4.50%
BBQ or other outdoor cookery (SQ031)	8	4.00%
Informal competitive sport (SQ035)	7	3.50%
Commercial food production (SQ014)	5	2.50%
Outdoor medical consultations (SQ023)	4	2.00%

 

Table 2. User Groups and uses/activities/facilities in rank order. Number (n) of respondents who choose this option.

Patients	n	Staff	n	Volunteers	n	Visitors	n	Local community or others	n
Walking (SQ002)	128	Walking (SQ002)	155	Walking (SQ002)	74	Walking (SQ002)	117	Walking (SQ002)	100
Informal gardening (SQ012)	56	Picnic areas (SQ016)	72	Informal gardening (SQ012)	50	Picnic areas (SQ016)	52	Cycling (SQ005)	45
Informal social (SQ027)	49	Active travel (SQ017)	64	Volunteering (SQ026)	49	Informal social (SQ027)	47	Running (SQ004)	44
Picnic areas (SQ016)	42	Informal social (SQ027)	64	Conservation tasks (SQ020)	37	Cycling (SQ005)	35	Picnic areas (SQ016)	43
Growing food (SQ013)	40	Cycling (SQ005)	63	Informal social (SQ027)	36	Wheeling (SQ003)	32	Informal social (SQ027)	35
Wheeling (SQ003)	32	Meetings (SQ019)	45	Growing food (SQ013)	35	Active travel (SQ017)	29	Informal gardening (SQ012)	32
Other exercise (SQ009)	30	Running (SQ004)	44	Picnic areas (SQ016)	34	Running (SQ004)	26	Other volunteering (SQ026)	30
Arts creativity (SQ022)	29	Informal gardening (SQ012)	44	Arts creativity (SQ022)	29	Informal play (SQ008)	25	Wheeling (SQ003)	27
Cycling (SQ005)	24	Other exercise (SQ009)	32	Active travel (SQ017)	24	Informal gardening (SQ012)	21	Informal play (SQ008)	26
Conservation tasks (SQ020)	24	Volunteering (SQ026)	31	Cycling (SQ005)	19	Volunteering (SQ026)	21	Birdwatching (SQ024)	22
Active travel (SQ017)	22	Changing facility (SQ010)	29	Other exercise (SQ009)	19	Other exercise (SQ009)	18	Other exercise (SQ009)	21
Birdwatching (SQ024)	22	Organised fitness (SQ011)	28	Meetings (SQ019)	19	Birdwatching (SQ024)	16	Active travel (SQ017)	21
Other Volunteering (SQ026)	20	Wheeling (SQ003)	25	Other nature study (SQ025)	19	Other nature study (SQ025)	14	Conservation tasks (SQ020)	21
Other nature study (SQ025)	19	Formal social (SQ028)	20	Running (SQ004)	18	Playground (SQ007)	13	Playground (SQ007)	20
Organised fitness (SQ011)	17	Growing food (SQ013)	19	Teaching (SQ015)	18	Arts creativity (SQ022)	13	Arts creativity (SQ022)	20
Informal play (SQ008)	15	Conservation tasks (SQ020)	18	Organised fitness (SQ011)	16	Meetings (SQ019)	10	Other nature study (SQ025)	20
Running (SQ004)	13	Birdwatching (SQ024)	17	Birdwatching (SQ024)	16	Foraging (SQ021)	9	Growing food (SQ013)	18
Meetings (SQ019)	13	Teaching (SQ015)	12	Formal social (SQ028)	15	Formal social (SQ028)	8	Organised fitness (SQ011)	16
Formal social (SQ028)	13	Medical uses (SQ018)	11	Wheeling (SQ003)	14	Other (SQ029)	8	Meetings (SQ019)	16
Medical uses (SQ018)	10	Arts creativity (SQ022)	11	Outdoor cookery (SQ023)	12	Organised fitness (SQ011)	7	Foraging (SQ021)	12
Outdoor cookery (SQ023)	10	Other nature study (SQ025)	11	Animal care (SQ014)	11	Growing food (SQ013)	7	Animal care (SQ014)	11
Teaching (SQ015)	8	Foraging (SQ021)	6	Foraging (SQ021)	11	Conservation tasks (SQ020)	7	Other (SQ029)	10
Foraging (SQ021)	8	Outdoor cookery (SQ023)	6	Informal play (SQ008)	9	Animal care (SQ014)	6	Competitive sport (SQ006)	9
Other (SQ029)	8	Competitive sport (SQ006)	5	Changing facility (SQ010)	9	Teaching (SQ015)	5	Teaching (SQ015)	9
Playground (SQ007)	7	Playground (SQ007)	5	Playground (SQ007)	5	Medical uses (SQ018)	5	Outdoor cookery (SQ023)	9
Animal care (SQ014)	7	Animal care (SQ014)	5	Medical uses (SQ018)	3	Outdoor cookery (SQ023)	5	Formal social (SQ028)	9
Changing facility (SQ010)	5	Informal play (SQ008)	4	Competitive sport (SQ006)	1	Changing facility (SQ010)	4	Changing facility (SQ010)	4
Competitive sport (SQ006)	3	Other (SQ029)	2	Other (SQ029)	1	Competitive sport (SQ006)	3	Medical uses (SQ018)	3

 

Table 3. Intensity of use by NHS Functional Area. Number of respondents in each category.

Answer	Medicine	Pathology	Clinical Oncology	Other cancer care	Imaging	Dental/Oral	Surgery eg orthopaedics	Obstetrics and gynaecology	Psychiatry
I do not know	119	132	129	118	135	136	129	136	91
No active use of the outdoor estate for therapeutic, medical or other service purposes to the best of my knowledge	14	22	12	12	19	18	13	14	11
Very limited active use of outdoor estate for therapeutic, medical or other service purposes to the best of my knowledge	5	0	11	14	1	0	9	3	18
Some active use of outdoor estate for therapeutic, medical or other service purposes to the best of my knowledge, including some use in treatment pathway plans and monitoring outcomes	15	2	5	12	0	0	5	1	25
Extensive active use of outdoor estate for therapeutic, medical or other service purposes to the best of my knowledge including active use or promotion in treatment pathway plans and active monitoring outcomes	4	2	1	1	1	1	1	1	15
Total number of answers	157	158	158	157	156	155	157	155	160
No answer	43	42	42	43	44	45	43	45	40

 

Answer	Occupational Health	Primary Care	Health Promotion	Clinical Support	General Acute, A&E	Estates	Facilities	Corporate	Other
I do not know	107	104	82	131	133	116	119	114	73
No active use of the outdoor estate for therapeutic, medical or other service purposes to the best of my knowledge	12	14	11	11	17	9	12	16	3
Very limited active use of outdoor estate for therapeutic, medical or other service purposes to the best of my knowledge	9	17	17	3	1	9	8	10	1
Some active use of outdoor estate for therapeutic, medical or other service purposes to the best of my knowledge, including some use in treatment pathway plans and monitoring outcomes	22	15	30	6	1	12	8	8	2
Extensive active use of outdoor estate for therapeutic, medical or other service purposes to the best of my knowledge including active use or promotion in treatment pathway plans and active monitoring outcomes	6	7	17	2	1	6	4	3	1
Total number of answers	156	157	157	153	153	152	151	151	80
No answer	44	43	43	47	47	48	49	49	120

 

Table 4. Other organisations and their involvement in health and well-being activity on the NHS outdoor estate in Scotland. Numbers responding for each category. The key to the table codes are in a separate table below.

Answer	LA	CHW	NA	CARTS	LG:HF	LG:SI	LG: CY	LG: EY	LG: CF	LG: O	Other
No knowledge (AO01)	107	93	121	118	103	133	123	120	113	114	82
Very limited involvement (AO02)	22	18	6	11	15	10	13	17	11	17	2
Some involvement (AO03)	21	27	12	11	21	6	14	13	13	13	1
Active involvement (AO04)	5	10	6	10	13	3	3	3	8	7	3
Active driver of activity (AO05)	4	11	10	5	6	1	0	1	9	3	4
No answer	41	41	45	45	42	47	47	46	46	46	108

 

Local Authority	LA
Charity: Health and Welfare Focus	CHW
National Agency eg Forestry Commission	NA
Conservation, Amenity or Recreation Charity or Trust	CARTS
Local Group: Health Focus	LG:HF
Local Group: Special Interest Focus (eg model engineering society)	LG:SI
Local Group: Children and Youth Groups	LG:CY
Local Group: Early Years	LG:EY
Local Group: Conservation focus	LG:CF
Local Group: other	LG:O

 

The top involved organisations identified as being either actively involved or an active driver of activity were:

1. Charities with a health and welfare focus (21/200 respondents).
2. Local groups with a health focus (19/200 respondents).
3. Local groups with a conservation focus (17/200 respondents).
4. National agencies like Forestry Scotland (16/200 respondents).
5. Conservation, Amenity and Recreation Trusts or Charities (15/200 respondents).

A surprising omission from this list, in view of some of the information from the earlier semi-structured interviews, are Local Authorities. However, if the response for ‘some involvement’ is included Local Authorities would occupy third equal position on the list with Local Groups with a Conservation Focus at 30/200 respondents each. On this basis the first two positions would still be occupied by Charities with a health and welfare focus, and local groups with a health focus respectively.

Property and Asset Management Strategies (PAMS) are the principal instrument by which the NHS estate is managed. Most respondents (66%) had not heard of PAMS, and another 19% had heard of them but had no idea of the extent to which they reflect health and well-being benefits (Table 5).

Table 5. Extent of recognition of health and well-being benefits of the outdoor estate within NHS Scotland PAMS.

Answer	Count	Percentage
I have never heard of PAMS (AO01)	132	66%
Heard of PAMS but no idea of the extent to which they reflect health and well-being benefits (AO02)	37	19%
Current PAMS do not reflect health and well-being benefits of the outdoor estate, potential or actual (AO03)	3	2%
Current PAMS do not reflect health and well-being benefits of the outdoor estate but there are signs that future revisions will reflect these (AO04)	8	4%
Current PAMS reflect the role or potential role of the outdoor estate but are vague or non-committal with regard to development and performance measurement (AO05)	8	4%
Current PAMS have embraced the role of potential role of the outdoor estate, with analysis of existing contribution, clear objectives for future development or deployment and the adoption of performance measures which are regularly reviewed (AO06)	4	2%
No answer	8	4%
Totals	200	100%

 

The few remaining respondents divided almost equally around the division between the top and bottom two categories in the Likert scale we developed for this question.

Several of the survey questions invited additional comments and the survey attracted 204 additional comments in total. We have not conducted a formal thematic analysis of these comments, some of which were extensive, but the following themes easily emerge from them:

• Dog walking as a use was mentioned in response to several questions, with at least six references to this activity.
• Outdoor smoking was also mentioned, with three mentions of this activity one acknowledging its illicit nature in hospital grounds.
• Awareness of the potential benefits was clearly a broad theme for many respondents, while there were a smaller number of others who had never really considered that the NHS outdoor estate might be a therapeutic resource, captured neatly by one respondent who said, “Completing this survey has opened my eyes to the possibilities that the NHS outdoor space CAN be used for. It is something I had never thought about. I've always enjoyed walking around the grounds during my break and lunchtimes but never considered any other uses by other departments. I genuinely hope that the departments and/or wider agencies are encouraged to use the outdoor spaces in a more fruitful way”.
• Equally common was the recognition amongst respondents that much more could be done with the NHS outdoor estate through the implementation of practical adoption measures. This was coupled with a strong enthusiasm among respondents for more to be done.
• Pragmatically respondents also recognised difficulties in implementing good ideas for the greenspace, coupled with a sense of frustration at the demands on existing NHS resources. This frustration extended to the grounds management at some hospital sites, where it was recognised that management of greenspace could be more ambitious and imaginative in its engagement with the local environment and the needs of users.
• There was also an underlying sense of isolation amongst respondents, in that so many had so little idea of what was happening or could happen in areas of the NHS outside their own immediate experience and role.

Taken as a whole the survey shows:

• There is an extensive set of uses of the NHS Scotland estate – wider than is currently recognised in published sources.
• Walking is the dominant activity across all users. Future work could seek to distinguish different types and purposes of walking, distinguishing, for example, necessary travel to and from work; movement within the working day; and walking for other purposes including its own therapeutic or well-being impact.
• The top 10 uses identified by respondents to the survey were, in addition to walking: secure bicycle storage, active travel to and from work, picnic areas, informal recreational gardening, cycling, running, informal social gatherings, outdoor therapeutic interventions or rehabilitation and organised fitness sessions.
• Most respondents work in the NHS. There is scope to increase the external perspective on the use of the outdoor estate. More than three-quarters of the responses related to the following NHS Boards: Ayrshire and Arran, Tayside, Greater Glasgow and Clyde, Borders.
• In theory there is considerable scope to do a great deal more for therapeutic and well-being purposes with the NHS estate, and these benefits could be as strong for staff, visitors, volunteers, local communities as for patients. The results may even suggest that the benefits to the former groups could be at least as great or greater than for patients.
• There is a great enthusiasm for more extensive and better uses of the NHS Outdoor estate, but one obstacle to building on this asset will be the time and other resources required to do so.
• More formal promotion of the role of Property and Asset Management Strategies in the promotion of health and well-being uses of the outdoor estate could help to secure focus.
• Greater work to explore the inclusion of greenspace within formal health and treatment pathway protocols may also help to secure focus and commitment.
• The discussions beforehand, and to a lesser extent the survey, suggest that more could be achieved by working closely with non-NHS organisations in the development of new solutions on the NHS outdoor estate.

As valuation is being considered in this project it is important to break down this concept further to ensure the environmental functions that lead to (physical) flows of goods and services (or benefits), and the economic production functions that lead to (monetary) flows of goods and services (or benefits) are considered separately. This splits the products of the natural system from the those of the social system and makes it clear which outputs require biophysical measurements and which outputs can be valued∗. As an example of this distinction, green health activities and water quality regulation are, respectively, final cultural and regulating ecosystem services, and stress reduction and clean drinking water are the health and well-being benefits that flow from these that can be quantified and valued.

3.1. Natural capital logic chain

One of the principal tasks of this project was to develop a conceptual model of the relationships between the natural capital assets of the NHS outdoor estate, and the health and well-being benefits that flow from them. A logic chain has been created (Figure 3) that describes the pathway that leads to a monetary value of those benefits. In addition, it includes the main factors that influence the delivery of health and well-being benefits from the NHS Scotland outdoor estate, as well as the beneficiary groups. Each stage needs to be measured to quantify the value.

The natural capital assets are the different habitats that may occur on NHS Scotland’s outdoor estates, e.g. woodland, gardens, allotments and grassland (Figure 3). These assets may alone give rise to final cultural ecosystem services such as recreation or restorative green health activities (e.g. walking, running, birdwatching), and certainly give rise to regulating services (e.g. air quality, noise and climate regulation). However, for many of the cultural services and the provisioning service of food production, further physical and social infrastructure will be required before the final ecosystem services and benefits can be realised. This might be the creation of cycle paths or footpaths and allotments, or organised activities such as exercise programmes (green gyms), conservation groups or therapeutic programmes. These all require labour and capital inputs. Whether or not the benefits are provided, or the extent to which the benefits can be provided, also depends on the accessibility of the greenspace provision (e.g. whether the natural capital asset is directly outside where a user is a patient or where they work, or is more than a few minutes away on foot or by bike, see Section 6 for discussion), how much greenspace there is available and the quality of the greenspace (whether it is well maintained or biodiverse).

The flow of health and well-being benefits are wide ranging (Figure 3), from stress reduction, increased mental health and happiness and sleep improvements, through lowering risk of chronic, metabolic and clinical diseases, to reducing pollution, noise, heat and flood hazards. This level of the flow of benefits is mediated by the exposure of beneficiaries to these greenspaces, whether any one visit is short or long, or whether these visits are daily, weekly or monthly. The benefits may increase if social interaction is also occurring during the visit/activity.

The logic chain (Figure 3) also outlines the beneficiaries of these benefits. In the NHS context these range from inpatients, outpatients, staff, and visitors and local communities, including individuals, families, school and nursery children. In relation to the cultural benefits these will flow directly to the users of the greenspaces. The regulating benefits will benefit those on site and those in surrounding communities. These benefits have value. Value can be captured in many ways, and we suggest an approach to evaluating and valuing these benefits in Section 5.

Any tool that is eventually developed for valuing the benefits that flow from the uses of the outdoor estate will also need to quantify the physical flows of these services. For provisioning and regulating services it is usual that the area and type of habitat is one of the determining factors that delivers a physical flow value (e.g. the area of woodland and species of tree will determine the amount of a pollutant adsorbed). It is more complicated for cultural services. The type, spatial location, accessibility, quality and quantity of greenspace will need to be measured as they certainly influence the type and frequency of activity that takes place, and hence the value. Ultimately the existence of greenspace determines whether there is a potential flow of these benefits or not. However, it is also necessary to quantify the number of people and their mental or physical response to being in the greenspaces, to complete the valuation. The Social Return On Investment framework proposed for use in the evaluation and valuation of health and well-being benefits (see Section 5 and 6) will pick up the full range of factors (environmental, social and economic) determining the value of the benefits whether or not they can be quantified. The importance of the natural capital assets will, therefore, be included. The type, location, accessibility, quantity and quality of the natural capital assets are even more important in a strategic context for the NHS Health Boards, as they determine how demand for these services can be met and where. Certainly, for organised activities like practical conservation and therapeutic gardening there needs to be the right amount of greenspace of the right type for the activity to go ahead. There can only be as many programmes as the space allows.

4.1. Physical flows literature

As mentioned above, a large number of the papers accepted for review were focused on the physical flows of the ecosystem services that give rise to health and well-being benefits. By this we mean studies that are quantifying the final ecosystem service, for example the green space activity (running, green gym or cycling) and the health and well-being benefit that is derived from that (e.g. stress reduction or reduction in morbidity). In order to be useful in the context of the NHS Scotland outdoor estate, it is important not only to record the metrics used to measure these, but also to note the type of greenspace from which these services and benefits were being delivered (e.g. allotment or woodland). This will enable an assessment of how appropriate these metrics are likely to be for the uses of the NHS outdoor estate that will be revealed by the survey.

Many of the physical flow studies focused on miscellaneous greenspaces, gardens or allotments, forests and urban greenspaces (Table 7). Fewer were associated with nature-based interventions, bluespaces, street trees, parks, trails and protected areas. A large proportion of the studies were concerned with the mental health benefits from activities in these greenspaces (Table 7).

Table 7. Type of greenspaces and benefits featuring in the studies focused on physical flows accepted for review, including the number of studies associated with them.

Greenspace type	No. studies	Final ecosystem services and benefits	No. studies
Misc. greenspace	54	Mental health	56
Garden/allotment	23	General health	25
Forests	15	Physical activity	12
Urban greenspace	13	Physical health	9
Nature-based intervention	7	Well-being	9
Bluespace	3	Mortality	5
Green exercise	3	Social cohesion	3
Street trees	3	Diet	2
Wetlands	3	Quality of life	2
Parks	2	Development	1
Trails	2	Morbidity	1
Protected areas	1	Recreation	1

 

Metrics captured the final ecosystem services using occurrence, frequency of number of visits to greenspaces and these were related to specific types of activities, for example walking or allotment gardening. The benefits were measured in a variety of different ways depending on its nature. Studies concerned with mental health used questionnaires with related health scales specifically designed to quantify changes in different aspects of mental health. There were 49 different scales used, for example the Warwick Edinburgh Mental Well-being Scale, and the Perceived Stress Scale. There were also questionnaires and health scales to measure physical activity, for example the International Physical Activity Questionnaire and SQUASH. Studies were also concerned with measuring physiological responses from time spent in greenspace, for example heart rate, cortisol in saliva, blood pressure, that relate to reduction in stress responses.

Overall, these studies do find a positive link between activity in greenspace and an increase in health and well-being, but they are of mixed quality. The largest proportion of the studies focussed on general activities in greenspace, but the second largest on gardens or allotments. Some of the studies had very small sample sizes and often with no control. This means it is not possible to be sure whether the measured benefits are directly related to being in greenspace. An additional summary table has been created documenting the metrics used for quantifying the benefits associated with each greenspace type. It contains a score for quality and the reference of the paper or report. An excel spreadsheet also breaks this information down by study. These files will be made available to the project team.

4.2. Monetary flows literature

The monetary flows literature was focused specifically on valuing the benefits from activities or interventions set in greenspaces. There were a much smaller number (31) of studies focused on the monetary flow of the health and well-being benefits, than for the physical flows. There were a number of greenspace settings ranging from woodland to farms, and some studies focused specifically on benefits from cycle and footpaths (Table 8). Generally, the studies were focussed on specific interventions, for example ecotherapy which is a facilitated therapeutic intervention based in a natural setting, or green gyms which are supported sessions of outdoor conservation activities. The benefits in these studies were measured in terms of physical and mental health outcomes. Many of the papers were reviews of existing evidence that such interventions or activities can give rise to health and well-being benefits.

Table 8. Greenspace type, intervention type and benefits associated with the monetary flows studies accepted for review (see Table A2 in Appendix 2 for a table detailing the metrics and values used including references).

Greenspace type	Intervention type or activity	Valuation methods for physical and mental health benefits
Woodlands and trees	Community Farm	Quality adjusted life year (QALY)
Urban woodland	Ecotherapy (e.g. Branching Out)	Disability adjusted life year (DALY)
Street trees	Green prescribing	Cost benefit analysis (CBA)
Protected areas	Recreational activity	Value of a statistical life (VOSL)
Farm	Gardening	Travel cost method (TCM)
Misc. green and blue spaces	Conservation	Contingent valuation (CVM) and Willingness to pay within this (WTP)
Community gardens	Walking	Health adjusted life year (HALY)
Cycle paths	Green gyms	Cost-effectiveness analysis (CEA)
Footpaths	-	Discrete choice experiment (DCE)
-	-	Social Return on Investment (SROI)

 

A range of methods have been used in these studies, for example a focus on a change in hospital visits as a result of the activity or intervention, avoided deaths, changes in quality of life, morbidity or mortality, to enable a monetary value to be attached to the benefits (these metrics are listed in Table 8). Each valuation method takes a slightly different approach to quantifying and valuing the health and well-being benefit, and they are not mutually exclusive, e.g. it is possible to use QALY to measure health benefits within a cost-effectiveness analysis, and the monetary value of one QALY can be set by a Willingness to Pay analysis.

The QALY is commonly used in the environmental economics literature on its own and in the health economics literature within a Cost Utility Analysis. It is perhaps viewed as the gold standard because it is based on a standardised measure of health related quality of life in the form of a simple generic questionnaire (EQ-5D) that can be used at the population level in clinical and economic appraisal. A monetary value of one QALY can then be assigned to estimate the overall value of an intervention. In some cases, it is possible to translate health benefits already measured into the EQ-5D scale for QALY use (Hinde et al., 2021). However, rather than attempting to translate survey results into the QALY framework, other metrics as outlined in Table 8 above, that allow a monetary value estimate should be acceptable for use in the context of the NHS Scotland’s outdoor estate.

Overall, the rapid review demonstrated that there are relatively few studies that have tackled valuing the health and well-being benefits of activities in greenspace. The studies employ a wide range of methods for estimating the economic value of non-market goods and services ranging from the Travel Cost Method (TCM), Contingent Valuation (CVM) and Willingness to Pay (WTP) to QALYs, DALYs and Social Return On Investment (SROI). This suggests that a broad range of valuation methods are applicable, and some of them can be used together. The SROIs were generally found in the grey literature, rather than in environmental economics or health economics literature. The studies did not predominate from a particular country, studies cut across the UK, other European countries as well as Australia and New Zealand, so there does not appear to be an established best practice approach emerging in the scientific literature from a particular country. As with the physical flows literature, an additional summary table has been created documenting the metrics used for valuing the benefits associated with each greenspace type (see Appendix A2). It contains a score for quality and the reference of the paper or report. An excel spreadsheet also breaks this information down by study. These files will be made available to the project team.

4.3. Natural capital toolkits

Alongside the more formal rapid evidence assessment, a review of natural capital toolkits was undertaken. Natural capital toolkits bring together a range of metrics that can describe or quantify a broad suite of ecosystem service benefits. The toolkits range from those devised for general use, across any geographical location but at a landscape scale (e.g. InVEST), to those created specifically for use at smaller scales and in relation to e.g. urban developments (originally the aim of the NATURE tool). Some of the toolkits are spatial so use GIS mapping, some are spreadsheet based. A number of the toolkits are focused only on the physical flow of benefits (e.g. EcoServ R) and do not include the valuation step. Some of these toolkits, although including cultural services, are qualitative measures (e.g. NATURE tool and the Environmental Benefits of Nature Tool). The focus here is on tools that can be used to quantify and value health and well-being benefits. A list of the most appropriate tools are listed in Table 9.

Table 9. Natural capital toolkits accepted for review. These toolkits quantify and value ecosystem service benefits including cultural services. 

Natural capital toolkits
Health Economic Assessment Tool (HEAT)
Environment Valuation Online (NEVO)
Outdoor Recreation Valuation (ORVal)
Integrated Valuation of Ecosystem Services and Trade-Offs (InVEST)
iTree Eco
Green Infrastructure Valuation Toolkit (GI-Val)
Co$ting Nature
Benefits Estimation Tool (B£ST)
Greenkeeper

 

Reviewing the natural capital toolkits (Table 10) showed that no one tool would be suitable for use in measuring the health and well-being benefits across the NHS Scotland’s outdoor estate. Certain elements of each of the tools may be useful in particular circumstances. The World Health Organisation’s HEAT tool is focused on the benefits of cycling and walking only, and the valuation is based on the reduced risk of walking where there is no traffic. This may have some use if NHS greenspaces are being used as alternative routes by recreational walkers or commuters.

The NEVO tool created by the University of Exeter maps and values a number of ecosystem service benefits (agricultural production, timber production, carbon sequestration and recreation). The recreation valuation in this tool uses a model derived from the ORVal tool, also created by the University of Exeter. The ORVal tool uses a statistical model called a Recreational Demand Model to predict the number of visits that are made to currently accessible greenspaces by adult residents of England. The number of visits are modelled using data from the Monitor of Engagement with the Natural Environment (MENE) survey, and adjusted based on factors such as socioeconomic characteristics of people, the day of the week, attributes of the greenspace, the availability and quality of any alternative greenspaces. The model, through a welfare function, also describes the welfare an individual derives from making different recreational choices, and the welfare values are, therefore, provided by the tool. The welfare gained from a particular greenspace will depend on a number of factors (e.g. socio-economic status, month of the year) and the benefits experienced at a site is traded- off against the costs of travelling to the site. These tools are unfortunately focused only on England. However, the metrics used for the suite of services they cover are transferable, and some could be useful in a tool focused on NHS Scotland’s outdoor estate.

InVEST is a suite of models used to map and value the benefits from nature, created by the Stanford University Natural Capital Project. The models include 17 different ecosystem services. These models are for use at the landscape scale, so would not be suitable for this context. There are models, such as urban cooling, urban flood risk mitigation, recreation and scenic quality that may contain metrics that could be transferred for use in this project.

iTree eco is a toolkit developed by the United States Forest Service that can be used in the UK. Based on data on woodland and individual trees it can quantify and value pollution removal and human health impacts, carbon sequestration and storage, and avoided run-off, interception and transpiration. These are useful models that can be applied to woodland and tree habitats of the outdoor estates.

GI-Val is a toolkit devised by the Mersey Forest in England. It is a set of spreadsheet tools that can quantify 11 different benefits that might flow from green infrastructure. These include recreation and health and well-being. However, the quantification and monetisation of the health and well-being services in this tool require further research. The tools are a mix of metrics and monetary values transferred from case studies or other toolkits. The toolkit is suitable for application at the estate scale as it has been designed to assess specific green infrastructure interventions. Some of the metrics could be useful for an NHS outdoor estate/urban natural capital toolkit.

Co$ting Nature is a spatial policy-support tool for natural capital assessment and accounting, developed by Kings College London, AmbioTEK and UNEP-WCMC. It maps 18 different ecosystem services and can combine these with maps of conservation priority. The focus is on the opportunity cost of protecting nature to produce ecosystem services, rather than valuing nature (although it does have some valuation models within it). It is useful for assessing the impacts on ecosystem services of human interventions for conservation prioritisation and planning. This is likely to work best at large scales, and due to this the resolution is unlikely to be appropriate for use in this context.

The B£ST created by Stantec and EcoFutures is a spreadsheet tool that provides guidance to estimate the monetary benefits of Blue Green Infrastructure, including Sustainable Drainage Systems and Natural Flood Management. It is able to quantify and value 14 different service benefits. It does not include health and well-being benefits. It is designed for use at small scales and there may be metrics that can be extracted from here and used in this project.

Greenkeeper is a spatial tool created by Vivid Economics, Barton Willmore and the University of Exeter to quantify and value the health and well-being and carbon sequestration benefits that flow from urban greenspaces in the UK. The tool uses a random utility recreational demand model (similar to ORVal) which estimates recreational visits to urban greenspaces. It uses these visit numbers and applies a series of valuation methods to estimate the monetary value of physical health and mental well-being benefits at the individual and local population level. It is the only existing toolkit that focuses on monetising the health and well-being benefits from urban greenspaces. Whilst it would be very applicable for use on the NHS Scotland estates, it is proprietary, so the exact methodologies used are not available. It is, therefore, difficult to assess the quality of this tool.

The review of the natural capital toolkits revealed a range of different metrics associated with health and well-being benefits. No one toolkit will be useful for developing a tool for measuring the benefits from the outdoor estate, but specific models or approaches within them may be appropriate for certain uses of the estate.

4.4. Expert consultation

An expert panel meeting was held on the 8th March 2023 via Teams. It brought together three leading experts in the field of Health Economics, Prof. Rhiannon Tudor Edwards founding Director of the Centre for Health Economics and Medicines Evaluation (CHEME) at Bangor University, Prof. Mary Lynch from the School of Health and Life Sciences at the University of the West of Scotland, and Prof. Emma McIntosh from the School of Health and Well-being at the University of Glasgow.

The aim of the expert panel meeting was to discuss the appropriateness and robustness of the methods and approaches to valuing the health and well-being benefits associated with the NHS outdoor estate identified in the review. Importantly, it was also to find out their recommendations on how to best approach the valuation of these benefits, what the aspirations for this challenge should be, and the data required to fulfil the project aim. The programme for the discussions is in Appendix 3 and outlines the specific questions devised to direct the conversation. However, from the beginning the academics had quite clear ideas as to what would be required to achieve the ultimate goal of valuing the health and well-being benefits of the NHS Scotland outdoor estate, and so the conversation evolved from these.

Time was spent discussing the key concepts on which any framework for valuation of the health and well-being benefits would need to be based. For example, those related to delivering prevention of chronic health conditions and health inequalities such as anchor organisations and the place-based approach. Discussions were also focused on the need to use methods that allow both qualitative and quantitative valuation of the benefits; recognising there will be different views of greenspaces, their use and value; viewing the green and bluespaces as natural experiments, and understanding that social and economic factors will impact on the success of green health interventions. The type of framework that could deliver this was then laid out, the merits of using a modular approach nesting frameworks like Cost Consequence Analysis with Social Return on Investment, and delivering a way of appraising options across all priorities in estate scale business plans. The discussion then turned to how the framework could be applied, the data that it would be necessary to collect on the natural capital assets, the quality and accessibility, use and benefits; the variety of greenspace uses by different groups, and ways of promoting greenspace use. The academics then advised on the areas to focus on in the short term that might have the most impact, e.g. a focus on the health and well-being benefits of NHS Scotland staff, and mental health across all users, and ideas for valuing benefits in the medium and long term.

The meeting was an excellent discussion. The academics were keen to highlight that what this project is attempting to do is cutting edge, and that tackling the challenge requires a broadening of the tools and techniques used by Health Economists. The following two chapters and the recommendations are based directly on the discussions.

The proposed framework has been designed specifically to capture qualitative and quantitative valuation of the health and well-being benefits of the NHS outdoor estate. Well-being benefits are notoriously challenging to capture because of the difficulties in quantifying the benefits and estimating non-market values. Consequently, it won’t be possible to estimate a monetary value for all health and well-being benefits, but the framework allows other types of (non-monetary) valuation to be captured for consideration in decision-making. Recognising this requires a reframing of the level of evidence required for valuation, an understanding that it will not be possible to complete randomised controlled trials within this context, so what is viewed to be the ultimate in robust evidence is not attainable. It is important to view the use of green and bluespaces that make up the outdoor estate as natural experiments, and to employ an evaluation process that captures monetary and non- monetary valuation.

Realist evaluation approach

A realist evaluation underpins this framework. Realist evaluation is based on the assumption that a specific intervention will not work in every context and for all beneficiaries. This approach focuses on the nuances of the impacts of the intervention, for example “what works, for whom under what circumstances and how” (Wong et al., 2016; Mercer et al., 2021). This recognises that social and economic systems are integrated and that factors such as culture, class and type of economic systems have a real effect on whether programmes work. This approach is used for evaluating complex interventions, such as green health interventions we might be concerned with in the context of the NHS outdoor estate. The three key pillars of a realist evaluation are context, mechanisms and outcomes (CMO).

Widening evaluative space

Importantly, the proposed framework is also widening the evaluative space. That is, it recognises that there is pluralism in values and that these can be different and conflicting and that they are not reducible to each other or an ultimate value. In this context there are likely to be different views of greenspaces, their use and their value, and it should be recognised that delivering a monetary value is only one way of capturing this (see evaluation and valuation above). The proposed process is designed to capture a wider array of possible values. To achieve this it is important that there is staff, patient and public involvement in the process of this evaluation to ensure the important benefits are being captured and the range of values are being considered in the process.

Integrating natural capital accounting and health economics

The proposed framework integrates the natural capital accounting approach and a novel health economics approach to measuring health and well-being benefits from the natural environment (borrowing methods from environmental economics). As outlined in the logic chain of the relationships between the natural capital assets of the NHS estate (Figure 3, Section 3), the ecosystem services and benefits, some health and well-being benefits are derived from the provisioning and regulating services (e.g. local food production and air quality regulation), but the health benefits from the cultural services (e.g. recreation) will be more numerous and significant. Step 2 of the framework (Section 5.2 below) will identify benefits that are derived from all of these categories, and appropriate methodologies can be applied. Environmental benefits that are not delivered as direct health and well- being benefits, for example, carbon sequestration, can also be identified at this point and dealt with using established natural capital valuation methods.

5.2. The framework

The proposed evaluation and valuation framework is an integrated and modular approach (see Figure 6). This figure sets out three building blocks sitting on a “place-based” approach taking a number of time-horizons into account. Along the right hand side we list a number of key considerations relating to stakeholders, methods, perspectives and focus. On the left we summarise the task which involves identification, measurement, valuation of both costs and outcomes of the use of the NHS outdoor estate to support health and well-being. The first step uses a cost consequence framework that captures costs and impacts associated with the outdoor estate activities and interventions (Figure 6). This aligns with guidance from the National Institute for Health and Care Excellence (NICE) (NICE, 2011 and 2012)  for the evaluation of public health interventions which emphasises the appropriateness of cost consequence and cost benefit analysis, taking a wider intersectoral perspective on the identification, measurement and valuation of costs and benefits. The second step uses a social cost benefit, Social Return On Investment (SROI) framework, centred on the NHS outdoor estate, for evaluating and valuing the benefits associated with it, using the Treasury Green Book as a benchmark. The third step is concerned with the prioritisation of competing demands at the whole estate level using multi-criteria decision analysis, for the assessment of competing demands on NHS estates.

Cost consequence analysis (CCA) is a form of economic evaluation where disaggregated costs and a range of outcomes are listed to allow the decision-makers to decide on their relevance and relative importance (National Institute for Health Research, 2018). Within the National Institute for Health and Care Excellence (NICE) framework, decisions on whether or not to fund interventions are based on incremental cost-effectiveness analysis using a standardised quality adjusted life year (QALY) (NICE, 2012). However, the outcomes from green health interventions or general recreational activities in the NHS outdoor estate do not fit neatly into this conventional economic evaluation framework, because there will be multiple and varied outcomes (both health and non-health) associated with them. For example, whether a greenspace is used or not, or how it is used and how often, will be influenced by socio-economic background, the location of the estate site, accessibility of the site, its quality and other health and lifestyle factors of the user/beneficiary. CCA allows the consideration of broader outcomes of these interventions and activities, hence broadening the economic evaluative space (Willings, 2017), which is considered important in relation to public health interventions.

The advantages of using this approach in step 1 of the framework, and in the context of the health and well-being benefits associated with the NHS Scotland outdoor estate, are that it:

• Allows a summary of a broad range of costs and benefits (outcomes) of the activities on the NHS outdoor estates, those that are associated with health and non-health outcomes. It provides a broader and richer source of economic information that will be needed in Step 3 of the proposed framework.
• Can include the whole range of activities, whether or not they have been valued.
• It is an approach that can be easily understood and applied by decision-makers.
• This process recognises that the activities associated with the NHS outdoor estate are complex interventions (Skivington et al., 2021)  and can identify this complexity. It will allow suitable economic methods to be refined to capture this complexity for a more robust evaluation and valuation of the benefits.

Step 2. Social Return on Investment

The next step of the evaluative process is to apply a Social Return on Investment (SROI) framework to assessing the activities/interventions in the NHS outdoor estate listed in the CCA (Step 1), at the same time as applying a mixed methods approach to valuation ensuring that the right methodology is used to value the right activity. The focus of the SROI would be the NHS outdoor estate itself (as opposed to an organisation or specific intervention). The SROI framework is specifically designed for measuring and accounting for a broader concept of value (Nicholls et al., 2012). It aims to promote human well-being at the same time as reducing inequity and environmental degradation. It does this by incorporating social and environmental costs and benefits in addition to the economic ones. This allows an understanding of the complexity of the intervention, the plurality of values, and uses monetary value to represent the outcomes. A cost benefit ratio is estimated, indicating the amount of benefit or social value (£) delivered for every £1 invested. SROI can be undertaken retrospectively or be used to predict the social value delivered in future scenarios.

The benefit of using this framework is to ensure that the full complexity of the value of the benefits or impacts is captured. The intention is that the appropriate methodology will be chosen for the activity in question. These are likely to be Stated Preference methods such as the Contingent Valuation Method (CVM), which includes Willingness to Pay or Willingness to Accept (WTP/WTA), or Choice Experiments. The Travel Cost Method may also be appropriate for measuring recreational benefits, and can be integrated with CVM. We will talk more about valuation methods and data required for use of these techniques in Section 6 below.

The benchmark for this step will be the Supplementary Green Book Guidance “Well-being Guidance for Appraisal”39. This lays out the stages for a robust evaluation and valuation of health and well-being benefits from cultural services, using Social Cost Benefit Analysis (Social CBA) which is akin to the SROI framework (Edwards et al., 2021; Fujiwara, 2014; Fujiwara, 2015; Hutchinson et al., 2019; New Economics Foundation Consulting, 2020; Nicholls et al., 2009). It presents principles for measuring, quantifying and monetising well-being as well as for monitoring and evaluation.

Similarly for the valuation of the provisioning and regulating services that give rise to health and well- being benefits as part of this step, appropriate methods can also be derived from the Green Book, but additionally the Defra ‘Enabling a Natural Capital Approach’, which appraises valuation methods across a range of provisioning and regulating (and cultural) ecosystem services (and contains the most commonly used methods (DEFRA, 2020). Whilst the Defra ENCA guidance does cover valuation methods for cultural services, we are not suggesting it is used in this context. This project is proposing a more nuanced and robust assessment of cultural services than provided in the ENCA guidance, and we are therefore suggesting that this is used only for the provisioning and regulating services.

Step 3. Prioritisation – options appraisal

Any framework for evaluating and valuing the health and well-being benefits from the NHS outdoor estate would not be complete unless it can feed into an options appraisal. It is clear from the conversations with NHS professionals engaged in improving public health, as part of this project, that the desire for the health and well-being benefits to be valued is driven by the need for these to be balanced against other priorities at the estate scale, for example, increasing grey assets within the estate, or options for the design of new hospital sites, that are more easily valued in a cost benefit analysis within a business plan.

We suggest multi-criteria decision analysis (MCDA) as a final step for the assessment of options across the NHS estate. It supports decisions makers that are faced with evaluating multiple conflicting alternatives and provides a way of combining them in one overall appraisal (Oliveira et al., 2019). MCDA provides a toolbox of concepts, models and tools and is a clear framework for making decisions about conflicting priorities and the most efficient allocation of resources (i.e. is appropriate when budgets are fixed). MCDA typically consists of the following phases: problem identification and structuring, model building and use, and the development of action plans (Thokala, 2011). MCDA modelling has four stages:

• Identifying the alternatives to be appraised.
• Identifying the criteria against which the alternatives are to be appraised.
• Scoring of the value of an alternative’s expected performance against the set criteria.
• Criteria weighting – reflecting which criteria are considered a priority over others.

The first two phases are problem structuring, which involves meeting all relevant stakeholders. After this there are a number of different mathematical models that can be used in MCDA that will aid the comparison of options, for example, (i) value measurement models that measure the degree to which one decision option is preferred to another by creating and comparing numerical scores, (ii) outranking models that is a pair wise comparison of criterion and (iii) goal, aspiration or reference level models that derive alternatives which are the closest to achieving the pre-set criterion in the most satisfactory way.

The advantages of using MCDA are:

• It is able to account for stakeholder preferences and values.
• It provides a transparent reporting format.
• It could aid the understanding of multiple values and data gaps.
• Highlights the difference between evidence and value judgement.
• Clear outputs that are easily understandable.
• Robust and accountable.

Practical considerations are that decision makers may need training in MCDA techniques and any specialist software required, although it is possible to employ facilitators and experts to aid the process.

References

Cheshmehzangi, A. 2022. Vulnerability of the UK’s BAME communities during COVID-19: The review of public health and socio-economic inequalities. Journal of Human Behavior in the Social Environment, 32(2), 172-188.

Cronin-de-Chavez, A., Islam, S. and McEachan, R.R. 2019. Not a level playing field: A qualitative study exploring structural, community and individual determinants of greenspace use amongst low-income multi-ethnic families. Health and Place, 56, 118-126.

Dawkins, T.R.T. 2022. Making cities green. Understanding willingness to pay (WTP) for components of green spaces within urban communities: A discrete choice experiment. Kent Economics Undergraduate Research Journal Vol 1.

Deidda, M., Geue, C., Kreif, N., Dundas, R. and McIntosh, E. 2019. A framework for conducting economic evaluations alongside natural experiments. Social Science and Medicine, 220, 353-361.

DEFRA, 2020. Enabling a Natural Capital Approach (ENCA).

Edwards, R.T. and Holt, A. 2023. Building blocks for evaluation – public health economics.

Edwards, R.T. and Lawrence, C.L. 2021. ‘What You See is All There is’: the importance of heuristics in cost-benefit analysis (CBA) and social return on investment (SROI) in the evaluation of public health interventions. Applied Health Economics and Health Policy, 19(5), 653-664.

Edwards, R.T. and McIntosh, E. 2019. eds. Applied health economics for public health practice and research. Oxford University Press.

Edwards, R.T. 2022. Well-being and well-becoming through the life-course in public health economics research and policy: A new infographic. Frontiers in Public Health, 10.

Fujiwara, D. 2014. Measuring the social impact of community investment: the methodology paper. London, England: Housing Associations Charitable Trust (HACT).

Fujiwara, D. 2015. The seven principle problems of SROI. London, England: Simetrica Ltd.

Greenspace Scotland, 2022. Open space strategy and play sufficiency assessment draft regulations report of health inequalities impact assessment scoping exercise.

H.M. Treasury, 2022. The Green Book.

Haines-Young, R. and Potschin, M. 2018. Common International Classification of Ecosystem Services (CICES) V5.1. Guidance on the application of the revised structure. Fabis Consulting.

Hinde, S., Bojke, L. and Coventry, P. 2021. The cost effectiveness of ecotherapy as a healthcare intervention, separating the wood from the trees. International Journal of Environmental Research and Public Health, 18:11599.

Holt, A.R., Dempsey, N., Henneberry, J.M., Ashby, M. and Lush, C. 2021. Biodiversity and climate change assessment for the NHS Lothian estate. Report to the NHS Lothian, Natural Capital Solutions Ltd, February 2021.

Hutchinson, C.L., Berndt, A., Forsythe, D., Gilbert-Hunt, S., George, S. and Ratcliffe, J. 2019. Valuing the impact of health and social care programs using social return on investment analysis: how have academics advanced the methodology? A systematic review. British Medical Journal Open, 9, e029789.

Joanna Briggs Institute, 2017. Critical Appraisal tools for use in JBI Systematic Reviews.

Joseph Rowntree Foundation, 2022. Harnessing the power of anchor institutions – a Progressive Framework.

Ladle, A., Galpern, P. and Doyle-Baker, P. 2018. Measuring the use of green space in urban resource selection function: An application using smartphone GPS locations. Landscape and Urban Planning, 179, 107-115.

Marmot, M. 2020. Health equity in England: The Marmot review 10 years on. British Medical Journal, 368.

Mercer, T. and Lacy, P. 2021. A brief introduction to realist evaluation. Public Health England.

Millennium Ecosystem Assessment, 2005. Ecosystems and human well-being: Synthesis. Island Press, Washington D.C.

National Institute for Health Research, 2018. Cost-consequence analysis: An underused method of economic valuation.

New Economics Foundation Consulting, 2020. Social return on investment.

NHS Education for Scotland, 2022. NHS Scotland Workforce: Latest statistics at 21st March 2022. An Official Statistics publication for Scotland, 7th June 2022.

NICE, 2011. Supporting Investment in Public Health: Review of Methods for Assessing Cost Effectiveness, Cost Impact and Return on Investment.

NICE, 2012. Methods for the development of NICE public health guidance (third edition).

NICE, 2013. Guide to the methods of technology appraisal 2013.

Natural Capital Committee, 2014. The state of natural capital: Restoring our natural assets. Second report to the Economic Affairs Committee. Natural Capital Committee, March 2014.

Nicholls, J., Lawlor, E., Neitzert, E. and Goodspeed, T. 2012. A guide to Social Return on Investment. The SROI Network.

Nicholls, J., Lawlor, E., Neitzert, E. and Goodspeed, T. 2009. A guide to social return on investment. Office of the Third Sector, Cabinet Office.

Oliveira, M., Mataloto, I. and Kanavos, P. 2019. Multi-criteria decision analysis for health technology assessment: addressing methodological challenges to improve the state of the art. The European Journal of Health Economics, 20, 891-918.

Olsen, J.R., Nicholls, N., Panter, J., Burnett, H., Tornow, M. and Mitchell, R. 2022. Trends and inequalities in distance to and use of nearest natural space in the context of the 20-min neighbourhood: A 4-wave repeat cross-sectional study, 2013-2019. Environmental Research, 213, 113610.

Public Health Scotland, 2022. Evidence behind the Place Standard Tool and Place and Well-being Outcomes.

Reed, S., Göpfert, A., Wood, S., Allwood, D. and Warburton, W. 2019. Building healthier communities: the role of the NHS as an anchor institution. The Health Foundation.

Skivington, K., Matthews, L., Simpson, S. A., et al. 2021. A new framework for developing and evaluating complex interventions: update of Medical Research Council guidance. British Medical Journal, 374.

Scottish Government, 2016. The Procurement (Scotland) Regulations 2016.

Scottish Government, 2021. A fairer, greener Scotland: Programme for Government 2021-22.

Scottish Government, 2022a. NHS Scotland Climate Emergency and Sustainability Strategy 2022-2026.

Scottish Government, 2022b. Care and Wellbeing Portfolio Board.

Scottish Government, 2022c. Local living and 20 minute neighbourhoods, Chapter 15  National Planning Framework 4.

Thokala, P. 2011. Multiple criteria decision analysis for health technology assessment. School of Health and Related Research (ScHARR), University of Sheffield.

The Scottish Parliament, 2022. Proposed Well-being and Sustainable Development (Scotland) Bill.

White, M.P. et al. 2016. Recreational physical activity in natural environments and implications for health: A population based cross-sectional study in England. Preventative Medicine, 91, 383-388.

Willings, B. 2017. A broader economic evaluative space for public health interventions: an integrated approach. PhD thesis, University of Glasgow.

Wong, G., Greenhalgh, T., Westhorp,G., Manzano, A., Greenhalgh, J. and Jagosh, J. 2016. RAMESES II reporting standards for realist evaluations. BMC Medicine, 14.