Realising the Potential of Scotland's Natural Health Service in Practice

Part 2 - Piloting Green Health Partnerships

During 2018, four GHPs were established in Dundee, Highland, Lanarkshire and North Ayrshire, collectively covering a range of both urban and rural areas in Scotland experiencing health inequalities, disadvantage and low levels of physical activity. 

Rooted in local circumstances and leadership, the origins of the development of each of the GHPs were different, as were the arrangements put in place to deliver them. For example, discussions about establishing a Lanarkshire GHP had been taking place for several years, stimulated by the mental health team in NHS Lanarkshire. Formative discussions in North Ayrshire, Dundee and Highland were initiated following the involvement of each area’s Health Board in the NHS greenspace project and recognition of the potential to broaden green health work to a wider community scale. Due to the different origin, scale and geography of each GHP, the relationship between health board and local authorities also varied including one health board to two local authorities (Lanarkshire GHP and Highland GHP); and part health board to whole local authority area (North Ayrshire GHP and Dundee GHP). 

The GHPs each received around £100,000 core funding per year for the first three years – this enabled each partnership to employ a dedicated project officer post providing the necessary additional capacity to drive forward and co-ordinate their work programme, supported by a small programme delivery budget. The balance of spending varied between GHPs depending on their existing resources, requirements and priorities. To supplement this core budget each of the partnerships drew on a range of national and local delivery partners and made use of other programmes and external funding streams to increase the leverage of the core funding and enable each to deliver an ambitious range of project-based activity. 

Each GHP developed differently with stakeholder involvement and governance arrangements established to suit local circumstances and priorities. Despite these differences, all the GHPs shared the following five aims:

1. An increase in the number of people having contact with nature.
2. Greater awareness in health professionals of the contribution of nature based health promotion and interventions to physical and mental health and wellbeing.
3. Public Health and Health & Social Care sectors routinely embracing nature based health promotion and interventions for prevention, treatment and care.
4. Greater public awareness of the benefits & opportunities for contact with nature as part of everyday life.
5. Nature based contributions to health mainstreamed and funded sustainably. 

These goals were delivered through a range of co-ordinated action by the local health board, local authorities, public bodies and voluntary sector organisations which included stakeholder engagement, building capacity for green health in each area, green health project delivery, promotion and advocacy. In the early stage, work by each of the GHPs focused on: 

• Engaging local stakeholders to raise the profile of green health and its benefits.
• Conducting a review of the most relevant local health priorities.
• Building support within the health board and local authority.
• Auditing existing green health opportunities and programmes to identify existing synergies and possible gaps in promotion, pathways and provision.
• Developing a work programme and evaluation framework.
• Establishing a website presence for the partnership.
• Delivering some quick wins – such as the provision of small green health projects or community challenge funds. 

Common types of activity developed by the GHPs to deliver these goals included the following.

• Improving access to green health information – collating information about accessible green spaces and green health projects to be integrated into information sources used by the public and health practitioners.
• Raising awareness of the value of green health within healthcare – communicating the benefits of green health to practitioners from the health, social care and voluntary sectors and ways to connect their service users to local opportunities.
• Developing referral pathways to green health projects – establishing green prescription pathways or incorporating green health options into existing physical activity, mental health, social prescribing and lifestyle pathways and programmes.
• Promoting the benefits of green health to the public – promoting green health activity such as active travel, volunteering, community gardening and informal recreation through social media, leaflets and animations shown in health and leisure settings and an annual Green Health Week.
• Developing green health projects and opportunities – working with partners and green health activity providers to deliver new or expand existing projects for the public or target locations / clinical groups.

Boxes 1-4 provide further detail on the individual journeys of each GHP and their main achievements. 

Inevitably, the delivery of some projects was impacted by COVID-19 restrictions, but many GHP projects were re-purposed and helpful resources were developed to communicate key messages about the benefits of contact with nature and to promote more use of local greenspace. Each of the GHPs also produced 'Keeping Healthy in the Outdoors during COVID' videos, organised walking challenges, and distributed 'Green Health' packs to encourage outdoor exercise and an interest in nature. 

All of the Partnerships experienced a degree of staff turnover during the pilot phase affecting leadership roles and project staff. This had some short-term impact on delivery, momentum and stakeholder relationships while new staff were recruited. 

At the end of the three-year funding period, the project evaluation and on-going discussion with the GHPs confirmed that strategic work towards mainstreaming of pilot activity had also been impacted by the pandemic and would require more time to gain traction. Between 2022 and 2024, a further 2 years of core funding of circa £100,000 per year was therefore provided to three of the four partnerships, with the fourth (and longest running partnership) in Lanarkshire being integrated into the structure and funding of the board’s health improvement department. 

This second phase of programme delivery embraced further action to develop and mature green health delivery in each of the three areas and the strategic development required to build the connections locally to create the case for mainstreaming the work in the longer term. As well as NatureScot and Transport Scotland, this further two years of funding was also supported by the Active Scotland Division in Scottish Government. This final two years of funding ended in March 2024. At the time of preparing this report, each of these partnerships remain active and are working to embed green health into their local health and community planning structures.

Part 3 - Impact and Evaluation

The impact of the pilot GHPs has been assessed in various ways throughout its five years, including a qualitative appraisal after year 1, quantitative assessments for years 1-3 underpinned by an evaluation framework; and a National Institute for Health and Care Research (NIHR) funded evaluation of the green health prescriptions in years 4-5. 

Evaluation Framework

At the outset of the GHP pilot programme an Evaluability Assessment (EA) of the GHPs and the wider ONHS programme was carried out by the University of Glasgow with Public Health Scotland to understand how best to evaluate these initiatives. 

The EA process concluded that the scale of investment (across the 4 GHPs) did not justify large scale primary health data gathering at that stage. Instead, the EA advised that the level of engagement was perhaps the strongest measure of effect in the early stages, and it was recommended that evaluation of the GHPs for years 1-3 should therefore focus most on processes: recording participation and engagement of local service providers and agency staff in the delivery and dissemination of GHP activities, participation of the public in events and schemes delivered by the GHPs, and contextual constraints and enablers of change.

A logic model, which presents the relationship between goals, activities, and short, medium and long-term outcomes of the program, was developed during the EA. This set out the kinds of activities that GHPs might undertake to generate the outcomes sought. These are depicted in the Timeline below.

The Timeline below depicts the Goals of the GHPs, the associated activities they might undertake to achieve these goals and then the short, medium and long-term outcomes against which their progress can be measured.

For the evaluation, the GHPs worked with the University of Glasgow and NatureScot to produce a set of more defined activities and core measures to measure progress for these activities (Table 1). This more defined set of activities and core measures drew on the operational experience of the GHPs as well as their capacity to collect certain data in a consistent and robust way. Data collection was piloted and refined to simplify and further standardise the data collection process.

Year 1 - Qualitative Assessment

To supplement the collection of quantitative data by the GHPs, a qualitative assessment of stakeholders’ views on the progress of the GHPs during their first year of delivery was also commissioned from Edinburgh Napier University. This involved telephone interviews with key strategic-level stakeholders and focus groups in each of the GHP areas with operational partners. The conclusions were broadly positive and helped to reinforce the approach taken to the quantitative evaluation. Key findings included:

• Employment of Green Health Partnership project officers was seen as pivotal to success as they provide focus, knowledge, and time to help develop green health interventions.
• GHPs identified a need to engage politicians and healthcare professionals at both a local and national level as green health champions.
• Stakeholders suggested that more focus on the mental health benefits of green health activities would increase strategic importance of the GHPs.
• Stakeholders were concerned about the short-term nature of GHP funding and about expectations for intervention delivery from third sector, community, and voluntary organisations.

Year 1-3 Evaluation Report

The substantial task of sourcing and recording the quantitative data was undertaken by the GHPs, with coordination, cleaning, analysis and interpretation of the data undertaken by NatureScot and the University of Glasgow who prepared a combined year 1-3 report: Green Health Partnerships in Scotland – evaluation of the first three years. 

This report concluded that, collectively, the GHPs had achieved connections across social, economic and clinical policy and practice, and delivered substantial local activity. The GHP model was considered to have been effective at facilitating green health opportunities, awareness, and capacity-building activities across sectors. Key quantitative findings include:

• GHPs facilitated or promoted nearly 550 opportunities for green health activities across all three of the ONHS ‘types’ of interaction with nature (everyday, promotional initiative, targeted intervention). Participation in these likely increased contact with nature and introduced new users to nature.
• GHPs undertook more than 440 awareness raising and capacity building activities with the data showing more than 11,500 health and social care, and nearly 8,000 green health delivery staff were engaged. The numbers and range of nature based health promotion activities and referral pathways increased over time, showing health professionals became aware and involved.
• The GHPs reported 63 referral pathways established or facilitated. These were for a variety of client groups / health problems or situations, including clinical therapies such as cardiac rehabilitation and cancer care.
• Around 300 public-facing outreach and information activities were completed.
• Green health / the GHPs were mentioned in 58 local policies and plans, including those focused on health. This is an important marker of mainstreaming and cross-sectoral reach. 

This report included an assessment of progress towards each of the five GHP aims by the end of year 3. The conclusions are summarised in Table 2 below. Overall, progress towards each aim or goal had been substantial, with certainty of progress established for some of them.

Public Health Evaluation - Years 4-5

At the outset of the programme, the evaluability assessment (EA) recommended that measuring and attributing contribution to health improvement and reduction in inequalities should only take place once GHPs had been successfully established and had their delivery and reach assessed. Further research was therefore carried out by the University of Hertfordshire during Years 4 and 5, following a successful joint application by the GHPs to the Public Health Intervention Responsive Studies Teams (PHIRST) programme, funded by the National Institute for Health and Care Research (NIHR). 

The research sought to evaluate the green referral pathways that were at varying stages of implementation in Dundee, Highland and North Ayrshire, through a series of interviews with referrers, link workers, activity providers, and service users across the three GHP areas to gather detailed feedback. The aim was to investigate:

• if green health prescriptions were considered to be​ acceptable, practical, effective, affordable, beneficial to people or groups equally, and if there were any negative side-effects; and
• whether green health prescriptions increase contact with nature, improve health and wellbeing, and have an impact on health inequalities. 

The detailed feedback from staff and service users of their perceptions and experience of using green health prescriptions enabled the researchers to draw several conclusions, including:

• Staff and service users generally found the concept of using green spaces and green health prescriptions acceptable, and there were reported improvements in a wide range of physical and mental health, and social outcomes for service users.
• The green health prescriptions were considered affordable in terms of the limited (if any) cost to attendees of the green health activity sessions.
• The main barrier for staff, particularly those referring people into the programme, was the lack of strong underpinning IT infrastructure in terms of noting that a referral had been made, communication with link workers, and feedback and data capture to reflect on service user progress. 

The evaluation report made several recommendations that would lead to further improvements, including the need for improved IT systems to support better data capture to track and evidence outcomes. It also highlighted the need to invest in:

• an ongoing programme of training and support for staff across the system to know how, what, and where to refer and to be able to confidently champion green health; and
• long-term funding for staff to maintain what is available and identify new opportunities to build the portfolio of activities on offer. 

Examining the staff time and costs involved in processing a green referral in Dundee to match an individual to a suitable green health activity, the research was able to conclude that a green health prescription typically cost £49 (ranging from £26-£61), based on 2022/23 actual Dundee staff costs. While this did not include the costs of staff (e.g. a GP) making the initial referral and other background activities required to deliver the pathway, the costs are comparable or better than those reported for physical activity.

The published research briefing and infographics from the evaluation can be accessed here: Green Health Prescription Evaluation (GRAPPEL) for Dundee, Highland and North Ayrshire. 

Part 4 - Next Steps for GHPs and Related Green Health Activity

The overall purpose of the pilot GHP intervention was to demonstrate the added value of collaborative and co-ordinated working and more effective use of nature based activity within the health sector for delivering health outcomes. The monitoring and evaluation exercise demonstrated that an increase in cross-sectoral collaboration and awareness of the potential contribution of nature to health has been achieved in the GHP areas.

Going forward, the GHP model can be considered effective at facilitating green health opportunities, awareness, and capacity-building activities across sectors. However, the pilots have ably demonstrated that the model needs to be tailored to local circumstances and priorities, rather than adopting a one size fits all approach. In these terms, the pilot has been highly successful and demonstrated the potential for wider roll out. 

The impact of this programme can be seen in the development of a range of similar green health partnerships and other green health activity elsewhere across Scotland, many increasingly funded though health budgets. Inspired by engagement with the NHS Greenspace demonstration project, NHS Lothian published its greenspace and health strategy in 2019 (updated for 2023-28), with the core aim of maximising ‘Lothian’s Natural Health Service’. Implementation, including the development of a green health prescribing programme, has been supported and led by NHS Lothian Charity’s Green Health Programme Team. Green health initiatives have been developed in other locations in the same Health Board area as the GHPs, including NHS Tayside (Angus and Perth & Kinross) and South Ayrshire (NHS Ayrshire & Arran), where a Green Health app and green health calendar helps link individuals with local green health activities. Building on work piloted by Highland GHP, nature prescriptions are now available from health and social care practitioners in Badenoch and Strathspey, as part of the National Heritage Lottery funded Cairngorms 2030 programme. Within the voluntary sector, RSPB have been delivering their nature prescription programme in Shetland, Edinburgh and more recently Orkney and Lanarkshire. Elsewhere in Scotland, green health initiatives have been developed in Fife (River Leven) and options have been explored for a partnership initiative in part of Glasgow. 

In seeking to maximise the health outcomes of existing or proposed nature based activity, the intervention was relatively low cost compared to conventional health programmes. In addition, it can help deliver outcomes for climate and nature. As such, it has delivered in practice many of the recommendations of the Christie report on the future delivery of public services, for example, stronger cross sector working by public bodies and the third sector (i.e. local and national health and environment partnership); services designed with and for people rather than top down (i.e. linking grassroots community initiatives to core public health provision) and maximising scarce resources by using available public/third sector resources to deliver multiple aims (i.e. delivering for health, climate and nature). While beyond the scope of the programme, further assessment of its cost effectiveness (e.g. cost of green health paths compared to conventional treatment; decreased drug prescription; savings from taking a preventative approach; valuing the community and environmental benefits etc.) and the longer-term impacts on health and wellbeing would be useful areas for further research. 

The links between health, climate and nature also now regularly feature in national policy, with recognition of green health partnerships and related green health activity in recent publications such as:

• Physical Activity for Health: Scotland’s National Framework
• NHS Scotland Climate Emergency and Sustainability Strategy

The latter includes several key steps for NHS Scotland and Public Health Scotland to continue to mainstream green health partnerships and related green health activity in routine health practice. These include the development of a learning network / community of practice to share experience and good practice across the green health initiatives in Scotland; new guidance on establishing green health initiatives across Scotland; funding for new GHPs; and action to improve and make more use of NHS greenspace for green health activity.

To realise the potential of green health partnerships and similar green health activity, it will be important to learn the lessons from the evaluation of the pilot GHPs. Further work may be needed to look at the costs-benefits of these interventions from both a health and environmental perspective. Perhaps more importantly will be a more strategic, joined up and longer-term approach to investment in the providers of green health activity and the nature-rich settings needed for it.

Acknowledgements

A special thank you to Ashleigh Henderson (NHS Tayside) and Mollie Ritchie (Dundee Volunteer and Voluntary Action); Dan Jenkins, Ailsa Villegas and Cathy Steer (NHS Highland); Gillian Jennings and Elaine Caldow (NHS Ayrshire and Arran); and Marie McKeown (NHS Lanarkshire) for their contributions to this report and highlighting the individual journeys and key achievements of each of the Green Health Partnerships. Also thank you to Professor Rich Mitchell (University of Glasgow) for guiding the evaluation of the Green Health Partnership programme and for his input into this report. 

References

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