A dose of nature
22 January 2016 by Dan Bloomfield
What do you get when you cross ecology with psychotherapy? Quite possibly you end up with profound benefits for people's wellbeing - and for the health of the NHS. Dan Bloomfield explains why for many chronically ill or isolated people help could lie just beyond their front door.
For nearly two years I've been running a project in Cornwall that brings together two quite different sectors: health and the natural environment. I've always been fascinated by how the two relate to each other. I started by studying ecology, first because nature fascinated me and then, I began to realise, because it made me happy. I noticed that being outdoors was the key to my physical health as well as my mental wellbeing. Nature pleased me, calmed me, gave me a sense of perspective. Somehow, it also made me walk a bit further, or climb a bit higher.
A few years ago I also began to train as a psychotherapist. The success of psychotherapy depends on the effectiveness of the relationship between the therapist and patient and the context of that relationship has an enormous bearing upon the outcome. Instead of sitting indoors I began to take clients outside for a walk and we both noticed the difference. It made me wonder; if going out in nature was beneficial to health and wellbeing, could we eventually reach a point where a doctor, rather than prescribing antidepressants or even statins, might offer a dose of nature instead?
That question led me to a Natural Environment Research Council fellowship in the field of knowledge exchange. This essentially means bringing together different groups of people outside academia to find out how and where research could be better applied, to maximise social and economic benefit. On the one hand, academics have a lot of knowledge about health, wellbeing and the natural environment, and also a lot of questions. On the other, environmental organisations are keen for people to value our natural assets more, and to bring the things that nature does for us - clean our water, circulate our carbon, control our pests and, perhaps, underpin our health - to everyone's attention. And on the third hand (one I often wish I could grow), the health system is very keen to reduce costs, to find alternative ways of caring for people, to reduce the impact of future epidemics of obesity and depression, and to involve the voluntary and community sector more. If we brought these agendas together, could we make nature prescription a reality?
Right from the start there was an enormous amount to learn and to share. The health system, with its acronyms and concepts like commissioning of services and care pathways, has its own language of which many of us - myself included - understand only a smattering. I got a rapid education in NHS restructuring and the like, but as my fellowship progressed I was delighted and relieved to discover many GPs, nurses and managers who 'got' the concept and wanted to take part.
The idea of using the outdoors for health is hardly new. It's what comes naturally to many of us, after all; to go outside when we need to clear our head or stretch our legs. It's part of the broader prevention and public health agenda, to reduce the risk of problems arising in the future. Initiatives like Project Wild Thing are doing a huge amount to reconnect children with play and adventure in natural outdoor places. But what about people who are already suffering from chronic conditions, or multiple health problems? What about people who are isolated, or have circulatory health problems combined with substance abuse, or depression, or who are obese?
Once the GPs, the environmental charities and trusts, and the academics began to talk to each other some things became clear very quickly. The actual diagnosis was less important than whether the doctor felt getting out in nature was something the patient might readily be encouraged to do. Transport can be a problem for some, but one that can be solved nonetheless. And there needs to be someone - a facilitator or leader - to receive the doctor's referrals and guide patients to put it into practice, otherwise it could amount to no more than easily-ignored advice.
So it was a question of bringing together the right people, something the fellowship was designed to do. Once we'd done that, patient referrals began.
We now have six Dose of Nature projects, each a partnership between local GP surgeries and the communities in which they sit.
There are huge challenges to all of this. Everyone is time poor, especially in primary care, and everyone is under budgetary constraints. Because of the need for facilitation, a course of nature-based activities is not free, and we are researching how the costs compare to other standard treatments, and whether the NHS prescription fee can follow such a referral.
But these are also problems that nature prescription can help solve, by reducing the number of people needing to see their doctor and eventually, we hope, by providing a new source of income for nature conservation. The project has created a lot of interest around the country, and the aim now is to spread what we have learnt out to all parts of the English NHS so it can be repeated elsewhere.
We are also instigating some further research, hopefully funded from the health side of things, that will look in more detail at what kinds of specific 'dose' for patients with different conditions we need to commission. We need to model the economics of this in such a way that eventually the costs are borne by the health system, perhaps via the prescription charge. And we also need to understand in finer detail what the advantages are to the natural environment of specifically using it in this way.
Eventually, I hope, we'll get to a point where a doctor will commonly order a dose of nature, and we'll have a Natural Health Service to work alongside the NHS. It's been a great journey so far, and one that I hope is just beginning.
Dr Dan Bloomfield is based in the Centre for Ecology & Conservation at the University of Exeter. Email: firstname.lastname@example.org.