Research and analysis

Exploring perceptions of green social prescribing among clinicians and the public

Published 30 March 2023

Applies to England

Executive summary

The Department of Health and Social Care (DHSC) commissioned IFF Research to gather robust evidence on perceptions and behaviours related to green social prescribing (GSP). IFF conducted 2 surveys:

• one with 4,000 patients or potential users of GSP services
• one with 501 clinicians

This was followed by some qualitative in-depth interviews to gain further insight into how GSP could be scaled up as an intervention.

Overall, the appetite for (green) social prescribing is high among both clinicians and the public:

• nearly all clinicians would refer patients to social prescribers in the future
• the majority of patients are open to discussing opportunities for mental health support in their local community with a healthcare professional, including spending time in nature

It is common for both audiences to regularly spend time in nature already, with the majority doing so at least weekly. This is a relatively ‘privileged’ activity: those with higher income, with no disabilities and in good overall health are likely to spend time in nature more frequently. Unsurprisingly, access also plays a significant role: those living in more rural areas spend time in nature more frequently. The public recognise that spending time in nature improves both their mental and physical health.

Clinicians do not always know or conceive of GSP as an intervention distinct from social prescribing in general: while most are aware and have previous experience of social prescribing, fewer could say the same for GSP. The public are also generally aware that their healthcare professional can refer them to non-medical support but it was relatively uncommon for patients to have prior experience of being referred to an organised nature-based activity. It was more typical for those seeking support for their mental health to have been given a more informal recommendation by their healthcare professional, such as to ‘try to get outside’.

Both clinicians and the public feel the potential benefits of GSP for improving patient mental health are clear. They also feel there are distinct benefits to be gained from spending time in nature compared to other interventions available through social prescribing - such as the outside world giving perspective to, and relief from, their thoughts. The specific type of activity that patients would be open to participating in depends on their individual preferences.

Clinicians see green social prescribing as part of a holistic approach to patient care, as do patients, that is an intervention which can work alongside more traditional interventions, such as medication or therapy. However, a significant minority of clinicians believe that patients would prefer more traditional interventions, which can discourage clinicians from talking to patients about nature-based activities.

Fewer clinicians see benefits from GSP to the wider health system, such as reduced patient need for additional services. Some feel it is too early to say due to the current modest scale of GSP and that additional investment into community services is needed to enable GSP to make an impact in this way.

Currently, the most common barrier to making a referral to a nature-based activity for clinicians is a lack of knowledge of how to refer. This is particularly the case for non-GPs, reflecting a difference in referral route: non-GPs tend not to have direct access to a social prescriber in their team. More information on who their nearest social prescriber is and the process for referring to them would help.

Clinicians also feel they currently lack knowledge of local nature-based activities which patients can take part in and would value more information on the availability of specific services or activities in the local area to which they can refer patients. They feel that feedback on patient outcomes following referral to a nature-based activity would be helpful to more accurately gauge the success of this as an intervention - at the moment they tend to only hear from patients where a referral has not been successful and the patient has returned to see them.

Similarly to clinicians, patients do not feel they have enough information on what options are available to them locally. Some also face barriers which would need addressing, both practical and attitudinal: some are concerned about the potential cost or logistical difficulty of taking part, while others lack confidence to go alone.

In line with how social prescribing is designed to work, clinicians feel that their role is to tell patients about potential non-medical options of support in the community, including nature-based ones, and to direct them to a social prescriber. It is then the responsibility of the social prescriber to explain the interventions and GSP in more detail, and to determine, along with the patient, the most suitable activity for them.

Background and methodology

Background and objectives

Social prescribing is an intervention in which clinicians refer patients to non-medical support in their local community, to improve their health and wellbeing. Green social prescribing (GSP) involves referrals into nature-based interventions and activities that link people to natural environments.

Currently, social prescribing is one of a range of interventions which clinicians may refer patients to (often via a link worker or ‘social prescriber’^{[footnote 1]} to support their mental health. However, it is unclear whether the general public and clinicians view this as a viable option for supporting patients’ mental health. A recent evidence review commissioned by Defra found evidence that at least some patients and clinicians were sceptical of the value of social prescribing, and GSP.

In this context, the Department of Health and Social Care (DHSC) commissioned IFF Research to gather evidence on perceptions and behaviours related to GSP, in particular relating to its use supporting mental ill health. The research investigated factors affecting the scalability of GSP in England and the role that nature-based interventions can play in improving the nation’s mental health by determining what barriers and enablers there are to expansion. It also identifies areas where further work is necessary to encourage the use and uptake of nature-based interventions. This involved speaking to both clinicians and members of the public, including those with mental ill health.

Methodology

The research involved both quantitative surveys to gather robust nationally representative evidence and qualitative techniques (in-depth interviews and focus groups) to add further insight and nuance to the findings. The approach to each element is set out in further detail below.

Quantitative surveys

IFF Research conducted 2 online quantitative surveys, one with clinicians, and one with the general public. Each lasted around 10 minutes on average. Prior to launch, each survey was cognitively tested and piloted to ensure the survey questions were comprehensible.

Public

4,000 members of the general public completed the survey between 21 March and 8 April 2022. This included:

• 2,181 people with current or recent (within the last 6 months) mental ill health - 55% of the total
• 961 people who had talked to a healthcare professional about their mental health in the last 12 months - 22% of the total

Sample was sourced from a consumer panel. Post-fieldwork, the profile was weighted to nationally representative statistics by age, gender, ethnicity, income, region and disability. The technical appendix contains a detailed breakdown of the achieved versus weighted completes against these indicators.

Clinicians

501 clinicians took part in the survey between 15 March and 19 April 2022. This included a mix of GPs (370) and non-GPs (131). Non-GP roles included:

• mental health specialist doctors based in hospitals
• mental health specialist doctors based in the community
• mental health nurses in hospitals
• specialist psychiatrists
• community psychiatric nurses
• consultant psychologists

Clinicians were also targeted to ensure good coverage by age, gender, ethnicity and region where they had obtained their primary medical qualification. Sample was purchased from a commercial sample provider and supplemented through a specialist panel of healthcare professionals. Weighting was applied post-fieldwork to ensure that, as far as possible, findings were representative of clinicians as a whole.

Please see the technical appendix for further information on survey methodology as well as further information on the demographic profile of the final sample for both clinicians and the public.

Qualitative interviews

Following the quantitative survey, IFF Research conducted qualitative follow-up research with both patients and clinicians between 6 July and 25 July 2022.

Public and patients

The qualitative research focussed on the experiences and perceptions of patients rather than the general public. ‘Patients’ were defined as people who were currently experiencing mental ill health or who had experienced mental ill health in the last 12 months.

All participants were recruited from respondents to the survey who had consented to taking part in further research on the topic.

In-depth interviews took place with 15 patients who had been to see a healthcare professional (HCP) about their mental health, including 10 who had been referred to a nature-based activity. The one-on-one format allowed a more private environment for in-depth questioning about the conversation they had had with their health professional.

Table 1: patients qualitative in-depth interviews profile

Patient in-depth interviews	Completed
Been to HCP but not referred to nature-based activity	5
Been to HCP and referred to nature-based activity	10
…of which, did not participate in nature-based activity	1

IFF Research conducted 2 focus groups (comprising 14 patients in total) with those who had not been to see an HCP about their mental health. The focus group did not touch on their own personal experience but rather was used to discuss overall views of GSP as a potential intervention to support mental health.

Across both in-depth interviews and focus groups, participants were recruited who had experienced a range of mental health issues, and a good mix was achieved by gender, age, ethnicity and region.

Clinicians

IFF Research conducted 25 in-depth interviews with clinicians. These included both GPs and non-GPs, given the survey highlighted some key differences by type of clinician in terms of level of awareness of GSP.

Clinicians were also purposively recruited with differing levels of GSP knowledge.

Table 2: clinicians qualitative in-depth interviews profile by role type and knowledge of GSP

Clinician in-depth interviews	GP	Non-GP
Knows a lot or a little about GSP	11	6
Doesn’t know much or not heard of GSP	4	4

See the technical appendix for a detailed breakdown of the demographic profile of participants in the in-depth interviews with clinicians and the public. Note that, due to rounding, the percentages for some questions may add to more than 100%.

Engagement with nature-based activities

This section covers the general public’s and clinicians’ current level of engagement with nature and/or nature-based activities. The key findings are:

• for both clinicians and the public, it is common to spend time in nature, with the majority doing so at least weekly
• those younger, living in more rural areas, with higher income, with no disabilities and in good overall health are likely to spend time in nature more frequently
• people enjoy a range of nature-based activities; the specific type of activity depends on the individual’s preferences
• the public recognise that spending time in nature can improve their mental and physical health

Current engagement with nature

Figure 1: frequency of time spent in nature by the general public

B1 - How often, if at all, do you spend time outside in green and natural spaces? This could include spending time around parks, commons, heaths, fields, woodland, rivers, nature reserves or the coast. Base: all public (4,000).

As shown in figure 1, 68% of respondents said they spend time outside in green and natural spaces on a weekly basis. The full results were:

• 39% said daily or several times a week
• 29% said around once a week
• 15% said once or twice a month
• 12% said less than once a month
• less than 10% said they don’t know or they prefer not to say

Spending time in nature is common - with two thirds (68%) of the public doing so at least weekly. This includes just under 4 in 10 (39%) who spend time in nature daily or several times a week. These findings are broadly in line with the People and Nature Survey for England results for January 2022, where over in 6 in 10 adults in England (61%) said they had spent time outside in green and natural spaces in the previous 14 days.

However, this is a relatively ‘privileged’ activity with the following groups more likely to spend time in nature daily or several times a week:

• those in good overall health (46% versus 24% in poor overall health)
• those without disability (41% versus 34% with a disability)
• those of white ethnicity (40% versus 31% of people from ethnic minority backgrounds)

Those from low-income households are more likely to rarely or never spend time in nature. One in 6 (16%) people from households earning less than £15,000 a year spend time in nature less than once a month and 7% never do, compared to 10% and 2% respectively for households earning more than £50,000 a year.

Unsurprisingly, when looking at difference by region, fewer patients and the public spend time in nature daily or several times a week in regions which have more heavily urban centres, including London (35%) and the North West (35%). A higher proportion spend time in nature frequently in regions likely to have greater access to more rural spaces, including the South West (49%).

Differences by age were slight. Under 35s are less likely than average to spend time in nature daily or several times a week (36% compared to 39%) but more likely to spend time in nature at least once per week (71% compared to 68% average).

Reflecting the quantitative survey findings, patients and public interviewed as part of the qualitative stage spoke of getting outside regularly - daily or weekly - with those who spend less time than this saying they would like to get out more frequently, in recognition of the fact that it is intuitively ‘good for you’. Participants in the depth interviews gave examples of activities they liked to do in nature including: (dog) walking, running, cycling, having picnics, gardening, and ‘just being’ in nature.

In the qualitative research, patients and public described how they spend time in nature as a way to help support their mental health and for many this is linked to, or part of, taking care of their physical health. Some patients and/or public mentioned that ‘just being’ in nature is healing and/or gives them a perspective on issues they face.

For some, it was important to spend time alone in nature, as it was felt to be an opportunity for peace and solitude, and time for their mind to wander freely.

Female, 25 to 34, patient depth said:

I prefer walking alone… it’s alone time to recharge.

For others, spending time in nature with others was felt to be helpful and appealing because it provides an opportunity to socialise and/or talk about their mental health. This could be with family or friends, the community or organised groups.

Male, 55 to 64, patient group said

It helps a lot of people… going out and being with like-minded people.

Similar levels of engagement with nature were reflected among clinicians, with the majority also spending time in nature at least weekly. In fact, clinicians spend more time outside in green and natural spaces than the public, with 8 in 10 (81%) saying they spend time at least weekly (versus 68% of the public). Around 4 in 10 clinicians (38%) spend time every day or most days, a similar proportion (42%) about once or twice a week, and over one in 8 (12%) once or twice a month. Just over one in 16 (6%) spend time in nature less than once a month and only 1% said never.

Figure 2: frequency of time spent in nature by clinicians

D5 - How often, if at all, do you spend time outside in green and natural spaces? Base: all clinicians (501).

Figure 2 shows that 38% of clinicians said every day, 42% said about once or twice a week, 12% said about once or twice a month, 6% said less often than monthly, and 1% said never.

Awareness of (green) social prescribing

This section covers the extent to which clinicians and the general public are aware of social prescribing and GSP. It also explores what clinicians know about the availability of GSP in their area, and what information they need in order to effectively prescribe and refer patients to nature-based activities. The key findings are:

• awareness of GSP among clinicians is relatively high, though fewer are aware of it than are aware of social prescribing
• the public are aware that their healthcare professional can refer them to non-medical support but are less clear on what options are available to them locally
• clinicians would value more information on the availability of local services or activities to which they can refer patients, as well as feedback about patient outcomes following referral to a nature-based activity

Awareness of green social prescribing among clinicians

Among clinicians there are high levels of awareness of social prescribing, with 9 in 10 (91%) knowing at least a bit about it. Fewer know of green social prescribing, though around half (51%) know at least a bit; see figure 3.

GPs have higher levels of awareness than non-GPs for both social prescribing in general (61% of GPs know a lot compared to 23% of non-GPs) and green social prescribing in particular (19% versus 9% know a lot).

Figure 3: awareness of social prescribing and GSP among clinicians

A1 - Have you heard of social prescribing, sometimes known as community referral? Base: all clinicians (501)

A2 - Have you heard of social prescribing to nature-based activities, sometimes known as green social prescribing? Base: all clinicians (501)

As shown in figure 3, the full results of question A1 are:

• 51% of clinicians had heard of social prescribing and know a lot about it
• 40% of clinicians had heard of it and know a bit about it
• 8% had heard of it but don’t know much or anything about it
• 1% of clinicians had never heard of social prescribing.

Also shown in figure 3 are clinicians’ responses to the question ‘have you heard of social prescribing to nature-based activities, sometimes known as green social prescribing?’ 16% of clinicians had and know a lot about it, 35% had and know a bit about it, 26% had but don’t know much or anything about it, and 24% of clinicians had not heard of it.

The relatively lower levels of awareness of the term ‘green social prescribing’ among clinicians may be because clinicians do not know of GSP as an intervention distinct from social prescribing. In the qualitative interviews, clinicians described how they would typically make a referral to a social prescriber when they felt that non-medical support would benefit a patient, without necessarily being specific about the type of intervention.

GP, high level of GSP knowledge, female, 35 to 44 said:

It’s the same for us, green or just social prescribing. Depending on what the patient needs are, I’ll say that I’ll refer them to a social prescriber, or give them some information… I let the social prescriber then carry on with it.

More information on the referral process can be found in the ‘Experiences of the referral process’ chapter.

Awareness of green social prescribing among public and patients

Among the public, awareness that HCPs can refer to non-medical support is relatively high (61% are aware, as shown in figure 4), but only a third feel that they have enough information about non-medical sources of mental health support (33%). Similarly, only a third of people are aware of the different nature-based activities available in their local area (34%).

Figure 4: the public’s awareness of non-medical sources of mental health support

A3a - Before completing this survey, were you aware that healthcare professionals, such as your GP, could refer you to non-medical sources of mental health support (for example, support groups or community activities)? Base: all public (4,000)

A3c - Do you have enough information about non-medical sources of mental health support within your local area (for example support groups or community activities)? Base: all public (4,000)

B3_1 - To what extent do you agree or disagree with the following statements? I am aware of the different nature-based activities available in my local area. Base: all public (4,000)

As shown in figure 4, 61% of respondents were aware that healthcare professionals such as a GP can refer patients to non-medical sources of mental health support (for example, support groups or community activities). 34% were not aware and 6% said they don’t know.

Figure 4 also shows that 46% of respondents felt that they do not have enough information about non-medical sources of mental health support, whereas 33% said they do have enough information, and 21% said they don’t know. Finally, figure 4 demonstrates that 34% of respondents are not aware of the different nature-based activities in their local area. 37% are aware of such activities and 29% said that they don’t know.

Those who have spoken to a healthcare professional about their mental health within the last 12 months are significantly more likely to feel that they have enough information about mental health support (49% versus 33% on average). This suggests that those who have interacted with a healthcare professional have been given the information that they needed. Those who have greater awareness of nature-based activities within their local area are those likely to be spending time in nature daily, or several times a week (38% versus 33% on average). As previously described, this includes those who are already in good health and living in a high-income household. Those educated to degree level are also more likely to be aware of local nature-based activities (38% versus 34% average).

The qualitative research highlighted that patients experiencing poor mental health are unlikely to be aware of GSP, so may not request it when seeking help from their GP or understand what it involves if referred.

In the qualitative interviews, patients commonly recalled that clinicians had mentioned ‘getting outside in nature’ to them during a conversation about their mental health. This generally ‘made sense’ to them as they were broadly aware that being outdoors and exercising is beneficial for supporting their mental health. However, it was rare to have been told about a specific organised activity or group. Where getting outdoors or doing some exercise had been mentioned, it usually had not been perceived as a formal ‘referral’ or ‘prescription’.

Female, 45 to 54, patient depth said:

There was some guidance, but it was just about going off and allowing yourself to connect with nature. It was reasonably informal.

Male, 55 to 64, patient group said:

I’ve seen on Gardener’s World… lots of group gardening activities prescribed by GPs but I don’t know if anything like that is available round my area… it’s never been offered to me.

Feedback from both clinicians and patients suggests that where (green) social prescribing does happen, it is not talked about using the term ‘prescribing’.

Experience of referring to (green) social prescribing

Exactly 4 in 5 (80%) clinicians have experience of social prescribing. Further, 7 in 10 (70%) clinicians who have ever referred patients to social prescribers do so at a rate of at least once per month, including 29% referring once per week or more, as shown in figure 5. Those who refer patients weekly are most likely to refer one to 3 patients per week (62%).

Figure 5: how often clinicians refer patients to link workers

B4 - How often do you currently refer patients to link workers? Base: HCPs who have referred patients to link workers in the past (403)

B5 - How many patients have you referred to link workers in a standard working week? Base: HCPs who currently refer patients to link workers weekly or more often (117)

As shown in figure 5, of 403 link workers who have referred patients in the past, 29% refer patients once a week. Full responses are:

• 41% said they refer patients once or twice a month
• 26% said they refer patients less than once a month
• 3% said they currently never refer patients and have only referred patients in the past
• 1% said they don’t know

Of the 117 link workers who refer patients on a weekly basis, 62% refer 1 to 3 patients a week. The mean average number of referrals made by link workers who refer weekly is 6 per week.

Although clinicians have knowledge at an overall level of the referral process for GSP - almost three quarters know how to refer a patient (74%) - detailed knowledge of local options is lacking. Figure 6 shows how under a third of clinicians (30%) are aware of the nature-based activities in their area.

Figure 6: clinicians’ knowledge of how to refer patients to social prescribing, and the availability of GSP in the local area

A3_1 - To what extent do you agree or disagree with the following statement? I am aware of how I can refer patients to a social prescribing link worker.

A3_2 - To what extent do you agree or disagree with the following statement? I am aware of the nature-based activities that are available in my area which social prescribing link workers could connect patients to. Base: all clinicians (501)

Figure 6 shows that overall, 74% of clinicians agreed they know how to refer patients to a social prescribing link worker. Of this 74%, 88% of GPs and 36% of non-GPs agreed. When clinicians were asked if they are aware of nature-based activities available in their local area which social prescribing link workers refer patients to, 30% of clinicians agreed overall. Of this 30%, 33% of GPs and 23% of non-GPs agreed.

GPs know more about social prescribing and GSP than non-GPs: they were more likely to have had experience of social prescribing (91% versus 48% of non-GPs), to know how to refer patients to social prescribers (88% versus 36% of non-GPs), and to know about the nature-based activities available in their local area (33% versus 23% of non-GPs). The greater familiarity with GSP among GPs may reflect a difference in referral routes, detailed later in the ‘Experiences of the referral process’ chapter.

In the qualitative interviews, while most clinicians were clear that a referral to GSP involves patients spending time outside, possibly walking or gardening, with most mentioning some form of exercise, the majority were unclear of specific activities within their local area. Most were also unaware about how to access or refer to them, even if they were aware of certain activities that were taking place for example local walking groups.

GP, high level of GSP knowledge, female, 45 to 54 said:

[GSP aims] to get people involved in outdoor activities that are good for them. But what those are and how to access them I don’t know.

Clinicians learned about GSP largely within the medical community including from academic journals, NHS newsletters, and hearing about it directly from colleagues. Most clinicians felt that the information currently available on GSP was not widely available enough and that information available on Google was not very clear.

Perceptions of (green) social prescribing

This chapter explores clinician and public appetite for (green) social prescribing as well as perceptions of the benefits it can bring and barriers to referral and participation. The key findings are:

• overall, the appetite for social prescribing is high among clinicians and nearly all say they would be likely to refer patients to social prescribers in the future. Similarly, patients and the public are open to trying a range of activities to help support their mental health, with the vast majority suggesting that this would include spending time in nature
• patients and the public anticipate experiencing a range of benefits from taking part in nature-based activities. Clinicians also widely feel that GSP has benefits in terms of the mental and physical health of their patients. Fewer clinicians – although still a majority – feel that GSP also benefits the wider health system
• clinicians value green social prescribing as part of a holistic approach to patient care, though a significant minority believe that patients would prefer more traditional interventions, such as medication and therapy. Feedback from patients confirmed this - while the majority are open to GSP as part of a holistic approach to managing their health, for some, medication and therapy are also important, particularly at ‘crisis’ points
• there are a range of (potential) practical and attitudinal barriers to engaging with nature-based activities: some patients are concerned about the potential cost or logistical difficulty of taking part, while others lack confidence to go alone. Addressing these barriers could help increase uptake and contribute to the success of GSP

Overall views on (green) social prescribing

The appetite for social prescribing is high among clinicians. As shown in figure 7, nearly all (97%) feel favourable towards the concept of social prescribing in general, with around 7 in 10 (68%) very favourable and 3 in 10 (29%) fairly favourable. Two per cent were not very favourable.

Figure 7: favourability towards social prescribing among clinicians

B12_1 - How favourable do you feel towards each of the following? The concept of social prescribing in general. Base: all clinicians (501).

Female clinicians are more likely to feel very favourable towards the concept of social prescribing than male clinicians (77% and 56% respectively).

Nearly all (94%) clinicians said that in the future they would be likely to refer patients to social prescribers: 7 in 10 (70%) would be very likely to do so and 2 in 10 (24%) fairly likely, as shown in figure 8.

Figure 8: how likely clinicians would be to refer patients to link workers for social prescribing in the future

B7 - How likely would you be to refer patients to link workers for social prescribing in the future? Base: all clinicians (501).

All clinicians (501) were asked how likely they would be to refer patients to link workers for social prescribing in future. The full results are:

• 70% of clinicians said they would be very likely
• 24% would be fairly likely
• 3% said they would not be very likely
• 1% said they would be not at all likely
• 2% said they don’t know or prefer not to say

There is a link between the personal behaviour of clinicians in relation to spending time in nature and their professional actions. Clinicians who spend time outdoors at least weekly would be more likely to refer patients to social prescribers in the future than those who spend time outdoors less than weekly (73% versus 57%).

The public are also open to the concept of social prescribing, with two thirds (67%) saying that they would be open to discussing opportunities for mental health support in their local community with a healthcare professional, as shown in figure 9.

Those aged 65 and over are slightly less likely to be keen to discuss this type of support (62% of this age group were open to it versus 68% of 35 to 64s and 70% of under 35s). However, it appears to be a complex picture by age with the very youngest age band, those aged 18 to 24, also a little more reluctant: 12% of this group are not open to discussing community opportunities for mental health support with a healthcare professional compared to 9% of all members of the public.

Figure 9: openness to discussing opportunities for mental health support in local community with a healthcare professional

A4 - To what extent do you agree or disagree with the following statement? I would be open to discussing opportunities for mental health support in my community with a healthcare professional, such a GP or nurse. Base: all public (4,000).

In response to question A4, 26% of respondents strongly agree and 41% of respondents tend to agree that they would be open to discussing opportunities for mental health support in their community with a healthcare professional. 6% tend to disagree, 3% strongly disagree, 20% of respondents said they neither agree nor disagree, and 4% of respondents said they don’t know.

Clinicians said they would consider social prescribing for a range of types of patients - not just those with clear mental health needs but also for those with complex social needs which affect their wellbeing (91%) and patients with one or more long-term physical health conditions (78%).

Around 9 in 10 clinicians would consider referring patients who are experiencing loneliness (91%), depression (90%) or anxiety (89%) to social prescribers in the future. Around 8 in 10 (78%) would consider referring patients who are experiencing grief and bereavement, and around 7 in 10 would consider referring patients who are recovering from severe and enduring mental illness (74%) or who have been experiencing stress for 3 weeks or more (71%). As shown in figure 10, large proportions of clinicians would also refer patients with other conditions: from around 6 in 10 (63%) who would refer patients with panic disorders to around four in ten (43%) who would refer patients with schizophrenia.

Figure 10: issues clinicians would refer patients to social prescribing for

B9 - For which mental health issues would you consider referring patients to link workers in the future? Base: HCPs who would consider referring patients to link workers in the future for mental health (487).

As shown in figure 10, the most common health issue for which healthcare professionals would consider referring patients to link workers is loneliness (91%) closely followed by depression (90%) and anxiety (89%). Other health conditions given were:

• grief or bereavement (78%)
• recovery of severe and enduring mental illness (74%)
• stress lasting 3 weeks or more (71%)
• panic disorders (63%)
• medically unexplained symptoms (61%)
• post-traumatic stress disorder (PTSD) (59%)
• dementia and other organic disorders (58%)
• obsessive compulsive disorder (OCD) (49%)
• substance abuse (48%)
• bipolar disorder (46%)
• phobias (45%)
• schizophrenia (43%)

Clinician appetite for green social prescribing is similarly high, as shown in figure 11, over 9 in 10 (94%) feel favourable towards the concept of prescribing to nature-based activities. Two thirds (65%) feel very favourable towards the concept, and 3 in 10 (29%) feel fairly favourable.

Figure 11: favourability towards green social prescribing among clinicians

B12_2 - How favourable do you feel towards each of the following? The concept of social prescribing to nature-based activities in particular sometimes known as green social prescribing. Base: all clinicians (501).

Figure 11 shows that 65% of clinicians feel ‘very favourable’ and 29% feel very favourable towards the concept of social prescribing to nature-based activities. 3% of respondents feel ‘not very favourable’ and 1% of respondents ‘don’t know’.

As with social prescribing in general, there are differences in attitude to GSP by type of clinician:

• female clinicians are more likely to feel favourable towards the concept of GSP than male clinicians (97% versus 90%)
• clinicians who have at least a little bit of knowledge of the concept are more likely to feel favourable towards it, compared to those who don’t know much or anything about it (96% versus 91%)

Those who are more likely to be very favourable to the concept include:

• those who spend time outdoors daily or most days (75% very favourable versus 42% those who spend time outdoors less than weekly)
• non-GPs (73% compared to 62% of GPs)
• those with disabilities (83% versus 66% of clinicians without disabilities)
• white clinicians (72% compared to 61% of clinicians from ethnic minority backgrounds)

Although clinicians are largely open to green social prescribing, there is no clear consensus on the types of patients that would particularly benefit from GSP rather than other activities included in social prescribing (see figure 12). A third of clinicians (36%) said they don’t know which patients would benefit from nature-based activities as opposed to other activities and one in 10 (13%) think that almost all patients would benefit from nature-based activities. A similar proportion (12%) think patients who are suffering from stress and/or anxiety or who have been diagnosed with other mental health conditions would particularly benefit. Around 2 in 10 (18%) think that patients who are lonely or isolated would particularly benefit. A minority suggest that other types of patients would benefit, including patients suffering from depression (8%) and patients suffering with chronic (long-term) conditions (4%). In the qualitative discussions, clinicians tended to feel that anyone could benefit from participating in green social prescribing.

Female, 45 to 54, GP depth said:

I can’t think of anyone who wouldn’t benefit from green social prescribing.

These findings suggest that clinicians would like to consider the appropriateness of green social prescribing for patients on a case-by-case basis.

Figure 12: types of patients who would particularly benefit from nature-based activities as opposed to other activities included in social prescribing

C4 - Which types of patients, if any, do you think would particularly benefit from nature-based activities as opposed to other activities they could be connected to through social prescribing? Base: all clinicians (501).

Note, this was an open-text question, with an option to select ‘don’t know’. The answers to this question were coded into categories during the data analysis stage.

Figure 12 shows that 13% of clinicians think that all or most patients would benefit from green social prescribing and 36% of clinicians don’t know who would benefit. Other patients they think would benefit are:

• patients who are lonely or isolated (18%)
• patients suffering from stress or anxiety (12%)
• patients diagnosed with other mental health conditions (12%)
• patients who wouldn’t normally undertake this kind of activity (9%)
• any patient who shows an interest in this type of activity (8%)
• patients suffering from depression (8%)
• patients suffering with chronic and/or long-term conditions (4%)
• patients with neurodevelopmental disorders (3%)
• elderly patients (3%)

GPs are more likely than non-GPs not to know which patients would particularly benefit from nature-based activities as opposed to other activities included in social prescribing (41% compared to 24% respectively), perhaps reflecting their greater likelihood to refer patients to a social prescriber who then discusses specific activities with patients. Male clinicians are also less likely to know (43% felt they did not know, compared to 30% of female clinicians).

Most clinicians (57%) feel that it is clear how effective social prescribing in general is, but fewer - slightly under half (47%) - feel that it is clear how effective green social prescribing is (see figure 13).

Figure 13: perceived effectiveness of social prescribing and green social prescribing among clinicians

C5_1 - To what extent do you agree or disagree with the following statements? It is clear how effective social prescribing in general is.

C5_2 - To what extent do you agree or disagree with the following statements? It is clear how effective green social prescribing in particular is. Base: all clinicians (501).

Figure 13 shows that 23% and 34% of clinicians strongly agree and tend to agree that it is clear how effective social prescribing in general is, respectively. 23% tend to disagree and 2% strongly disagree with this. 25% neither agree nor disagree and 4% don’t know.

For green social prescribing, 19% strongly agree and 29% tend to agree that it is clear how effective it is. Whereas 12% and 4% tend to disagree and strongly disagree respectively. 8% of clinicians said they don’t know and 29% tend to disagree.

Around one in 10 (9%) clinicians feel that there is a risk that taking part in nature-based activities could do patients more harm than good. This may relate to the lack of information clinicians have about the activities available in their area leading to concerns that activities may not be suitable for some patients.

Activities to support mental health

As shown in figure 14, clinicians feel that a range of nature-based activities could be beneficial for patients’ mental health, most commonly sport or exercise-based activities (92%) but with over 4 in 5 clinicians also feeling positive about horticulture type activities, for example community gardening, food growing (88%), craft-focused activities, arts and crafts activities using natural resources (86%), farming and caring for animals (85%), conservation (84%) or alternative therapies such as mindfulness in a natural setting (82%). Nature-based talking therapies (78%) and wilderness focussed activities (73%) were also considered potentially beneficial by most clinicians.

Figure 14: nature-based activities that clinicians think could be beneficial for patients’ mental health

C3 - To what extent do you agree or disagree that the following nature-based activities could be beneficial for patients’ mental health? Base: all clinicians (501).

The public are open to trying a range of activities to support their mental health in the future, if needed. Nearly 9 in 10 (87%) would be likely to spend time in nature and a similar proportion (90%) would be likely to spend time with friends and family. Exactly 8 in 10 (80%) would be likely to try exercising and around half (54%) would be likely to engage with arts, crafts and creative activities, for example painting or writing. A similar proportion would take prescribed medication (53%) or attend therapy (45%) - see figure 15.

The public are also receptive to, and likely to act on, advice given by healthcare professionals or social prescribers about how to support their mental health. Across all activities, the public would be more likely to take part if they were advised to do so by a healthcare professional or social prescriber. Importantly, 6 in 10 (59%) would be more likely to spend time in nature if advised to do so.

Figure 15: activities the public would take part in to support their mental health if needed in the future, and impact of being advised to by a healthcare professional or link worker

A2 - How likely is it that you would do each of the following to support your mental health, if needed in the future?

A3 - How much more likely, if at all, would you be to do any of the following activities if you were advised to by a healthcare professional or link worker? Base: all public (4,000).

Respondents were asked if they are likely to complete a range of activities if the activities are likely to support their mental health. As shown in figure 15, the results of this question were:

• 90% said they would spend time with friends and family
• 87% said they would spend time in nature
• 80% said they would exercise
• 54% said they would do arts and crafts
• 53% said they would take prescribed medication
• 45% said they would attend therapy
• 41% said they would meditate
• 40% said they would volunteer in the community
• 31% said they would attend support groups

All respondents from the public were asked if they would be more likely to do these activities if they were recommended by a healthcare professional or link worker. The option ‘take prescribed medication’ was not included as a response for this question. As shown in figure 3, the results were:

• 57% would be more likely to spend time with friends and family
• 59% would be more likely to spend time in nature
• 59% would be more likely to exercise
• 44% would be more likely to do arts and crafts
• 53% would be more likely to attend therapy
• 42% would be more likely to meditate
• 37% would be more likely to volunteer in the community
• 45% would be more likely to attend support groups

Many patients said that they would be likely to take part in a nature-based activity if advised to by a healthcare professional in the qualitative research too, especially if it was an activity that they enjoyed. Most said they would be excited to get out and try something new, though a few did emphasise that they did not want to be forced out of their comfort zone, particularly when feeling low. Broadly, the type of activity they were open to reflected how they liked to spend time in nature more generally - whether alone or connecting with others.

Some examples of activities included:

• walking groups
• water sports, for example kayaking
• gardening
• care farming (the therapeutic use of farming activities for example, looking after animals or growing vegetables)
• yoga
• horse-riding

Perceived benefits of green social prescribing

Among clinicians, there is a strong belief in the benefits of green social prescribing.

Most commonly, clinicians suggest that green social prescribing is likely to lead to improved mental health (87%) and physical health (83%) for referred patients, as well as individuals being able to take greater ownership of their health (76%). Large numbers of clinicians also feel that green social prescribing can reduce inequalities in access to nature (71%) and result in reduced prescription of medicines (63%). It is slightly less common for clinicians to feel that GSP could lead to benefits to the wider health system - reducing the need for additional primary (60%) or secondary (53%) care services or reducing the pressure on wider government services such as local authorities, the Department of Work and Pensions, and so on (56%) - see figure 16.

Figure 16: perceived benefits of green social prescribing among clinicians

C1 - To what extent do you agree or disagree that green social prescribing is likely to lead to the following benefits? Base: all clinicians (501).

Non-GPs were more likely than GPs to agree that green social prescribing could reduce the need for additional secondary care (63% compared to 49%).

The qualitative research gives an insight into why some clinicians do not feel that green social prescribing has (yet) benefitted the wider health system. Clinicians talked about GSP having the potential to make a positive impact on the wider health system, for example taking pressure off services through supporting people after being discharged from secondary care. However, they felt that these effects of green social prescribing are a long way off being realised, given that it is a relatively new and (currently) small-scale policy.

Male, 45 to 54, GP depth said:

I don’t think it reduces the pressure [on the health system] at all at the moment because green social prescribing is not big enough.

Clinicians also felt that green social prescribing may not in isolation positively impact the wider health system, as other changes and strategies are also needed. For example, a few clinicians suggested the need for greater government intervention to encourage behaviour change and/or increased community funding.

The public see a range of potential benefits of taking part in a nature-based activity. As figure 17 shows, nearly two thirds (66%) think that they would experience an increased feeling of calm or relaxation after attending. Around 6 in 10 think that they would experience improved physical health (58%) and an increased connection to nature (56%). Around 4 in 10 think they would experience an increased sense of purpose or motivation (45%), decreased symptoms of mental ill health (41%), increased sense of self-esteem and/or confidence (41%) and an increased sense of community and/or belonging (39%). One in 5 (20%) could also envisage taking part in a nature-based activity leading to greater employability or the gaining of new skills. Four per cent of respondents thought there are no perceived benefits and 9% said they don’t know.

Figure 17: perceived benefits of green social prescribing among the public

B5 - Which of the following benefits, if any, do you think you might experience after attending a nature-based activity as suggested by a healthcare professional, such as a doctor or nurse? Base: all public (4,000).

Individuals with current or recent mental ill health were more likely to think they might experience each of these benefits after attending a nature-based activity. Those aged 65 and over were among the most likely to say that they wouldn’t experience any benefits after attending a nature-based activity (6% compared to 4% average) and that they don’t know what benefits they might experience (13% compared to 9%).

The unique benefits of time in nature versus other socially prescribed interventions

As shown in figure 18, 8 in 10 (80%) clinicians think that spending time in nature offers unique benefits to patients. Thirty-six per cent of clinicians strongly agree and 44% tend to agree that nature-based activities offer unique benefits to patients. 14% of clinicians neither agree nor disagree, 2% tend to disagree and 1% strongly disagree.

Figure 18: agreement with nature-based activities offering unique benefits to patients

C5_8 - To what extent do you agree or disagree with the following statements? Nature-based activities offer unique benefits to patients. Base: all clinicians (501).

Non-GPs are more likely than GPs to feel that nature-based activities offer unique benefits to patients (86% compared to 78%). Similarly, white clinicians are more likely to feel that nature-based activities offer unique benefits to patients compared to their ethnic minority counterparts (85% versus 78%).

In the qualitative research, clinicians advocated the therapeutic effects of simply being in nature.

Female, 55 to 64, non-GP depth said:

It brings people back to nature and it’s very relaxing. It is the most natural form of therapy for anyone.

The unique benefits of spending time in nature are also clear to patients and the public. In the qualitative research, many described why they felt being in nature is uniquely beneficial for their mental health and how it differs to other interventions, such as therapy and medication.

They suggested that spending time in nature provides:

• time for oneself to ‘recharge’
• ability to ‘get away’ from the structure of everyday life
• a multisensory experience
• a change of scenery
• opportunity to see problems in a new light or put them in perspective
• ability to focus on an external setting, as opposed to one’s internal mind. This can be something that is often difficult to do for those with mental health issues

Female, 45 to 54, patient depth said:

There is so much to look at and focus on that isn’t yourself.

A holistic approach to mental health support

Almost 9 in 10 (87%) clinicians believe that green social prescribing has value as part of a holistic approach to patient care, which could also include the use of pharmaceuticals and talking therapy, as shown in figure 19.

Figure 19: GSP having value as part of a holistic approach

C5_5 - To what extent do you agree or disagree with the following statements? Green social prescribing has value as part of a holistic approach which may also include use of pharmaceuticals, talking therapy and so on. Base: all clinicians (501).

Figure 19 shows that 46% of clinicians strongly agree and 41% of clinicians tend to agree that green social prescribing has value as part of a holistic approach. Whereas 1% said they tend to disagree and 1% said they strongly disagree. 9% said they neither agree nor disagree and 2% of clinicians said they don’t know.

While clinicians clearly see the value of green social prescribing, 4 in 10 (39%) think that patients would prefer ‘traditional’ treatments, such as medication and therapy, as shown in figure 20.

Figure 20: clinician views on patients’ preference for ‘traditional’ treatments

C5_4 - To what extent do you agree or disagree with the following statements? Patients would rather be prescribed ‘traditional’ treatments, such as medication or therapy than green social prescribing. Base: all clinicians (501).

Figure 20 shows whether clinicians agree that patients would rather be prescribed traditional treatments (such as medication or therapy) than green social prescribing. 7% of clinicians strongly agree and 32% of clinicians tend to agree. 32% of clinicians neither agree nor disagree, 21% tend to disagree and 5% strongly disagree. 3% of clinicians said they don’t know.

Clinicians who spend time outdoors less than weekly are more likely to feel that patients would prefer ‘traditional’ treatments (49% compared to 32% of those who spend time outdoors once or twice a week respectively). This suggests again that clinicians’ personal behaviours and attitudes influence their views on green social prescribing.

In the qualitative research, some clinicians suggested that some patients prefer medication as they think of it as a ‘quick fix’. They mentioned examples of patients who, in seeking support for their mental health, specifically requested medication or a referral to a specialist.

Female, 45 to 54, GP depth said:

There are people who contact us who just want medication or just want a referral to a specialist and they’re not really interested in [green social prescribing].

Other clinicians suggested that there is a general lack of awareness of options such as (green) social prescribing among patients and that this could contribute to patients requesting, or opting for, more traditional treatment options, such as medication or therapy.

In the qualitative research with patients and the public, there were mixed - and strong-feelings on the benefits of medication to support mental health.

Patients and the public acknowledged a strong link between mental and physical health and many spoke of taking a ‘holistic’ approach to managing their health. For many, this involves spending time in nature, as well as making an effort to ensure they sleep well (for example, going to bed earlier or using sleepcasts to fall asleep), eating well, exercising regularly, and for some, this also includes taking medication and attending therapy.

Openness to pharmaceutical intervention depended on individuals’ circumstances and personal views on medication. For example, on the state of their mental health at the time of appointment and/or concerns about, or history with, addiction. Some suggested that medication is needed in certain situations when someone is really struggling with their mental health, and that these individuals may realistically struggle to take part in a new (nature-based) activity at a time of crisis. In these cases, it was suggested that medication could help individuals to ‘rebalance’ and get to a point where they would be receptive to, and benefit from participating in a nature-based activity.

Female, 45 to 54, patient depth said:

I know 100% that medication helps… but I do think there are definitely alternative methods. Meditation and yoga would really help me. If I went to the GP and they suggested trying these things, it would depend how my anxiety was, to how I would respond. If I was really bad I would be like ‘give me the drugs’.

Similarly, some suggested they would feel ‘fobbed off’ if they were solely prescribed a nature-based activity, as they felt it might indicate the clinician was not taking their situation seriously.

Female, 25 to 34, patient depth said:

If it was the only advice given, I would feel disappointed. It is something my mum would tell me, not a doctor. If the advice was part of a plan with other things, then it would be a much more rounded approach.

This view was also shared by clinicians, who described a hesitancy among some patients to participate in nature-based activities, perceiving that it minimises their situation or condition.

Conversely, some patients described how they had felt (or would feel) ‘fobbed-off’ when only offered medication or offered medication straight away without any other options being discussed first. Many felt they would be pleased if they were offered a nature-based activity instead of, or in addition to other interventions such as medication and therapy.

Overall, patients emphasised their desire to be listened to by their clinician and given a range of treatment options. They want clinicians to acknowledge their individual needs and preferences, and consider their health in a holistic way, in the same way they view their own health.

Female, 45 to 54, patient depth said:

[It was important that my clinicians] understood that what I needed was not a one-size-fits-all approach.

Barriers and enablers of taking part in green social prescribing

Just over 2 in 10 (22%) of the public would realistically be unlikely to take part in a nature-based activity even if it was recommended by a healthcare professional, as shown in figure 21.

Figure 21: likelihood to take part in a nature-based activity if recommended by a HCP

B3_7 - To what extent do you agree or disagree with the following statements? Realistically I would be unlikely to take part in a nature-based activity even if recommended by a healthcare professional. Base: all public (4,000).

Figure 21 shows that 25% of respondents tend to disagree and 22% strongly disagree that they would be unlikely to take part in a nature-based activity even if recommended by a healthcare professional. 7% of respondents strongly agree and 16% tend to agree. The remaining 26% neither agree nor disagree.

This reflects a range of potential barriers to engaging with nature-based activities.

When shown a list of potential barriers to participation, the 2 most commonly chosen among the public as a whole were practical ones related to concerns that the activity would involve spending money (36%) and that it would be difficult to get to (33%). These were closely followed by attitudinal barriers, including not wanting to take part in activities with unknown people (32%) and a lack of confidence (27%).

Other barriers include not having the time (27%), needing more evidence that it works (11%), and a belief that ‘traditional’ treatments for mental health are better (7%) - see figure 22.

Figure 22: factors that could prevent patients from attending a nature-based activity as suggested by a healthcare professional

B6 - Which of the following barriers or downsides, if any, do you think could stop you attending a nature-based activity as suggested by a healthcare professional? (Base: all public, 4,000).

The most likely groups to suggest these barriers include people currently experiencing mental health problems, those with poor overall health, those with a disability, women, younger people (18 to 34), those with an income under £15,000 and those living in London. These groups tend to be among the least likely to already spend time in nature, particularly those with an income under £15,000 and those living in London.

In the qualitative research, patients echoed some of these concerns around the potential time, cost and accessibility of activities, reservations about taking part in group activities and wanting more information about what the expected benefits would be. These are described in more detail below.

For those who raised concerns about cost, it was suggested by patients in the focus groups that a small fee could be acceptable but that it should be minimised as much as possible to avoid deterring people from taking part. Reassurance that attending a nature-based activity would be free or would involve only a minimal cost is critical.

For those with disabilities or poor health, the provision of transport or a representative at the activity to make introductions would help to encourage uptake.

Female, 45 to 54, patient group said:

There needs to be support for disabled people… it’s not possible for [a lot of older people and disabled people] to get out on their own.

The company of family and friends, at least at an initial session, would also be helpful for those nervous about attending an unknown activity for the first time.

Those who held doubts about the effectiveness of taking part in nature-based activities would value more information about what the expected benefits are. They would also like to be reassured that they could revisit their clinician if they were not experiencing these benefits after a certain period of time.

Female, 25 to 34, patient depth said:

I would want to know what the expected benefits are… between different activities and settings.

Clinicians in the qualitative research also mentioned needing to be clear about what the expected benefits are in order to encourage uptake among patients.

Female, 45 to 54, GP depth said:

[We] need to be specific about what is available and what the benefit will be – perhaps through evidence of how it has helped others.

Experiences of the referral process

This chapter looks in more detail at the referral process. Key findings are:

• around a fifth of patients have spoken to a healthcare provider about their mental health, typically their GP. Tone is particularly important at this first point of contact, given the distressed and vulnerable state many patients are in when first seeking support for their mental health
• a significant minority do not take up their referral to a nature-based activity - particularly those who do not spend time in nature regularly anyway. Barriers include lack of enthusiasm or motivation, not wanting to, or being prevented by a health condition. This suggests that there are some people for whom a HCP referral to a nature-based activity alone would not be sufficient to overcome the practical or attitudinal barriers they face
• the most common barrier to clinicians making a referral is a lack of knowledge of how to refer. Non-GPs are particularly likely to be unsure how to refer patients to social prescribers, reflecting that they tend not to have direct access to a social prescriber in their team
• clinicians feel that their role is to tell patients about potential non-medical options of support in the community, including nature-based ones, and to direct them to a social prescriber. They then feel it is the responsibility of the social prescriber to explain the interventions and GSP in more detail, and to determine which activity is most beneficial for the patient

Talking to a healthcare provider about mental health

One in 5 (22%) members of the public have spoken to a healthcare provider about their mental health in the last 12 months. In the qualitative interviews, patients described how their first point of contact had most commonly been a conversation with their GP. This was then sometimes followed by a session or sessions with a psychiatrist, therapist, counsellor, or a mental health nurse, if their GP referred them on. Patients described how they had ended up discussing their mental health with their GP for a number of reasons. Some had sought support intentionally, while others had been pushed to seek help by a concerned relative, friend or co-worker. A few had gone to see their GP for a different reason but had ended up discussing their mental health.

It is clear that patients often feel very vulnerable or ‘not themselves’ at the point they see their GP, with some patients describing how emotional they felt during that initial conversation. This highlights the importance of healthcare providers considering their tone and communicating in a sensitive manner.

Patients understand that GPs, in particular, only have a short time with them. However, some felt their appointment had been ‘rushed’ and that they had not been listened to.

Patients generally had a good experience if they:

• felt that their healthcare provider listened to them
• felt that their healthcare provider understood their experience
• felt that their healthcare provider gave them something personalised
• understood why they were being referred on, if that was the next step

Female, 45 to 54, patient depth said:

She’d [psychiatrist] always include me in the conversation, rather than saying ‘you’re going to take this, you’re going to take that’, she’d give me a leaflet… and ask is this something that you want to try? I got the final decision.

The minority of patients who knew their GP generally reported a better experience, as they felt their GP understood them and their specific needs. Patients who spoke to a GP less well known to them had more varied experiences.

Female, 45 to 54, patient depth said:

Speaking to other people and their experiences… the doctors only have 10 minutes so sometimes it can be rushed. Mine listened really well and were very professional and kind…. They cared beyond the individual, asked about my brothers and sisters and really gave personal attention.

It is relatively uncommon for patients to have been prescribed a nature-based activity: only 7% of individuals had received such a referral. Patients described how it was more typical to be advised to ‘get outside’ by their GP. For those who had been referred, activities included walking (typically with a walking group), conservation, meditation, gardening and camping.

Those referred to a nature-based activity were more likely to be:

• disabled (14%)
• under 35 (14%)
• ethnic minorities (15%)
• from London (15%)
• income under £15,000 (11%)
• male (9% versus 6% female)

Of those referred, around four fifths (78%) participated in the activity that they were referred to. Around a fifth (18%) chose not to attend despite the referral, although the rate of non-attendance was more than double (40%) among those who usually spend time outside monthly or less. This suggests that these individuals face barriers to spending time in nature which a ‘prescription’ from a healthcare professional does not help to overcome.

Patients who had been referred by a healthcare professional or social prescriber to a nature-based activity but did not participate gave a few different reasons for this, including that they did not want to (16%), that a health condition prevented them (14%), and that they had heard it was not reliable (9%), highlighting a need for more evidence of effectiveness.

Figure 23: reasons that patients did not participate in a nature-based activity that they were referred to

A8 - Why did you not participate in the activity you were referred to? Base: all who have ever been referred by a healthcare professional or link worker to a nature-based activity but did not participate (49)

Figure 23 shows that 47% of respondents who did not participate in their prescribed nature-based activity would prefer not to say the reason they didn’t attend. Other reasons for non-attendance were the respondent refused/didn’t want to go (16%), a health condition prevented them from doing so (14%), they heard it isn’t reliable (9%), they were referred but no one contacted them (5%).

In the qualitative interviews, one person had not taken up their referral. They explained that this was because they lacked motivation to do anything, including taking part in a nature-based activity, due to how bad they were feeling. This suggests that some individuals who are very unwell at the point of referral may require additional support to participate in the referred activity, such as their social prescriber accompanying them to the activity, or other treatment including medication.

Making a referral

The most common barrier to clinicians referring patients to a social prescriber is not knowing how to do so (43%), or not being aware that this was an option (38%). In other words, a lack of knowledge of the infrastructure rather than a lack of belief in the efficacy of (green) social prescribing. Very few clinicians had not referred due to a belief that social prescribing was ineffective (3%) or that patients are reluctant (2%).

Figure 24: factors preventing clinicians from referring patients to a link worker

B6 - What is preventing you from referring patients to a link worker? Base: HCPs who have not referred patients to social prescribing (93)

The most common reason that HCPs have not referred patients to a link worker is they are ‘not sure how to do so’ (43%). 38% were ‘not aware it was an option’, 27% said ‘there are no link workers for me to refer to’. 21% said it was because they are not sure what a link worker does. The least common reasons were ‘there aren’t enough suitable activities in my area’ (18%) and ‘I have not yet seen a patient I think it would be suitable for’ (12%).

Other practical barriers discussed in the qualitative interviews included:

• lack of time to discuss the benefits of social prescribing in GP consultations
• it being difficult to gauge patient reactions and emotions in telephone consultations
• perceived patient preference for medication by some clinicians

Non-GPs were more likely to report being unsure how to refer patients to social prescribers.^{[footnote 2]} The difference in referral process is likely to play a role in this. In the qualitative interviews, most GPs reported having a social prescriber working in, or with, the surgery, to whom they would send an electronic ‘task’ or email, containing patient notes and a brief explanation for the referral.

Female, 55 to 64, GP depth said:

In our practice it’s very well set up, we very simply just have to write a task to our social prescriber who will pick it up.

Female, 35 to 44, GP depth said:

It’s very simple, we use a computer system called EMIS, within that is a task system. I type an email in the patient notes and there’s a group for the social prescribers and it goes to all of them.

Meanwhile, non-GPs spoke of a less defined and more varied ‘process’. It was more common to refer individuals directly to charities or local voluntary organisations, rather than having access to the social prescribers themselves.

Male, 45 to 54, non-GP depth said:

Perhaps I haven’t looked hard enough, but there don’t seem to be that many obvious routes to [social activities]. There’s no easy central resource or co-ordinator for that. It tends to be what you’ve come across and compiled.

Facilitating easier and more direct access to a social prescriber for non-GPs may help to increase referrals among these clinicians.

Clinicians did not tend to receive feedback as to whether the patient took up the referral to social prescribing, and what activity they were referred to. GPs only reported finding out about this type of information where the patient proactively came back to see them, in which case the referral had largely been unsuccessful (as patients typically presented with the same issue as before the referral took place). They would value feedback more consistently, including when a referral had been successful, in order to judge the intervention more accurately.

GP, high level of GSP knowledge, female, 45 to 54 said:

The biggest thing for me would be to know if it’s making any difference - it’s feedback. It doesn’t have to be a lot… the value of that is that you can say to people who come in subsequently, I’ve referred people to this and they have found it really helpful.

Some non-GPs were more involved in long-term care and were therefore more likely to know the outcome of referrals that were made. However, a couple of psychiatrists working within mental health teams still felt they lacked feedback about the outcome of their referrals from organisations offering nature-based activities. They felt that organisations should be more pro-active in providing feedback to them.

Non-GP, low level of GSP knowledge, male, 55 to 64 said:

I never really get any feedback. I don’t think there’s ever been anybody from these organisations coming back to me saying thanks for the referral, this is what we have done with the referral, or can we ask you a few more questions.

GP, high level of GSP knowledge, female, 35 to 44 said:

Positive feedback would be helpful to remind us to send a referral when you’re within a busy clinic… it’s another few minutes that needs to happen.

Role of each healthcare provider

Just over half of clinicians (53%) feel that it is the responsibility of the healthcare provider to talk about nature-based activities in a way that encourages patient take-up; see figure 25.

Non-GPs are more likely to feel this responsibility than GPs (63% versus 50%), which reflects that they are less likely to have strong links with social prescribers and so are more likely to be the only ones talking to their patients about nature-based activities.

Figure 25: clinicians’ level of agreement that it is the responsibility of HCP to talk about nature-based activities in a way that encourages patient take-up

C5_7 - To what extent do you agree or disagree with the following statements? It is the responsibility of the HCP to talk about nature-based activities in a way that encourages patient take-up. Base: all clinicians (501)

As shown in figure 25, clinicians’ responses to this statement were:

• 19% strongly agree
• 34% tend to agree
• 29% neither agree nor disagree
• 10% tend to disagree
• 6% strongly disagree
• 2% don’t know or prefer not to say

The qualitative interviews suggest that, overall, clinicians tend to feel that their role extends to increasing awareness amongst patients and directing them to a social prescriber. They felt it would then be the responsibility of the social prescriber to explain the interventions and GSP in more detail, and to determine which activity is most beneficial for the patient.

Clinicians felt that social prescribers add a lot of value to patients because it is impossible for clinicians to remember all of the different activities and options available. In general, clinicians emphasised the need for healthcare professionals across the social prescribing pathway to ‘talk from the same script’.

GPs were particularly likely to feel that their role is to signpost to the social prescriber, not to talk in detail about GSP or nature-based activities. This was either because they lacked the time in their 10-minute consultation or because they felt that it is not their domain. Non-GPs were more likely to feel that they would have time to discuss the benefits of nature-based activities with their patients.

Female, 35 to 44, non-GP depth said:

The GP has a responsibility to mention, even briefly… the benefits of getting outside for mental health. For the GP to then tell someone what to do and where to go is just not feasible. The responsibility in that regard is on the GP to use that social prescriber.

Female, 35 to 44, GP depth said:

Depending on what the patient needs are, I’ll say that I’ll refer them to a social prescriber, or give them some information… I let the social prescriber then carry on with it.

This is supported by findings from the survey, where non-GPs who have referred patients to social prescribers in the past are more likely than GPs to have talked to a patient about the benefits of participating in a nature-based activity (84% versus 66%), and to have given an example of a nature-based activity to a patient when referring them (76% versus 38%). See figure 26.

Figure 26: frequency of talking about the benefits of nature-based activities or giving an example of an activity when making a referral

B10_X - Have you ever done the following? Base: HCPs who have referred patients to link workers in the past (403): GPs (340), non-GPs (63).

69% of healthcare professionals have spoken to a patient about the benefits of participating in a nature-based activity. Of these, 84% of GPs have and 66% of non-GPs have. 44% of healthcare professionals have given an example of a nature-based activity to a patient when referring them to a link worker. Of these, 76% of non-GPs have and 38% of GPs have.

Clinicians are also more likely to have done both if they:

• spend time outdoors daily or most days, compared with less than weekly (77% versus 55% talked about the benefits; 51% versus 32% had given an example of an activity)
• perceive green social prescribing to be effective, compared with those who did not (80% versus 61% talked about the benefits; 59% versus 30% had given an example of an activity)
• know at least a little bit about GSP, compared with those who did not know much or at all (84% versus 50% talked about the benefits; 61% versus 22% had given an example of an activity)

Clinicians felt it was then the responsibility of the patient to follow through with the referral.

Patients generally recognised that the social prescriber was likely to have more time to explain the interventions and the activities available and benefits than their GP. They also recognised that the social prescriber may have more knowledge in this area. While the GP’s voice was felt by a few to add credibility, it mostly was not seen as crucial to patient uptake for the GP to mention the nature-based activity.

Male, 25 to 34, patient group said:

[I’d be] more inclined for a link worker’s prescription than a GP. Haven’t had a good relationship with most GPs. Their skillset and job focus is more general. A link worker is more specialised.

Male, 55 to 64, patient group said:

I might if the link worker knew more about what was going on in the community. I’d go for the link worker, I’d hope that they had a wide range of things to offer you.

Female, 65 and over, patient group said:

The amount of time the GP has for you isn’t enough… link workers do [have enough time].

Patients had mixed views on nature-based activities being ‘prescribed’, with some viewing the term as too medicalised and off-putting. On the other hand, some felt that it could encourage uptake and lend credibility if a nature-based activity was prescribed by a professional. In general, using the word ‘prescribing’ or ‘prescription’ was not felt necessary, as long as it is clear to patients that this is a referral that they need to follow through on. A check-in with the GP after a referral was also felt to be very important.

Female, 25 to 34, patient depth said:

To have a healthcare professional say you have to do it means I probably would.

Female, 55 to 64, non-GP depth said:

It’s probably a bit too clinical-sounding… [but patients] might take it more seriously if the term prescribing is used.

Scaling up green social prescribing as an intervention

This section considers the evidence clinicians and the public need to be convinced of GSP. It also explores the recommendations from clinicians on whether and how to scale up GSP, with particular attention to increasing awareness and referrals among non-GPs. The key findings are:

• while some clinicians did not know what would encourage greater engagement with GSP amongst healthcare professionals, others feel that better promotion of the intervention, providing more information for clinicians (such as statistics on outcomes), and making referrals easier would help
• overall, when asked to consider the benefits of including GSP in the National Institute for Health and Care Excellence (NICE) guidelines, clinicians think inclusion presents significant benefits, including making clinicians more confident in referral, prompting them to consider GSP and improving the acceptability amongst patients
• however, there are risks of inclusion in the NICE guidelines including limiting the types of patients the guidelines suggest for referral to meet evidence requirements, and potentially complicating the referral process for clinicians with stricter guidelines than clinicians feel is necessary

Information or evidence needed

When clinicians were asked what would encourage greater engagement with green social prescribing among healthcare professionals, almost half (49%) said they did not know what would help. This was more prevalent amongst GPs than non-GPs (52% versus 40%).

Of those who provided suggestions, around 4 in 10 (41%) clinicians feel that increasing awareness and promotion of GSP would encourage greater engagement with the intervention among healthcare professionals. Additionally, almost a third (30%) of clinicians feel that increasing the information available for professionals, including research, statistics on outcomes and general education would encourage engagement.

A quarter (26%) feel that making it easier for clinicians to refer patients and for patients to access nature-based interventions would encourage engagement. This goes hand-in-hand with the one in 6 (15%) who feel that increasing capacity and opportunities for GSP are critical to encourage take-up.

Figure 27: clinician suggestions for encouraging greater engagement with green social prescribing amongst healthcare professionals

C6 - Is there anything you would like to add about how to encourage greater engagement with green social prescribing? All clinicians who suggested additions (216).

As shown in figure 27, the full results to this question are:

• 41% said increased awareness and promotion of GSP
• 30% said more information available for professionals (for example, research and statistics)
• 26% said make it easier to refer, access and prescribe
• 15% said more capacity and GSP opportunities
• 8% said support with access and ensuring that referrals are picked up
• 6% said more research into the benefits
• 4% said longer running or more consistency across GSP schemes
• 3% said good communication from local providers
• 2% said ensuring GSP and link workers are adequately skilled and qualified

To enhance the public’s awareness of GSP, clinicians suggested using media channels such as TV, radio and social media to help make information more accessible. Some also suggested that it would be beneficial to place posters in hospitals or waiting rooms to advertise the options to those who it might help, for example, those exiting long-term patient care facilities.

Clinicians also felt that information available to them about GSP was not specific enough to local areas, which led to a gap in their knowledge of which activities were available locally to which they would be able to refer their patients.

Non-GP, low level of GSP knowledge, female, 55 to 64 said:

[Information] is all at a national level still. … I couldn’t see any local examples of how [GSP] was going to be put into place.

Clinicians suggested that being able to access a directory which is searchable by local authority would be helpful. This could collate information about which nature-based activities are taking place in the local area, where they are happening, who to contact at the organisation, and availability. This could then be used by clinicians themselves to understand quickly and easily what is available in their local area. This would also ensure that clinicians would not mention a type of activity to their patient if it is oversubscribed and therefore not available as an option.

Non-GP, high level of GSP knowledge, male, 45 to 54 said:

It would be incredibly useful to have that information, ideally at the point of discussing it with a patient. The gold standard for me would be I talk to a patient about walking in nature, and I hand them a leaflet at that point in time.

Clinicians also wanted to know more about outcomes for patients who had been referred to activities. This would inform clinicians’ future decision-making and would allow them to more effectively refer someone who may benefit from an intervention.

Including green social prescribing in the NICE guidelines

In the qualitative interviews, when asked to consider the benefits of including GSP in NICE guidelines, most clinicians felt that its inclusion could help to encourage the uptake of GSP amongst the public. This was predominately due to clinicians feeling that having the intervention specified in the guidelines would lend credibility and prompt investment in the infrastructure around it. One clinician likened this to the inclusion of acupuncture in the guidelines previously.

Male, 45 to 54, GP said:

[Having it in the NICE guidelines] was a game-changer for opening up acupuncture, and we had to commission it as a health service.

Clinicians also felt that being included in NICE guidelines would boost its credentials in the medical community and the acceptability of discussing referral as a treatment option. Some clinicians would refer to NICE guidelines when considering referral and treatment options and felt that seeing GSP there would prompt them and other clinicians to consider it. They also felt it would help in justifying the treatment to patients.

Female, 35 to 44, GP said:

Having stuff in the NICE guidelines makes a difference… having the guideline backs up our decision-making quite a lot. I can say to the patient… the guidelines are…

One clinician also felt that its inclusion in NICE guidelines would empower patients to ask for GSP.

However, clinicians raised a few concerns. Some felt the inclusion of GSP in NICE guidelines would not be necessary as many clinicians are already convinced of the benefits of GSP. Given the evidence base requirements for inclusion in the guidelines, those clinicians felt that it could narrow down the criteria for patient referral.

Finally, a few clinicians were concerned that including GSP in the NICE guidelines would not help clinicians decide how to treat non-typical or more complex patient cases.

Male, 45 to 54, non-GP said:

NICE guidelines are very useful for uncomplicated cases… as soon as you get into more complex cases, you have to base your prescriptions on more than just NICE guidelines.

Conclusions

Both clinicians and the public buy-in to the idea of green social prescribing and believe that there are a variety of benefits to be gained from spending time in nature.

Both audiences also feel that there is a useful role for healthcare professionals to play in terms of:

• explaining to patients the benefits of specific nature-based activities for them
• encouraging patient uptake of nature-based activities, through talking about nature-based activities in a positive way as part of a holistic care plan

A holistic care plan would include:

• nature-based activities being offered at the right time to patients (when mental ill health symptoms are not too acute as patients are unlikely to be receptive to trying out a new activity when in crisis)
• other options such as medication and/or therapy being considered alongside nature-based activity based on a discussion between the clinician and the patient
• a timeframe being agreed for ‘trying out’ nature-based activity, with an invitation to return to the clinician if an improvement is not seen after this time

Clinicians would also value knowing the outcome of referring patients to nature-based activities so that they can start to build knowledge of the success of these referrals.

Social prescribers (or link workers) are valued by both clinicians and patients for the extra time they are able to devote to helping patients choose the right option for them. The most common reason that clinicians had not referred a patient to a social prescriber was that they were unsure how to do so and this was particularly common among non-GPs. Building the infrastructure so that there are more social prescribers available - and stronger links between secondary care and social prescribers - feels critical to scaling up green social prescribing.

While social prescribers are felt to hold the key role in terms of giving details of activities available to patients, making information on local activities available to clinicians would increase their ability to give relevant examples of local activities to patients at the point of referral.

Including green social prescribing in the NICE guidelines would generally be welcomed by clinicians to boost its credentials as a treatment option, as long as the terms governing its use are not too prescriptive.

Having a variety of nature-based activities available is desirable so that patients can choose something they will enjoy and that is suitable for them. Activities should be affordable and easy to access. Patients need to be given enough information about what to expect from activities and practical details such as what to wear, bring and so on.

Activities must be welcoming given that people can be wary of attending activities with people they don’t know, particularly when feeling low or anxious and so on. Allowing people to take a friend, at least initially, or to meet a group leader in advance could help alleviate such concerns.

Despite fairly modest referral rates at present, there is certainly scope to scale up GSP as:

• clinicians feel that it is suitable for a wide range of types of patients
• most members of the public would consider spending time in nature to support their mental health in future

It is likely to need many stakeholders working together to make the system work optimally, including clinicians, social prescribers, policy makers, commissioners and the providers of nature-based activities.

However, the need for this work is clear. Scaling up green social prescribing maximises the chances that benefits to the wider health system will be seen, such as reducing need for secondary care services, as well as - critically - providing benefits for patients’ physical and mental health.

Technical appendix

This appendix provides more detail on research approach including information on cognitive interviewing, sampling, pilot fieldwork, quality control processes and profiles of achieved interviews.

Cognitive interviewing

IFF Research conducted 15 cognitive interviews during February 2022 to ensure that the questionnaires for the mainstage surveys were thoughtfully designed and easy to understand. This was particularly important since the patients and public survey touched on sensitive subjects, such as mental ill health of respondents, and the clinicians survey included some degree of complexity, covering both social prescribing in general and green social prescribing in particular. Sample was provided from 2 recruitment panels, known to have access to clinicians and those experiencing mental ill health.

IFF conducted 5 interviews with clinicians, comprising 2 GPs, one mental health specialist nurse and one community psychiatry nurse. 10 interviews were conducted with the general public, comprising 5 who self-identified as experiencing mental ill health at the time of interview, and 5 not experiencing mental ill-health.

Respondents were asked to read through the draft questionnaire, commenting on clarity, relevance and ease of answering. They were probed on specific understanding of definitions (including that of social prescribing, GSP and link workers), phrasing (including ‘support your mental health’) and asked for wider comments on the list of pre-coded options provided in the draft questionnaire.

Following this, a few changes were made to the survey questions ahead of the quantitative research phase, including:

• simplifying language around types of nature-based activities and their descriptions for example, not limiting what is considered as exercise or sport by providing a list of activities
• removing certain options which weren’t well understood or chosen by respondents for example, mention of ‘green gyms’ and ‘citizen science’
• ensuring that common mental health problems which are likely to be linked to social prescribing were included in the pre-coded lists as suggested by clinicians for example, grief or bereavement, substance abuse and schizophrenia
• adding questions on household income and education level for patients and the public to gain a good indication of the sample’s social deprivation levels
• reiterating GDPR statements at the end of the survey when asking for contact information to add additional reassurance for participants

Sample

Public

Sample for the public survey was sourced from Bilendi, a consumer panel. Targets for these were set using ONS statistics on gender, age, ethnicity, region and achieved qualifications to ensure the data was nationally representative.

Clinicians

A total of 14,350 records were sampled from Wilmington Healthcare’s databases of clinicians:

• 10,501 GPs
• 1,957 specialist hospital doctors
• 1,207 specialist hospital nurses
• 703 community psychiatric nurses

Any duplicate records were removed (identified using email address), and any individuals that had previously unsubscribed from other IFF Research projects were also excluded. 351 survey completes were from contacts from Wilmington Healthcare.

To ensure representative findings from doctors, the M3 Panel was used to source additional respondents. 150 survey completes were achieved from their panel members.

Pilot fieldwork

Both surveys had a 3-day pilot phase during March to ensure that fieldwork was running smoothly and to assess survey length and response quality.

Pilot fieldwork was conducted with 100 members of the public, and 18 clinicians. Their answers were included in the mainstage results subject to passing quality control checks (see below).

A few changes were made to the clinician survey, such as minor routing amends or adding a new answer option (for example, ‘mental health specialist doctor working in the community’ to the question asking about job role).

No amends were made to the public questionnaire.

Quality control

Strict quality control processes were applied to the survey data. This included removing anyone who completed the survey in under 4 minutes, as this was deemed too quick to be able to answer the questions meaningfully, removing those who ‘flatlined’ across questions (that is, those who had selected the same answer option at every question) and those who didn’t enter legitimate responses in free text boxes.

Profile of participants in the quantitative stage

Public

The tables below show the number and proportion of completed interviews achieved with the public by various factors of interest. It also shows the final profile of interviews after weighting was applied to ensure the dataset was nationally representative.

Rim weights were applied to the dataset by gender, age, region, ethnicity, household income, and disability to ensure as close a match as possible to nationally representative statistics.

Table 3: patient and public profile by gender

Gender	Achieved (n=)	Achieved (%)	Weighted (%)
Female	2,357	59%	51%
Male	1,617	40%	48%

Table 4: patient and public profile by age

Age	Achieved (n=)	Achieved (%)	Weighted (%)
18 to 24	276	7%	11%
25 to 34	567	14%	17%
35 to 44	609	15%	16%
45 to 54	709	18%	18%
55 to 64	576	14%	15%
65 to 74	862	22%	16%
75 to 84	289	7%	6%
85 and over	17	*%	*%

Table 5: patient and public profile by region

Region	Achieved (n=)	Achieved (%)	Weighted (%)
East of England	368	9%	9%
East Midlands	487	12%	11%
London	589	15%	16%
North East	233	6%	5%
North West	510	13%	13%
South East	647	16%	16%
South West	418	10%	10%
West Midlands	340	9%	10%
Yorkshire and the Humber	388	10%	10%

Table 6: patient and public profile by education

Education	Achieved (n=)	Achieved (%)	Weighted (%)
Degree or higher	1,378	34%	39%
A-level or equivalent	790	20%	21%
GCSE, O-level, CSE or equivalent	994	25%	22%
Other	538	13%	12%
No formal qualifications	215	5%	4%

Table 7: patient and public profile by household income

Household income	Achieved (n=)	Achieved (%)	Weighted (%)
Under £15,000	785	20%	10%
£15,000 to £29,000	1,140	29%	25%
£30,000 to £50,000	750	19%	23%
Over £50,000	535	13%	22%

Table 8: patient and public profile by ethnicity

Disability status	Achieved (n=)	Achieved (%)	Weighted (%)
Disability	1,274	32%	22%
No disability	2,569	64%	74%

Clinicians

The tables below show the number and proportion of completed interviews achieved with clinicians by various factors of interest. It also shows the final profile of interviews after weighting was applied to ensure the dataset was nationally representative.

Rim weights were applied to the GP data (based on medical register data from the GMC data explorer) to ensure as close a match as possible to nationally representative statistics by gender, age, ethnicity, and area where the clinician gained their primary medical qualification. Non-GP data was not weighted due to a lack of available population statistics.

Table 10: clinician profile by role

Role type	Achieved (n=)	Achieved (%)	Weighted (%)
GP	370	74%	n/a
Non-GP	131	26%	n/a

Table 11: clinician profile by age

Age	Achieved (n=)	Achieved (%)	Weighted (%)
Under 30	6	1%	1%
30 to 49	217	43%	41%
50 and over	217	43%	46%

Table 12: clinician profile by gender

Gender	Achieved (n=)	Achieved (%)	Weighted (%)
Male	208	42%	42%
Female	279	56%	55%

Table 13: clinician profile by ethnicity

Ethnicity	Achieved (n=)	Achieved (%)	Weighted (%)
Ethnic minorities	148	30%	32%
White	323	65%	57%

Table 14: clinician profile by origin of primary medical qualification (PMQ)

Origin of PMQ	Achieved (n=)	Achieved (%)	Weighted (%)
UK	405	81%	76%
European Economic Area (EEA)	20	4%	5%
Outside UK/EEA	63	13%	16%

Table 15: clinician profile by disability status

Disability status	Achieved (n=)	Achieved (%)	Weighted (%)
Disability	33	7%	6%
No disability	444	88%	88%

Profile of participants in the qualitative stage

Patient depths and patient groups

Table 16: patient depth and patient group profiles by mental health issue

Mental health issue	Depths achieved	Groups achieved
Anxiety	10	11
Stress lasting 3 weeks or more	5	8
Loneliness	2	4
Depression	11	4
Panic disorders	1	1
Post-traumatic stress disorder (PTSD)	1	1
Phobias	0	2
Obsessive compulsive disorder (OCD)	1	0
Bipolar disorder	0	1
Grief or bereavement	0	4

Table 17: patient depth and patient group profiles by gender

Gender	Depths achieved	Groups achieved
Female	8	7
Male	7	7

Table 18: patient depth and patient group profiles by age

Age	Depths achieved	Groups achieved
18 to 24	0	1
25 to 34	2	4
35 to 44	5	3
45 to 54	7	2
55 to 64	1	3
65 and over	0	1

Table 19: patient depth and patient group profiles by region

Region	Depths achieved	Groups achieved
East of England	2	0
East Midlands	0	1
London	5	2
North East	2	1
North West	0	5
South East	4	2
South West	1	0
West Midlands	1	3
Yorkshire and the Humber	0	0

Table 20: patient depth and patient group profiles by ethnicity

Ethnicity	Depths achieved	Groups achieved
White	8	8
Ethnic minorities	7	5
Prefer not to say	0	1

Clinicians

Table 21: clinician profile by role

Role type	Achieved
GP	15
Non-GP	10

Table 22: clinician profile by non-GP role type

Non-GP role type	Achieved
Mental health specialist doctor based in a hospital	3
Mental health nurse based in a hospital	1
Mental health doctor based in the community	1
Specialist psychiatrist based in the community	2
Community nurse	1
Consultant psychologist	1
Other	1

Table 23: clinician profile by gender

Gender	Achieved
Female	15
Male	10

Table 24: clinician profile by age

Age	Achieved
35 to 44	4
45 to 54	10
55 to 64	10
65 and over	1

Table 25: clinician profile by ethnicity

Ethnicity	Achieved
White	20
Ethnic minorities	5

1. While we used the term ‘link workers’ in the questionnaires, we use ‘social prescribers’ throughout this report to reflect the language that clinicians most commonly used in the qualitative interviews. ↩

2. A difference of 54% non-GPs versus 19% GPs in the survey is not statistically significant due to the small base size for GPs (26), but this also came out in the qualitative research. ↩