Research and analysis

National green social prescribing delivery capacity assessment: final report

Published 30 March 2023

Applies to England

Executive summary

The aim of this national green social prescribing (GSP) delivery capacity assessment is to quickly improve our understanding of the existing provision of green and nature-based activities across the country and help determine whether the current level of provision is sufficient to support social prescribing referrals equitably to these activities if rolled out nationally.

To address this aim, we developed a methodology that combines extensive and intensive research phases. In the extensive phase we build a broad picture of the GSP landscape in England. In the intensive phase we provide more granular insights into GSP focused on 6 deep dive locations across the country.

Methods employed included 3 surveys, interviews with key stakeholders, and desk-based research, including a literature review. A 7-element framework was used to analyse and discuss the capacity of green activity providers, link workers, service users and the GSP system as a whole. These elements are:

• performance capacity
• personal capacity
• workload capacity
• facility capacity
• support service capacity
• system capacity
• structural capacity

Drawing upon this framework allowed us to be comprehensive in our treatment of delivery capacity and so resist overly reductive claims about the actual potential for GSP to scale up. At the same time, this study is a rapid assessment. The research was undertaken in a short timeframe and with limited resources, meaning a comprehensive audit of provision was out of scope.

The study identifies many areas of interest for anyone concerned with GSP in England and its potential to be rolled out nationally. From this learning, the following conclusions are drawn:

Nature of GSP

GSP provision in England is diverse, patchy and dynamic. This is the case not just over large areas but also at local levels. Despite the considerable variety in provision, the range of activities typically referred to by link workers is much narrower - predominantly sports and exercise. This suggests there is scope to promote referrals to a greater diversity of nature-based activities, better realising the benefits associated with nature connection (while recognising that sports and exercise activities set in nature also offer opportunity for nature connection).

Current capacity

Many providers have the capacity to support more service users. There are also often many more green activity providers operating in an area than are currently being referred to by link workers. It is by examining other aspects of GSP delivery capacity relating to green activity providers, link workers and service users that we discover why this apparent capacity in provision is not being realised.

Regarding green activity providers, performance capacity is undermined by reliance on a short-term, competitive and precarious funding model. Personal capacity (knowledge, skills and confidence) is variable but often not sufficient to accommodate service users with complex health needs. Workload capacity appears to be low, on average, with low numbers of paid and volunteer staff impacting on service delivery. Finally, support service capacity is variable. Some providers are able to offer support for people with mental health needs through partnerships with mental health organisations while others point to a lack of integration with health providers and inadequate support from mental health services.

Regarding link workers, personal capacity is often sufficient to support clients with mild to moderate mental health needs. However, personal capacity issues arise when clients have complex needs that extend beyond the support they can offer. Workload capacity of link workers is variable. A majority of link workers in the national survey report that demand for their services is well matched to their paid working hours while a significant minority reported that demand exceeds their paid hours. For link workers, mental health support service capacity represents a substantial challenge, especially as people with mental health needs make up a high percentage of link worker clients. This is made more difficult given the number of link workers who feel they receive clients whose mental health needs are too complex to support.

Regarding service users, one capacity challenge is a lack of interest in green and nature-based activities. However, regardless of a service user’s preferences, green and nature-based activities may simply not be a priority. People who have pressing needs - with examples from this study including housing and finance issues - can feel they have little or no time to engage with GSP. At the same time, service users with mental and physical health needs may struggle to attend green and nature-based activities or feel that they are not for them. Finally, many service users have complex needs that require specialist forms of support, often relating to their mental health. Link workers and green activity providers may lack the capacity to work with these service users, especially in the absence of appropriate specialist support services.

Transport

In keeping with the literature, this study finds that affordability and availably of transport is a major factor limiting service user engagement with green and nature-based activities. For example, accessible natural green space is more likely to be available if people are able to travel further. We also found that people with mental health needs can experience the prospect of taking transport as daunting in its own right, inducing stress and anxiety. This adds an additional layer of complexity to the challenge of transport.

At the same time, in 6 locations across the country the study identified more green activity providers than are currently being referred to by link workers. In some cases, substantially more. This suggests there is scope to harness more GSP opportunities within relatively close proximity to service users - although not without addressing many of the capacity challenges outlined in the previous section.

Two further approaches could help to tackle the issue of transport. Firstly, making more of the potential of existing local green space as settings for health, cultural and heritage activities. Secondly, prioritising the development of well-managed local green spaces that can be used for social prescribing activities.

GSP and mental health

GSP services are widely used by people with mental health needs. Many link workers and green activity providers have at least some training and skills to support these service users, especially if their condition is mild to moderate. However, there are other capacity issues that undermine the ability of link workers and green activity providers to offer a service to users with mental health needs. These are detailed above in the section on current capacity.

There is a worrying pattern of link workers and green activity providers receiving patients with complex health conditions that they are not equipped to work with. Often these patients have moderate to severe mental health needs. In effect, these could be considered to be inappropriate referrals. Compounding the issue, we found that providers and link workers lacked specialist support. This can result in a situation that is unfair and risky for these service users while also placing unfair demands on link workers and green activity providers. Rather than GSP being integrated into the NHS in England in a way that enhances overall care, there is a danger it instead acts as a holding system for service users who require more specialised support that is not available to them.

System-wide changes

To enhance GSP delivery capacity, the focus on local provision must be accompanied by system-wide changes. The areas identified include:

1) funding, with a need to move away from short-term competitive funding that drives inefficiencies and uncertainty in provision and incentivises new and different green and nature-based activities at the expense of continuity

2) knowledge and information, with a need to generate awareness of the benefits of green and nature-based activities among GPs, link workers and service users

3) consistency and contextuality, with a need to develop consistent language, metrics and accreditation in an overarching framework that also encourages local variety of green and nature-based activities in ways that meet the needs of communities

4) networks, with a need to strengthen cross-sectoral partnerships and collaboration to facilitate resource and knowledge sharing between the health and third sector

Introduction

Nature offers a diverse array of benefits for health and wellbeing. A growing body of research on the mental health benefits of nature (outlined in the ‘Literature review’ section) shows that in general nature interactions lead to increased psychological wellbeing, reducing the risk and burden of some types of mental illness.

At the same time, opportunities for nature interactions are becoming increasingly limited for many people. Green social prescribing is seen as one way of countering this issue by supporting people to engage in nature-based interventions and activities, including to improve their mental health. It operates through social prescribing link workers (and other trusted professionals in allied roles), who connect people to community groups and agencies for practical and emotional support, based on a ‘what matters to you’ conversation.

In England, there has been a surge of interest and investment in GSP, particularly in the aftermath of the COVID-19 pandemic. The UK government is exploring the role that nature-based interventions can play in improving the nation’s mental health. Here the Department of Health and Social Care (DHSC) is working with partners across government to run the ‘preventing and tackling mental ill health through green social prescribing’ programme, which involves several ‘test and learn’ sites. In addition, DHSC is seeking to improve the evidence on the effectiveness of GSP by commissioning National Institute for Health and Social Care (NIHR)-funded clinical trial work to investigate the impact of nature-based interventions on mental health outcomes.

Further to the workstreams above, DHSC is now interested in 2 areas of research on GSP. The first is nationally representative research to increase our understanding of the scalability of GSP across England. The second, which is the concern of this report, is a national green social prescribing delivery capacity assessment to understand the existing level of provision and its capacity to support a national rollout of GSP.

The expansion of GSP is intended to provide an effective, cost efficient and holistic strategy for addressing health inequalities. As a key component of the personalised care approach (NHS, 2019), GSP aims to tackle wider social determinants of health and reduce a culture of ‘over-prescribing’. Meeting this ambition depends on the extent to which the green and nature-based activities at the heart of GSP are accessible, equitable and sustainable over time. In this regard, a key knowledge gap exists with respect to the current provision of green and nature-based activities in England and the capacity of the system to support demand. Without this knowledge, it is difficult to make informed decisions about how to equitably roll out GSP nationally.

This study helps to address this knowledge gap by providing an assessment of GSP delivery capacity in England. It focuses on the providers and provisioning of green and nature-based activities. At the same time, it recognises that delivery capacity is broader than this, encompassing processes and systems beyond a narrow focus on the prevalence of green activity providers or numbers of spaces on green and nature-based activities. It is a rapid assessment. The research has been undertaken in a short timeframe and with limited resources, meaning a comprehensive audit of provision was out of scope. Findings and conclusions should be understood in this light.

Aim and research questions

The aim of this national GSP delivery capacity assessment is to quickly improve our understanding of the existing provision of green and nature-based activities across the country and help determine whether the current level of provision is sufficient to support social prescribing referrals equitably to these activities if rolled out nationally.

Given the scale of this topic, and the short timeframe of the study, a comprehensive assessment is out of scope. We have nonetheless developed a set of research questions that pave the way for a composite approach to understanding GSP delivery capacity in England, and the potential to scale up. The intention is to arrive at a robust, if preliminary, understanding to inform decision-making going forward. Particular attention is given to the intersection of equity and mental health as it relates to GSP delivery capacity.

The research questions are:

• Question 1: what is the nature of GSP provision in England?
• Question 2: what is the delivery capacity of GSP at present and what are the main determinants of this capacity?
• Question 3: what key factors influence the equitability of GSP delivery capacity?
• Question 4: what key factors influence the sustainability of GSP delivery capacity?
• Question 5: what are the opportunities and barriers to scaling up GSP equitably and how can these inform a sustainable national roll out?

Taken together, these questions seek to develop a picture of the current GSP landscape and to understand causal variables underpinning delivery capacity, including its equity and sustainability dimensions. In developing an understanding of the nature of GSP provision, we are interested in a range of factors that include: the types of providers involved in delivering activities; the types of activities being delivered; seasonal variation in provision; the average length of activities; how providers are funded; the characteristics of participants; and levels of mental ill health and wellbeing catered for by existing provision.

To understand delivery capacity, we are interested in the key actors and processes that give rise to GSP in England and the opportunities and barriers they face in practice. Equity, then, is partly a result of capacity challenges, with a focus on how these challenges disproportionately disadvantage some service users. Sustainability, too, is partly understood as a capacity challenge; one that accounts for the delivery of GSP over time and the functioning of the GSP system as whole. In the Methodology we outline how we set out to answer these questions. The approach is informed in the first instance by a review of the literature, which follows.

Literature review

This section reviews the literature on GSP. Publications reviewed specifically focus on GSP or on social prescribing more generally but where there is clear relevance to GSP. The review is undertaken in relation to 4 themes that together comprise the remit of this report:

• GSP and its benefits
• GSP as a system
• GSP and capacity
• GSP and equity

In later sections, we draw out relevant learning from the 4 themes to inform the development of the research design and discussion of the findings. First, we provide a short synopsis of the review.

Synopsis

The health benefits of GSP can be understood either as proactive, preventing poor health symptoms from manifesting, or restorative, where targeted activities and services support people with existing health needs. The literature identifies 3 elements of GSP that provide health and other benefits to service users:

• natural surroundings
• meaningful activities
• social context

These elements have the potential to tackle the wider social determinants of health and bring about psychological wellbeing as service users engage with green and nature-based activities that allow them to develop new skills, gain a sense of achievement and build confidence. At the same time, the social nature of GSP activities creates opportunities for service users to interact and form relationships with others. The benefits of this are particularly important where GSP is aimed at addressing social issues such as isolation or loneliness.

To explore questions of capacity and equity, it is necessary to understand the wider GSP system in which green activity providers and service users are embedded. The GSP processes linking people to green and nature-based activities occur within a complex network of interdependent actors spanning scales and levels. These processes include different referral pathways and 4 types of intervention model. The appropriate level of intervention depends on the needs of the service user in question.

With respect to GSP and capacity, the literature focuses on the role of specific individuals as well as the nature of activity providers, communities, sectors and the GSP system more widely. Regarding individuals, the primary focus is on the role of link workers and other social prescribers. Capacity is understood in relation to both the volume and complexity of their work - where high levels of both are often reported on. The capacity of activity providers relates in part to:

• skills and training
• knowledge of the social prescribing system
• a connection to link workers

Also key to provider capacity is sustainable funding and the size of the organisation, where low staff numbers may mean providers are not able to offer the appropriate levels of support for some service users.

At the levels of community, sector and the GSP system, key capacity challenges relate to questions of coordination and consistency. A crucial way of overcoming these challenges is through the development of coordination networks that include relevant GSP stakeholders. These networks can act as a means of sharing resources and knowledge, establishing more consistent models of delivery and good practice, and for supporting a coherent voice for GSP. The broad range of foci, domains and concerns attended to in the literature highlight the importance of taking a systemic approach to understanding GSP delivery capacity.

Regarding GSP and equity, 2 main themes emerge. The first theme is concerned with how green spaces and nature-based activities are unevenly distributed geographically. England, for example, is characterised by a marked disparity in access to green space and particularly a strong correlation between green space deprivation and ethnicity. The second is concerned with the barriers different social groups face when accessing and engaging with green and nature-based activities. These barriers include affordability and availability of transport, social anxiety and stigma, mobility issues, expense issues, language issues, inconvenient timings of green and nature-based activities, and the unstructured nature of some green activities. Other barriers to engagement stem from a reliance on medical interventions and scepticism about the benefits of non-clinical approaches.

GSP and its benefits

The benefits to service users are the main motivation for developing GSP as part of England’s public health strategy. GSP has the potential to both promote and restore mental health and wellbeing (Robinson and Breed, 2019). The distinction between health-promoting and health-restoring activities is important for understanding what levels of service are available and to inform the commissioning of services (Bragg and Leck, 2017).

Health-promoting GSP forms part of a proactive approach to healthcare that seeks to prevent symptoms from manifesting. GSP can promote health and wellbeing by linking the general public to nature-based activities that support healthy lifestyles or prevent ill-health (Maller and others, 2006).

On the other hand, GSP aimed at restoring mental health forms part of a reactive approach to healthcare aimed at tackling existing mental health needs. Restorative GSP provides targeted activities and services to support people with defined needs. An example of a restorative GSP project in England is surf therapy, which provides respite from PTSD experienced by war veterans (Caddick and others, 2015). Research suggests that in England, health promoting GSP is most common, with activity providers targeting a generalist audience (in other words, not a specific condition) or ‘generalist plus’ mental health audience (Bragg and Atkins, 2016), where the focus is on overall mental health and wellbeing (Garside and others, 2020).

Mechanisms of GSP benefits

GSP activities comprise 3 main elements that provide benefits to service users: natural surroundings, meaningful activities and social context (Bragg and Atkins, 2016). Here we briefly summarise the mechanisms linking each element to health and wellbeing benefits for service users.

Firstly, by taking place in natural surroundings, GSP facilitates nature interactions that can have psychological wellbeing benefits (Keniger and others, 2013). For example, walking in nature can have a positive effect on people experiencing major depressive disorders (Berman and others, 2012). Gardening, including therapeutic horticulture, can help reduce depression and anxiety (Soga and others, 2017). A meta-analysis of 50 studies shows that GSP has greater benefits for measures of psychological wellbeing than for physical health (Coventry and others, 2021). However, research on the psychological wellbeing benefits of nature interactions reveal mixed findings, indicating a complex picture that requires further research (Keniger and others, 2013). Some authors argue that there is a need to develop an understanding of how specific ‘types’ or ‘elements’ of nature affect health outcomes (Houlden and others, 2021; Marselle and others, 2019).

Secondly, GSP provides benefits through participation in meaningful activities that support a sense of achievement, build confidence and develop new skills. For example, a study of the working abilities of people with severe psychiatric disorders found that over a 3-month intervention involving interacting with farm animals there were improvements in the intensity and exactness of their work, as well as in self-efficacy (Berget and others, 2007). The opportunity to access training and develop skills that could lead to employment can be an important motivation for service users (Garside and others, 2020) and offers a route for marginalised groups to reintegrate into society (O’Brien and others, 2011).

Thirdly, service users derive benefits from engaging in social interactions and build relationships through both the GSP referral process and participating in nature-based activities. For example, in some models of GSP intervention link workers provide long-term and personalised support. For the service user, their relationship with the link worker can be a key determinant of their experience of GSP (Wildman and others, 2019). Indeed, Husk and co-authors (2016) suggest that social prescribing is best understood as a series of relationships rather than as a single intervention. Engaging in nature-based activities supports intrapersonal processes (for example, autonomy, competence) and interpersonal processes (for example, relatedness, shared learning) (Leavell and others 2019). It also creates opportunities for social networking and cooperation (Fieldhouse, 2003), which strengthens social cohesion and connectedness (Kingsley and Townsend, 2006). The benefits of the social context are particularly important where GSP is aimed at addressing social issues such as isolation or loneliness.

Beyond the health and wellbeing benefits to the service user, GSP has the potential to support several co-benefits. The co-benefits of GSP are particularly relevant to policy making and are an area deserving further research (Frumkin and others, 2017), as little empirical evidence currently exists (Robinson and Breed, 2019).

Firstly, GSP can support wider societal benefits, for instance by reducing pressure on GPs and the health system, supporting community development and creating opportunities to build up the voluntary and community sector (Ohmer and others, 2009; SPN, 2016).

Secondly, GSP provides economic benefits. A case study assessment of 5 projects that engaged people living with poor mental health in nature-based activities found significant economic benefits to the state, for example through reduced prescriptions and living allowance costs. Here the greatest economic benefits occurred when GSP led to employment (Vardakoulias, 2013).

Thirdly, through strengthening connections between people and nature GSP is likely to have environmental benefits. For example, service users of a GSP project run by the Wildlife Trust had significantly higher nature-relatedness scores after the project (Sumner, Sitch and Stonebridge, 2020). Nature-relatedness is associated with pro-environmental attitudes and behaviours (Wang and others, 2022; Nisbet, Zelenski and Murphy, 2009). Thus, GSP may lead to improved attitudes to environmental sustainability.

Despite the range of potential consequences for individuals, communities, economies and the environment, the wider outcomes of social prescribing are not routinely measured (Polley and others, 2019). The limited evidence base for social prescribing outcomes is insufficient for evaluating whether interventions are successful or cost-effective (Bickerdike and others, 2017). To support the meaningful evaluation of social prescribing, there is a need to measure the general, physical, psychological, welfare, spiritual and social outcomes and impacts on wider social determinants of health. These include work and volunteering; social; education and skills; crime; housing; legal; and income and welfare (Polley and others, 2019)

GSP as a system

An understanding of the wider system provides an important framing for GSP delivery capacity, including its equity and sustainability dimensions. GSP provision takes place within complex networks of actors and interests (Garside and others, 2020). GSP, and social prescribing more generally aims to widen the scope of healthcare and create communities of health practitioners by linking together multiple actors within particular areas (SPN, 2016). The capacity and capabilities of the different actors involved and the processes that link them together determines the types and numbers of service users supported by GSP. In any GSP system, there are potential ‘pinch points’ that impact on overall delivery capacity (figure 1).

Figure 1 illustrates the 4 main GSP pathways that link service users to providers of green activities and pinch points that may impact these pathways. The diagram shows how different actors, including service users, referrers (for example, GPs), link workers (for example, NHS link workers), signposting directories, and green providers (for example, conservation organisations) are linked in the different referral pathways. The 4 referral pathways are labelled alphabetically. In referral pathway A, the service user is linked to the green provider through the referrer and then a link worker. In referral pathway B, the service user is linked to the provider through the referrer and then a directory. In referral pathway C, the service user is linked to the provider through a link worker, bypassing the referrer. In referral pathway D, the service user is linked directly to the provider.

Examples of potential pinch points impacting on actors include:

• service users: public attitudes towards GSP, individual time availability of service users, and social barriers
• referrers: primary care funding, time constraints to referral sessions, knowledge and/or attitudes towards GSP in primary care, training in GSP and/or psychosocial approaches in primary care
• link workers: funding, time and the number of referrals made from primary care
• green providers: funding, spaces available and/or group sizes, mental health training of staff, demand (for example, referrals)

Examples of pinch points impacting on pathway links include:

• service user - referrer link: individual’s access to health system
• service user - provider link: public awareness of and/or access to green activities
• referrer - directory link: awareness and availability of up-to-date directory of local green providers
• referrer - link worker link: awareness of and networks with link workers
• directory - green provider link: green providers being listed in GSP directories
• link worker - green provider link: link worker awareness of and networks with green providers

Figure 1: the 4 GSP pathways link service users to green providers (adapted from Garside and others, 2020) and potential pinch points in the system

In pathway A, the service user is referred from primary care to a link worker who identifies suitable services for the referral. In pathway B, the service user is referred from primary care to a directory of services, which they access sometimes with the help of a health professional. In pathway C, the first point of contact for the service user in the GSP system is the link worker who identifies suitable services for the service user. In pathway D, the service user directly identifies and accesses services.

The main GSP actors include individuals and organisations from the health and social care sector, environmental sector, national and local government, the voluntary, community and social enterprise (VCSE) sector, and service user groups (Willows Rough, 2021). Each actor may fulfil one or more roles in the system, including making referrals, connecting service users to activities, providing activities or offering intermediary support.

GSP systems can also involve partnerships with academic institutions that support evaluation and monitoring (Garside and others, 2020). The specific actors involved and their relationship to the GSP system varies with context and is influenced by factors such as existing partnership structures, sources of funding and employment (Polley and others, 2017).

The way that a service user engages with a GSP network depends on the referral pathway and intervention model. There are 4 main referral pathways linking service users to nature-based activities, characterised by different networks of relationships (Garside and others, 2020). A visual summary of these pathways is presented in figure 1, above.

Intervention models refer to the different levels of support a service user receives through the GSP process. Kimberlee (2015) distinguishes between 4 models of intervention ranging from ‘signposting’ to ‘holistic’. The appropriate level of intervention depends on the needs of the service user. These needs include the severity of their symptoms, the complexity of their social requirements, and their motivation and preferences (Friedli, Jackson and Abernethy, 2008). However, there are also challenges associated with conceptualising such a broad range of approaches, including agreement on what constitutes GSP and how to establish standardised referral processes (Bragg and Leck, 2017).

GSP and capacity

The commission behind this report describes GSP capacity as ‘the existing level of provision of green social prescribing activities in England.’ To inform this framing, it is productive to understand how existing research into social prescribing has approached the question of capacity. Broadly speaking, this literature focuses variously on the capacity of individuals, organisations, communities, sectors and of the GSP system as a whole.

Capacity of link workers

Regarding individuals in the GSP system, the literature primarily focuses on the role of link workers and other social prescribers. Capacity is understood in relation to both the volume and complexity of their work. Thus, several studies highlight the extent to which link workers are inundated with referrals, where their role involves ‘time-consuming, intensive case management’ (Skivington and others, 2018: e487). Restraints on time and other resources make it difficult for link workers to provide each patient with the care and attention they require (Whitelaw and others, 2017; Wildman and others, 2019).

A link worker quoted in one study expressed: “I’m inundated, I can’t cope with the numbers, I’m always running to a backlog, I can’t, I don’t know how to do it” (Garside and others, 2020: 100). At the same time, many of the patients referred to link workers have complex needs relating to their mental and physical health. This requires levels of skill and experience from link workers that in some instances only comes with years of training and experience (Hazeldine and others, 2021) but is also considered by many to be beyond the appropriate remit of social prescribing (Apter, 2019).

Another source of complexity is the dynamic nature of the system, where there is often considerable fluidity in terms of the green and nature-based activities on offer. For link workers and other social prescribers, this can be hard to keep up with (Garside and others, 2020: 129). Moreover, Watkins and co-authors (2022) show that the individual heuristics of link workers influence who they refer to, where there is a preference to choose familiar organisations.

Finally, Foster and co-authors (2020) observed that a system that relies on volunteers to support link workers can undermine service capacity, ‘indicating the need for social prescribing services to have sufficient paid link worker capacity’ (page 1,446).

Capacity of providers

The capacity of green activity providers has been considered by several studies (Beardmore, 2019; Juster-Horsfield and Bell, 2022; McHale and others, 2020). The most comprehensive treatment is offered by Garside and co-authors (2020), who discuss provider capacity in terms of:

• skills and training to work with participants who may have complex mental health and other needs. The authors found varied levels of formal training, where some providers were keen to point out that their expertise did not extend to dealing with severe mental health issues
• knowledge of the social prescribing system, where the authors note ‘a wide variation in social prescribing knowledge among those providing nature-based activities’ (page 14)
• a lack of connection to link workers even if the provider does have knowledge of the GSP system. The study identified green activity providers who were aware of the GSP system but were not connected to link workers, feeling that they did not need to be. Moreover, several providers in the study described how they had attempted to contact GPs directly to promote their nature-based projects but felt that they had little success

Finally, Garside and others (2020) identify challenges relating to the capacity providers have in terms of staffing, to be able to give service users the level of support they need. Many providers in their study were small organisations with one or 2 people delivering the programmes. This meant that they could not give the appropriate levels of support for service users with complex health needs. A lack of attention to the actual capacity of activity providers to receive referrals and provide appropriate support is considered to be a barrier to the provision of high-quality social prescribing (SPN, 2016).

Care farming, one type of GSP activity for which there is annual monitoring across the UK, serves as a good case study for understanding capacity among providers. In keeping with research on green providers more generally, a report published by Bragg (2022) indicates that many care farms are not currently operating at full capacity. This suggests there is stretch potential in the system, as outlined in the case study below.

Care farming case study

Since 2006, the UK-wide charity Social Farms and Gardens has provided monitoring of care farming across the UK. Here we present a summary of their 2021 report (Bragg, 2022).

Care farms refer to places and organisations that deliver health and social care or specialist education services through a variety of therapeutic activities that include an element of farming (for example, horticulture, livestock husbandry, and so on). They support people with a defined need and provide activities for an average of 4 service user groups. Adult groups most commonly worked with are those with a learning disability (62%), mental ill-health (61%) or autism spectrum disorders (ASD) (61%). Service users under 18 tend to have a learning difficulty (52%) or ASD (52%).

Care farms in the UK currently provide hundreds of thousands of places and have the capacity to support over 1 million service users. On average, 11 service users are supported per day, where services are offered 5 days per week for 47 weeks of the year. Based on these figures, it is estimated that care farms currently provide 15,620 places per week in the UK or around 734,140 places per year. This is an increase of 57% since the previous report in 2020. However, 62% of care farms reported that they were currently not running at full capacity. It is estimated that if all places were filled, care farming could provide a total of 1,184,000 places per year in the UK.

Care farms access funding from a variety of sources, including funding associated with referrals. In general, referrals from social care and education are better funded than referrals from health. To cover additional costs, care farms seek funding from grants or charities (66% of care farms), donations (57%), or fundraising activities (45%). Funding and operational costs are perceived as the biggest challenge by care farms (32%).

Capacity of communities and sectors

Beyond the capacity of individuals and individual providers, the literature also pays attention to the capacity of communities and sectors. Broadly speaking, this research focuses on the nature of relationships between individuals and actors in the GSP system, as well as the wider context in which they operate. Several authors ground their research in the context of years of austerity in the UK, and more generally ways in which a lack of funding, and unsustainable funding models, undermines capacity (Bertotti and others, 2018; Brown and others, 2021; Wildman and others, 2019).

In this light, Morris and co-authors (2022) consider the capacity of communities to deliver GSP outcomes. The authors propose a model of ‘community enhanced social prescribing’ (CESP), with a need to recognise “the importance of communities to individuals and the importance of engaging with, and investing in, communities” (page 179). By developing and deepening relationships between members of the community, they argue that CESP can “facilitate communities in assessing how connections can be mobilised to improve capacity” (page 188).

Allied to the concept of community is a focus on the voluntary sector - typically the network of non-governmental and not-for-profit providers of green and nature-based activities. Crombie and Coid (2001) caution against seeing the voluntary sector as a ‘white knight’ that will come to the rescue of diverse individuals and social groups. In this regard, South and co-authors (2008) identify 3 factors that challenge the capacity of the voluntary sector. These are:

• variety, in terms of size, function, ownership and funding (Taylor, 1997)
• quality and accountability issues (Johnson and others, 1998)
• a degree of instability that can affect access and impact the support on offer

System capacity

Several authors highlight the need to think about capacity in terms of the whole GSP system. Willows Rough (2021) notes that a major limitation to the effective delivery of GSP as a “holistic, transectoral practice” is a “lack of a common language and a tendency of actors involved to work within their respective paradigms” (page i; see also Bertotti and others, 2018; Bloomfield, 2017; Polley and others, 2017). This results in siloed working and minimises the realisation of potential co-benefits.

In response, Willows Rough (2021) develops a systems approach to explore the channels of communication between social prescribers and green activity providers, as well as the role of boundary organisations in mediating the effects of siloed working. Capacity here relates primarily to the ability for GSP actors and sectors to communicate and operate across boundaries. In this regard, coordination within GSP systems and between GSP and wider health and social care systems is seen as essential to its success.

In their report, Garside and co-authors (2020) outline the importance of coordination networks for sharing resources and knowledge, establishing more consistent models of delivery and good practice, and supporting a coherent voice for GSP. Other studies support this framing, highlighting a need to nurture the capacity of the overall GSP system by developing strong partnerships that overcome current coordination issues (Potter and Brough, 2004; Whitelaw and others, 2017). Strong partnerships from the outset can help establish a shared understanding of the aims and objectives of GSP to support more effective service delivery (Farenden and others, 2015).

Moreover, a lack of coordination can directly impact referrals. For instance, the dynamic landscape of green and nature-based activities means that it can be challenging for link workers to keep up to date with the activities on offer unless there is a coordinating body to provide this information. Garside and co-authors (2020) also highlight coordination issues with funding. This is due to a reliance on third party funders “whose goals loosely align with national level priorities of the health system (for example, the focus on better mental health) but not necessarily with local needs” (page 131). The mismatch between what is being delivered and what is needed represents a considerable shortcoming in the effectiveness and efficiency of GSP, undermining system capacity.

Taken together, the literature on capacity encompasses a range of foci, domains and concerns. These are usefully attended to by the approach proposed by Potter and Brough (2004) for addressing systemic capacity building. The authors identify a pyramid of 9 separate and interdependent components that form a 4-tier hierarchy of capacity building needs:

• structures, systems and roles
• staff and facilities
• skills
• tools

This hierarchy of needs moves beyond simplistic approaches to capacity building that often focus narrowly on initiatives such as additional training. Instead, the authors argue that “emphasising systemic capacity building would improve diagnosis of sectoral shortcomings in specific locations, improve project/programme design and monitoring, and lead to more effective use of resources” (page 336).

GSP and equity

As with capacity, ‘equity’ is a key term that informs the remit of this report. Thus, the commission behind the report asks whether the current capacity of the system “would be sufficient to equitably support GSP roll out across the country”. Again, it is instructive to consider what existing literature has to say. Two themes emerge:

1. how green spaces and green and nature-based activities are unevenly distributed geographically
2. the barriers different social groups face with respect to accessing and engaging with green spaces and green and nature-based activities

Distribution of green space

A wider literature highlights the uneven distribution and quality of green spaces (de la Barrera and others, 2016; Iraegui and others, 2020; Lee and Maheswaran, 2011). Here, England is characterised by “a marked disparity in access to green space and particularly a strong correlation between green space deprivation and ethnicity” (Zylva and others, 2020). For example, studies reveal that urban green space distribution can disproportionately favour privileged social groups. Among these are groups with a higher socio-economic status and those from white ethnic backgrounds (Wolch and others, 2014; Wüstemann and others, 2017). Other studies point not only to green space distribution or spatial proximity but to the ways in which green space quality, composition, and access differs between areas of higher and lower deprivation (Jones and others, 2009; Mears and others, 2019; Roe and others, 2016).

Within this context, Robinson and co-authors (2020) note that the distribution of GSP has yet to be comprehensively mapped. Going some way to addressing this gap, their study found that green space presence and abundance within close proximity to GP surgeries (100 metres and 250 metres), as well as green activity provider presence within 5 kilometres, were associated with higher levels of GSP provision. At the same time, lower levels of deprivation were associated with a higher frequency of green activity providers.

The authors conclude that “the availability of green spaces and [providers of nature-based activities] could be important for green prescribing provision, but there could be greater opportunities in less deprived areas” (ibid: 1). Moreover, Skivington and others (2018) observe that while austerity cuts have undermined the capacity of GSP providers everywhere, “evidence from England and Wales has shown that community organisations in the most deprived local authority areas have experienced a greater decline in funding”.

Access barriers

Multiple barriers to accessing and engaging with nature and nature-based activities are identified in the literature. Several studies examine barriers in relation to the general population (for example, Whitelaw and others, 2020; Carstairs and others, 2020). Other studies focus on specific service user groups, defined either by their social position (such as Zhang and others, 2021) or a mental or physical health condition (such as Baxter and others, 2022). Others still explore barriers in relation to a particular green and nature-based activity, such as parkrun (Reece and others, 2022) or urban social farming (Mitchell and others, 2021).

A barrier common to many of these studies is affordability and availability of transport (for example, Mitchell and others, 2021). Other common barriers include social anxiety and stigma (for example, Stuart and others, 2021); mobility issues, particularly for older people and people with disabilities (for example, Hamilton-West and others, 2020); expense issues, including the cost of equipment, clothing and of green activities themselves (for example, Garner-Purkis and others, 2020); inconvenient timing of activities (Pescheny and others, 2018), language issues, for example in the case of migrant communities (Zhang and others, 2021); and the unstructured nature of some green activities, which might be a particular challenge for people with mental health needs (Baxter and others, 2022).

Moreover, the ways in which barriers intersect are often complex and context dependent. For example, Bell and co-authors (2019) highlight differences in the ways that people come to conceptualise and interpret nature in their everyday lives. From within the health sector, challenges have been identified with engaging patients who are dependent on medical solutions or who are sceptical of the benefits of social prescribing (Pescheny and others, 2018). As a result, bringing GSP into mainstream health systems is inherently complex and must be situated in an understanding of this social complexity.

People’s perceptions of nature and green spaces also vary in relation to whether they feel safe and welcome (Fixsen and Barrett, 2022; Lee and Maheswaran, 2011). As with these and many of the barriers identified in the literature, their determinants are often structural in that they tend to be associated with social positions relating to a person’s ethnicity, class, gender and so forth. Limited understanding of the ways that different groups access, use and value nature results in a lack of insight into the diverse relationships between nature and health and how they influence health inequalities (Frumkin and others, 2017; Hartig and others, 2014).

Fixsen and Barret (2022) argue that for GSP to address health inequalities, wider structural inequalities in society must also be addressed - an imperative that has become even more pressing since the COVID-19 pandemic. The authors characterise this as a multi-sector problem dependent on widespread policy change that is able to account for the barriers faced by different social groups. Gibson and co-authors (2021) argue that without such an approach, social prescribing risks reproducing and exacerbating existing health inequalities because of the ways in which the personal care system in England tends to frame wider structural conditions as something that individuals are accountable for.

Methodology

Research design

We employed a 2-phase methodology geared towards addressing the aim and research questions set out in the Aim and research questions section. The approach is informed by learning from the literature review and insights provided by researchers, practitioners and other stakeholders with experience of GSP in England. Discussions were held with these individuals in June and July 2022.

The first phase of our methodology is extensive, investigating GSP nationally. The second phase is intensive and involves drilling down into 6 ‘deep dive’ locations in 3 of the NHS regions. Combining extensive and intensive research phases paves the way for a composite understanding of the complex social dynamics underpinning GSP delivery capacity in England. We outline each phase in more detail below.

Extensive phase: NHS regions

The aim of the extensive phase is to build a broad picture of the GSP landscape in England, identifying patterns and themes across the country. We focus on the 7 NHS regions that make up England:

• East of England
• London
• Midlands
• Northeast and Yorkshire
• Northwest
• Southeast
• Southwest

The NHS region was chosen as the unit of analysis for the extensive phase because it is the scale at which key stakeholder organisations, including the National Academy of Social Prescribing (NASP) and Natural England (NE), currently support coordination of GSP. The integrated care system (ICS) was considered as an alternative unit of analysis to the NHS region. It was decided against because there are 42 ICSs in England, making it too complicated to undertake the research within the timeframe and resources available for this project.

Data for the extensive phase were gathered using:

• stakeholder interviews with NE health and environment leads
• a national stakeholder survey
• a national activity provider survey
• a national link worker survey

The link worker and activity provider surveys were advertised and distributed on national online platforms and through relevant networks and key contacts (details on data collection methods are outlined below). Primary data from the different sources are summarised in the analysis and triangulated in the discussion to provide a national perspective of the current nature of GSP provision, delivery capacity, equity and sustainability.

Intensive phase: local deep dives

The aim of the intensive phase is to provide more granular insights into GSP in England. This phase comprises research in 6 deep dive locations across the country, exploring mechanisms, processes and capacities that shape the delivery of GSP on the ground. Through the deep dives we gain a more in-depth understanding of the factors influencing the (in)equitable delivery of GSP. We also provide a measure of the ‘stretch potential’ of GSP (see below). These insights complement the broader perspective developed in the extensive phase of the study.

We used the primary pare network (PCN) as the unit of analysis for each deep dive location. PCNs are a localised and relatively coherent unit within the NHS healthcare system. They are not so large that the complexity of the GSP system becomes unmanageable or so small that relevant dynamics are omitted. PCNs therefore represent a useful scale for exploring the complex dynamics underpinning the delivery of GSP.

Primary data for the deep dives was collected using surveys with link workers assigned to the PCN in question, and with the green activity providers that these link workers refer clients to. Using desk-based research, we identify green activity providers that are not currently linked into the GSP system. Comparing data on green activity providers referred to versus green activity providers not referred to offers one measure of the gap between current and future delivery (or ‘stretch potential’).

We undertook 2 deep dive studies in each of 3 NHS regions. These regions have been decided upon during discussions with NHS and NASP colleagues. They were selected to capture key differences across the country, including the ‘north-south divide’, urban and rural GSP provision, and different socio-economic circumstances. The 3 NHS regions selected are the Northwest, Southeast, and Midlands. Within each region, 2 PCNs were identified through discussions with stakeholders at the regional and local levels, together making up the total of 6 deep dives. Stakeholders consulted to identify deep dive locations include the managers of link worker teams, senior staff in relevant organisations from the VCSE sector, and GSP partners across regional networks.

In each NHS region, the deep dive locations attempted to reflect 2 scenarios: a relatively well-established GSP ecosystem (‘hotspot’) and a less established ecosystem (‘cold spot’). In practice, this distinction is less clear than intended. This is largely because identification of deep dive locations was dependent on the willingness of stakeholders to assist with the process, the availability of key contacts in each location who could facilitate the research, and the short timeframe available to locate and finalise study sites.

In each deep dive, we used NE’s Green Infrastructure mapping tool to evaluate the accessible natural green space inequalities assessment (NE, 2021). The tool plots accessible natural green space inequalities at the scale of the Lower Layer Super Output Area (LSOA) - which contain an average population of 1,500 people or 650 households - and offers several spatial buffers. This allows accessible green space to be calculated within different proximities of an LSOA (see annex 1 for further details on how accessible natural green space inequalities are calculated).

We summarise accessible natural green space inequalities for each deep dive using both a neighbourhood buffer (10 hectares within 1 kilometre, 15 to 20 minutes walk, 3 to 4 minutes cycle) and a district buffer (100ha within 5km, 15 to 20 minutes cycle). While at each of these scales the indices of multiple deprivation (IMD) decile of an LSOA remains the same, the percentage of accessible natural green space may change with the inclusion of a different spatial area. Thus, presenting 2 buffers of varying distance provides insight into the potential for transport to influence the availability of accessible green space.

Data collection and analysis

Datasets were generated in the extensive and intensive research phases using a range of methods that engaged different GSP stakeholders and at different scales. Of these methods, the extensive phase employed the 3 surveys (stakeholder, green activity provider, and link worker surveys) at a national level. The intensive phase employed the green activity provider and link worker surveys alongside a desk-based research component. Methods were tailored to the stakeholder groups within the GSP system to capture their experience and knowledge. Collection and analysis methods are described below.

Desk-based research

This component of the research set out to develop a measure of ‘stretch potential’ by identifying green providers that are not currently referred to by link workers. It was undertaken in each of the 6 deep dive locations, using existing online VCSE directories. This involved undertaking searches for all VCSEs listed in a primary directory whose geographical reach includes the area in which the deep dive is located.

The use of a primary directory was augmented by searches of national directories of green providers and green and nature-based activities, often available on the websites of specific VCSEs. The search criteria included a 5km radius around the PCN, consistent with the district buffer zone for the accessible natural green space inequalities assessment detailed in the section above on local deep dives. After consulting key contacts in the NHS and NE, 5km was considered a feasible distance that a service user may travel to attend a green and nature-based activity - with the caveat that a range of other criteria shapes a service user’s willingness or ability to travel.

The desk-based research generated a list of green activity providers for each deep dive location. The lists are stored on an Excel spreadsheet alongside details of the green activity provider, the activities they offer and the directory used to locate them.

Interviews

Semi-structured interviews were carried out with 7 NE regional health and environment leads (hereafter health leads) in July 2022. The interviews were conducted remotely by the lead authors on MS Teams. Interviewees were provided with a list of questions in advance. These questions, along with further prompts, were used to guide the interviews (annex 2). Each interview took around one hour to complete. Six interviews were recorded and transcribed in real time using built-in software on MS Teams. One interview was recorded on handwritten notes.

Interview transcripts and notes were stored and analysed using a combination of inductive and deductive coding in NVIVO (qualitative social science software). Coding identified key themes and dynamics relating to GSP at the regional and national scale.

Surveys

Surveys were used to collect primary data from different groups of GSP stakeholders for both the regional overview and the deep dives. Specifically, we developed 3 online surveys (see annex 3) targeted at:

• national stakeholders
• green activity providers
• link workers

To reduce time demands on participants, the surveys are designed to be completed in less than 30 minutes. Each survey includes a combination of closed and open-ended questions relating to the current nature of GSP provision, GSP delivery capacity, equitability and sustainability, and key barriers and opportunities to scaling up GSP. In line with the focus of this study, there are also questions that focus on the delivery of GSP for people with defined mental health needs. How questions across the 3 surveys address the different concerns of this study are summarised in table 1.

The 3 surveys were digitised and made available online in September 2022 using Qualtrics software. They were distributed to their target audience through different pathways, including:

• embedding survey links in the wider annual social prescribing link worker (SPLW) survey
• promoting the surveys alongside activities that advertise the annual SPLW survey - several internal newsletters, including the social prescribing bulletin and social media posts
• posting on the Social Prescribing Collaboration Platform
• posting on the Green Social Prescribing Collaboration Platform and flagged as a news item
• promoting the surveys in the Regional Expansion Teams newsletter
• including it in the GSP bulletin
• through requests for partners, including NASP and Sport England, to promote the surveys in their networks

In total the surveys were completed by 16 national stakeholders, 104 green activity providers and 165 link workers. A breakdown of the sample distribution is available in table 1.

Survey data was downloaded from Qualtrics and collated into Excel, where it was cleaned and coded for analysis. Quantitative analysis was carried out in R statistical software using descriptive statistics. In some instances, qualitative data collected in the longer format open-ended survey questions was manually coded into key themes using inductive coding and then summarised quantitatively.

Delivery capacity framework

The literature review identified different areas of the GSP system that impinge on questions of delivery capacity. It suggests a need to develop a composite understanding of delivery capacity that avoids an overly simplistic or reductive approach. In this sense, Potter and Brough’s (2004) hierarchy of capacity building needs provides useful inspiration. In their article, the authors develop a list of component elements which we adapt to the needs of this study, as shown in table 1. These elements inform our approach to thinking about, analysing and discussing delivery capacity in this report.

Table 1: the 7 elements of GSP provider capacity (adapted from Potter and Brough, 2004)

Element of capacity	Definition	Criteria
Performance capacity	Availability of money and equipment to deliver green and nature-based activities	Funding for green providers
Personal capacity	Sufficiently skilled and knowledgeable staff and volunteers	Green provider and link worker training, skills and capabilities
Workload capacity	Enough paid staff and volunteers to cope with the workload	Green provider staff and volunteer numbers and time; link worker staff numbers and balance of service demand versus paid working hours
Facility capacity	A suitable venue and/or site to host green and nature-based activities	Site infrastructure and accessibility for green and nature-based activities; transport to reach green providers and/or activity sites
Support service capacity	Sufficient support services in place to provide care and expertise, including for service users with mental health needs	Health sector support; availability of specialist mental health services
System capacity	Timely and effective flows of money and information to deliver GSP equitably and sustainably	Effective referral process with sufficient client information; sustainable funding models; up-to-date and accessible green provider databases and directories
Structural capacity	Well established roles and responsibilities that are co-ordinated and joined up	Cross-sectoral collaboration and communication; local VCSE and health sector partnerships; common definition of GSP; consistent evaluation metrics and provider accreditation

Results

Health and environment lead interviews

This section presents the findings of the analysis of 7 interviews with NE’s health and environment leads (‘health leads’). It considers these findings in relation to the nature, capacity, equitability and sustainability of GSP. Findings should be qualified by inherent limitations that health leads face. Each health lead is assigned an NHS region (except for the Midlands, which is currently shared by 2 health leads). This is a large area for an individual to cover, making it difficult to have a good understanding of GSP in all places and at all times. This was a point consistently raised during the interviews. Moreover, some health leads had only been in post for a short period at the time of interview, meaning they had relatively limited experience of GSP in their region. To provide anonymity, each health lead was assigned a code from H1 to H7.

Nature of GSP

Given the size of an NHS region, it is not surprising that all health leads highlighted the great diversity within their jurisdiction when it comes to the current provision of green and nature-based activities, as well as the types of providers who deliver them: “If you just take one city [in my NHS region] as an example and you looked at what was going on there would be a host of different things delivered by different sorts of organisations” (HL6). The seasons influence the types of activities that can be undertaken, where colder months and particularly wintertime can make it hard to put on outdoor activities. At the same time, activities do go throughout the year, from walks and bike rides to social gatherings on beaches and in parks and community gardens (HL3, HL6).

When it comes to the nature of GSP referrals, interview respondents drew attention to a range of challenges. Firstly, there is a sense that many green and nature-based activities are not necessarily being referred to as part of the GSP system: “I think there’s a lot going on, but whether people are using it I don’t know; I don’t think it’s a smooth system with people being referred to it” (HL1).

Referral pathways in practice do not seem to align with how they are meant to work in theory: “When I’ve met with providers and social prescribers, the referral pathways don’t seem to be there at all. It’s very rare where I’ve actually seen examples of social prescribing happening in the way it’s meant to” (HL7).

Moreover, the level of referrals appears to vary considerably from one area to another, regardless of whether there are green and nature-based activities available to refer to: “I don’t think it’s happening in a lot of areas. I mean I hear about ‘this is what’s supposed to happen’ but some areas seem to be well developed and others not at all” (HL1).

As a result, some health leads felt that GSP happens most often through self-referrals rather than referrals from a link worker or other community connector. For example, one respondent observed that “most of the green social prescribing referrals that I have seen, and we’ve seen the evidence for, are self-referrals. It’s still not coming through the referral path. There’s actually more self-referrals than there are referrals” (HL3). Another respondent (HL7) echoed this point:

So whenever I’ve met social prescribers, they basically said like they don’t really refer to much green stuff. And they’re not aware of the green provision that’s out there. And then if I speak to good kind of health and nature projects and ask if they are getting referrals from prescribers, they normally say no it’s just self-referrals and they’re struggling to get in touch with social prescribers. So like the connections don’t seem to be there and if they are it’s like ‘wow, it’s actually working!’

When referrals are common, in many cases this might be down to particular individuals with the time and enthusiasm for green and nature-based activities. This relates both to individual link workers but also to GPs and GP surgeries, as highlighted by these health leads (HL4 and HL1, respectively):

I think it will always come down to individuals. Umm, you know, you get a lot of brilliant link workers who can’t do enough of this this type of work and I think a lot of others just perhaps it hasn’t occurred to them or it’s not on their radar, or I don’t know what the issue might be. Could be a GP thing as well. I mean some quite old-school GPs have always tended to go down the pharmaceutical route. Perhaps they see [GSP] as a risk.

I know in GP surgeries you may have a GP that is really keen on the environment and they’re going to be pushing for that area of work and they’re going to want leaflets in their surgery that push for that. Other people aren’t so keen and it’s going to vary, and it does come down in every aspect to people’s personal preferences and their backgrounds.

Related to the time and enthusiasm that link workers and GPs have for green and nature-based activities, is their awareness of them. In the first instance, this concerns the challenge link workers face to become aware of the different activities and activity providers in their area. It also concerns an awareness of the benefits green and nature-based activities offer service users.

Health leads shared concerns that in many instances this awareness is not there. One respondent noted a need “to raise the profile of the benefits of connecting with nature and that there really are nature-based activities going on that [link workers] can refer to” (HL5). Another suggested that increasing link worker awareness may help increase GSP demand by strengthening pathways to nature-based activities (HL2).

Gaining an awareness of relevant green and nature-based activities is also made difficult for link workers because of the unsustainable nature of most funding. The result is activities that might only be available in the short term or as a one-off opportunity. This is typically not conducive to the ways in which link workers need to operate. As one HL5 respondent described it:

A lot of the social prescribing link workers are looking for activities that they can refer to that are going to be continuous. So if it’s just like a one-off activity, depending on when they link up with that particular patient, they may have already missed it…. Say a local forest trust decided to put on a woodworking activity for 6 weeks because they were able to access some funding. If a link worker then got to hear about that 6-week activity they may not necessarily promote it because it depends when they’re actually linked up with that patient. It could take weeks for them to have those conversations. It could be a further week before that person actually feels confident to say ‘I’d like to go’. And so you’ve already got a month’s worth of activities that they’ve probably missed out on.

A challenge raised for link workers is therefore the dynamic and unpredictable nature of provision. The lack of continuity makes it hard for them to keep up with the green and nature-based activities that are currently available. Several respondents mentioned that this is made harder still because link workers often have limited capacity - a point that is addressed in the next section.

Capacity of GSP

With respect to provision, NE’s health leads identified several key areas that affect capacity. As one respondent summarised on the challenges facing activity providers: “It’s a case of capacity, staff time and funding” (HL4). Other respondents added to these 2 factors, highlighting staff skills and training as key to understanding capacity, especially for accommodating groups with defined health needs: “Service providers are not always comfortable to take referrals as they don’t have the skills and training. Consequently they tend to be wellbeing rather than health focused” (HL2).

Of the factors affecting the capacity of providers, funding was most consistently raised by health leads. One issue they noted is the sporadic and unpredictable nature of funding opportunities: “Yeah, [funding is] very, very patchy. It’s probably the biggest barrier really to expanding the whole thing: not having any money” (HL4). Several respondents drew attention to the challenges the VCSE sector in particular faces in accessing funds, despite being central to the success of GSP. HL3 and HL5, respectively:

The third sector, they’re such an underused resource. They really are, and they’re overlooked. Time and time again, like I said, money bypasses them and then they have to scramble and scramble to keep themselves going. But they know the provision more than anyone else because they’re at the heart of their communities.

Any conversations that you have with community groups, it always comes back to funding. So the need and the want to do it is always there but they have to fund it. And so that can always be a barrier. They’re probably in the best position to actually run nature-based activities.

As a result, one respondent argued that the “voluntary sector needs to be included as part of the [health] system, not just an add on to the NHS, so that funding from personalised care is accessible to activity providers” (HL2). And while all green and nature-based activity providers face funding challenges, respondents highlighted that these are particularly acute for smaller organisations. HL3:

But you rarely hear of these small, small providers because by the time you do, they either are probably really struggling, or they’ve probably folded because of money… Their main gripe is that a lot of funding goes to these bigger organisations as they have the infrastructure, time and resources to spend on applying for funding.

Alongside funding, a second set of challenges for providers of green and nature-based activities revolves around staff capacity. Here a lack of staff capacity - either in terms of personnel or time - has the potential to seriously undermine the activities and services an organisation can provide. This situation is made more challenging given what some respondents perceived as a high staff turnover rate: “And the sector in terms of people working in it, they change jobs quite a lot…you know people thinking right, probably I’ll move…So as soon as you could get something up and running, that person might leave for a different green job” (HL3).

Again, there is a disparity between the large and small providers, with larger organisations typically having more staff capacity. As a result, small providers are often heavily dependent on volunteers: “Whenever you have a conversation with local groups, it’s have you got any funding? You know we want to do this. Do you know of any volunteers?” (HL5). However, larger organisations are also often stretched when it comes to staff capacity, with many relying on volunteers (HL1). Funding and staff time intersect directly when it comes to the capacity green activity providers require to continuously apply for new funding. The less staff capacity an organisation has the less potential there is to apply for funding. HL4:

And then you get funding, it’s only for what a year or 2 or something and I was talking to [a person] who runs this amazing garden, therapeutic horticulture place…He’s saying he spends probably at least half his time writing bids. Which you know when most of them don’t work or are unsuccessful, it’s must be soul destroying.

The last point concerning provider capacity relates to the importance of networks. Several health leads pointed to the ways in which providers who are linked together in networks are better able to both make and take advantage of opportunities when they arise. HL3 and HL6, respectively:

Anytime I have conversations with organisations [in a particular location], whether that be local authorities or whether that be NHS or green care providers…they’re trying to join everything up, so everyone’s not doing everything piecemeal. You know, they are trying to do that and it is working.

I mean, some of them try and leverage funding by kind of joining wider partnerships. And I know [a partnership in a particular location] is quite a big collective of different groups and organisations and you know they can influence funding and raise their profile and that sort of thing when they do that.

As with the previous section, the importance of individuals with time, energy and an interest in green and nature-based activities was highlighted by several respondents. For example, 2 respondents discussed the ways in which a certain individual served as the catalyst for forming a wider network of green and nature-based activity providers. HL4:

And I think that’s another critical thing. It often comes down to individuals…so you’ve got [a certain individual] running this green care network. He’s like a sort of dynamo of energy. He’s brilliant. And without him I don’t think any of that would have happened. So he’s brought together all of this stuff into a network. New activities are happening simply because you’ve got that one individual who’s really bought into it all. And, you know, we could do with [a person like this] in every county really.

Regarding referrals, the major capacity challenge concerns the difficulties faced by link workers. In general, respondents pointed to the ways in which link workers are struggling under a heavy workload. This leaves them with very little capacity to establish links with different green and nature-based activity providers in their areas: “And if there is [green and nature-based] provision the social prescribers aren’t linked into it because they tend to be too busy to actually be able to get linked into the community like that and go along and try things out” (HL7). This is a point echoed by several of the health leads, for example HL6 and HL3 (respectively):

Obviously social link workers, they’re really, really important because they provide the signposting for the patient, if you like. And they always tell me they’re really, really busy. They just do not have enough time and they need the information at their fingertips.

They’re working so hard. You know they’ve got that many patients per day and where is the time for them to know about new activities…they will have their 3 or 4 go-to nature-based activities, I can guarantee.

Equitable GSP

Many of the GSP capacity issues detailed above translate into equity challenges. For example, the GSP opportunities available to people with defined mental health needs may be limited when link workers or staff at provider organisations lack the requisite skills and training, or do not have the time needed to facilitate engagement with these groups. Beyond this, the health leads identified other factors concerned with the equitability of GSP in England.

Firstly, respondents pointed to disparities in availability of green space, which in turn undermines the provision of green and nature-based activities in an area: “I feel that where there are lower levels of provision, this is possibly due to less access to areas of natural green space. And when we say natural green space [we mean] quality green space” (HL3).

A connection was made between the availability of green space and wider issues of social inequality and deprivation. For example, one respondent noted that “it’s no mistake that a lot of the issues, the inequality issues if you overlay them, it’s with these areas that don’t have the accessible green spaces. You know, it all kind of ties in” (HL6). Another respondent (HL3) described how accessible green space and deprivation levels can vary within small distances:

So you know, I’ve got quite a lot of green space where I live. There’s not as much deprivation where I live but literally the next borough to me or not even the next borough, the next ward to me is red [on the map]…It’s got low levels of natural green space and is considered to have high levels of deprivation. So really it doesn’t just vary from county to county; it’s borough to borough and then ward to ward. It’s like anything else, you only have to drive 5 minutes in a city to see the disparity.

On the side of provision, and in addition to the capacity issues of the previous section, one health lead (HL2) argued that for GSP to be equitable the activities provided must align with what communities actually want and need. It was noted that at present there is no measure of this. Two suggestions were offered. Firstly, greater effort could be made to establish community hubs where local people can input into decision-making around the evolution of GSP in their area. Secondly, better grassroots communication channels would facilitate the sharing of wants and needs, as well as generating an understanding of what opportunities are available locally. Both points share common ground with the importance several respondents gave to the role of networks in the previous section.

On the side of referrals, again in addition to the capacity challenges detailed in the previous section, several health leads pointed to barriers that undermine the potential for GSP to be equitable. Here too links exist between these specific challenges and wider issues of social inequality and deprivation. Key barriers include transport and appropriate clothing, as highlighted by HL6 and HL2, respectively:

Because that’s another massive thing is transport and actually the first step to getting someone who may have complex issues to actually attend a session somewhere. It’s such a big thing…And then do they have the right kit, [especially] some people living in maybe deprived communities. Do they have waterproofs and do they have footwear to go out and go for a walk?

One respondent suggested that even where there is accessible green space, deprivation and locality can undermine levels of provision: “You’ve got the likes of [a particular county] which has loads of coastal towns and they’re more deprived along that coastal route…very deprived, isolated coastal towns. Although they probably have green space and they’ve got a blue setting” (HL3). And finally, a different respondent raised race and ethnicity as significant factors, where “specific ethnic minority groups may not feel welcome [in a green space] but [who] also want different things from nature connection.

Sustainability of GSP

The health leads drew attention to different aspects of the current GSP system that undermine its sustainability. Respondents repeatedly pointed to the challenge of sustainable funding: “To be honest, I don’t think there’s any long-term funding these days. You may get it for a couple of years but that’s the big, big pots of money that you’re looking at” (HL5). This has ramifications for the whole system, including its ability to deliver services equitably (HL7):

Providers are always saying that they have to be like chasing, you know, one-year funding pots and it’s taking so much time and you can’t do things like link with hard-to-reach communities if you only have a year. They need to have time to build trust. So they always say it isn’t sustainable, like it isn’t long-term and stable enough.

Allied to the challenge of continuity, several respondents noted that funding opportunities tend to incentivise new or different projects and programmes, rather than maintaining existing ones as they are. For example, HL4:

Funders don’t like funding existing work, they like funding new stuff. So you’re in that dilemma where you know the funder will say ‘we’re not gonna fund you just to carry on doing what you’re doing’. So then people doing the work on the ground, they have to change what they’re doing to make it look like a new project and in some cases that changes the whole ethos of the work. And although they might be more successful getting the funding it changes the, you know, the whole dynamic of the delivery.

Many capacity issues turn out to be sustainability challenges. For example, one respondent (HL6) points to the issue of staff capacity, again with respect to challenges smaller activity providers face in particular:

When I speak to some providers, especially the smaller ones, and they talk about funding and I say: ‘Oh well, are you, you know, plugged into…all that stuff that’s going on? And, you know, there’s learning opportunities. There’s connection opportunities’. And they go: ‘well I’m not paid. I haven’t got time to go on a webinar’.

In the face of the difficulties the GSP system faces, health leads provided insight into actions that could enhance capacity and sustainability. In the first instance, this entails clear messaging so that it is widely understood what GSP is and is not. One respondent (HL2) suggested that the term ‘GSP’ is not specifically used by funders yet and that the lack of an agreed definition for GSP is problematic. For example, should a definition of GSP include both proactive and reactive support, and what exactly do these terms mean? It was argued that a clear and commonly adopted definition of GSP would help with monitoring and assist providers in framing what they deliver.

Many respondents highlighted the importance of knowledge-sharing. In large part, this relates to a database or directory of green and nature-based activities that is up-to-date and widely accessible. As one respondent suggested, at present there tends to be overlap, duplication and fragmentation: “I also think that the distribution of knowledge…everyone’s trying to do the same thing. Everyone’s trying to get their own directory together. Everyone’s trying to and it’s a bit of a mish mash at the minute” (HL3). A point echoed by another respondent: “And I think if there was a way that it was all in one place, I think we’d all help each other a lot more rather than investing this time and money where someone else might already be doing that, but they don’t know someone else is doing it” (HL5).

Also highlighted was the need for a system that is less changeable: “There’s been so many changes and you know, the NHS and the ICS, and so everything’s just changing the whole time. That can be difficult to keep up-to-date with. So you know you might have made that connection and then something else has changed” (HL5). Two respondents argued that, alongside consistency, agreed standards in GSP are important. This would bring a range of benefits and enhance capacity and sustainability (HL6):

I think it would be helpful to have some more general standardisation…somebody needs to be confident if they’re signposting or referring somebody to a provider or activity, they need to be confident about things like safeguarding and making sure it’s legitimate, and it’s a quality activity and it’s safe… so there may well be a role for some kind of accreditation…And although they might do things differently in the Southwest compared to up in the Northeast, for example, we could learn lessons off each other. I’m sure we could have something that was almost like an overarching standard, if you like.

Finally, monitoring and evaluation was raised as an area that could be improved. It ties in with the need for greater system continuity and standardisation, and for an agreed definition of what GSP is. Building on these imperatives, one respondent (HL2) discussed monitoring and evaluation as part of the referral cycle. They suggested it should be used to ensure the impacts and benefits feed back into the wider health system, gaining support for GSP in the process. This would require establishing appropriate and consistent metrics.

National stakeholder survey

In total, 16 stakeholders completed the survey (table A1 - see annex 1). Stakeholders included individuals working in GSP strategy and coordination roles in organisations such as NASP, VCSE networks and local councils. Most of the stakeholders surveyed worked at the regional scale (81.2%), 12.5% of the stakeholders worked at the national level, and 6.2% at the local level.

Nature of GSP

On average, stakeholders reported that 7.9 different types of green and nature-based activities were available in the area where they work. The most common type of green activity was sports or exercise (93.8%), with all other types of green activity also reported by over half of stakeholders, except for nature-based talking therapies (31.2%, figure 2).

Figure 2 shows what percentage of national stakeholders reported each of the different types of green and nature-based activities as being available in the areas where they work. The full results are as follows: 93.8% sports or exercise; 87.5% nature appreciation and connection; 87.5% horticulture activities; 87.5% craft-focused activities; 87.5% conservation; 81.2% heritage activities; 75.0% care farming; 68.8% alternative therapies; 56.2% wilderness activities; 31.2% talking therapies and 31.2% other types of green and nature-based activities.

Figure 2: types of green and nature-based activities reported to be available by regional stakeholders

Stakeholders described a varied picture of the geographic and seasonal availability of activities, with many being widespread and continually available while others were only available in certain places and at certain times. In part the availability of activities is attributed to the nature of the activity. For instance, nature walks were commented on as being popular because they are ‘very easy to start and maintain’, while gaps in the availability of wilderness focused activities were attributed to perceptions that a professional guide was required. When asked whether there were any specific gaps in the delivery of green and nature-based activities, some stakeholders commented on geographic gaps or localised pockets where provision was limited. Some other stakeholders took a different perspective on gaps, for instance mentioning gaps in funding or awareness and publicity.

Many stakeholders commented that it was hard for them to describe a typical demographic of people who access GSP because their role was removed from delivery, or because of the widely varied profiles of service users. When asked whether there were any service user groups who did not access the system, several stakeholders commented on the underrepresentation of ethnic minorities. Other underrepresented groups mentioned included children and young people, including specifically young men, refugees and migrants and people with disabilities. One stakeholder commented on the importance of appropriate support to engage people who might not normally be interested in GSP, stating: “Just like when trying new foods some people may be reticent but if supported appropriately can develop a taste for the new activity”. Another stakeholder described how engagement was hindered by the “perception that these types of activities are for certain types of people”.

Factors influencing supply and demand for GSP

Stakeholders were asked what they thought were the main factors influencing supply and demand of GSP sector. The role of current funding models in shaping the supply of GSP emerged as a common theme across responses. The reliance of green providers on short-term grants was identified as being problematic and unsustainable. Piecemeal funding streams undermine the long-term and stable provision of activities, which are important for supporting the delivery of GSP and building trust and engagement with service users. Stakeholders commented that for the voluntary sector to be able to respond to increasing pressures, additional resources and more sustainable funding models are needed.

In terms of demand for GSP, stakeholders commonly mentioned that low awareness of and support for GSP from referrers, including link workers, and from the health sector limits the numbers of people engaging in GSP. A lack of knowledge in the health sector of the types of green activities available and their potential health benefits were perceived as leading to low numbers of referrals into GSP and contributing to a lack of awareness and engagement among the public. For instance, one stakeholder commented on how there are misconceptions around the levels of mobility and physical health needed to engage in GSP and that it was the responsibility of GPs and link workers to address these to promote engagement. The influence of better connections with the health sector on the provision of GSP was also mentioned by stakeholders in relation to creating partnerships, sharing information and accessing funding.

Opportunities for equitable GSP

Stakeholders were asked what, from their perspective, would be the 3 most important changes that would enable GSP to benefit more people equitably in the area where they work. Unsurprisingly, changes to funding were often mentioned and particularly the need for long-term and sustainable funding. A few stakeholders specifically suggested funding should be directed towards local providers and better matched to local demand. Some stakeholders also called for funding to be linked to referrals and personal healthcare budgets.

Beyond funding, stakeholders identified several other ways to support more equitable GSP. These include:

• establishing better networks and partnerships within the system
• raising awareness and engagement amongthe public, link workers and the health sector around GSP and its potential benefits
• strengthening the evidence base for GSP
• improving the referral process, including by providing more training to link workers

In relation to improving the referral process, one stakeholder specifically called for a “distinction between levels of ‘care’ needed and delivered” so that services can be better matched to the individual. They highlighted that this would help reduce the risks of service users with more complex needs being sent to providers who do not have the capacity to support them. Stakeholders also identified the need to make GSP more accessible, for instance providing activities in different languages, avoiding costs to service users, improving transport links and tailoring activities to target underrepresented groups.

Green activity provider survey

In total, 104 green activity providers were surveyed (table 1), over one quarter of whom were located in the Northwest NHS region of England (26.9%) and one fifth in the Southeast (21.2%). Response rates were lower among green activity providers in the Northeast (15.4%), Midlands (13.5%), Southwest (5.8%), East of England (5.8%) and London (1.9%), and 9.6% were located in ‘Other’ areas. One consequence of the targeted survey distribution and self-selection sampling methods used in this study is that green activity providers sampled are likely to be those who identify as providers of GSP. Our findings do not therefore capture the wider provision of green and nature-based activities delivered by organisations who are not aware of their role in health.

Nature of GSP provision

Providers of green and nature-based activities included in the sample spanned a wide range of organisations such as garden centres, conservation charities, volunteer networks, family centres and care farms. Most of those surveyed were third sector organisations (80.8%, table A2 - see annex 1), a majority were either local (51.0%) or regional (26.9%) in their reach (table A3 - see annex 1) and two-fifths were micro-organisations (40.4% table A4 - see annex 1). Annual incomes of green providers varied widely, with most somewhere between £10,000 and £10 million (table A5 - see annex 1). Delivering green and nature-based activities was the primary focus of many of the activity providers surveyed, with most reporting that either all (34.6%) or most (34.6%) of their activities were green or nature-based (table A6 - see annex 1).

Most green activity providers deliver multiple types of green and nature-based activities, with 79.8% of those surveyed offering between 3 and 7 types. The most common types of green and nature-based activities delivered were nature appreciation and connection activities (81.7%), craft-focused activities (71.2%), horticulture activities (68.3%) and conservation activities (65.4%, figure 3). Nature-based talking therapies (11.5%) and care farming (7.7%) were least common.

Figure 3 shows what percentage of green activity providers surveyed deliver the different types of green and nature-based activities. The full results are as follows: 81.7% nature appreciation/connection; 71.2% craft-focused activities; 68.3% horticulture activities; 65.4% conservation; 51.9% sports/exercise; 45.2% heritage activities; 43.3% alternative therapies; 36.5% wilderness activities; 11.5% talking therapies and 7.7% care farming.

Figure 3: types of green and nature-based activities offered by green activity providers

The regularity and duration of green and nature-based activities varies widely. Almost all green activity providers deliver green and nature-based activities year-round (97.1%), but many providers commented that the number and types of activities available can vary with season, be weather dependent, demand-driven or funding-dependent. Individual activity sessions may last anywhere from 30 minutes up to a full day. Some activities are offered as a one-off or seasonal event, such as tree-planting, while others are held regularly, for instance being offered on a weekly basis over a set period, for example 6 to 12 weeks, or even indefinitely. The length and duration of activities is often determined by the nature of the activity and the needs of service users.

Numbers of annual service users attending green and nature-based activities varied across activity providers surveyed, with one-fifth reporting over 1,000 service users each year (19.2%, table A2 - see annex 1). Service users of green activities include a range of groups (figure 4), including the general population (49.0%) as well as specific target groups. The most common groups targeted by green activity providers include people with mental health needs (58.7%), people experiencing loneliness or social isolation (55.8%), people living in areas of socio-economic deprivation (55.8%), and people with a physical health condition (50.0%). Green activity providers also identified other specific groups that they support, where one of the most mentioned were people from different ethnic minority backgrounds.

Figure 4 shows the percentage of green activity providers that target different service user groups. The full results are as follows: 49.0% general population; 58.7% people with mental health needs; 55.8% people experiencing loneliness and social isolation; 55.8% people living in areas of social deprivation; 50.0% people with a physical health condition; 48.1% adults over the age of 50; 46.2% people with learning disabilities; 37.5% people considered clinically vulnerable in the pandemic; 34.6% people who are unemployed or job seekers; 34.6% people who are carers; 31.7% asylum seekers and refugees; 30.8% people under 18 years old; 27.9% people living in rural areas; 23.1% other groups.

Figure 4: specific groups targeted by green activity providers

When asked what the typical demographic make-up was of people who participate in green and nature-based activities, green activity provider responses painted a varied picture. Some providers simply commented that service users are diverse and span all demographics, suggesting there is no ‘typical’ type. Other green providers described very specific profiles of services users, in some cases distinguishing between the demographics of service users who participate in different types of activities.

Where green activity providers named specific demographic groups who make up the majority of their service users, common groups included adults or older adults and retirees, women, mostly white, and those from low socio-economic backgrounds. Some providers also specified that services users were representative of the local population, for instance in terms of the percentage of service users from different ethnic minority backgrounds.

Capacity of provision

In terms of spaces available, many green activity providers have the capacity to support more service users (figure 5). Nearly two-thirds of activity providers surveyed reported that they have spaces available in at least one nature-based activity (63.5%), including 17.3% who are currently operating at 50% capacity or lower. It was commented on by multiple providers that capacity levels varied between specific activities or groups and at different times of the year. Notably, many comments, including from those green activity providers currently at full capacity (9.6%), stated that capacity was directly dependent on having sustainable funding; for example: “More sustainable funding will allow us to have more people on site in a year”.

Figure 5 shows the percentage of green activity providers surveyed that currently have spaces available in green and nature-based activities. The results are as follows: 9.6% of green providers are currently at full capacity and may or may not be operating waiting lists; 63.5% of green activity providers have spaces available in at least one of the green and nature-based activities that they deliver; and 10.6% responded ‘Other’.

Figure 5: current capacity levels of green activity providers

Volunteers support multiple aspects of the delivery of green and nature-based activities, including carrying out activities (77.9%), supporting service users (62.5%), administrative tasks (33.7%) and other roles (5.8%). A number of green activity providers commented that volunteers were at the heart of their organisation; for example: “Volunteers are integral to our organisation and our ethos …”. Only 15.4% of providers said that volunteers were not involved in the delivery of activities. Most green activity providers said that without volunteers they would have to reduce the delivery of green and nature-based activities (36.5%) or that they would be unable to provide activities altogether (29.8%). Less than one quarter said that without volunteers they would be able to continue to provide their current level of activities (23.1%). It is also important to note that often volunteers are GSP service users, with volunteering roles being referred into.

Sustainability of provision

Referrals into green and nature-based activities rarely have associated funding, with over half of green activity providers reporting that none of the referrals they receive come with funding (57.7%, table A8 - see annex 1). Consequently, green activity providers are heavily dependent on other sources of funding, especially charities or grants, which were the most common (80.8%) source of funding for two thirds of providers (67.3%, table A9 - see annex 1). Fundraising (44.2%) and donations (40.4%) were a source of funding for over a third of providers, with other sources of funding (25.0%) including retail and site hire, session fees, commissions and contracts, and statutory funding. Overall, nearly one-fifth of green activity providers depend entirely on grant-funded income (18.3%, and another quarter rely on grant funded income for 70% of their income (26.0%, table A10).

Provision for people with mental health needs

Over half of green activity providers reported that at least some of their service users have mild to moderate mental health needs (65.8%) and moderate to severe mental health needs (52.9%, figure 6). The percentage of service users with mild to moderate mental health needs was generally higher; for example, 34.7% of providers estimate that all or more than half of service users have mild to moderate mental health needs compared with only 7.7% who estimate that more than half have moderate to severe mental health needs.

Figure 6 shows what percentage of service users have different levels of mental health needs according to green activity providers. For mild to moderate mental health needs, the findings are as follows: 1% of providers reported that all their service users have mild to moderate needs; 33.7% reported that more than half but not all their service users had mild to moderate needs; 30.8% said that some but less than half of service users had mild to moderate needs; and 13.5% did not know. For moderate to severe mental health needs, the findings are as follows: 7.7% of providers reported that more than half but not all service users had moderate to severe needs, 45.2% said that some but less than half had moderate to severe needs; 6.7% said none of their service users had moderate to severe needs; and 23.1% did not know.

Figure 6: percentage of service users with different levels of mental health need

In terms of their capacity to support people with mental health needs, most activity providers have the capacity to support people with mild to moderate health needs (86.5%, figure 7), whereas less than one-quarter reported having the capacity to support people with moderate to severe mental health needs (23.1%). This is an important finding considering that, as mentioned above, over half of providers reported having service users with moderate to severe mental health needs. These findings indicate a mismatch between service user needs and the capacity of providers.

Figure 7 shows the percentage of green activity providers who have the capacity to support service users with different levels of mental health need. The findings are as follows: 6.7% of green providers have no capacity to support service users with mental health needs, this response was exclusive; 86.5% have capacity to support people with mild to moderate mental health needs; and 23.1% have capacity to support people with moderate to severe mental health needs.

Figure 7: levels of mental health green activity providers have capacity to support

When asked about what challenges they faced supporting people with mental health needs, activity provider responses pointed to several key themes. The most common challenge related to the workload and personal capacities of staff and volunteers (43.3%), with providers describing having insufficient numbers of staff and volunteers, and not having staff and volunteers with the appropriate training needed to support service users with mental health needs.

Challenges around staff and volunteer capacity were often directly linked to funding issues, which were mentioned by 19.2% of providers as impacting their ability to support people with mental health needs. Another 19.2% of green activity providers described challenges engaging people with mental health needs. For instance, a lack of confidence or motivation associated with anxiety and depression were seen as major barriers to getting people to attend green and nature-based activities.

Green activity providers also reported receiving insufficient information on the needs of service users (15.4%), which was further reiterated by the fact that while most providers receive information on whether service users have an identified mental health need (68.3%), 16.3% do not receive this information.

Other challenges identified included a lack of integration with health providers and support from mental health services (15.4%) and shortcomings in the social prescribing referral system (12.5%).

For staff at green activity providers, the most common types of training or support available for working with people with mental health needs were induction training (42.3%) and specialist training (40.4%), including mental health first aid (MHFA) training. Many activity providers also offer support for working with people with mental health needs through team meetings (38.5%) and regular supervision (35.6%), while external or clinical supervision was less common (8.7%).

Barriers and opportunities to scaling up

Green activity providers were asked what barriers they face in scaling up green and nature-based activities and in being able to support more service users. By far the most common challenge mentioned was funding (55.8%), which was highlighted as being a key determinant of whether organisations could support the staffing and resources needed to deliver activities. Many green activity providers voiced the need for a more sustainable funding model, describing the difficulties of relying on insecure funding sources and the inefficiencies inherent to grants applications.

Challenges relating to staffing and volunteers (39.4%) were also commonly mentioned as barriers to scaling up by green activity providers. Green providers identified the need for more staff time and training, and the challenges around recruiting and retaining staff and volunteers, again highlighting the importance of workload capacity and personal capacity for delivering GSP. Nearly one-quarter of providers mentioned barriers relating to site, infrastructure and equipment (22.1%), such as needing to improve site accessibility and facilities. Other barriers included problems with the GSP system and referral process (12.5%), service user engagement (5.8%), the need to establish partnerships and networks, particularly with health and social care organisations (5.8%), and transport (4.8%).

When asked where they see their organisation in the next 5 years, several themes emerged. These included aspirations to scale-up and increase the reach of the services they deliver. One of the most common themes among providers was the desire to increase the number and diversity of service users they support, including improving the engagement and accessibility of activities for hard-to-reach or minority groups.

Providers also mentioned wanting to expand their organisation geographically and in terms of the numbers of staff and volunteers, and to be able to provide more activities or more regular activities. In relation to these aspirations to scale-up, some green activity providers specifically described their hopes for more sustainable funding models, including having access to core funding and funded referrals.

Another theme in the aspirations of green activity providers was for stronger networks and partnerships, particularly with the healthcare sector, to enable them to better deliver GSP in the future.

Link worker survey

In total, 165 link workers were surveyed, 40.6% of whom were located in the Northwest NHS region of England and 29.7% in the Southeast (table A1 - see annex 1). There were lower response rates across the Midlands (10.9%), Northeast (9.1%), Southwest (5.5%), East of England (3.0%) and London (1.2%). Nearly half of link workers surveyed were employed by a third sector organisation (47.9%) and one-third were employed by a primary care provider (33.3%, table A11 - see annex 1). Over half had a permanent contract (56.4%, table A12 - see annex 1) and most were employed in their role for 30 hours or more per week (80.0%, table A13 - see annex 1).

Nature of referrals

Link workers support a wide range of clients and in many instances provide a general service - in other words, they support anyone in the locality (47.3%, figure 8). Link workers who provide targeted support spanned a range of client groups, with people under 18 years old (10.9%) and people living in rural areas (23.6%) notably the least represented (figure 8). Most link workers support over 30 clients in a typical month (52.1%) and another quarter (26.7%) support between 21 to 30 (table A14 - see annex 1).

Unsurprisingly, full-time link workers tend to support more clients per month than part-time link workers. For instance, 58.3% of full-time link workers surveyed (n=132) support over 30 clients per month compared with only 27.3% of part-time link workers (n=33). Link workers can receive over 60 new referrals in a month, but most receive up to 40 (A15). Referrals to link workers usually come from GPs or primary care staff, with nearly half of link workers (46.1%) reporting that over 75% of the referrals they receive were from GPs or primary care staff and another 18.8% reporting that all referrals were from GPs or primary care staff (A16).

Figure 8 shows the percentage of surveyed link workers who support different client groups. The full results are as follows: 47.3% general population; 45.5% adults over the age of 50; 44.8% people experiencing loneliness and/or social isolation; 44.8% people living in areas of social deprivation; 42.4% people with a physical health condition; 42.4% people with mental health needs; 42.4% people who are carers; 41.8% people who are unemployed or job seekers; 38.2% people considered clinically vulnerable in the pandemic; 38.2% people with learning disabilities; 32.7% asylum seekers and refugees; 23.6% people living in rural areas; 10.9% people under 18 years old; and 9.1% other groups.

Figure 8: target groups supported by link workers

Surveyed link workers almost universally stated that they believe engaging with nature and nature-based activities is important for mental health and wellbeing. Yet 53.3% of link workers reported that less than a quarter of the referrals they make in a typical month were into green and nature-based activities and 6.1% reported that none of their referrals were (table A17 in annex 1). Further, over one-fifth of link workers said that they know of providers of green and nature-based activities who they do not make referrals to (21.8%). The most common reasons given for not making referrals were a lack of transport for clients and activities being unsuitable for or not of interest to clients.

When asked what 3 main types of green and nature-based activities they make referrals to, nearly three-quarters of link workers reported sports or exercise (73.3%) and slightly less than half referred to craft-focused activities (45.5%) and horticulture activities (43.6%, figure 9). Very few link workers made referrals into care farming, nature-based talking therapies or wilderness activities.

Figure 9 shows the percentage of link workers that make referrals into different types of green and nature-based activities. The full results are as follows: 73.3% sports or exercise; 45.5% craft-focused activities; 43.6% horticulture activities; 32.7% alternative therapies; 16.4% nature appreciation/connection; 13.9% conservation; 11.5% heritage activities; 5.5% care farming; 4.8% talking therapies, 4.2% wilderness activities; and 6.1% other types of green and nature-based activities.

Figure 9: types of green or nature-based activities link workers make referrals to

Capacity to refer

In terms of the balance between demand for their services and paid working hours, 58.2% of link workers reported that demand was well matched with their working hours (figure 10). However, over one-third of link workers stated that demand for their services exceeded their paid hours (34.5%) suggesting the capacity of some link workers is overstretched. Most link workers are not supported by volunteers (81.2%), and for those who are, volunteers mostly support clients to attend activities (15.2%) and in a few cases assist with administrative tasks (4.8%).

Figure 10 summarises link worker responses regarding the balance between demand for their services and their paid working hours. The findings are as follows: 34.5% of link workers said that demand exceeds their paid working hours; 58.2% of link workers said that demand for their services was well matched with their paid hours; 1.2% said that demand was lower than their paid hours; and 6.1% preferred not to give an answer.

Figure 10: balance between demand for link workers and their paid working hours

Link workers were asked what main challenges they faced receiving referrals. Of those who responded or for whom the question was applicable (77.0%), 17.0% said that they experienced no challenges. For other link workers several themes emerged (A18). The most common challenge for link workers was inappropriate referrals, with link workers receiving referrals for clients whose needs are more complex and extend beyond what they or the social prescribing system cater for, including people in crisis. Other common challenges included referrals being made with incomplete information about the client’s needs and referral history and a lack of awareness, understanding or support for link workers and social prescribing among GPs.

Equitable referrals

A high percentage of link worker clients have mental health needs. A majority of link workers reported that at least half of their clients have mental health needs (83.3%), including 43.6% who reported that over three-quarters of their clients have mental health needs and 8.5% who said that all their clients have mental health needs (A19).

When asked what main challenges they face to support clients with mental health needs, link workers commonly cited a lack of suitable services or support (41.8%), such as free counselling or long-term mental health support. Many link workers also specifically described long waiting lists for mental health services (29.1%), which in some cases were reported to have wait times over 12 months.

Other common challenges related to engagement (19.4%), with clients’ mental health impacting their willingness and ability to engage with link workers and attend activities. For example, one link worker commented “People don’t want to go to groups, they either aren’t motivated or they don’t want to. We can’t force our clients to attend groups, even if we think it will be good for them.”

Link workers again described issues of receiving referrals of clients whose needs extend beyond the support they can offer (17.6%). Related to this, some link workers noted that GPs use them as a holding system for people with complex needs while they wait to access more appropriate services. Limits to their personal capacity, including not having appropriate training, was identified by 12.7% of link workers as being a challenge to supporting people with mental health needs.

Specifically in relation to referring people with mental health needs to green and nature-based activities, the main barrier identified by link workers was transport and other costs being prohibitive to clients (39.4%). Other common barriers related to the needs and abilities of clients, including anxiety or a lack of confidence preventing people attending activities (30.3%), clients not having the interest or motivation (26.7%), for instance because they have other priorities, such as housing issues, and poor mobility or physical health limiting client ability to participate in activities (10.9%). In some circumstances, clients require accompanying to green and nature-based activities, a level of support that many link workers are unable to offer (11.5%).

Link workers also mentioned a lack of spaces available with suitable green and nature-based activities (13.9%), or specifically that green activity providers did not have the capacity to support people with mental health needs (2.4%). Poor weather was mentioned as a barrier by 6.7% of link workers.

Sustainable referrals

All but one of the link workers surveyed recorded information about their cases, with the majority using GP-related systems (67.3%, table A20 - see annex 1). Most link workers also stated that it would be straightforward for them to identify the organisations that they had made referrals to (58.8%). However, nearly one-third reported it would be possible but difficult (31.5%) and 8.5% said it would be impossible.

A majority of link workers conduct follow-up work after making referrals, with only 9.7% closing the case after making the referral. After making a referral, nearly-two thirds of link workers stay in contact with their clients to provide further support (65.5%), over half collect follow-up outcome measures (59.4%), and nearly one-quarter contact the organisation to which the referral was made to understand what support was provided to a client (23.0%).

Deep dive studies

This section presents findings of the intensive phase 2 of the research. As detailed in the section ‘Intensive phase: local deep dives’, the intention is to provide more granular insights into GSP in England alongside the broader picture offered by the extensive phase 1. Phase 2 comprises 6 local deep dives: 2 PCNs from each of the Northwest, Midlands and Southeast NHS regions of England. For each location, we first provide a summary of the context (for example, number of GPs, population served, accessible green space versus deprivation). This is followed by a comparison of green activity providers currently linked into the GSP system with the total number of green activity providers identified within a 5km radius of the PCN. Selected findings from the deep dive activity provider and link worker surveys are then detailed in ways that address questions of GSP delivery capacity and equity, with a focus on mental health.

First, we provide an overview of the PCNs, including numbers of green activity providers that are currently referred to and additional green activity providers that are not referred to within a 5km radius. Each deep dive has been assigned a code comprising the abbreviated form of the NHS region where it is located (Northwest = NW; Midlands = M; Southeast = SE), alongside a number that is either ‘1’ or ‘2’.

Overview

The 6 deep dive PCNs varied in size, being made up of between 3 and 17 GPs that serve populations ranging from 35,000 to 129,000. Within each PCN, there were up to 12 link workers operating, with no more than 12 green activity providers that these link workers refer clients to (table 2). We examine in more detail the numbers of link workers and green activity providers relative to population size for each PCN in the sections below.

Table 2: population size, number of GPs, link workers and green activity providers that link workers refer to for each deep dive PCN

PCN	Population (1000s)	GPs (n)	Link workers (n)	Activity providers referred to (n)
NW1	129	17	8	12
NW2	38	4	7	7
M1	43	6	2	1
M2	44	7	1	2
SE1	35	3	1	6
SE2	56	4	12	5

In all 6 deep dives there are many potential providers of green and nature-based activities that are not currently linked into the system (figure 11). In all but one of the sites (SE1), link workers currently make referrals to less than half of potential providers and in some cases substantially less. For instance, in M2, link workers only make referrals to around 5% of potential green activity providers. Notably, there are in excess of 30 green activity providers (inclusive of current and potential) in NW1, NW2 and M2.

Figure 11 shows the number of green activity providers currently linked into the GSP system (in other words, those referred to by link workers) in each deep dive PCN and the number of additional green providers within a 5km radius that were identified in the desk-based research. The findings are as follows: in NW1 there are 12 green providers linked into the system and an additional 38 were identified; in NW2 7 green providers are linked into the system and an additional 26 were identified; in M1 one green provider is linked into the system and an additional 9 were identified; in M2 2 green providers are linked into the system and an additional 41 were identified; in SE1 6 green providers are linked into the system and an additional 5 were identified; and in SE2 5 green providers are linked into the system and an additional 6 were identified.

Figure 11: numbers of green activity providers within a 5km radius of the PCNs, indicating those currently referred to and additional providers identified in this research

To evaluate the provision of green and nature-based activities in relation to population size, in each deep dive PCN we calculated the number of people per link worker and per activity provider, including those already referred to as well as total green activity providers (figure 12). There was a large amount of variation in the numbers of people per link worker, ranging from 4,700 in SE2 to 44,000 in M2. Similarly, numbers of people per activity provider referred to varied from 5,400 in NW2 to 43,000 in M1. However, when all potential green activity providers were accounted for there were less than 5,000 people per provider in all sites.

Figure 12 illustrates the scale of the GSP system relative to the population size in each deep dive PCN. For each site, the figure shows the numbers of people per link worker, per green provider currently linked into the system and per green provider including all additional providers identified. The findings are as follows:

• NW1: 16,100 people per link worker, 10,800 people per current green provider, and 2,600 people per green provider including additional providers
• NW2: 5,400 people per link worker, 5,400 people per current green provider, and 1,200 people per green provider including additional providers
• M1: 21,500 people per link worker, 43,000 people per current green, and 4,300 people per green provider including additional providers
• M2: 44,000 people per link worker, 22,000 people per current green provider, and 1,000 people per green provider including additional providers
• SE1: 35,000 people per link worker, 5,800 people per current green provider, and 3,200 people per green provider including additional providers
• SE2: 4,700 people per link worker, 11,200 people per current green provider, and 5,100 people per green provider including additional providers

Figure 12: number of people per link worker, current green activity providers and total green activity providers (inclusive of current and potential) for each deep dive

These findings highlight the importance of accounting for possible supply and demand to gauge the stretch potential of GSP delivery capacity at local levels. They also demonstrate how high amounts of variation in GSP provision do not simply reflect numbers of activity providers on the ground but also whether these providers are linked into the system. On the face of it, the high numbers of activity providers that exist but are not currently referred to by link workers indicates opportunity for substantial growth in GSP.

Northwest 1 (NW1)

NW1 is a large PCN in the Northwest of England, encompassing 2 coastal towns and surrounding areas. It is made up of 17 GP surgeries that serve a total population of 129,000 patients (66,000 male, 63,000 female). This equates to an average of 7,600 people per GP surgery (table 2). NW1 is one of the oldest populations in the country. Accessible natural green space inequalities scores were varied across NW1. A majority of Lower Layer Super Output Areas (LSOAs - see section ‘Intensive phase: local deep dives’; and annex 1 for explanation) that make up NW1 are in medium or high IMD deciles with some low IMD deciles in the north of the PCN. At the neighbourhood scale, most LSOAs have high coverage of accessible green space (in other words, most are H2, H3, some H1). There are also several LSOAs with medium coverage of accessible green space (M1, M2) as well as small areas with low coverage of accessible green space (L1, L2 and L3 LSOAs). These were typically in areas furthest from the coastline. However, when measured at the district scale, all LSOAs in NW1 have high accessible green space coverage (mostly H2 and H3, some H1).

There are 8 link workers assigned to NW1 PCN who currently make referrals to 12 different providers of green and nature-based activities (table 2). This equates to 16,100 people per link worker in NW1 and 10,800 people per green activity provider currently referred to (figure 12). We identified a further 38 green activity providers within a 5km radius of NW1 that are not currently referred to (figure 11). Accounting for these other providers, there is a total of 50 potential green activity providers in NW1. If linked into the GSP system, they could bring the ratio of provision down to 2,600 people per provider (figure 12).

Activity provider survey

Of the 12 activity providers that link workers in NW1 refer to, 6 completed the survey (table 3). These activity providers ranged in size from micro to medium enterprises, and all had some capacity to accept more people. All activity providers had volunteers supporting the delivery of green and nature-based activities. When asked how important volunteers are for the delivery of nature-based activities, 2 respondents said they would be able to continue providing activities at the current level, 2 said they would have to run a reduced range of activities, and 2 said they would be unable to provide nature-based activities.

Five providers answered that they have the capacity to support service users with mild to moderate mental health needs, with one provider saying they have no capacity to support service users with mental health needs (table 3). Regarding support and training offered for working with people with mental health needs, 4 respondents said induction training, 2 said specialist training for the role, 5 said team meetings, and 3 said regular supervision within the organisation. At the same time, respondents cited a range of challenges they face in supporting people with mental health needs. These included having the skills and knowledge to support complex cases and having trained volunteers or additional staff to support individuals, including on a one-to-one basis. One respondent added that “people often vent their frustration at [mental health] services and use us while they await specialist support”.

Table 3: summary of green activity provider survey responses in NW1

NW1 activity providers	Responses (total = 6/12)
Size of organisation	Micro-enterprise (1); small enterprise (3); medium enterprise (2)
Current capacity level	75% and can accept more people (5); 50% and can accept more people (1)
Role of volunteers	Help carry our activities (5); administrative tasks (2); support participants (5)
Without volunteers, provider would…	Continue providing activities at current level (2); have to run a reduced range of activities (2); be unable to provide green and nature-based activities (2)
Capacity to support people with mental health needs	Mild to moderate mental health needs (5); none (1)

Providers were asked to describe any barriers they face in being able to scale up nature-based activities and take on more participants. Two respondents cited staff levels, with another citing the need for staff training. Two respondents cited limited space or storage, with one saying they “would struggle to run large scale nature-based projects due to this.” Other answers included the cost-of-living crisis, the age of volunteers, the weather, and the difficulty of “recording of the outcome measures for participants enrolled on the programme so that we can demonstrate the value of the interventions.”

Respondents have a range of answers to the question about where they see themselves in 5 years’ time in terms of the types of nature-based activities they would like to be providing. Several answered that they would like to scale-up existing activities, but it would depend on staffing levels and the ability to recruit volunteers, both of which are challenging. Respondents also highlighted the desire to better understand the needs of service users in relation to nature-based activities to “be able to demonstrate the impact of these interventions on people’s health and wellbeing.” Several stated they would like to see more green spaces for their activities. One responded that they would like to be operating in a more joined up way:

We would like to be involved in the green-space agenda and work with VCSE organisations across the city to increase capacity, allowing us to work collaboratively to facilitate these sessions for members.

Link worker survey

All 8 link workers assigned to NW1 completed the survey. Detailed in table 4 is the weekly hours these link workers are employed, their length of employment contract, whether they feel that demand is about right or exceeds what they are able to deliver within their paid working hours, any support they receive from volunteers, and the percentage of clients they support with mental health needs.

Table 4: summary of link worker survey responses in NW1

NW1 link workers	Responses (total = 8 of 8)
Weekly hours employed	More than 30 hours (7); 22.5 to 30 hours (1)
Employment contract	Permanent (1); 2 to 5 years (2); 1 to 2 years (5)
Supply-demand balance	Demand about right (5); demand exceeds hours (3)
Role of volunteers	Support service users to attend activities (4); administrative activities (1); no volunteers (4)
Percentage of clients with mental health needs	All (1); over 75% (6); 50 to 75% (1)

The typical demographic makeup of clients that these link workers support is over 60 and white British. For example, one link worker reported serving a “mixture of male and female, high proportion of elderly clients, mainly white British, some with poor mobility or unable to leave the home. Retired or unemployed”. Another link worker serves clients who are “female, over 60, white British, limited mobility, lonely and/or isolated”. However, one link worker serves a younger demographic in an “area of high deprivation - low-income households, young families, single households, unemployed, mental health conditions and long-term health conditions. Age tends to be under 60, and it is predominantly white”. One link worker notes a shift whereby “more people who own their own home or have a mortgage are now seeking social prescribing support than previously”.

All link workers reported serving a high proportion of clients with mental health needs (table 4). Six link workers said that most (more than three-quarters of referrals) had mental health needs, one said over half (half to three-quarters of referrals), and one link worker said all clients referred had mental health needs. Among the general referral issues that link workers in NW1 face, several noted that they are referred clients “who are housebound or cannot get out of the house without support which sadly we are unable to offer”.

When asked specifically about challenges these link workers face when supporting people with mental health needs, responses highlighted the complex mental health needs many of their clients have, which they are not equipped to deal with. This, coupled with a high workload, means these link workers are unable to give enough time to their clients and where “access to mental health services is limited and [there are] long waiting lists”.

All link workers thought that engaging with nature and nature-based activities is “very important”, “extremely important” or “vital” for supporting and improving people’s mental health and wellbeing. At the same time, when asked approximately what proportion of people they refer or signpost to nature-based activities in a typical month, this tended to be reasonably low. Link workers listed a range of barriers they face in referring people with identified mental health needs to nature-based activities. Typical responses included the weather and time of year, transport and location, low confidence and high levels of anxiety among clients, and a lack of nature-based activities to refer clients to. Six of the link workers responded that there are no other providers of nature-based activities that they know about that they could refer clients to, despite this research identifying a further 38.

Northwest 2 (NW2)

NW is an inner city PCN in the Northwest of England made up of 4 GP surgeries who serve a total population of 38,000 (19,000 male, 19,000 female), equating to an average of 9,500 people per surgery (table 2). LSOAs in NW2 are mostly in the lowest IMD deciles and at the neighbourhood scale most have low coverage of accessible green space (mostly L1, some L2). Contrastingly, when measured at the district scale the coverage of accessible green space for most LSOAs is high (mostly H1, some H2).

There are 7 link workers assigned to NW2 PCN who currently make referrals to 7 green activity providers (table 2), which equates to 5,400 people per link worker and per green activity provider currently referred to (figure 12). We identified a further 26 green activity providers within a 5km radius of NW2 that are not currently referred to (figure 11). Accounting for these other providers, there is a total of 33 potential green activity providers in NW2. This would bring the ratio of provision down to 1,200 people per provider (figure 12).

Activity provider survey

Of the 7 green activity providers that the link workers for NW2 refer clients to, 2 completed the survey (table 5). One provider is a micro-enterprise and the other is a large organisation. The large organisation provides wellbeing courses and activities and said they are currently at about 75% capacity and can accept people to join. The micro-enterprise runs guided walks. As this is outdoors, there are no real capacity issues in terms of numbers of people, unless a walk is being run in a restricted area. The large organisation relies on volunteers to support participants and without these volunteers they would have to run a reduced range of activities.

Table 5: summary of green activity provider survey responses in NW2

NW2 activity providers	Responses (total = 2 of 7)
Size of organisation	Micro-enterprise (1); large organisation (1)
Current capacity level	75% and can accept more people (1); other (1)
Role of volunteers	Help carry our activities (1); support participants (1); no volunteers (1)
Without volunteers, provider would…	Have to run a reduced range of activities (1); don’t know (1)
Capacity to support people with mental health needs	Mild to moderate mental health needs (2); moderate to severe mental health needs (1)

Both providers answered that they have the capacity to support service users with mild to moderate mental health needs (table 5). The large provider answered that they also have the capacity to support service users with moderate to severe mental health needs. Regarding support and training, staff are offered for working with people with mental health needs, the large provider said induction training, specialist training for the role, team meetings and regular supervision within the organisation. The micro-enterprise has received “no actual training, just experience and understanding.”

When asked what barriers they face in being able to scale up nature-based activities and take on more participants, the large provider highlighted that “the main barrier is funding in that we don’t know from one year to the next whether our service will be refunded. Our current grant covers the bare minimum and we have to seek extra small grants for the bee-keeping activities. We have a very small budget for equipment.” They also noted that in order to scale up they would need more space and staff - both of which require additional funding. For the micro-enterprise, the main barrier is the “time involved, as [they] currently work to a comfortable capacity [and where their] inclination at the moment it that [they are] happy with the balance of walks/activities.” In terms of where they see themselves in 5 years’ time, and the types of nature-based activities they would like to be providing, the micro-enterprise answered “the same as the present day”. On the other hand, the large organisation stressed the desire to secure more funding so they can scale-up existing activities.

Link worker survey

There are 7 link workers assigned to NW2 PCN, of which 5 completed the survey (table 6). Four of the link workers surveyed were employed for more than 30 hours per week and 4 had permanent contracts; 3 thought demand was well-balanced with their working hours; while 2 thought demand exceeded their hours. None of the link workers had volunteers supporting them.

Table 6: summary of link worker survey responses in NW2

NW2 link workers	Responses (total = 5 of 7)
Weekly hours employed	More than 30 hours (4); 15 to 22.5 hours (1)
Employment contract	Permanent (4); 2 to 5 years (1)
Supply-demand balance	Demand about right (3); demand exceeds hours (2)
Role of volunteers	No volunteers (5)
Percentage of clients with mental health needs	Over 75% (1); 50 to 75% (4); 25 to 50% (1)

The typical demographic makeup of the clients supported varies between link workers. It also depends on whether a link worker has a specific remit. Thus, one link worker “often support[s] people who have had a diagnosis of cancer” while another link worker provides support “for those who are pregnant and new parents”. Across the responses the “majority of referrals are for those on low incomes and experiencing economic deprivation”. One link worker stated that “50% [of clients] do not have English as their first language and are aged between 18 to 35 years [where] almost all who are referred are living [off] basic benefits.” Another responded that they “generally [work with] people who are in need of support to address practical issues such as poverty, debt, homelessness etc.”.

Nearly all link workers reported serving a high proportion of clients with mental health needs (table 6). One link worker said that most (more than three-quarters of referrals) had mental health needs, 4 said over half (half to three-quarters of referrals), and one link worker said some clients referred had mental health needs. Regarding specific challenges link workers face to support people with mental health needs, all highlighted a lack of services and excessively long waiting lists for access to mental health support, counselling and so forth. Related to this, one respondent answered that a challenge they face is “limited training in mental health, therefore sometimes [I] feel unable to engage/communicate and help/encourage clients to identify what matters to them and move forward/progress as they want to”. Another respondent noted the challenge of “managing expectations due to long waiting lists [for mental health services]”.

Link workers in NW2 generally felt that engaging with nature and nature-based activities is important for supporting and improving people’s mental health and wellbeing. Responses included “very important” and “powerful and therapeutic for some clients”. At the same time, 4 respondents qualified their answer by noting that their clients are reluctant to take up green and nature-based activities, or that these activities are not as much of a priority as “other things, for example accessing mental health services or getting financial assistance”. One link worker noted: “I think nature-based activities are a great offer but I haven’t come across many clients who join/try or even want to hear about those types of activities.”

When asked approximately what proportion of people they refer or signpost to nature-based activities in a typical month, this tended to be low. Link workers listed a range of barriers they face in referring people with identified mental health needs to nature-based activities. These included a “client’s preferences, for example a client may prefer one-to-one based activity, or indoors activity”; “new mums I work with just are not interested”; “social anxiety/agoraphobia/low confidence”; and “people with poor mental health can isolate themselves, leaving the house is difficult!”. None of the respondents were aware of other providers of nature-based activities that they could refer people to.

Midlands 1 (M1)

M1 is an inner city PCN in the Midlands. It comprises 6 GP surgeries who serve a population of 43,000 (21,500 male and 21,500 female). This equates to an average of 7,200 people per GP surgery (table 2). Most LSOAs in M1 PCN are in low to medium IMD deciles and at the neighbourhood scale have high coverage of accessible green space (mostly H1 and H2) with a very small area with medium coverage of accessible green space (M2). Similarly, when measured at district scale the coverage of accessible green space for most LSOAs in M2 is also high (H1, H2) but there are LSOAs in the south of the PCN with low and medium levels of coverage (L1, L2, M1, M2).

There are 2 link workers assigned to M1 PCN who currently make referrals to one green activity provider (table 2). This equates to 21,000 people per link worker and 43,000 per green activity provider currently referred to (figure 12). This is the highest number of people per activity provider found in any of the deep dives. We identified a further 9 green activity providers within a 5km radius of M1 that are not currently referred to (figure 11). Accounting for these other providers there is a total of 10 potential green activity providers in M1, which if accessed could bring the ratio of GSP provision down to 4,300 people per green provider in the PCN (figure 12).

Activity provider survey

The one green activity provider that the link workers in M1 currently refer clients to, completed the survey (table 7). It is a medium-sized organisation, whose remit includes “delivering a wide range of free activities and services aimed at improving wellbeing at an individual and community level, increasing participation in physical activity and exercise.” This provider is currently at full capacity and operating waiting lists. They rely on volunteers to support participants. Without the help of volunteers, this provider would have to run a reduced range of activities. For example, this provider notes that “there are a number of community walks, running clubs and led cycling sessions we deliver solely through volunteers. Our volunteers are trained, supported through leadership and given a qualification to deliver such activities.”

Table 7: summary of green activity provider survey responses in M1

M1 activity providers	Responses (total = 1 of 1)
Size of organisation	Medium organisation (1)
Current capacity level	Full with waiting lists (1)
Role of volunteers	Support participants (1)
Without volunteers, provider would…	Have to run a reduced range of activities (1)
Capacity to support people with mental health needs	Mild to moderate mental health needs (1); moderate to severe mental health needs (1)

This respondent answered that they have the capacity to support service users with both mild to moderate and moderate to severe mental health needs (table 7). The provider receives information on whether service users have identified mental health needs. They estimate that over half (50 to 75%) of service users have mild to moderate mental needs, with few (less than 25%) having significant or severe and enduring mental health needs.

Regarding support and training staff are offered for working with people with mental health needs, the respondent said induction training, specialist training for the role, team meetings and regular supervision within the organisation. The respondent also cited a range of challenges the organisation faces in supporting people with mental health needs, including that:

Participants often require additional support from our staff to accommodate, be available to listen, and support them. Low social confidence to make friends and low confidence to participate in activities requires strong people skills in staff to engage, motivate and facilitate social cohesion. Staff have encountered irritability, hostility and aggression from some patients and have had to mediate between other patients to help them to foster healthy relationships with each other. Some people struggle to manage boundaries and rules and may find it difficult to maintain attention and concentration.

In terms of where this organisation sees themselves in 5 years’ time, the respondent stressed the role of local buy in, participation and the role of networks: “[we would like to see] a larger percentage of greening growing work with well-established greening and growing projects that are owned by residents and operate with the support of a network of community organisations feeding into and cultivating each project based on an asset-based community development model.”

Link worker survey

There are 2 link workers assigned to M1 PCN. Both work permanent part-time contracts and both felt demand was about right for their hours, with neither having any volunteers supporting their service (table 8). Regarding the demographic makeup of the people they support, one respondent said that they “support people who are over 50, sometimes having mobility or mental health issues, generally working for lower pay, retired on state pension or on benefits”. The other answered that they “probably [support] more women than men. Maybe older patients over 60 but generally equal socio-economic status, race, mobility and physical health”.

Table 8: summary of link worker survey responses in M1

M1 link workers	Responses (total = 2 of 2)
Weekly hours employed	22.5 to 30 hours (2)
Employment contract	Permanent (2)
Supply-demand balance	Demand about right (2)
Role of volunteers	No volunteers (2)
Percentage of clients with mental health needs	Over 75% (2)

Regarding general referral issues link workers in M1 face, one respondent answered “none” while the other cited “Doctors not knowing who is suitable for referral because they are not sure what social prescribing is and what it can do”. Both link workers reported that most (more than three-quarters of referrals) of the people they support have mental health needs (table 8). One link worker stated that the challenge they face in supporting clients with mental health needs is “having the correct training [which] is crucial and I currently don’t have mental health first aid training so it can be challenging when faced with people in a crisis”. The other link worker noted that the challenge they face is working with people with “high-level mental health needs especially if people also have substance misuse issues”.

The 2 link workers assigned to M1 PCN felt that engaging with nature and nature-based activities is “extremely important” and “vital” for supporting and improving people’s mental health and wellbeing. They also reported that in a typical month they refer over half (half to three-quarters of referrals) and most (more than three-quarters of referrals) of clients to nature-based activities. One respondent noted that they face no barriers in referring people with identified mental health needs to nature-based activities. The other respondent answered that “some of the spaces are not accessible such as pathways being uneven or ramps unsuitable”. Finally, one link worker was not aware of any other providers of nature-based activities that they could refer people to. The other link worker was aware of other green activity providers but could not remember their name. They also noted that these “are activities I don’t refer to because they are outside my PCN’s locality”.

Midlands 2 (M2)

M2 is an inner city PCN in the Midlands. M2 is made up of 7 GP surgeries who serve a total population of 44,000 (22,000 male, 22,000 female), equating to an average of 6,300 people per GP surgery (table 2). All LSOAs in M2 PCN are in low or medium IMD deciles, and when measured at neighbourhood or district scales, most have high coverage of accessible green space (H1, H2) but there are also some areas with medium (M2) and low (L1, L2) coverage.

There is one link worker currently assigned to M2, who makes referrals to 2 green activity providers (table 2), which equates to 44,000 people per link worker, the highest of all the deep dive sites, and 22,000 per green activity provider currently referred to (figure 12). We identified a further 41 green activity providers within a 5km radius of M2 that are not currently referred to (figure 11), taking the total number of potential providers in the PCN up to 43. If all these providers were linked into the GSP system, this would bring the ratio down to 1,000 people per green provider in the PCN (figure 12).

Activity provider survey

Both activity providers that the link worker refers clients to in M2 completed the survey. One of these is the same provider that operates in M1 PCN. Please see the previous section for details of this provider. The second provider (table 9) is a micro-enterprise (1 to 9 staff), a “very enthusiastic collective of artists, nurturing creativity and community spirit across the constituency”. Activities include a community garden and heritage walks. This provider is currently at about 50% capacity and can accept people to join their activities. At the same time, they note: “We are constantly increasing our capacity as the need for our services increases. Our capacity depends on how many facilitators we can fund. Our capacity is based on what funding is received.” Volunteers help carry out activities, especially in relation to the community garden. Without these volunteers “it would be very hard to keep the garden well maintained and producing harvests”.

The respondent answered that they have the capacity to support service users with both mild to moderate and moderate to severe mental health needs (table 9). Regarding support and training staff are offered for working with people with mental health needs, they said induction training, team meetings and regular supervision within the organisation. The staff at this organisation take part in the specific training offered by local organisations that provide a wide range of training, including working with people with mental health needs. In terms of challenges this provider faces in supporting people with mental health needs, they stressed the importance of funding: “Trying to run the garden while constantly applying for funding to keep it open and to run events with trained facilitators.”

Table 9: summary of green activity provider survey responses in M2

M2 activity providers	Responses (total = 1 of 2)
Size of organisation	Micro-enterprise (1)
Current capacity level	50% and can accept more people (1)
Role of volunteers	Help carry our activities (1)
Without volunteers, provider would…	Have to run a reduced range of activities (1)
Capacity to support people with mental health needs	Mild to moderate mental health needs (1); moderate to severe mental health needs (1)

Regarding barriers this provider faces in being able to scale up nature-based activities and take on more participants, they responded: “It all comes down to funding, the more we can receive the more we can provide for the community. It is getting harder and harder to obtain funding while the need for community activities and support keeps increasing.” In relation to the question about where they see themselves in 5 years’ time in terms of the types of nature-based activities they would like to be providing, this respondent answered:

We want to be able to open the garden at least 5 days a week, with a trained member of staff on site. This would allow for more workshops to take place both for specific groups and open to all. We would also like to have set up another community garden in one of the areas we work in.

Link worker survey

One link worker is assigned to M2 PCN (table 10). They are on a permanent full-time contract of 30 hours or more and feel that service demand is about right for what they are able to deliver within their paid working hours. They do not have volunteers supporting their service. The respondent did not answer the question concerning the demographic makeup of the people they support. However, they answered that most clients they support (more than three-quarters of referrals) have mental health needs.

This link worker felt that engaging with nature and nature-based activities is “key” for supporting and improving people’s mental health and wellbeing. At the same time, in terms of barriers they face in referring people with identified mental health needs to nature-based activities they noted that “those that struggle with mental health don’t like to leave the house. [They] will not engage in any activities due to feeling anxious”. In a typical month, the link worker assigned to M1 PCN referred a few clients (less than a quarter) to nature-based activities. They were not aware of any providers of nature-based activities beyond those they already refer people to.

Table 10: summary of link worker survey responses in M2

M2 link workers	Responses (total = 1 of 1)
Weekly hours employed	More than 30 hours (1)
Employment contract	Permanent (1)
Supply-demand balance	Demand about right (1)
Role of volunteers	No volunteers (1)
Percentage of clients with mental health needs	Over 75% (1)

Southeast 1 (SE1)

SE1 is a relatively small PCN located in the Southeast of England. SE1 is made up of 3 GP surgeries that support 35,000 patients (16,000 male, 19,000 female) which is an average population of 11,600 people per surgery (table 2). LSOAs in SE1 are mostly in low or medium IMD deciles, with some high IMD deciles. When measured at the neighbourhood scale, around half of LSOAs in SE1 have low coverage of accessible green space (L1, L2, L3), while the other half is made of LSOAs with medium (M2) and high (H1, H2) coverage of accessible green space. When measured at the district scale, the coverage of accessible green space in most LSOAs in SE1 is high (H1, H2), with a large area of low and medium coverage (L2, M2).

There is one link worker currently assigned to SE1, who makes referrals to 6 green activity providers (table 2). This equates to 35,000 people per link worker and 5,800 per green activity provider currently referred to, which is the lowest number of people per provider in any of the deep dives (figure 12). We identified a further 5 green activity providers within a 5km radius of SE1 that are not currently referred to (figure 11). The total number of potential providers in SE1 is therefore 11 and if all these providers were linked into the GSP system, this would bring the ratio down to 3,200 people per provider (figure 12).

Activity provider survey

Of the 6 green activity providers that the link worker for SE1 refers clients to, 4 completed the survey (table 11). All were micro-enterprises, one was at full capacity, 2 respondents said they are currently at about 75% capacity and one respondent said they are currently at about 50% capacity. All the providers rely on volunteers to assist with a range of tasks and, without volunteers, 2 respondents said they would have to run a reduced range of activities and 2 said they would be unable to provide nature-based activities.

Table 11: summary of green activity provider survey responses in SE1

SE1 activity providers	Responses (total = 4 of 6)
Size of organisation	Micro-enterprise (4)
Current capacity level	Full capacity (1); 75% and can accept more people (2); 50% and can accept more people (1)
Role of volunteers	Help carry our activities (4); support administrative tasks (2); support participants (4); other (1)
Without volunteers, provider would…	Have to run a reduced range of activities (2); be unable to provide green and nature-based activities (2)
Capacity to support people with mental health needs	Mild to moderate mental health needs (4)

All 4 providers answered that they have the capacity to support service users with mild to moderate mental health needs (table 11). Their staff have received some form of support and training for working with these people, with one saying induction training, one saying team meetings, 2 saying regular supervision within the organisation, and one saying “core specialist training and where possible (if training is available for free or we can cover costs…then) additional specialist training.” Respondents cited a range of challenges they face in supporting people with mental health needs. These included a lack of funding to employ enough staff who are trained specifically in mental health support; getting service users with mental health needs to attend activities and feel motivated when they do; and difficulties these service users face in building relationships with other attendees.

Providers were asked to describe any barriers they face in being able to scale-up nature-based activities and take on more participants. Key issues relate to a lack of funding and recruitment of dedicated volunteers. For example, one respondent wrote: “Almost impossible to get funding to cover core activities, so we’re operating without a coordinator which makes planning, and therefore scaling up, difficult.” Another answered:

There is a high demand from the BAME community for us to deliver throughout the year. However, we are physically exhausted because we need funds to develop our platforms; meet core activity costs; pay members already delivering activities; take on more members (we have a suitable candidate right now but we cannot take her on); so that each of us is not doing the job of 2 people; and to take on someone to cover admin so that we can continue delivering and focusing on our sites.

We are growing exponentially, and it is leading to burn out. Feel totally unvalued because of the constant anxiety to find funds. Filling funding forms is stressful and takes a huge time for small charities like ours.

In response to the question on where they see themselves in 5 years’ time in terms of the types of nature-based activities they would like to be providing, 3 providers’ answers related simply to being able to provide the same service but at full capacity and with secure funding. One provider also stressed the desire to be recognised as a “reputed local charitable organisation…with more numbers of qualified and dedicated volunteers in a wider location within [our] working area.”

Link worker survey

One link worker is assigned to SE1 PCN (table 12). They are on a permanent full-time contract of 30 hours or more and feel that service demand exceeds what they are able to deliver within their paid working hours. They do not have any volunteers supporting them with their service. The majority of the clients supported by this respondent are white British, with a smaller number of clients of other ethnicities. Most of the clients (more than three-quarters of referrals) have mental health needs. Regarding specific issues this link worker faces in supporting people with mental health needs, they note:

Pathways especially into secondary care have long wait lists up to 12 months or more and people are left with no support while they wait for that service. They can often not be picked up by other mental health services because they are open to whatever secondary care service they are on the wait list for. People get pushed towards talking therapies and don’t realise they can say that the service doesn’t work for them and to ask for something else. Often it seems that when people have completed a course of therapy they are not signposted to other 3rd sector services that could help them with ongoing support, which might prevent them from going backwards…I have spoken to clients in crisis and struggled with the dealing with them and what they are going through.

Table 12: summary of link worker survey responses in SE1

SE1 link workers	Responses (total = 1 of 1)
Weekly hours employed	More than 30 hours (1)
Employment contract	Permanent (1)
Supply-demand balance	Demand about right (1)
Role of volunteers	No volunteers (1)
Percentage of clients with mental health needs	Over 75% (1)

The link worker for SE1 responded very positively when asked how important engaging with nature and nature-based activities is for supporting and improving people’s mental health and wellbeing, stressing the social aspects and its ability to improve both physical and mental health:

I think it can have a great benefit especially the activities take place within their local communities as they get to know others who live locally who are going through something similar and makes people feel they are not alone in going through it…[It] improves both physical and mental health without people realising they are undertaking therapy.

They answered that some of the clients they work with (a quarter to half of referrals) are referred to nature-based activities. Regarding any barriers this respondent faces in referring people with identified mental health needs to nature-based activities, they answered:

Transport: clients have to use at least one bus, and this can be physically or mentally too difficult. Clients need hand-holding to the first couple of sessions. I may not have capacity to do this. Some providers charge - clients can’t afford it and I don’t have capacity to apply for funding. Keeping track of what is on and when. It can take a while to build up a client to attend a new activity and if the project only has funding for say 6 sessions, these might have all nearly finished before you can get them along.

This link worker was aware of 5 other green activity providers that they do not refer clients to. In each instance they offered reasons for why they do not do this. These reasons include that the “timing and locations of their activities haven’t matched those of the clients”; “generally my clients are not physically able enough to take part”; “I just haven’t had any adults with autism who have been interested in gardening”; and “transport to the garden is an issue as not accessible by bus.” As a further comment, the link worker for SE1 stated:

I think one of the greatest barriers for our local green activities is getting continual core funding so they can offer regular sessions. Then as a social prescriber I would have time to get to know what is running and refer clients to it before it ends. Our clients need long-term input not time bound interventions.

Southeast 2 (SE2)

SE2 is a medium-sized PCN in the Southeast of England. It contains 4 GPs surgeries who serve a total population of 56,000 (29,000 male, 27,000 female), which is an average of 14,000 per surgery (table 2). LSOAs in SE2 are all in low or medium IMD deciles. At the neighbourhood scale, coverage of accessible green space is mostly low (L1 and L2) with the remainder predominantly high coverage (H2 and a small area of H1), and a smaller amount of medium coverage (M2). Likewise, when measured at the district scale coverage of accessible green space for LSOAs was mostly low (L1, L2), but also with a large area of high (H2) and medium (M2) coverage.

There are 12 link workers currently assigned to SE2, who makes referrals to 5 green activity providers (table 2). This equates to 4,700 people per link worker and 11,200 per green activity provider currently referred to (figure 12). We identified a further 6 green activity providers within a 5km radius of SE2 that are not currently referred to (figure 11), taking the total number of potential providers in SE2 up to 11. If all these providers were linked into the GSP system, this would bring the ratio down to 5,100 people per provider (figure 12).

Activity provider survey

Of the 5 green activity providers that the link workers for SE2 refer clients to, one completed the survey (table 13). It is a micro-enterprise, a “community garden providing day provision for people with learning difficulties and/or mental health issues.” The provider is currently at about 75% capacity and can accept people to join their activities. Volunteers help carry out activities and to support service users and without volunteers they would have to run a reduced range of activities.

Table 13: summary of green activity provider survey responses in SE2

SE2 activity providers	Responses (total = 1 of 5)
Size of organisation	Micro-enterprise (1)
Current capacity level	75% and can accept more people (1)
Role of volunteers	Help carry our activities (1); support administrative tasks (1)
Without volunteers, provider would…	Have to run a reduced range of activities (1)
Capacity to support people with mental health needs	Mild to moderate mental health needs (1)

The respondent said their organisation has the capacity to support people with mild to moderate mental health needs (table 13). Any support and training for staff working with service users with mental health needs takes place in team meetings. The challenge this provider faces in supporting service users with mental health needs relates to “attaining funding”. In terms of the barriers this provider faces in being able to scale-up nature-based activities and take on more participants, they responded: “the actual size of the area in which we operate”. Regarding where they see themselves in 5 years’ time in terms of the types of nature-based activities they would like to be providing, they responded: “On a level that we’re on now.”

Link worker survey

There are 12 link workers assigned to SE2 PCN, of which 8 completed the survey (table 14). All of the link workers surveyed work 30 or more hours per week, most were employed on permanent contracts or for between 2 to 5 years. Six link workers felt that service demand is about right for what they are able to deliver within their paid working hours, while 2 respondents felt that service demand exceeds what they are able to deliver. None of the respondents have volunteers to support them with the service they provide.

Table 14: summary of link worker survey responses in SE2

SE2 link workers	Responses (total = 8 of 12)
Weekly hours employed	More than 30 hours (8)
Employment contract	Permanent (3); 2 to 5 years (3); 1 to 2 years (2)
Supply-demand balance	Demand about right (6); demand exceeds hours (2)
Role of volunteers	No volunteers (8)
Percentage of clients with mental health needs	Over 75% (3); 50 to 75% (1); 25 to 50% (4)

The typical demographic makeup of clients that these link workers support varies. A few noted that most of their clients are white British, while others answered that they work with people from a range of cultures and countries, including Eastern European countries. Most respondents noted that their clients are from poor or deprived backgrounds, with several also noting that a high proportion of their clients are elderly.

Thus one link worker responded: “I support patients over the age of 18. Most of my patients are 50+, I deal with a lot of housing issues, deprivation, poor mobility and the European community.” Another answered: their “race is mainly white British. However, we do offer target outreach and health promotion to Roma and Eastern European families. Mobility can vary but is often more an issue in older adults. Socio-economic status most likely more so working class as well as dealing with highly deprived and vulnerable.” While another said: “I work in a very deprived area of the country and work with different communities and cultures.”

Link workers assigned to SE2 currently identified several issues with receiving referrals. These included delays between referral requests being given to medical secretaries and being sent to their team and that some staff are not using the referral process. Others responded that clients referred to them may have complex needs that are beyond the scope of their practice. For example, one link worker noted:

We often receive a high amount of referrals that are mainly due to complex health issues and/or complex mental health issues. These can be more difficult to support and often involve needing more ‘hand-holding’ than a typical social prescribing referral. Because of this the time for a patient to remain in service is a lot longer than the desired 6 weeks and results can vary and we can often have little to no impact in the first instance, needing to offer more targeted and intensive work to get positive outcomes.

Respondents generally felt that a high proportion of people they support have mental health needs, with 4 answering some (a quarter to half of referrals), one answering over half (half to three-quarters of referrals), and 3 answering most (more than three-quarters of referrals) (table 14). Regarding specific challenges link workers face to support people with mental health needs, many highlighted poor mental health services with long waiting times. For example, one respondent answered: “There is simply not the capacity for local services, which leaves patients with mental health issues without the correct support.” Another respondent note: “We struggle as we are not clinically trained, nor specifically trained to support patients with mental health issues - the more complex the harder it is for us to help in a specific timeframe.”

Seven link workers assigned to SE2 thought that engaging with nature and nature-based activities are very important for supporting and improving people’s mental health and wellbeing. The other respondent answered that it “depends on the person, [it] can be very rewarding but for some can be a complete waste of time.”

When asked approximately what proportion of people they refer or signpost to nature-based activities in a typical month, this tended to be low. Link workers listed a range of barriers they face in referring people with identified mental health needs to nature-based activities. Responses included issues around confidence, anxiety and mood; issues with transport, including availability and affordability; that staff of green activity providers are not equipped to handle “challenging behaviour”; a lack of awareness of green activity providers; and people with poor mental health not wishing to leave the house.

Another respondent answered that GSP “is something we have found difficult to promote as there is a reluctance around trying new things and also a lack of communication between us and potential service providers around green prescribing.” None of the respondents were aware of other providers of nature-based activities beyond those they already refer people to.

Discussion

This section discusses the findings of the study by bringing them together and considering them in relation to the wider literature. As noted previously, the report is based on a rapid assessment of GSP delivery capacity. It has been conducted in a short timeframe, where sample sizes are relatively small. The discussion should be understood in light of this fact.

Nature of GSP provision

This study set out in part to understand the nature of GSP provision in England, including the types of green and nature-based activities currently on offer, their distribution, and the service user groups who access them. Alongside this, understanding the nature of GSP provision requires insight into referral processes. Thus, we also examined the role link workers play in connecting service users to activity providers. Our findings highlight the diverse, patchy and dynamic nature of the current GSP landscape in England.

Provision of green and nature-based activities

Results from the stakeholder and activity provider surveys reveal a wide variety of green and nature-based activities in England. Many individual providers offer different types of activity, with the most common including nature-based sports and exercise, nature-appreciation and connection activities, craft focused, horticulture, and conservation. Talking therapies and wilderness-focussed activities were the least common types of green activity on offer, with the latter being described by one national stakeholder as ‘niche’.

Most green activity providers are third-sector organisations, many of whom are local and micro (1 to 9 staff) or small (10 to 49 staff) organisations. Green activity providers span mental health charities, conservation organisations, volunteer networks and businesses. Providers can be individuals who deliver one activity, through to national organisations with a broad remit and who offer several different types of activity at any given time. The diversity captured by this research reflects the broad scope of activities and modes of delivery considered to constitute GSP (Husk and others, 2019).

The length and regularity of green and nature-based activities is varied and dependent on the nature of the activity, the resources available to the provider and the needs of service users. For instance, certain activities may be one-off seasonal events, such as tree-planting. Other activities, such as wellbeing walks, which are easy to set up and maintain, may happen regularly. Some activities are offered as short drop-in sessions, while others involve a longer-term commitment from service users. For example, one activity provider runs a project in which service users attend weekly sessions for 18 months during which they create art and host an exhibition. These different levels of time commitment can suit a variety of service user needs. However, it is also important to note that the regularity of activities offered by many providers is very much determined by constraints to funding and staffing.

The availability of green and nature-based activities differs between localities and at different points in time. This was highlighted by the health leads who described the complexities of accounting for localised variation when trying to paint a regional picture. Similarly, several national stakeholders commented that activities may only be available in certain places and at certain times. The deep dives also illustrate how numbers of activity providers can differ substantially between PCNs, even when they are near each other in the same city.

Some health leads attributed fine spatial differences in the provision of GSP to the local availability of green space and levels of social deprivation, which aligns with other research that shows how GSP provision correlates with the distribution of green space and activity providers (Robinson and others, 2020). The fine spatial scale at which accessible green space and social deprivation can vary was illustrated in the deep dives, which show how different LSOAs within the same PCN can span a range of IMD deciles and have varying levels of green space coverage (see the methodology section for information on LSOAs and IMD). In the ‘Delivery equitably’ section, we further discuss the implications of this relationship between accessible green space and social deprivation for achieving equitable GSP.

Both the interviews and surveys highlighted how difficult it is to separate the prevalence of green and nature-based activities from the availability of funding. Green activity providers are often heavily reliant on competitive short-term funding. This shapes the types of activity on offer. It also impacts on how much can be delivered, given the amount of time spent applying for funding. Determinants such as where, when and how long a green or nature-based activity runs for depends significantly on the funding that providers can secure. Some funding also specifically favours novelty, making it hard for providers to sustain activities. Health leads, national stakeholders, link workers and activity providers all commented on how the current funding model undermines sustainable and equitable delivery of GSP. We discuss the implications of this for scaling up sustainably in the section ‘Scaling up sustainably’.

In summary, there is a diverse array of green and nature-based activities currently available in England. However, the provision of activities is highly localised and dependent on funding, resulting in a GSP landscape that is unpredictable, transient and precarious. Attempts to summarise the distribution of GSP can therefore only provide a snapshot at a given time (Garside and others, 2020). At broad scales this is extremely difficult to do. To build an understanding of the complex and dynamic landscape of GSP in England requires long-term monitoring at scales relevant to demand and delivery (in other words, the PCN). Such an approach would enable important questions around gaps in delivery to be answered in a meaningful way. Several respondents pointed towards the need for a directory or mapping tool to provide a comprehensive and up-to-date picture of what is actually available on the ground.

Referrals to activities

By connecting service users to green and nature-based activities, link workers play a central role in shaping the GSP landscape. Link worker roles predominantly sit within the third sector and NHS primary care sector. Most work in full-time roles but only around half have permanent contracts. Survey results show that each month individual link workers typically support over 30 individuals, with most referrals coming from GPs. Significantly, despite widespread awareness of the benefits of GSP among link workers, most only refer a small percentage of their clients to green and nature-based activities. It was far more common for link workers to refer to sports and exercise than any other type of green and nature-based activity.

These findings suggest that link workers may only be facilitating pathways to a limited section of available activities, echoing comments from activity providers and stakeholders about the low numbers of link worker referrals, and comments by health leads about the prevalence of self-referrals. In the ‘Link work capacity’ section, we discuss reasons behind the limited numbers and types of referrals made by link workers to green and nature-based activities and implications for GSP delivery capacity. It is important to note that not all referrals into GSP come from link workers and that the focus of this study on link worker referrals does not capture the other pathways and networks that facilitate GSP.

Service users

Across activity providers, the numbers of service users that attend green and nature-based activities annually ranged from less than 20 to several thousand. Many providers struggled to estimate numbers of service users due to variability in attendance and the different types of engagement. For instance, some providers have a core group of regular service users but then also support high numbers of one-off service users. Group sizes are also sometimes intentionally limited by providers to ensure the quality of experience and levels of support they can provide. Numbers of service users in part reflect the scale of the provider organisation but also the nature of activities; for example, self-guided wellbeing walks are open to many more people than structured and professionally guided activities. These differences highlight how the scope of activities and levels of engagement captured within definitions of GSP can lead to very different evaluations of numbers of service users.

In terms of who is currently accessing the GSP system, survey results from link workers and activity providers suggest that there is a wide range of service user types. Link workers and activity providers reported working with the general population as well as with specific groups. These groups commonly include people with mental health needs, people experiencing loneliness or social isolation, people living in areas of socioeconomic deprivation, and people with a physical health condition. As recognised elsewhere (Cartwright and others, 2022), service users with mild to moderate mental health needs are those who benefit most readily from social prescribing. It is therefore unsurprising that these are the groups most targeted by GSP. However, our survey results show that as well as supporting service users with mild to moderate mental health needs, over half of activity providers also have service users with moderate to severe mental health needs - a situation that often exceeds provider capacity, as discussed further in the ‘Provider capacity’ section.

Many providers stated that there was no typical demographic profile of service users. Others noted higher engagement among certain demographic groups. These most often included white, adult or older adult, female, and those from low socio-economic backgrounds. These findings are broadly in line with social prescribing referral trends (Cartwright and others, 2022). The groups least represented in GSP referrals and activity provision include people under the age of 18, people living in rural areas, and asylum seekers and refugees. The underrepresentation of young people in GSP has been described elsewhere (Cartwright and others, 2022; Garside and others, 2020), representing a notable gap in provision.

As well as understanding broad trends, it is also important to recognise that patterns of engagement are also localised and activity specific. For example, some activity providers mentioned specifically targeting people from different ethnic minority backgrounds while several other activity providers and stakeholders mentioned the underrepresentation of people from different ethnic minority backgrounds. Similarly, although there may generally be higher engagement in social prescribing by women, there are examples of projects that specifically target men (for example, men’s sheds) and in the survey some providers mentioned how for certain activities service users were predominantly men. Taken together, these findings illustrate the complexities of understanding who engages in GSP and highlights the need for a more granular approach.

GSP delivery capacity

The national green activity provider survey found that many providers have the capacity to support more service users. At the same time, the 6 deep dive studies revealed large gaps between green activity providers that are currently being referred to and other providers that are not being referred to - a point supported by NE’s health leads. On their own, these findings suggest that there is existing capacity for GSP delivery to increase, in some cases quite considerably.

Why is this capacity not being realised? We consider this question by examining other aspects of GSP delivery capacity as they relate to green activity providers, link workers and potential service users. This section is structured in relation to Potter and Brough’s (2004) hierarchy of capacity building needs (see table 1), identified in the literature review. Drawing upon this framework allows us to be comprehensive in our treatment of delivery capacity and so resist overly reductive claims about the actual potential for GSP to scale up.

Provider capacity

We discuss the overall capacity of green activity providers by considering performance capacity (including the availability of money, tools and equipment to run activities); personal capacity (including adequate staff knowledge, skills and confidence); workload capacity (including enough staff with the correct skills to cope with workloads); facility capacity (is the venue or size big enough and is it accessible?); and support service capacity (with a focus on mental health support).

Performance capacity

The research findings suggest that the performance capacity of activity providers is undermined by challenges relating to funding. NE’s health leads highlighted the difficulties activity providers face to secure funds to run activities, with many providers having to “scramble and scramble to keep themselves going” (HL3). Thus, while “the need and want to [run activities] is always there” (HL5), often the funds are not. The national activity provider survey underscored this point, where 55.8% of respondents cited funding as the primary barrier to securing the staffing and resources needed to run activities.

Across the 6 deep dive locations, funding again represented a key challenge to performance capacity, with one provider noting that it is “almost impossible to get funding to cover core activities” (SE1) and another stating that “it is getting harder and harder to obtain funding while the need for community activities and support keeps increasing” (M2). Other providers linked funding challenges to different aspects of performance capacity, including the challenge of securing equipment to run activities.

Personal capacity

In line with this commission, the national green activity provider survey specifically explored staff skills for working with people with mental health needs. Here the personal capacity of staff within provider organisations is variable, with one health lead noting that “service providers are not always comfortable to take referrals as they don’t have the skills and training, consequently they tend to be wellbeing- rather than health-focused” (HL2). The national provider survey and deep dive studies suggest that many organisations do provide one or more of a range of training and support options for their staff. Typically, this equips these staff members with the skills to work with people with mild to moderate mental health needs, with 86.5% of respondents in the national survey stating this.

However, more green activity providers reported working with service users with moderate to severe mental health needs than reported having the capacity to support people with moderate to severe mental health needs. Respondents across several of the deep dives also pointed to situations whereby service users had complex needs, combining mental health needs with other conditions. Often staff were not equipped to deal with these individuals, a finding supported in the literature (Garside and others, 2020).

The staff of activity providers who target user groups with mental health needs were more likely to have the personal skills and training to work with these service users. Other providers noted that their staff did not receive any training in this regard, sometimes gaining the skills by learning from experience. Insights from the deep dives suggest, anecdotally at least, that a lack of appropriate or specialist skills can undermine staff confidence because of the challenging nature of the situations they are confronted with, as the following quote (M1) suggests:

Staff have encountered irritability, hostility and aggression from some patients and have had to mediate between other patients to help them to foster healthy relationships with each other. Some people struggle to manage the boundaries and rules and may find it difficult to maintain attention and concentration.

Workload capacity

Workload capacity appears to be low across many of the providers in this study. The national survey found that 43.3% of activity providers described having insufficient numbers of staff or volunteers. This is particularly the case with staff who have the training to provide the levels of support needed for people with complex mental health needs. The health leads reinforced this picture, with interviewees repeatedly pointing to challenges providers face in relation to staff time and availability.

Coupled with this, health leads pointed to a high staff turnover rate in the sector. This has a tendency to erode institutional memory, interfere with the emergence of networks and other relationships staff make over time, while undermining the day-to-day running of the organisation itself (Stein, 1995; Urbancova and Depoo, 2011). In the deep dive sites, several providers highlighted the challenge of workload capacity. Without the funding to employ new staff, existing staff are faced with a daunting workload. One respondent described how each staff member in their organisation is doing the job of 2 people, leading to burnout.

Alongside paid staff, volunteers play a central role in the delivery of GSP. Results from the national survey show that without volunteers many green activity providers would be unable to maintain current service levels. However, England’s VCSEs are stretched and this was exacerbated during the COVID-19 pandemic, with increasing demand corresponding to funding cuts, which left staff and volunteers fatigued and under resourced (Thiery and others, 2021).

Data from the Office of National Statistics (ONS, 2021) shows a decline in the numbers of people involved in formal volunteering (in other words, giving unpaid help to groups or clubs), and in the national survey green activity providers mentioned challenges recruiting or retaining volunteers as barriers to scaling up their services. One stakeholder noted that provision is unstable because green activities are predominantly delivered by volunteers, whose roles are dependent on funding. These findings reflect how reliance on stretched VCSEs undermines GSP delivery capacity.

Facility capacity

The deep dive studies shed some light on challenges providers face with facility capacity. Providers in 4 of the deep dives cited a lack of space and storage as barriers they face in being able to scale-up nature-based activities and take on more participants. In the national survey, several providers also mentioned the need to secure a lease on land to be able to scale-up or even continue their activities.

Alongside the size of venue or lease of the site, respondents raised challenges relating to accessibility. For example, service users in older age groups or with mobility issues may not feel comfortable accessing outdoor activities. One reason for this is the difficulty of navigating uneven terrain, unsuitable ramps and other infrastructure, and the potential for falling and injuring themselves. Beyond site accessibility, a major access challenge this study highlights is transport, with affordability and availability of transport making it difficult for many potential service users to attend green and nature-based activities. This is a point consistently reiterated in the literature (Aughterson and others, 2020; Fixsen and others, 2020; Foster and others, 2020; Hamilton-West and others, 2020; Baxter and others, 2022; Garner-Purkis and others, 2020; Featherstone and others, 2021; Mitchell and others, 2021; Simpson and others, 2021), which we return to in section ‘Service user capacity’.

Support service capacity

Regarding support service capacity, some providers in the national survey described being able to offer support to people with mental health needs through partnerships with mental health organisations. Conversely, 15.4% of providers pointed to the problem of a lack of integration with health providers and inadequate support from mental health services. The deep dive studies further substantiated this issue. Several providers noted a lack of support from mental health services, suggesting instead that green activity providers are referred service users whose needs require specialist health services that are often lacking or absent: “[they] use us while they await specialist support” (NW1).

Link worker capacity

We discuss the overall capacity of link workers by considering their personal capacity (including adequate knowledge, skills and confidence); workload capacity (including enough staff with the correct skills to cope with workloads); and support service capacity (with a focus on mental health support).

Personal capacity

12.7% of link workers in the national survey noted a lack of skills and training as being a challenge to supporting people with mental health needs. This suggests that while there are some personal capacity issues, on the whole link workers are equipped to deal with clients with mental health needs. Countering this point is the finding that 24.2% of link workers cited inappropriate referrals as their most common referral challenge. Link workers receive clients whose needs are complex and extend beyond the support they can offer, including clients who are in crisis.

While many link workers do not have the skills and training to work effectively with these people, the findings suggest this is not considered an issue of personal capacity because these clients should not have been referred to them in the first place. Inappropriate referrals were often attributed to GPs having no other option or not understanding the scope of social prescribing. These findings point to the need for more clarity and better communication around what social prescribing can offer and who it may best serve.

Workload capacity

The literature review raised workload capacity of link workers as a clear challenge (Skivington and others, 2018; Whitelaw and others, 2017; Wildman and others, 2019; Garside and others, 2020). The findings of this study partially support this claim. Health lead interviews pointed to the ways in which link workers are struggling under a heavy workload. One effect noted is that link workers have minimal capacity to establish links with a wide range of green and nature-based activity providers in their areas. This insight could help explain a key finding of the deep dive studies, where far fewer green activity providers are referred to by link workers than actually exist. For example, deep dive location M1 only has one link worker assigned to it, who refers clients to 2 green activity providers out of a possible 41. On the other hand, the national survey painted a more mixed picture, with nearly 60% of link workers reporting that demand was well matched to their paid working hours. However, a third of link workers (34.5%) also reported having less capacity, with demand for their services exceeding their paid hours.

When focusing in on the data from the deep dives, a similarly mixed picture is found, with a majority of link workers stating demand matches their paid working hours (18 link workers) and a notable minority (7 link workers) stating that demand exceeds their capacity to deliver within paid working hours. It should be noted that there is a possible bias in the survey towards link workers with more availability and therefore more time to engage in a survey such as this one. This would mask the actual extent of the challenge link workers face in terms of workload capacity.

Support service capacity

For link workers, support service capacity represents a substantial challenge. This is especially the case with clients who have mental health needs, which according to the national survey accounts for a high percentage of the clients’ link workers support. Over half of link workers reported that more than three-quarters of their clients have mental health needs. Given this finding, it is significant that a large number of link workers in this survey cited a lack suitable services or support (41.8%) and long waiting lists for services (29.1%) as the main challenge they face in supporting clients with mental health needs.

This is made more difficult given the number of link workers who feel they receive clients whose mental health needs are too complex to support. As with green activity providers, there is a feeling among some link workers in this study that they are acting as a coping mechanism for a health system with inadequate services and support. The deep dive studies reinforce major issues with support service capacity, as captured by one link worker (SE2) who noted: “There is simply not the capacity for local services, which leaves patients with mental health issues without the correct support.”

Service user capacity

The third aspect of delivery capacity we discuss here is service user capacity. To do this, we focus on service user preferences, priorities, ability, access barriers and support needs. The different elements of service user capacity shed light on some of the challenges of engaging the public in GSP, helping to explain low referral rates from link workers to green and nature-based activities.

Preferences

Both the national activity provider survey and national link worker survey found that one challenge to engaging people in green and nature-based activities is a lack of interest. In the deep dives this was substantiated by answers from link workers who pointed to differences among clients in terms of their preferences, which may not be for nature-based activities. As one link worker (NW2) noted: “I think nature-based activities are a great offer but I haven’t come across many clients who join/try or even want to hear about those types of activities.” Another link worker in the national survey mentioned that most of their clients “think it’s silly/won’t help”. The challenge of engaging people who are not already interested in green and nature-based activities was described by one stakeholder who stated: “Just like when trying new foods some people may be reticent but if supported appropriately can develop a taste for the new activity”.

Differences in preferences and values across social groups was noted by one health lead (HL2), in this case arguing that “specific ethnic minority groups may…want different things from nature connection”. This is a point supported by the literature, which argues that there is limited understanding of the ways that different groups access, use and value nature. This variation has implications for understanding the complex relationship between nature and health (Frumkin and others, 2017; Hartig and others, 2014) - with clear implications for GSP.

Priorities

Regardless of a service users’ preferences, green and nature-based activities may simply not be a priority even if they remain a possibility. People who have pressing needs - with examples from this study including housing and finance issues - may feel they have little or no time to engage with green and nature-based activities. This is a situation that is likely compounded if GPs, link workers and service users are not aware of who GSP is for, and the range of benefits that green and nature-based activities offer (see section ‘Delivering equitably’).

Deprivation levels of an area and the socio-economic status of service users are therefore likely to be factors in the priority given to these activities. Poorer and more precarious life circumstances might lead service users to favour other types of activity that more explicitly address pressing needs. For instance, one link worker in the national survey commented that “most people we see have basic needs that are not being met such as housing, finances, food and so this needs sorting before they can consider any activity.” This point continues to be of relevance given the current economic climate and the cost-of-living crisis. Other studies (Bertotti and others, 2018; Brown and others, 2021; Skivington and others, 2018; Wildman and others, 2019) have similarly highlighted the ways in which austerity and economic inequality shape the form and functioning of the social prescribing system in England.

Ability

At the same time, this research points to differences in the ability of service users to attend green and nature-based activities, particularly in relation to their mental and physical health. 30.3% of link workers in the national survey cited anxiety and a lack of confidence as a barrier to their clients attending green and nature-based activities. 26.7% also listed poor mobility and physical health among barriers their clients face. These findings are substantiated in the deep dive studies, where link workers consistently point to poor mental and physical health, social anxiety and low confidence as barriers to referring clients to green and nature-based activities - with some clients even struggling to leave the house.

For example, a link worker in NW2 observed that “people with poor mental health can isolate themselves, leaving the house is difficult!”, while a link worker in M2 said “those that struggle with mental health don’t like to leave the house. [They] will not engage in any activities due to feeling anxious.” However, one stakeholder suggested that it was misconceptions around the high levels of physical health and mobility required for GSP that limited demand among service users.

Access barriers

Regarding access, this study reflects research that points to transport as a major impediment to service users attending green and nature-based activities (Aughterson and others, 2020; Fixsen and others, 2020; Foster and others, 2020; Hamilton-West and others, 2020; Baxter and others, 2022; Garner-Purkis and others, 2020; Featherstone and others, 2021; Mitchell and others, 2021; Simpson and others, 2021). In the national link worker survey, transport was the commonly cited barrier, with 39.4%.

Both the health lead interviews and deep dive studies also raised issues with the affordability and availability of transport. The importance of transport for accessing green space is demonstrated by the findings of the deep dives that show LSOAs with low coverage of accessible green space at the neighbourhood scale often having high coverage at the district scale. This suggests that for many people accessible green space is available if they are able to travel further (in this case up to 5km).

Transport was noted as a particular challenge for people with physical and mental health needs: “Transport - clients have to use at least one bus, and this can be physically or mentally too difficult” (NE1). Moreover, of the fifth of link workers in the national survey who are aware of other green activity providers in their area but do not make referrals to them, a lack of transport for service users was most commonly cited as the reason for this. The health lead interviews also identified a lack of appropriate outdoor clothing as a barrier to accessing green and nature-based activities. Again, affordability is a key determinant, suggesting that socio-economic status and deprivation are important variables.

Support needs

Finally, many service users have needs that require specialist forms of support. As the national survey found, often these needs relate to a service user’s mental health. Both the activity provider and link worker capacity sections (see above discussion) have highlighted clear shortfalls in terms of mental health support and services. Beyond this, the findings of this study demonstrate other ways in which a lack of adequate support undermines service user capacity. This is most clearly seen in the deep dives, where both green activity providers and link workers note the levels of support required by service users that they are not able to provide.

In large part, this is because they lack the capacity. Thus, one activity provider in M1 stated that “participants often require additional support from our staff to accommodate, be available to listen, and support them,” while a link worker in SE2 answered that they “often receive a high amount of referrals that are mainly due to complex health issues and/or complex mental health issues. These can be more difficult to support and often involve needing more ‘hand-holding’ than a typical social prescribing referral.” In some cases, providers noted that service users have the wrong expectations of the level of support on offer or have needs that are inappropriate for group situations. These pose risks not only to the service user themselves, but also potentially to the provider and to other service users.

Delivering equitably

The discussion of delivery capacity in the previous section has clear implications for the equitability of GSP. Here we draw out and build on these, focusing on the systemic and structural factors that shape GSP in ways that are often inequitable.

We start by considering the equitability of GSP in relation to service users with mental health needs. Beyond being a central concern of this study, mental health is an important focus area because over half of link workers in our national survey reported that at least three-quarters of their clients have mental health needs, while 58.7% of activity providers target service users with mental health needs.

It is clear from the previous section that challenges to provider capacity, link worker capacity and service user capacity all impact the ability of GSP to cater for people with mental health needs - particularly if these needs are moderate to severe. In this regard, the research findings do not draw attention to the failings of individual support service staff, GPs, link workers and activity providers. Rather, they suggest that the health service is a system currently lacking the capacity to adequately support clients with mental health needs. As a result, clients may be inappropriately referred to a link worker and from there to a green activity provider. In this scenario, GSP can serve as a holding system for service users who require more specialised care and support. These circumstances are unfair and risky for service users but similarly it is an unfair demand to place on link workers and green activity providers. One stakeholder specifically called for a “distinction between levels of ‘care’ needed and delivered” to better match service users’ needs with the capacity of activity providers, as part of more equitable GSP delivery.

There are, however, many service users with mental health needs who would benefit from engaging with GSP. The most common barriers this study identified for these groups are transport issues, anxiety and a lack of confidence, and a lack of interest or motivation. Regarding transport, the findings from the deep dives demonstrate how being able to travel can substantially increase the availability of accessible green space to populations. However, it is clear that affordability and availability of transport remains a key challenge across many service user groups. Alongside this, our study suggests that people with mental health needs may find taking transport a daunting prospect in its own right, inducing stress and anxiety. More generally, we found that anxiety and a lack of confidence makes attending green and nature-based activities difficult for some people with mental health needs. It is not surprising therefore that link workers reported a need to accompany clients to activities, especially in the first few sessions. This is a need that link workers said they struggle to meet, especially if they lack workload capacity.

Other service users with mental health needs lacked an interest in attending green and nature-based activities. In some circumstances the reason for this is that these service users have pressing issues that relegate green activities down their list of priorities. For instance, several link workers commented that when supporting clients in crisis, referrals to green and nature-based activities are unsuitable because they do not address the clients’ needs. This suggests a need to address the core issues faced by many people in the social prescribing system. It also suggests a need to identify ways of better offering green and nature-based activities alongside activities that directly address these core issues.

There also appears to be an issue of awareness, where link workers and/or their clients do not see the benefits of green and nature-based activities or are not aware of what activities are available. In these circumstances, having more evidence and an understanding of the benefits of GSP is important - a point raised by both the health leads and national stakeholders. Having access to an up-to-date register or database of green activities and activity providers is also important if link workers are to identify appropriate opportunities for clients with mental health needs. Following from this is the question of who is responsible for resourcing, holding and maintaining such a database, and at what scale? We return to this point in section ‘Scaling up sustainably’.

This study also highlights equity challenges relating to other characteristics of service users, including socio-economic status, race and ethnicity, gender, age and physical health. In particular, the relationship between socio-economic status (with its links to areas of affluence and deprivation) and GSP access was often mentioned by health leads and survey respondents. Service users from poorer backgrounds are more likely to struggle with the costs associated with GSP. These include transport, appropriate outdoor clothing and equipment, and any participation fee for green activities. As the previous section noted, service users from poorer backgrounds are also more likely to face economic challenges, such as precarious housing or difficult financial situations. These inevitably take priority in terms of the types of social prescribing service sought out.

Another common gap in relation to equitable GSP identified by health leads and regional stakeholders is the underrepresentation of people from ethnic minority backgrounds. This mirrors trends in referrals to social prescribing broadly, in which ethnic minority groups tend to be underrepresented compared to the demographic makeup of local communities (Cartwright and others, 2022). Differences in levels of representation could in part be explained by the ways that different groups perceive and engage with ‘nature’ and nature connection, and how this shapes expectations they have concerning green and nature-based activities.

More importantly, however, is the need to recognise the ways in which people’s identities are complex, typically comprising intersecting forms of privilege and inequality. Moreover, these identities are not static or immutable. Such dynamism and complexity is one reason why both the literature review and health lead interviews suggest that for green and nature-based activities to be appropriate, they must have community buy-in.

Three approaches may help to achieve this, Firstly, a national framework for facilitating local decision-making, perhaps at the level of the PCN. Secondly, by funding local grassroots organisations, as these will be better tailored to local needs and demographics, rather than funding larger organisations who may lack the focus on individual communities. Thirdly, through participatory processes that allow local communities to express their wants and needs, and to shape the form and functioning of green and nature-based activities in line with these.

At the same time, calls for greater inclusion and more participation should be approached with an awareness of the well-known dangers of such processes (Cleaver, 1999; Cook and Kothari, 2001). Not least, the potential for participatory processes to be co-opted by powerful local individuals and groups (Lund and Saito-Jensen, 2013; Mansuri and Rao, 2013), or for authorities to deploy the language of participation and inclusion to legitimise processes that in practice have limited community involvement (Arnstein, 1969).

Scaling up sustainably

So far, we have considered the different aspects of GSP delivery capacity and related equity concerns. Now we consider what the research findings tell us about the ability for GSP in England to scale-up sustainably. This is a key question underpinning the government’s ambition to roll out GSP nationally. We approach it in 4 parts: funding model; knowledge and information; consistency; and networks and cross-sector collaboration.

Funding model

The short-term and competitive funding environment for GSP was found to be a major issue across the different components of this study. The national activity provider survey suggests that only a small amount of funding comes from referrals, with providers instead being dependent on charities or grants. Yet these funding streams are characteristically short-term and very competitive - a point both the health leads and national stakeholders consistently drew attention to.

One consequence of this is a loss of sustainability in the provision of green and nature-based activities. The impacts of short-term funding on project longevity interrupts the delivery of activities and the development of provider networks, compromising the level of support available (Groundwork, 2022). This undermines trust and understanding among service users who are not able to establish meaningful engagements with GSP, or to realise its purported benefits over the longer term. It also substantially undermines the ability for existing green activity providers to increase capacity, or for new providers to become established and grow. Furthermore, the transient nature of activity provision associated with current funding models is a barrier to green activity providers being linked into the social prescribing system. Link workers struggle to know what activities are available at any given time and in some cases find that once they have a suitable client for an activity, the activity is no longer available.

Thus 55.8% of providers in the national survey answered that funding is the major challenge they face to scaling up and supporting more service users. One survey respondent summed this up succinctly: “More sustainable funding will allow us to have more people on site in a year.” In the deep dive locations, many providers underscored the importance of sustainable funding for scaling-up. For example, a provider in NW2 observed that “the main barrier is funding in that we don’t know from one year to the next whether our service will be refunded. Our current grant covers the bare minimum.” While a provider in M2 responded: “We are constantly increasing our capacity as the need for our services increases. Our capacity depends on how many facilitators we can fund. Our capacity is based on what funding is received.” Beyond the short-termism of current funding, health leads also noted that funders favour new or different projects and activities over existing ones. This leads to a lack of continuity. As one health lead put it: “Funders don’t like funding existing work, they like funding new stuff. So you’re in that dilemma where you know the funder will say ‘we’re not gonna fund you just to carry on doing what you’re doing’” (HL4).

Taken together, the current funding model represents a stern challenge to any ambition for GSP delivery capacity to grow both equitably and sustainably. It embeds inefficiencies with substantial costs to the sector that detract from the shared goal of funders and recipients to achieve maximum impact (Barnard, 2022). This challenge has clear implications for the potential benefits service users might otherwise gain from green and nature-based activities. It also represents an existential challenge to many green activity providers, especially the smaller ones. Providers in this study expressed the difficulties created by the current funding landscape in terms of their ability to deliver at capacity over time and in terms of the effect it has on staff workload capacity, morale and retention. As a provider in one deep dive site (SE1) responded: “[We] feel totally unvalued because of the constant anxiety to find funds. Filling funding forms is stressful and takes a huge [amount of] time for small charities like ours.”

Knowledge and information

A second challenge to scaling up GSP sustainably concerns knowledge and information. The study findings highlight 2 points. The first concerns a lack of knowledge about the benefits of nature-based activities among GPs, link workers and service users. Health leads suggested that this undermines demand for GSP because pathways to these activities struggle to become established as they are not recognised as important. Stakeholders in the national survey also raised concerns about the challenge of convincing the health system, link workers and service users that nature-based activities have the potential to benefit people across the board. One stakeholder noted “a perception that these types of activities are for certain kinds of people, which hinders engagement.”

Both health leads and national stakeholders recognised a need to strengthen the evidence base for green and nature-based activities. The ways in which this information is shared is then dependent on the target audience. In the case of a GP, for example, it may be through better communication of the scientific evidence about the benefits of nature connection and nature-based activities. For link workers, practical examples of how nature-based activities benefit people in their area could be appropriate. For service users, part of the approach might entail GSP ‘community champions’ - trusted members of the community who promote and endorse engagement with green and nature-based activities.

The second point regarding knowledge and information concerns the difficulties link workers face in developing an up-to-date understanding of the green and nature-based activities in their area. Again, the health leads and national stakeholders pointed to this as a factor restraining the ability for GSP to scale up. They noted a situation whereby different individuals and organisations are generating their own databases but with little information-sharing or attempts to develop centralised directories. This leads to fragmentation, overlap and duplication of efforts, which is neither efficient nor sustainable.

In contrast, however, our desk-based research into green activity providers in the 6 deep dives was undertaken by identifying and examining relevant online directories. Notably, this research generated lists of additional activity providers beyond those already referred to, which were sometimes considerable (see section ‘Deep dive studies’). For example, in NW1 we found an additional 32 green activity providers beyond the 12 that link workers in this PCN refer clients to. That we could generate such lists from online sources suggests that relevant and accessible directories do already exist, at least to a point. It is an interesting question as to why these are not better utilised. Thus, in the same PCN (NW1), 6 of the 8 link workers who participated in the study said that there are no other providers of nature-based activities that they know about that they could refer clients to.

Consistency

For GSP to scale-up sustainably, the system needs to become more consistent while still enabling variation at local levels and in ways that meet demand. Confusion around what constitutes social prescribing, what ‘success’ looks like and how it should be measured, and the diversity of approaches and localised nature of delivery all add to the challenge of robust monitoring (Husk and others, 2019).

Health leads drew attention to the benefits that follow from a consistent definition of GSP that is clear and widely understood, a GSP landscape that is less unstable, common metrics that can be used to monitor and evaluate GSP processes and outcomes, and related standards and forms of accreditation that green activity providers can aspire to. Again, respondents in the national stakeholder survey supported health lead views. Attention was paid to the need for consistent approaches to evaluation and a better evidence base across the system to instil trust and underpin decision-making as to where and how resources are allocated.

Greater consistency must not come at the expense of local variety, which is key to meeting the specific needs of communities. One approach could be the development of an overarching framework, rooted in core values that reflect the ambitions of GSP in England, that enables degrees of local variety (of green activities and activity providers). A framework approach that is both consistent and contextual could positively impact many facets of the GSP system already considered in this discussion. One way of doing this is by providing a more stable operating environment for the different actors involved, which is likely crucial if GSP is to be scaled-up sustainably and in ways that are appropriate to local situations and needs.

Networks

Finally, this study suggests that networks and cross-sectoral collaboration are key to increasing capacity and scaling up sustainably. These networks concern different actors and interests within the GSP system and cover a variety of scales. We attend to 3 of them: community/grassroots networks; provider networks; and intersectoral networks.

Firstly, the discussion on equity in the previous section suggested that community engagement is important for developing appropriate green and nature-based activities in specific localities. The health lead interviews pointed to the establishment of local networks as vehicles for achieving this. Better grassroots communication channels can help to facilitate the sharing of community wants and needs, as well as generating an understanding of what opportunities are available locally. This would go some way to achieving what Morris and co-authors (2022) call ‘community enhanced social prescribing’, whereby developing and deepening relationships locally can “facilitate communities in assessing how connections can be mobilised to improve capacity” (page 188).

Secondly, green activity provider networks appear to offer a range of benefits for scaling up sustainably. They are seen as ways of generating momentum for GSP across an area, facilitating learning and knowledge sharing, while leveraging funding. Building on this point, across the health lead interviews, national stakeholder survey and national activity provider survey were calls for greater integration of the different facets of the GSP system - including better intersectoral working. Stakeholders advocated for better networks and partnerships, including between activity providers, link workers, the health sector, landowners and infrastructure organisations. Providers pointed to the importance of strengthening networks and partnerships for better future delivery of GSP, including specifically with the healthcare sector.

This was also a point raised by the health leads, who took this need for integration further by arguing that the “voluntary sector needs to be included as part of the [health] system, not just an add on to the NHS, so that funding from personalised care is accessible to activity providers” (HL2). This mirrors the argument made by South and co-authors (2008), that social prescribing should be seen as a way of extending primary care through building partnerships rather than a way of offloading patients onto a different sector.

The potential for bridging between the health sector and third sector to better utilise VCSEs within the personalised care agenda is one of the key driving forces behind GSP (Islam, 2020). However, our findings suggest there is still some way to go to achieving this. At the same time, recent ICS reforms are aiming at better integration through the ICS Partnerships, which should include VCSE sector partners. As these reforms are new it is possible these partnerships have not yet become properly established and so were not identified in our study. Willows Rough (2021) has suggested that one way of promoting integration is through boundary organisations capable of developing links across sectors and systems that otherwise do not communicate adequately. Our study found that often the establishment of ad-hoc networks, especially at more local levels such as the county, city or town, is due to the activity of particular individuals with the requisite energy, time and skills.

Conclusion

This report set out to provide a national delivery capacity assessment of GSP. The focus is on understanding the nature of GSP provision, opportunities and barriers to scaling up equitably, and how these insights inform a sustainable national roll out. Here we do not attempt to revisit all the learning detailed in the findings and discussion. Instead, we provide 5 concluding remarks that speak directly to the study aim and research questions set out in the ‘Aim and research questions’ section. It is important to recognise that this is a rapid assessment of GSP delivery capacity. Findings and conclusions should be understood in this light.

Firstly, GSP provision in England is diverse, patchy and dynamic. This is the case not just over large areas but at local levels where there is considerable variation in the types of activities delivered, the availability of accessible green space and the prevalence of green activity providers - even between adjacent PCNs. Attempts to assess variation in GSP provision at the national level is thus very difficult and, as such, localised understandings are critical.

However, despite the considerable variety in provision, the range of activities typically referred to by link workers is much narrower - predominantly sports and exercise. This suggests there is scope to promote referrals across a greater diversity of nature-based activities, better realising the benefits associated with nature connection (while recognising that sports and exercise activities set in nature also offer opportunity for nature connection).

Secondly, we found that many providers currently linked into the GSP system have the capacity to support more service users. At the same time, within the 6 deep dive locations, there were often many more green activity providers operating in an area than are being referred to by link workers.

On their own, these 2 findings suggest that there is existing capacity for GSP delivery to increase, in some cases quite considerably. To understand why this apparent capacity is not being realised it is important to employ a more comprehensive framing that considers different elements of delivery capacity relating to green activity providers, link workers, service users and to the whole GSP system. In developing just such an approach, this study identifies areas where capacity is low (see the ‘National stakeholder survey’ section above). Although further research is needed to substantiate our findings, we recommend focusing on these areas to enhance delivery capacity.

Thirdly, in line with the literature this study finds that affordability and availability of transport is a major factor limiting service user engagement with green and nature-based activities. This was apparent across the different elements of the study. It is illustrated by the findings from the deep dive research where in many locations being able to travel substantially increases the availability of accessible green space to populations. Our study suggests that people with mental health needs may also find transport a daunting prospect in its own right, inducing stress and anxiety. This adds an additional layer of complexity to the challenge of transport.

Fourthly, GSP is widely used by people with mental health needs. A high prevalence of service users in this study have mild to moderate mental health needs, with a notable proportion having moderate to severe mental health needs. On the one hand, this is promising as GSP has the potential to both promote and restore mental health and wellbeing. Many link workers and green activity providers have at least some training that equips them to work with people who have mental health needs, especially those whose needs are mild to moderate. However, there are other capacity issues that undermine the ability of link workers and green activities to provide meaningful support to service users with mental health needs, particularly those with more severe or complex needs.

There is a worrying pattern of link workers and green activity providers receiving patients with complex mental and physical health conditions that they are not equipped to work with. In effect, these could be considered to be inappropriate referrals. Compounding this issue, we found that providers and link workers lacked specialist support for people with moderate to severe mental health needs. This can result in a situation that is unfair and risky for these service users while also placing unfair demands on link workers and green activity providers.

Rather than GSP being integrated into the NHS in England in a way that enhances overall care, there is a danger it instead acts as a holding system for service users who require more specialised support. Improving awareness within the health sector of the levels of need that social prescribing caters for, while increasing the availability of more specialised support services, would help to reduce numbers of inappropriate referrals.

Fifthly, this study suggests that to enhance GSP delivery capacity, the focus on local provision must be accompanied by system-wide changes. There is a pressing need for a more sustainable funding model for GSP. Many green activity providers are reliant on grants to fund their activities, and to establish themselves and grow over time. The current funding landscape is characterised by short-termism, precarity and a focus on new or different activities over existing initiatives. This creates a plethora of capacity challenges that inhibit the delivery of activities. It also erodes staff morale, hinders the integration of activities into the GSP system, and undermines trust and understanding among service users who are not able to establish meaningful engagements with GSP.

Alongside funding issues, there is currently not enough awareness among many GPs, link workers and service users of the benefits of engaging with green and nature-based activities. Where there is awareness of these benefits, there is still a lack of understanding about what activities are available.

These knowledge gaps could be addressed as part of a wider initiative to promote a consistent approach to GSP in England. Our study suggests a need for a definition of GSP that is clear and widely adopted, a GSP landscape that is more stable (especially with regards to funding), common metrics that can be used to monitor and evaluate GSP processes and outcomes, related standards and accreditation that green activity providers can aspire to, and up-to-date and accessible directories that signpost to local activity providers. A consistent approach to evaluation and a better evidence base across the system has the potential to instil trust and inform decisions about where and how resources are allocated.

To facilitate these system-wide changes, this study points to the value of establishing networks comprising combinations of healthcare organisations and service providers, green activity providers, local communities and other GSP stakeholders. By promoting cross-sectoral collaboration and facilitating knowledge and resource sharing, networks improve system coordination and consistency. We found that networks are often established by individuals who see the value in nature connection and nature-based activities and have the time, energy and skills to link up initiatives and create a critical mass for GSP. Resources should be made available to support these individuals in their efforts.

At the same time, establishing networks that enhance GSP delivery capacity should not fall on individuals alone. Finding ways of supporting the emergence and growth of networks that operate across multiple scales and sectors should be a strategic priority area and part of a more consistent yet contextual approach to GSP in England. This approach would look to provide an overarching framework that joins up coordination and support organisations at national and regional levels with local VCSE and healthcare networks. This has the potential to create a multi-sector system rooted in core values that reflect the ambitions of GSP in England, while still enabling variation at local levels and in ways that meet the needs of communities.

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Report details

Natural England Project manager

Caroline Emmerson - Principal Adviser, Health and Environment Programme, Connecting People with Nature Team 

Contractor

Department of Health and Social Care (DHSC)

Authors

Ruby Grantham, Natural England - Senior Specialist in Social Sciences

Luke Whaley, Natural England - Senior Specialist in Social Sciences 

Acknowledgements

The authors of this study would like to thank all those who contributed to the research. A special mention to:

• Professor Ruth Garside, University of Exeter, and Dr Kerryn Husk, University of Plymouth, for advising on the initial approach taken
• Dr Alexis Foster, University of Sheffield, who designed the original link worker and green activity provider surveys that were adapted for the purposes of this study
• NHS partners and in particular Sam Alford for all her help in developing and distributing the 3 national surveys
• the National GSP Steering Group for their input and comments
• Dave Solly and Josh Ryan at NASP for their guidance and support
• the Natural England health and environment leads for their input and willingness to engage with the research