Back to nature: why some GPs are prescribing the great outdoors

When Jacob Farr was at his lowest point, overwhelmed by suicidal thoughts, the only thing that got him to leave his house was taking the family dogs for a walk whenever his dad called round.

Other than these dog walks, Farr was, by his own admission, “quite a hermit” and was closed off to the world outside his own four walls.

After taking the decision to get his own dog, his life was transformed almost overnight: suddenly he had a dependant who needed to go outside three times a day. He had a reason to leave his flat.

He would go to the local beach, the reservoirs, walk up Edinburgh’s hills, walk through woodlands and it was this connection with nature, this increasing ability to take comfort from the water, the trees, the views, the animals he encountered, that helped Farr get his depression under control.

“I was actually, at that time, quite suicidal,” Farr tells Holyrood. “I ended up getting a job that I hated and getting signed off my work, and really the only thing that got me out the house at any period was my dad coming by and asking me if I wanted to go for a walk with the dogs.

“The minute I got my own dog in 2017/18, it really changed my whole persona and way of doing things. I was becoming quite a hermit, becoming quite closed off, really just a shell of a person. I got him and that was a dependency, he had to go out three times a day, every day of the week.

“On Sunday, for example, me and my partner went for a walk up Blackford Hill and through the Braids and even just getting my wellies on and standing in the water that runs through there felt like all my thoughts were draining away.

“I have the same experience taking the dog down to Lauriston Castle and I spend hours there getting lost in the Japanese garden or looking at the architecture of the building. All these things can really make you feel that you’re actually doing something with your day, you’re actually achieving something. It gives you that connection again with the world.”

Farr says that having a purpose to leave the house helped him to maintain social contact and also gave him a reason to make an effort with his personal appearance.

“A lot of the time when I was in the house, I would let my beard grow and my personal grooming was really bad when I was depressed, so even going out on walks really encouraged me to start shaving, start sorting my hair out,” he says.

“It allows you to reset and take a wee bit more pride. Sometimes when I was really low I’d bump into old women on a walk and I’d find myself standing talking to them for 40/50 minutes and it’s just speaking to a stranger that has no idea what’s happening in your life, but just having a normal conversation can be so big to people.”

Farr’s story is not unique. The benefits to mental health of being outside, of connecting with nature, are widely documented and include helping sleeping patterns, reducing stress, improving mood and self-esteem, and providing meaningful social contact.

Just getting my wellies on and standing in the water that runs through there felt like all my thoughts were draining away

Research has found that people in Scotland who use green spaces for physical activity have a much lower risk of poor mental health than those who use non-natural environments such as the gym or streets.

During lockdown, 76 per cent of people in Scotland became more aware of nature in their everyday life, according to a poll carried out earlier this year.

And it is this awareness of the benefits the great outdoors can have on health that has led to a new pilot being trialled in Edinburgh, with five GP surgeries signing up to find out how ‘prescribing’ nature can help their patients.

It follows a successful scheme in Shetland, which saw the initiative – a partnership between RSPB Scotland and NHS Shetland – rolled out to all ten GP practices in 2018.

by Liam Kirkaldy

Communities, Housing & Planning

GPs across Shetland to hand out ‘Nature Prescriptions’

“We’ve all got an increasing awareness of the benefits to health of being outside and there was a lot of publicity in relation to the Shetland project,” says Dr Louise Bailey from one of the pilot surgeries, St Triduana’s Medical Practice in north Edinburgh. “It’s such a truly unique location and the access to nature there is obviously very different to an urban environment, so when we heard about them looking to apply the project to an urban setting, I was just really interested to hear how that might work. I wasn’t quite clear how that might translate within a city.”

With the help and expertise of RSPB Scotland, patients considered suitable for a nature prescription are offered resources including a check list of simple suggestions about how to get connected with nature, such as looking for the first star to appear in the night sky, getting to know a city tree and watching how it changes through the seasons, and walking barefoot in the grass.

Each participating surgery has its own map highlighting walks, public parks, woodlands and cycle paths in the local area to make it easier for patients to see all the things they can do on their doorstep.

“The RSPB gave us some resources as part of the project and they’ve done a really fabulous map with our practice at the heart, so they’ve mapped all the nature and natural resources in our location,” says Bailey. “There’s also a monthly diary which has a list of different things or activities that people could undertake. It’s a remarkable resource for patients if they’re interested.

“Some patients are able to access outdoor spaces by themselves, but some patients require some encouragement. It’s great to have this information so that if we have a discussion with a patient and we think that being outdoors or in contact with nature might be something that would help them, then we’ve got some resources to give them to help them.”

Increasingly in consultations, I’m asking people what they’re doing and how much they’re getting outside

This is one of the things Farr says needs improvement in Edinburgh, as a lot of the city’s green spaces and walking routes can be difficult to find if you don’t know already about them.

“The walks in Edinburgh are not the best advertised and it’s really been through trial and error that I’ve found nature trails and different things to explore that really monumentally do improve your mental health,” he says. “A lot of it has to come from word of mouth or actively seeking it out.”

He believes giving people the tools to use nature through this pilot project will prove to be of enormous benefit to anyone experiencing depression or other mental illness.

“I’ve been back and forth to the doctors a million times since I was 16, I’m 27 now. Each time they’ve tried to put me on medication, never once have they suggested to me ‘have you been going on walks’. They ask ‘are you exercising’ but for most people they don’t equate exercising with walking so a lot of it was self-discovery.”

Bailey agrees, though says going down the nature prescriptions route is not suitable for all her patients, so she makes a judgement on a case-by-case basis about whether they would benefit from it.

“I’ve gone into this with a very open mind,” she tells Holyrood. “I was speaking to a lady who has gone from part time to full time working, sitting at home with a young family on a computer all day and increasing levels of stress and anxiety.

“With nature prescriptions I suppose what I’m doing is I’m allowing her time to go outside and give some thought to that.

“The prescription gives a little bit of structure and preparation for what she can do. I suppose what it does is enables people to explore the community around them.

“It’s very much a personal thing, it’s really what matters to the patient so that you can connect the appropriate resource to the person. Increasingly in consultations, I’m asking people what they’re doing and how much they’re getting outside. I think a lot of people have become very anxious during these times and if being outside is not something they’ve given thought to, this is something that does give them some structure and purpose to what they might do.

“There are times when it’s appropriate to discuss the outdoors and nature and other non-medical ways of addressing some of the challenges they’re facing, but it’s certainly not right for everyone. There are some people who definitely wouldn’t consider it or they’re not interested in that sort of conversation so it’s just tailoring your support or conversation to what really matters to the patient themselves.

“One of the things we think about in our daily work is about patients who are disadvantaged or health inequalities, so this is about offering something to people who would not normally engage with nature. It’s adding a useful tool to my toolkit.”

Of course, it’s not just mental health which can benefit from being outdoors and connecting with nature  – there is a significant evidence base for the range of individual and wider social health and wellbeing benefits that can be achieved.

Key benefits include better physical health and guarding against future illness; therapeutic and restorative qualities which enhance recovery; reduced social isolation and greater community cohesion, and opportunities to establish lifelong healthy behaviours.

The only minutes I had with any pain relief were in the water. I think it was the numbing effect of the cold water

A brisk 30 minute walk on five days of the week can, for example, reduce the risk of heart attack and stroke, diabetes, hip fractures, bowel cancer, breast cancer, and dementia.

Naomi Heller was diagnosed with arthritis in her hip nearly three years ago after she had a labral tear.

It degenerated quickly and after an unsuccessful operation in 2018, she ended up having a hip replacement at the age of 36 in September this year.

Heller found that the only thing that could help her with the pain caused by her arthritis was cold water swimming, which she did in the sea at Portobello.

“It was relentless pain,” she tells Holyrood. “It was unbearable. It wasn’t touched by the painkillers or anything. The only minutes I had with any pain relief were in the water. I think it was the numbing effect of the cold water.

“It’s so hard to find moments of peace when you’ve got chronic pain. There’s also the mental health meditative process. Meeting people in the swimming group has also been really social and having that camaraderie.”

As a doctor herself, Heller can understand the physiological benefits of wild swimming and is a supporter of the logic behind nature prescriptions.

“It allows people to have that discussion with their GP about what the rest of their life involves – it’s called holistic medicine for a reason.

“Those things make people feel like they’re not just the tablets that they take or the label of the diagnosis – because that can really steal your identity – and I feel like exercise and nature can have a place not just as an activity, but also in your heart and mind when you’re not just that illness.

“For a few of my colleagues, as doctors, it’s a good lesson to learn about how people need more than just medicine to get better.”