How we used a social prescription programme to reduce feelings of depression in 60% of attendees
Dr Saul Marmot explains how a prescription for ‘ecotherapy’ reduced feelings of depression and social isolation amongst patients referred
As austerity measures bite and poverty increases, those at the bottom of the pile are at a far greater risk of being crushed. The Bromley by Bow Health Partnership and Bromley by Bow Centre look beyond simply treating clinical conditions.
The often quoted statistic is that one in four people will be affected by a mental health problem at some point in their lives. There has been recent evidence though, that this statistic is likely to be an under-estimate of the true extent of the problem, with rates of depression and anxiety rising year on year. It may be that the population is indeed becoming more distressed or alternatively, (and I sincerely hope that this is the case) that more people feel able to come forward and seek help.
We are very lucky in Tower Hamlets to have excellent primary care psychology provision but even so, the service is oversubscribed. Sadly, in many parts of the country psychological services are either not available at all, or waiting times are too long to be of practical help. The other option for GPs is medication. According to the Centre for Economic Performance, about a quarter of all visits to a GP practice are related to a mental health problem (approx. £1.9 billion per year nationally) and £1.2 billion pounds a year are spent on prescriptions for these conditions. Although both of these options can be extremely beneficial to our patients, we are fortunate to have a variety of other choices to offer our patients.
What we did
At Bromley by Bow, we set up a project called PoLLeN (People, Life, Landscapes, Nature) which has received funding from Mind, the mental health charity as part of its Ecominds scheme. GPs, nurses and HCAs can refer patients to PoLLeN, through the ‘social prescriber’ project at the centre. PoLLeN also accept referrals directly from Mind in Tower Hamlets, as well as from the CMHTs and other local GP practices.
People who attend PoLLeN take part in a variety of therapeutic horticulture activities, which mainly involve growing plants, flowers and vegetables from scratch. The activities range all the way from making pots in which seeds are germinated, to helping design a landscape garden.
All of the participants in the PoLLeN project are affected by mental health problems, from anxiety and depression to long-term mental health problems such as bipolar disorder, and learning difficulties. The groups are as varied as the local population is, with people from all ages and ethnic backgrounds growing together. The advantage of such an approach is that PoLLeN forms a natural, mutually supportive environment for its participants. Working in a garden is also physically invigorating and the beneficial effects of physical activity on mental and physical health are well known. A number of participants have also gained a level one horticulture qualification and a few are currently working towards their level two.
The overall effect for our patients, is that they are able to get out and about, to meet new people who they can rely on and who will not judge them (and to therefore be less socially isolated). The positive effects of exercise and of helping to nurture life are well documented, as are the effects of learning new things and gaining new skills. It is much easier to get on with life when your self-esteem is not at rock-bottom.
Debbie’s story shows how PoLLeN has been able to help local residents. Debbie was given a diagnosis of depression and offered CBT. After CBT didn’t work for her, the GP referred her to PoLLeN. Her experiences have given her the self-confidence to improve her skills and meet new people in a relaxing outdoor environment. Debbie is now feeling confident and happier with life, and is aiming to get a level two diploma in horticulture and garden design and wants to work for an organisation like the National Trust.
Participants of PoLLeN have also seen an added benefit. They have access to a broad range of other services at Bromley by Bow, which they may have been unable to access previously, due to a lack of personal empowerment and reduced motivation to negotiate the maze of services by themselves.
The GP practice works in close partnership with the Centre. The ‘Social Prescriber’ initiative is the mechanism by which we can make direct referrals into all the services at Bromley by Bow; it is the way we can prescribe for the social determinants of health. The ‘Social Prescriber’ project has been a tremendous success and is seen by the CCG as having great potential to improve care across Tower Hamlets, at the same time as making much needed savings to the budget.
The table below is compiled from feedback from participants:
|Coming to PoLLeN has||% agree or strongly agree|
|Helped me to feel happier||95|
|Helped me make new friends||90|
|Given me something to look forward to||90|
|Helped me feel good about myself||90|
|Increased my social contacts||90|
|Helped me make new friends||90|
|Given me support from project staff||90|
|Given me increased confidence||85|
|Allowed me to be more creative||85|
|Reduced social isolation and loneliness||85|
|Helped me relax||80|
|Been therapeutic for me||80|
|Helped me to cope better||80|
|Given me a sense of achievement||75|
|Helped me have a sense of purpose||75|
|Helped me feel more optimistic about the future||75|
|Helped me reduce my worries and anxieties||70|
|Helped me develop my social skills||65|
|Reduced feelings of depression||60|
|Improved my physical fitness||50|
|Helped me look after my physical health better||50|
|Helped me relate better with my family||45|
|Increased my level of physical exercise||45|
|Given me opportunities for physical exercise||40|
|Helped me gain qualifications||35|
|Helped me gain employment||30|
According to to the Feel Better Outside, Feel Better Inside report by Mind and the University of Essex seven in ten people (69%) experienced a significant increase in well-being by the time they left an Ecominds project and three in five people (62%) with mental health problems reported an increase in self-esteem.
There is good evidence that ecotherapy can lead to substantial savings in the NHS, especially in areas of prescribing, in reducing consultation rates, in easing the burden on CMHTs and in reducing interventions by Psychiatric services.1 In the wider economy, such interventions have also been shown to reduce ESA and DLA benefits and to increase employability, leading to increased tax and NI contributions.2
I’ve been delighted (but not at all surprised) to see the recent statistics from the Feel Better Outside, Feel Better Inside report from Mind, including a substantial evaluation from the University of Essex, which showed a multitude of benefits of ecotherapy.3
The profound consequences of poor mental health on the body and mind are not in question. What we, as health professionals, can do to lessen this impact, while justifying the way we spend our resources, is the question we have to keep asking. The benefits of ecotherapy to our patients are abundant but in these times of austerity, can we justify spending on what has been seen by some as a ‘soft therapy’?
While rates of mental distress are rising and an increasing number of people are sinking deeper into the quagmire of deprivation and of despondency, it is immensely gratifying to feel that new approaches are still being developed and that there is still opportunity in the evolution of services.
Dr Saul Marmot is a GP at the Bromley by Bow Health Partnership.
For more information about The Bromley by Bow Centre and the social prescriber project visit www.bbbc.org.uk and to find out more about TheBromley by Bow Health Partnership visit www.bbbhp.co.uk. For information about Mind’s Ecominds scheme and its new research into the benefits of ecotherapy for mental health visit: www.mind.org.uk/ecotherapyworks
1 Mind/NEF. The Economic Benefits of Ecominds. 2013. http://www.mind.org.uk/media/338566/The-Economic-Benefits-of-Ecominds-report.pdf
2 Mind. New research shows benefits of ecotherapy for mental health and wellbeing. http://www.mind.org.uk/news-campaigns/news/new-research-shows-benefits-of-ecotherapy-for-mental-health-and-wellbeing/
3 Mind. Feel better outside, feel better inside. http://www.mind.org.uk/media/336359/Feel-better-outside-feel-better-inside-report.pdf