Scotland General practitioner

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Nature’s remedy: doctors in Shetland give ‘green prescriptions’

NATURAL BENEFITS: GP Ruth Booth with husband Graham

If you need a prescription in Shetland, you might just be prescribed the islands themselves. Peter Blackburn reports from a nature-based scheme which could have far-reaching influence

In Shetland you’re either a Shetlander, or you’re from ‘the Sooth’. Dundee, Doncaster or Dover – it makes no odds.

There is a distinct sense of identity and place among these hundred beguiling islands, a unique wilderness which draws people from all over the world. You’re never more than a stone’s throw away from water – the quiet and calm lochs and voes or the drama and beauty of the coast.

The windswept landscape is dotted with a mix of traditional crofting cottages and Scandinavian timber lodges, and the people are fierce and friendly.

Flung to the far north-east of the Scottish mainland, Shetland is more than 100 miles closer to Oslo than Birmingham. But, for all its isolation and sense of independence, doctors and wildlife experts have come up with a scheme here which could have positive implications for the rest of the UK.

It’s a project that looks to improve health and wellbeing using only what is freely available on our doorsteps, connecting people to nature in a bid to overcome growing mental health problems and the causes behind many long-term conditions.

Nature prescribing was first dreamed up by Karen MacKelvie, a community engagement officer for RSPB Shetland, who lives and works on the islands.

‘I also work as a counsellor at Women’s Aid, and I do therapy on the beaches and I know how restorative and helpful it can be,’ says Ms MacKelvie, at her traditional white stone house, overlooking a seemingly endless, shimmering, sea loch.

‘When we did the research, the evidence for nature working in health and wellbeing was overwhelming. It’s not just about exercise outdoors, which of course helps, but the connection is even more important.’

Ms MacKelvie’s idea quickly became reality in a pilot project last year – before being rolled out more widely after being deemed a success. The RSPB produced a leaflet now stocked in GP surgeries across the islands.

It explains the potential benefits of interaction with nature: reduction of hypertension; respiratory tract and cardiovascular illnesses and anxiety; improved concentration and mood – and even increased life satisfaction and happiness. It goes on to give GPs different lengths of walks to prescribe, as well as suggestions for activities to connect with nature.

A calendar with seasonal activities is published every month in the island magazine Shetland Life and the local NHS website.


‘Green prescription’

The evidence base for similar schemes is growing. A project in England from the Centre for Sustainable Healthcare, called Prescribing Green Space, found that six to eight months after receiving a ‘green prescription’ – where people are encouraged to help plant forests and spend time in local green spaces – 63 per cent of patients were more active and 46 per cent had lost weight.

And the need for efforts in these areas could not be clearer. The overall cost to the economy of physical inactivity in England alone is thought to be £8.2bn per year – with ‘inactive’ people spending 37 per cent more days in hospital and also visiting the GP more often.

The Centre for Mental Health put the health and social care costs of mental health problems at £21.3bn in 2009/10. The ‘human cost’, its estimate of the negative effect on quality of life, was £53.6bn.

As for implementing this new approach: ‘The cost to the NHS amounts to the few minutes the GP might spend talking about this thing and how it might fit in as part of the solution, and that’s all really,’ says Mark Maudsley, a GP in Scalloway, a village on the largest of the Shetland Islands.

He supports the social prescribing initiative.

‘It feels that this is a public health push. It’s not saying to somebody, here’s a eureka moment that you’re better. But you can throw it in with minimum expenditure and a bit of time and say that getting out among nature is potentially part of a solution to why you’re not feeling great – and here’s some ideas that get changed every month.

‘If more people were doing that, spending more time outdoors and noticing things that can make them feel better about the world, it’s likely to make people’s lives better.’


Wellbeing boost

The philosophy behind the RSPB approach is not just about fresh air and exercise – it’s about developing a relationship with the nature and wildlife being experienced. Evidence from projects in the UK suggests a relationship between connection and engagement with nature and improved health and wellbeing.

It is a theory backed by society and employers in Scandinavia, where people are supported to take time away from the office and be outdoors – a concept called ‘friluftsliv’.

Dr Maudsley explains: ‘It’s not just to do with exercise and fresh air, what they are picking up on is the idea of going out and connecting. If you go out and you are paying enough attention to what is going on around you rather than just what is in your own head and what you take out there yourself, you can see things and notice the way things are happening in nature. That takes you out of yourself and you can end up feeling better about things.’

Perhaps it won’t be for all people – one sceptical patient remarked, ‘at least you didn’t ask me to talk to a horse’ when a GP had finished explaining the idea – but for those willing to have a go, it seems to be a risk-free, almost costless option in a GP’s arsenal. After all, general practice is at its best when there’s time to look at the causes of problems, and options to tackle those drivers are available.

‘It’s not something you wheel out every time you see a patient with a mood disorder or someone who is isolated,’ Lerwick GP Dylan Murphy (pictured below) says. ‘It might come up in conversation and, as part of the discussion, you will outline various processes – psychological therapy and self-help. And one type of self-help, for example, is this. Sometimes it’s just a spur for someone to do something – to have it in their hands and they have a contract with themselves.’

‘It’s like anything else – when you take a history from a patient you try and put yourself in their shoes: what are things like at home, where are you from originally, what work do you do, what are your hopes and aspirations. Sometimes that’s not easy for some patients and this can open up a dialogue with patients who don’t like talking.’

Dr Murphy – whose office must be a contender for the best view from a GP’s desk of anywhere in the world, looking out across the sea, which laps against the rocks just strides away – adds: ‘Time-pressured GPs can often give patients medication for mood disorders because it’s what is available to us. We know it’s not always the right thing. You could medicalise them or cause them harm. Doing things like this can help.

‘And I have a lot of male patients who say: “I don’t want pills doctor, and I don’t want to talk about it.” So, this is a potential way of getting to people. For some people it might be a better option than a box of pills.’



It is not difficult to see why conditions are perfect for this idea in Shetland: the cliffs at Hermaness and Esha Ness, the beaches at St Ninian’s Isle and Meal, the abundant water and wildlife. Just an hour spent alone walking in the winds here is enough to wash away the worries.

GP Ruth Booth agrees. She lives on the island of Fetlar, known as the ‘garden of Shetland’, but works 24-hour on-call shifts on the most northerly island, Unst, where the local GP is effectively the ambulance too.

‘I personally have experienced the benefit of being out in nature – both the physical wellbeing it brings but also the mental improvement for myself. This environment really contributes to that,’ says Dr Booth, who also runs a retreat with her husband, Graham.

‘Encouraging people to slow down, be part of the environment and enjoy the beauty and be mindful of what they are seeing has huge benefit.’


But there’s no reason why this project cannot be exported elsewhere. Dr Maudsley says: ‘It’s true that here you don’t have to go very far to see the sea, to find yourself among natural beauty, but there are peregrines nesting in belfries in towns across England. Nature is doing its thing all over the place.’

The timing could hardly be more perfect with the recent GP contract announcement including the setting up of primary care networks across England; each area of 30,000 to 50,000 people will have a social prescribing link worker, with the aim of connecting patients to the groups and activities in their area that could positively affect their health. It seems a no-brainer to involve projects such as nature prescribing in any future vision for primary care.

GP leaders are positive about the potential of social prescribing. BMA GPs committee chair Richard Vautrey has said: ‘Social prescribing has the potential to reduce GP workload by supporting patients and, where appropriate, linking them to other services in the community that can offer longer-term help.’

The nature prescribing seen in Shetland may just be the start though, if those involved have their way. In an ideal world Ms MacKelvie would like the scheme to be more formalised, perhaps through commissioning and funding from the local health body NHS Shetland, which could see activity groups set up and coordinators employed to link patients to projects and possibilities.

In Shetland, the community has always had to live off the land for what it needs, and now they are finding healing there, too.

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