24th August 2020
In our new article, Lloyd Tingley explores the wider societal and behavioural factors that will impact the success of green prescribing and the obesity strategy, and the role companies will play in driving a society wide approach that impacts infrastructure, adherence, health inequalities, and more.
In the past month the Government has announced two vital new policies aimed at improving the physical health of people in the UK using preventative strategies. The policies are intended to reduce the prevalence of obesity, high cholesterol, and other underlying conditions which can lead to the onset of conditions such as cardiovascular disease, diabetes and cancer. Not only are these policies aimed at reducing the burden on the population, they can also reduce the cost-burden on the NHS - current annual spend on medicines is £16billion, £9billion of which is solely from GP prescribing.
Firstly, Environment Secretary George Eustice announced a two-year £4million trial for ‘green prescribing’, whereby people are prescribed exercise by their GP such as cycling and walking to support both their physical and mental health; potentially replacing previously established medication regimes for some patients.
Shortly after, the Government released the new Tackling Obesity strategy. This report was particularly timely following the release of research that shows that the risk of serious illness or death from COVID-19 grows substantially as body mass index (BMI) increases. Nearly 8% of critically ill patients with COVID-19 in intensive care units have been morbidly obese, compared with 2.9% of the general population.
Prime Ministers in recent administrations have tended to focus priority strategies and funding towards specific health conditions, including mental health and Alzheimer’s. At the obesity strategy’s launch Boris Johnson spoke of his own personal battle with weight and the impact this had on his recovery from COVID-19; signalling his intent to make tackling obesity part of his legacy on healthcare in the UK.
Green prescribing is an important lever in the Tackling Obesity strategy, alongside clearer calorie labelling and tighter restrictions on shelf placement and advertising of unhealthy foods. It is a proactive approach, that fits with the wider Government strategies aimed at preventing the development of serious health conditions, as outlined in the Advancing our Health: Prevention in the 2020s Green Paper. The approach is potentially game-changing, if implemented properly, further pushing forward a more interventionist approach to prevention over pills.
In principle these measures are simplistic. A GP prescribes exercise to a patient, the individual undertakes exercise they would not have otherwise done, has improved general health and thus reduces the chances of them developing life-threatening conditions in the future.
Unfortunately, the reality of green prescribing has been more complex.
Green prescriptions have been widely used in New Zealand since 1998, with eight out of ten GPs saying they have prescribed exercise instead of medication at some point and 71% of patients prescribed green activity noticing long-term positive changes to their health. However, over 30% of New Zealand’s population are measured as obese, placing it third worse in the world, only behind the obesity ratings of Mexico and the US. Despite positive impacts with some patients, the country’s overall rate has risen since green prescribing’s introduction, demonstrating the complex backdrop of policies and lifestyle choices influencing obesity.
Below we explore how these varied societal factors can make or break the potential success of green prescribing:
Green prescribing makes assumptions about access to safe and suitable physical spaces for exercise. For those living in built up cities with less green spaces and more concern over road safety for cyclists there are additional layers of challenge. In many areas air pollution also provides cause for concern. This is particularly prevalent in built up areas with high car usage, including Luton, Crawley and Leamington Spa which have the highest pollution levels in the UK relative to size.
To ensure success, the Government must prioritise making cities safer spaces to cycle, greener spaces to run in, and improving facilities such as swimming pools, with a focus on accessibility for people with disabilities.
Last month the Government pledged £2billion to tackle elements of bike safety and theft (another common deterrent to exercise). However, this pales in comparison to the £27billion promised to build new roads in the UK. If the Government is serious about improving the nation’s health through widespread green prescribing, this thinking must be built into national and local planning and borne out in national transport policy which gives greater consideration to the needs of pedestrians and cyclists.
The Royal Pharmaceutical Society estimates that between one third and one half of patients on long-term medication regimes do not take their medicines correctly, hindering effective care.
The taking of medicines has a much lower day-to-day impact than a commitment to exercising, for example from a time perspective, so it is feasible that adherence to any green prescribing measures could be an even bigger potential problem.
As with medication prescriptions, the answer to improving adherence for green prescribing is often ensuring that health professionals take a shared decision-making approach. This method, in which health professionals ensure any decisions on patient care are taken alongside the patient, involves them in their care to help improve adherence. For green prescribing, this may mean discussing the forms of exercises a person is more likely to enjoy and feel comfortable undertaking, rather than just wasting resources on a shiny new bike that they ultimately won’t use.
Tackling obesity and the nation’s health fits very well into Boris Johnson’s ‘levelling up’ agenda for the UK, to redress the historical underinvestment in infrastructure in areas such as the North of England.
The regional inequalities also carry across to health outcomes. Two reviews carried out by Sir Michael Marmot in 2010 and 2020 found that people living in the most deprived areas of the UK have a higher prevalence of lifestyle factors known to be risk factors for conditions such as cardiovascular disease and cancer, including smoking, poor diet and low exercise. Research highlighted that those people in more deprived areas spend more of their short lives in ill-health than those in less deprived areas.
This has a further detrimental economic impact. Analysis in 2018 by the Northern Health Science Alliance identified that poor health accounts for one third of the productivity gap between the North and the rest of the UK, at a cost of £13.2bn a year.
The Government must prioritise health inequalities generally, but also look to target green prescribing at areas suffering from worse health outcomes to ensure that the scheme can have the biggest impact. Again, these must be delivered with awareness and sympathy to wider constraints on patients’ lifestyles, and through partnership between physicians and patients to ensure solutions maximise adherence.
Any policy change in the NHS is only as good as the health professionals on hand to roll it out. Green prescribing marks a large shift in the UK’s pill-focused approach, with physiotherapy and mental health services historically under-resourced, and medicine spend high.
GPs therefore will need to have a mindset change ingrained into them in order for the potential benefits of green prescribing to be realised. It is therefore vital that the Government works closely with Clinical Commissioning Groups (CCGs) and the Royal College of GPs (RCGP) to ensure that GPs fully understand the new strategy and receive appropriate information and training to ensure its effective roll-out.
Clearly, green prescribing has the potential to improve the health of the UK’s population, but only if the approach is embraced within decision-making on regional investment and national and local policy making, particularly around planning and transport infrastructure.
Companies within the healthcare sector also have a key role to play in the shift in mindset that will be necessary to move towards healthier lifestyles. We can learn from other countries such as New Zealand which is a prime example. New Zealand is a country with lower pollution, more green space and lower levels of health inequalities that has adopted green prescribing with successful patient reported outcomes. However, obesity rates are higher than when green prescribing was first adopted. This demonstrates the mindset challenge that any health system faces in tackling obesity.
If the UK Government is to make a success out of green prescribing and the Obesity Strategy, it is vital they address the psychological elements that impact people’s relationship with food and exercise. Companies and Government must move away from a reliance on awareness raising tactics such as advertising campaigns that have a superficial impact. These campaigns should be replaced or at least supplemented with research and policies aimed at embedding deep-rooted behavioural change.
Research and policies should centre around behavioural economics, which focuses on the under-lying mechanisms that drive public choice. By channelling the resources that would have been spent on awareness raising into behavioural economics, companies and Government can address the underlying factors that impact both market and patient decision-making and will create the necessary foundations that can ensure green prescribing is given the best opportunity to influence a reduction in obesity in the UK.
There is clearly a huge opportunity to address health inequalities, improve our green and transport infrastructure to meet the health needs of the public, and to open up new areas of product development and service. Business will play a critical role in supporting Government in driving the society-wide approach that needs to be taken for the aims of reducing obesity and associated health conditions to become a reality.