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Ethical Challenges to Green Social Prescribing in the UK Mental Health System

We examine the ethical and operational challenges of Green Social Prescribing (GSP) within the UK mental health system. Despite growing policy enthusiasm, GSP is currently underpinned by limited evidence, inadequate infrastructure, and inequitable access. We argue that without addressing these issues, GSP risks reinforcing health inequalities and undermining patient trust.

Key concerns include:

  • A weak and inconsistent evidence base for GSP’s effectiveness
  • Lack of referral and outcome tracking systems within the NHS
  • Structural barriers to green space access for marginalised groups

We propose clearer communication with patients, national infrastructure reform, and policies grounded in collective responsibility to support ethical implementation.

Menon, S., Lyreskog, D., Hohnen-Ford, W., McKeown, A., Wilhelm, K., Pulcu, E., Iyadurai, L. & Singh, I. (2025). Ethical Challenges to Green Social Prescribing in the UK Mental Health System.

Looking through autumn trees in a park with a figure in the distance

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Green Social Prescribing (GSP) is gaining traction in UK health policy. This approach involves referring individuals experiencing mental health difficulties to nature-based activities such as gardening, park walks, or conservation volunteering. Scientific research is increasingly associating these activities with improved wellbeing [1], and GSP is now being integrated into efforts to reduce strain on NHS services by drawing on community and environmental resources [2].

GSP features in both the NHS Long Term Plan [3] and the government’s 25 Year Environment Plan [4], and recent initiatives have involved government-backed efforts to expand delivery across England. However, key questions remain:

  • How strong is the evidence base for nature-based interventions in mental health care?
  • Who is currently able to access GSP, and who faces barriers to participation?
  • Is the NHS equipped to deliver it fairly and effectively?

In our recent paper (pre-print), Ethical Challenges to Green Social Prescribing in the UK Mental Health System, we argue that although GSP shows promise, its implementation within NHS services is currently premature, both ethically and operationally. Without attention to key shortcomings, it risks becoming a well-intentioned but flawed response to complex challenges in mental health care.

We highlight three core areas where GSP is falling short:

A limited and inconsistent evidence base

Although some studies suggest that nature-based activities can improve mental health, the overall evidence base remains limited and inconsistent [5]. Research designs differ considerably in sample size, methodology, and outcome measures, making it difficult to draw firm conclusions or compare results across studies [6]. Many studies rely on self-reported outcomes, do not include control groups, or combine several elements at once, such as time outdoors, physical activity, and social engagement, making it unclear which components are responsible for any observed effects [7].

This lack of clarity has practical consequences. When GSP is described in clinical settings as a form of prescription, patients may expect predictable or treatment-like results. If improvement does not occur, individuals may internalise responsibility, blaming themselves for not engaging in the right way. This reflects a broader issue in public health known as responsibilisation, in which outcomes shaped by structural conditions are placed back onto individuals as matters of personal effort or choice [8].

Weak infrastructure

GSP programmes are most often delivered by voluntary and community organisations that operate outside formal NHS systems. At present, there is no national infrastructure for making referrals, recording participation, or monitoring outcomes. This means that clinicians may have no way of knowing whether a patient has taken part in an activity or whether it had any benefit [9]. Many providers are underfunded, undertrained, and disconnected from primary care services, and link workers often lack the resources or coordination needed to support long-term follow-up [10].

These gaps limit the transparency and accountability expected of health interventions delivered through the NHS. Without reliable systems, it becomes difficult to evaluate effectiveness, allocate funding appropriately, or build trust among patients and professionals. As interest in GSP continues to grow, these infrastructural shortcomings present a significant barrier to responsible and sustainable delivery.

Inequitable access to green space

Access to green space in the United Kingdom is deeply unequal. High quality green areas that are safe, rich in biodiversity, and easy to reach are far less common in more deprived neighbourhoods and among many racialised communities. According to the Office for National Statistics, over one third of people from Black and minority ethnic backgrounds have no green space within walking distance of their home, compared to just one in ten White people. These disparities persist even after accounting for factors such as income and age [11].

Taken together, the challenges of limited evidence, weak infrastructure, and unequal access raise serious concerns about the current direction of GSP. Without stronger foundations, GSP risks falling short of its promise and placing additional burdens on those it is intended to support. Addressing these limitations is not simply a technical matter. It is essential to ensuring that GSP is delivered in ways that are credible, ethical, and genuinely responsive to the needs of mental health care.

What needs to change

We argue that if GSP is to contribute meaningfully to mental health care, policymakers and system leaders must address its current ethical and operational weaknesses. This includes:

  • Providing patients with accurate information about what GSP involves and what it can reasonably be expected to achieve.
  • Developing national infrastructure to support referrals, monitor outcomes, and coordinate delivery across the NHS, voluntary sector, and local authorities.
  • Improving access to green space in underserved communities through public investment, local planning, and community-led initiatives.

GSP should not be treated as a substitute for clinical care, nor as a quick fix to systemic issues. It must be implemented with clear expectations, reliable systems, and a commitment to equity. Without this, GSP risks reinforcing the very inequalities it is meant to address.

Written by William Hohnen-Ford

This blog is based on the paper: Menon, S., Lyreskog, D., Hohnen-Ford, W., McKeown, A., Wilhelm, K., Pulcu, E., Iyadurai, L. & Singh, I. (2025). Ethical Challenges to Green Social Prescribing in the UK Mental Health System.

The full pre-print version of the paper can be accessed here: https://doi.org/10.31234/osf.io/ehbq5_v2

Bibliography

  1. Buckley RC, Zhang ZJB, Underdahl S, Cooper MA, Sclippa K, Brough P, et al. Nature-based mental health: research and implementation agenda. The Lancet Planetary Health. 2024;8(8): e528–e529. https://doi.org/10.1016/S2542-5196(24)00166-9.
  2. Robinson JM, Breed MF. Green prescriptions and their co-benefits: integrative strategies for public and environmental health. Challenges. 2019;10(1): 9. https://doi.org/10.3390/challe10010009.
  3. England NHS. Nhs england » creating a new 10 year health plan. https://www.england.nhs.uk/long-term-plan/ [Accessed 2nd June 2025].
  4. 25 year environment plan. GOV.UK. https://www.gov.uk/government/publications/25-year-environment-plan [Accessed 2nd June 2025].
  5. Lomax T, Butler J, Cipriani A, Singh I. Effect of nature on the mental health and well-being of children and adolescents: meta-review. The British Journal of Psychiatry. 2024;225(3): 401–409. https://doi.org/10.1192/bjp.2024.109.
  6. Menhas R, Yang L, Saqib ZA, Younas M, Saeed MM. Does nature-based social prescription improve mental health outcomes? A systematic review and meta-analysis. Frontiers in Public Health. 2024;12: 1228271. https://doi.org/10.3389/fpubh.2024.1228271.
  7. Shanahan D, Astell–Burt T, Barber E, Brymer E, Cox D, Dean J, et al. Nature–based interventions for improving health and wellbeing: the purpose, the people and the outcomes. Sports. 2019;7(6): 141. https://doi.org/10.3390/sports7060141.
  8. Brown RCH, Maslen H, Savulescu J. Against moral responsibilisation of health: prudential responsibility and health promotion. Public Health Ethics. 2019;12(2): 114–129. https://doi.org/10.1093/phe/phz006.
  9. Husk K, Blockley K, Lovell R, Bethel A, Lang I, Byng R, et al. What approaches to social prescribing work, for whom, and in what circumstances? A realist review. Health & Social Care in the Community. 2020;28(2): 309–324. https://doi.org/10.1111/hsc.12839.
  10. Exploring perceptions of green social prescribing among clinicians and the public. GOV.UK. https://www.gov.uk/government/publications/green-social-prescribing-perceptions-among-clinicians-and-the-public/exploring-perceptions-of-green-social-prescribing-among-clinicians-and-the-public [Accessed 2nd June 2025].
  11. Access to public green space in Great Britain - office for national statistics. https://www.ons.gov.uk/economy/environmentalaccounts/datasets/accesstopublicgreenspaceingreatbritain [Accessed 3rd June 2025].