GPs’ views on green social prescribing in Scotland: analysis of a national cross-sectional survey

Summary

This study is the first to report on GPs’ views of GSP in a national survey. Most GPs were aware of GSP and would be happy to refer patients to NBHIs. More than two-thirds felt that GSP would be suitable for older patients with multimorbidity but fewer than half thought that patients from deprived areas would access NBHIs. After controlling for other individual and practice characteristics, GPs from ethnic minority backgrounds remained significantly less aware (P<0.002) , and GPs who worked fewer sessions per week significantly more aware of GSP (P<0.002) but were just as willing as other GPs to refer patients to NBHIs. In terms of the suitability of older patients with multimorbidity for GSP, GPs who worked more sessions a week were less positive and those with higher job satisfaction were more positive. GPs with higher job satisfaction and those who worked in deprived areas were also more positive about whether patients in deprived areas would access GSP.

Strengths and limitations

A key strength of this survey was that it included all qualified GPs in Scotland, with a relatively good response rate for GP surveys, and responders were broadly nationally representative in terms of age, gender, whether a partner or not, practice deprivation, and rurality. The focus of the survey was on a wide range of workforce factors and views relevant to GPs’ working lives, including the new Scottish GP contract. Furthermore, given that it was not explicitly focused on GSP (four questions in the 10-page survey), those who responded are unlikely to be biased advocates for GSP.

Although the sample size was quite large (1378), some of the subgroups were limited in numbers. For instance, the results of our study on ethnicity should be viewed with some caution owing to the small sample size of the GPs from ethnic minorities. In addition, there were only four dichotomous questions on GSP and therefore deeper exploration of the rationale for their response was not possible. We do not know if the GPs had previously referred patients to GSP, only whether they believed they would. Including more detailed questions would have provided more information but we were limited in the number of questions we could include on GSP, as the main focus of the survey was about GP working life and job satisfaction.¹⁸ Future work is required to explore GPs’ views on GSP in more depth, and the use of Likert scales rather than dichotomous answers in any future work should be considered.

Comparison with existing literature

Our overall findings are comparable with a study in England that found 76% of clinicians had heard of GSP.¹² Regarding ethnicity, 72% of White clinicians compared with 61% of clinicians from ethnic minority backgrounds in England were more favourable towards GSP.¹² This contrasts with our findings that GPs of ethnic minority backgrounds were as willing to refer patients as White GPs, but fewer had heard of GSP. This finding is notable particularly as other research shows that ethnic minority patient groups have more difficulties accessing primary care and have poorer health outcomes.²¹ If a GP’s ethnic background influences awareness of the benefits of being in nature, this could further increase health inequalities. However, this finding requires a deeper understanding of the cultural variation and historic experiences that may influence how some people from ethnic minority backgrounds value being in nature²² and consequently how this might influence a GP’s decision to refer patients to NBHIs. This is important as evidence suggests that people from lower socioeconomic status and minority groups are less likely to have the opportunity to enjoy nature, yet they are more likely to benefit from GSP than other more affluent groups.^9,22 Further research may be needed to understand these findings to be able to develop strategies to reduce ethnic inequalities in health care.²³

The English study found that female clinicians were more positive about GSP than male clinicians¹² and a pilot study of GSP in primary care reported that most prescribers to NBHIs were women,¹⁷ but in both studies there was no adjustment for other factors. Our results indicate the importance of taking GPs’ individual and practice characteristics into account when examining such associations.

It is of interest that most GPs in our study felt that older people with multimorbidity would be suitable for GSP, given the increasing prevalence of multimorbidity owing to the ageing population. Encouraging such patients to participate in GSP could lead to a range of beneficial outcomes, including reducing the severity of frailty.²⁴ However, these findings were again modified by the working patterns of the GPs, and by job satisfaction. A positive association between GP job satisfaction and enthusiasm for social prescribing has been reported previously owing to GPs feeling that social prescribing increased their job satisfaction and benefited patients’ health and wellbeing.²⁵ GPs in Scotland and across Europe are reporting increasing workloads leading to potential burnout^18,26 and it is likely that they have less time to think enthusiastically about innovative interventions. Thus, this may be a reason why some GPs with low job satisfaction are less likely to refer patients to GSP. Conversely, GPs with a higher job satisfaction are less likely to suffer burnout²⁶ and providing preventive care, such as GSP, is positively related to higher job satisfaction.²⁶

It is also noteworthy that most GPs in our study did not think that patients from deprived areas would participate in GSP, but this was again modified by job satisfaction with more positive views for those with higher job satisfaction. GPs who worked in deprived areas were more likely to be positive. We suggest this is because they may have a deeper knowledge and understanding of their patients and their patients’ needs and are therefore more inclined to be optimistic about GSP compared with GPs working in more affluent areas whose views were possibly more speculative. This is an important finding to build on given that people from deprived areas stand to gain the most from GSP.⁹

Implications for research and practice

Despite the apparent enthusiasm for GSP in our study, engaging GPs in the GSP referral process is challenging^5,25 and GPs need additional support to provide new or innovative interventions. Although awareness of GSP is developing,^5,27 more research is required for a greater understanding of the practical barriers to referring patients to GSP, especially in areas of high deprivation, to enable interventions and policy solutions to prevent a widening inequality gap. These barriers may include, for example, awareness across cultural and ethnic groups; the training needs of staff; improving motivation; patient health literacy; NBHI access issues such as transport, costs, and disability; along with sustainability and funding of NBHIs that are predominantly provided by third sector organisations. Such understanding can then lead to primary care-based interventions that support GPs to engage in GSP, thus enabling patients — especially those living in deprived areas — to access NBHIs and thereby reap the many health benefits associated with such activities.