Invest in Nature: the best route to secure social value across the NHS estate

How green infrastructure can help deliver against the NHS Triple Aim

Whilst the legacy of Covid-19 leaves the NHS facing huge challenges in delivering care and services, CCGs and NHS providers are also needing to stay on track with transforming services and facilities to deliver a sustainable health service. CCGs and NHS providers share duties, detailed in the NHS Long Term Plan, to promote the ‘Triple Aim’ of better health for everyone, better care for all patients, and the sustainable and efficient use of resources, both for their local NHS services and for the wider NHS. Whilst much attention has been given to NHS buildings and services, there is more that could be done to measure, enhance and monitor the value of the wider NHS estate. The NHS owns 6.9 million hectares of land across the UK and this land could be working far harder to meet the proposed common duty set out in the Health and Care Bill to deliver against the Triple Aim.

NHS England’s Delivering a ‘Net Zero’ National Health Service identifies working to reduce air pollution and improve local environments as key priorities, highlighting the need to consider carbon offsetting and mechanisms to secure negative carbon emissions. Through the provision of high-quality green infrastructure, CCGs and NHS providers could support the delivery of these priorities, contributing to NHS sustainability and better health and care for patients, staff and communities.

What is Green Infrastructure?

In Public Health England’s 2020 report Improving Access to Green Space green infrastructure is described as a “network of multi-functional green space, urban and rural, which can deliver a wide range of environmental and quality of life benefits for local communities.”

Building with Nature is the UK’s first benchmark for green infrastructure, providing a clear definition of ‘what good looks like. The BwN Standards Framework provides both industry and policymakers with a set of quality standards and ‘how-to’ guidance, to meet the challenges of the climate, ecological and health emergencies. Developed with leading experts from the built and natural environment, including representatives from industry and government, Building with Nature is now being used to assess and accredit places that put nature at the heart of design.

What are the Benefits of Green Infrastructure?

Public Health England’s 2019 report Putting Health into Place: Design, Deliver and Manage details the benefits of green infrastructure as:

• Improving people’s mental and physical health
• Encouraging physical activity
• Reducing air pollution
• Protecting against climate change; by helping to reduce flood risk, cooling urban areas during heatwaves, storing carbon or preventing soil erosion
• Increasing biodiversity
• Growing food locally
• Attracting investment
• Improving the soundscape.

How can Green Infrastructure help deliver against the NHS Triple Aim?

A Greener NHS is the NHS’s flagship programme aimed at tackling climate change and making the NHS the world’s first net carbon zero health service. Their recent report Delivering a ‘Net Zero’ National Health Service notes the multiple benefits of increasing green space and trees on NHS sites in providing opportunities for improving air quality, providing active travel routes, supporting mental health and social prescribing, and supporting biosequestration as a core strategy in achieving net zero. The report also demonstrates how the NHS can contribute to the levelling up agenda, detailing how nature nearby can be pivotal in preventative and restorative care:     

“Access to green spaces has positive mental and physical health impacts, and these beneficial effects are greatest for those from socioeconomically disadvantaged groups. However, these groups also have the least access to green spaces. Black, Asian and minority ethnic groups are disproportionately affected by high pollution levels, and children or women exposed to air pollution experience elevated risk of developing health conditions.”

A positive outcome from the pandemic is that more people are valuing and accessing nature. According to Natural England’s People and Nature Survey nearly half of adults in England report spending more time outdoors than before the pandemic (March 2022). Close to four in ten say that nature and wildlife are more important than ever to their wellbeing (March 2022).

In summary, multi-functional green infrastructure can deliver a positive response to the climate emergency, support community health and wellbeing, improve water quality and management, and deliver increased biodiversity.

What does high-quality green infrastructure look like in a healthcare setting? 

• Introducing Building with Nature accredited health-care facilities that showcase the value of delivering high-quality green infrastructure. 
• Exploring how a set of green infrastructure quality standards can support decision-making from outline proposals through to management and maintenance of estates.

Forth Valley Royal Hospital and Larbert Woods is a hospital development replacing Falkirk and Stirling hospitals, delivering 25 wards and 16 operating theatres. At the point of construction, it was the largest NHS construction project in Scotland. The scheme received the 2020 Landscape Institute Building with Nature national award in recognition of its exemplary design, delivery and maintenance of high-quality green infrastructure.

Key benefits of the scheme are:

• Increased patient, staff and community health and wellbeing through improved access to the natural environment and new social prescribing opportunities
• Greater climate resilience through tree planting and reducing the risk of flooding
• Increased active travel and a reduction in air pollution
• Sustainable water management and improved water quality
• Enhanced biodiversity through improved connectivity, targeted regeneration and conservation of habitats and species
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The Forth Valley Royal Hospital and Larbert Woods high-level case study, providing further detail of this scheme, can be downloaded from the Building with Nature website.

Our Health Meadow at University Hospital Llandough is a second example of a Building with Nature awarded healthcare facility that delivers multiple benefits through green infrastructure.

How can collaborative approaches deliver affordable solutions?

Forth Valley Royal Hospital and Larbert Woods demonstrate how a shared vision for protecting and enhancing existing natural features can be achieved through collaborative working at all stages of planning, design and delivery. The central partnership between NHS Forth Valley and Forestry and Land Scotland benefited from the input of the Green Action Trust who provided the detailed design of the woods area, and from landscape architects RFB who designed the hospital grounds, as well as set out a masterplan and design guide for the woods area. There is also a new Maggie’s Centre situated near the lake, making the most of the natural environment.

The cost of restoring and enhancing the green space and woodland around the hospital constituted around 0.1% of the total build budget. Kevin Lafferty, formerly of Forestry and Land Scotland, who acted as a key partner throughout this collaborative project and continues to work with NHS Forth Valley to manage and maintain the green infrastructure, suggested that this small percentile of the overall project spend was perceived by the Director of Estates have the highest return on investment in terms of social value:

“BwN Award is a validation of the investment that’s been made at FVRH. It cost over £300m to build this new hospital, and for the transformation of the greenspace and the woodlands, just over £0.5m. The Director of Estates that we work with here at NHS Forth Valley said that in their career that was the best investment that they had made in terms of return for social value, so great use of public money and public spend.”

Forestry and Land Scotland continue this legacy investment by providing nature-based engagement activities for patients, staff, and community members on the hospital grounds.

Next step(s)

Join Dr Gemma Jerome FLI at the Institute of Government and Public Policy’s Second Annual Transforming the NHS Estate event on 27^th September 2022 to hear more about how the Building with Nature Standards can help the NHS re-imagine and transform its estate to provide the high-quality green infrastructure that delivers the triple aim, creating a sustainable NHS that supports the health and wellbeing of communities. High-quality green infrastructure across the NHS estate can be achieved if we act now to design and deliver the solutions required to meet our future needs.

The BwN Standards Framework can be downloaded from the Building with Nature website and used to inform design decisions for new builds and for retrofit schemes. Building with Nature also offers a voluntary accreditation scheme, and a list of BwN Approved Assessors can be found on the Building with Nature website.

Written by - Gemma Jerome FLI, Director, Building with Nature