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Branching Out

Branching Out is an innovative programme which offers woodland activities on referral for mental health service users.

Each group runs once a week for 12 weeks, and includes activities as diverse as health walks, conservation projects, bushcraft activities and tai chi. Activities are chosen to suit the physical ability of individuals in the group, as well as other factors such as time of year, woodland site and weather.

Research has shown that Branching Out has a very low attrition rate, can help people increase their physical activity levels, and has benefits to physical, mental and social wellbeing. The programme aims to act as a stepping stone to encourage individuals to move on to more socially inclusive activities, while also acting as a adjunct treatment to their mental health issues.

***PAHA Award Winner 2014***

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How It Started

Branching Out was envisaged as a way of bringing the benefits of woodland based activities to people with mental health issues.

People with mental health issues are less likely to be physically active than the general population and also more likely to have a wide range of accompanying physical health conditions. Green exercise and other outdoor activities have been shown to be beneficial for both mental and physical health.

However there are many additional barriers to people with mental health conditions accessing local facilities, which include social isolation, lack of support to attend projects, anxiety, low self esteem, physical health conditions and medication side-effects.

Branching Out aims to remove, or minimise, some of these barriers by providing a tailored programme of greenspace activity specifically for mental health service users. The service was developed, and is continuously improved, through consultation with mental health professionals, Branching Out leaders, client groups and with reference to the changing evidence base for green exercise programmes.

Each project is adapted to suit the individual needs of participants. This has enabled them to successfully work with people aged 16-88 from a huge range of mental health services and with additional health considerations such as dementia, learning conditions, obesity and mobility issues.

Partners Involved

Branching Out is led by a steering group of environmental and healthcare professionals from a broad range of organisations.

In each NHS area they work with one main identified lead to help promote and organise the project. These include a Health Improvement Lead, Senior Health Promotion Specialist, and a Public Mental health and well-being Manger.

Other current steering group members include a representative from the Scottish Government Sports and Activity Division, a Director of Scottish Association for Mental Health and a Park Manager, who represent the wider interests of the environmental sector.

The NHS has shown continued support to the programme by providing funding over a six year period. Some of this has been direct funding to support the running of groups. There has also been a huge amount of in-kind contribution by local services providing staff such as Occupational Therapists and Community Psychiatric Nurses to work with the project. Staff time is not only required to support patient attendance, but also to arrange appropriate referrals and support the evaluation of this project.

Having high-level support from steering group members means that more local buy-in from services is easier to achieve.

Forestry Commission Scotland, as the programme lead, have invested considerable time and resources into Branching Out since 2007. This includes match funding many of the projects, and core funding the now permanent Branching Out Programme Manager post.

Branching Out is led by a steering group consisting of representatives from Forestry Commission Scotland, Clyde Muirshiel Regional Park, the Scottish Association for Mental Health and a Health Promotion lead from each NHS board area covered.
There is also a delivery sub-group, which brings together all Branching Out leaders twice a year to discuss new developments, and an evaluation sub-group which meets as and when required.

New mental health groups are engaged via steering group members, by contact at conferences and events or via press release and articles in professional magazines or newsletters.
However, more increasingly, personal recommendation between professionals is important in reaching new groups.

Service users are encouraged to opt into the project via informatio leaflets and presentations.
Participants are also consulted regularly about their views on the programme through formal mechanisms such as feedback forms and case studies, and more relaxed methods such as group reviews or anonymous comment boxes.

Process

Individuals attending the programme have a mental health condition and also often have accompanying physical health issues. By providing green exercise activities in a supportive environment participants are able to improve their mental wellbeing and increase their activity levels, which has positive benefits on a wide range of health outcomes.
An example of which is qualitatively described below:

“I feel it’s actually benefited my health, because I do suffer from asthma. It seems as if I’m getting more fresh air and I feel a wee bit healthier. I feel that, in a way, it is making me lose a wee bit of weight. I used to be twenty stone now I’m only eighteen.”

People with mental health conditions are more likely to have physical health conditions than the general population, but are also less likely to access mainstream physical activity options such as leisure centres. Branching Out acts as a stepping stone to encourage participants to become more physically active, initially with a peer group and then by encouraging people to move on to community-based projects such as health walks or conservation volunteering.
This is examplified in the quote from a participant below:

“As a result of the programme I went on to complete walk leader training, and I will gradually increase my role within my local mental health walking group. I hope to eventually take the lead in these walks and encourage other people to take part.”

Results and Impact

Attendance at the Branching Out programme has been unusually high for a mental health group. The average number of attendees completing the programme (attending 5+ weeks) is stable at 75%.

Part of the appeal seems to be that the physical activity is incorporated within activities rather than being a purpose in itself. For example, a conservation activity might include walking, lifting weights, balance and coordination. Participants tend to focus on the end goal of the activity rather than worrying about the exercise involved.

At the end of each project, Branching Out promote a wide range of local opportunities for people to continue to engage with green exercise. In order to ensure sustainability, and encourage people to move onto more socially inclusive activities, the majority of these options are community-based activities. Examples include health walks, conservation volunteering, citizen science and local training courses.

Other participants have successfully moved on to training and employment opportunities, both in the environment and green exercise fields or other interests.

Branching Out have also developed a peer mentoring scheme so that past participants can support and encourage participation of new patients.

A recent economic study on the Branching Out programme found that participants increased both their levels of vigorous and moderate physical activity levels over the course of the programme (measured using the IPAQ questionnaire). There was also a significant increase in Quality Adjusted Life Year (QALY) scores (p<0.05) for participants, and a cost per QALY of £8,600 (well within the usual £30,000 NICE prescribing guidelines).

Lessons Learned

Currently Branching Out require at least one member of staff from the referring service to accompany each group and be responsible for any mental health issues on site.
However, as these healthcare practitioners gain experience and confidence in the outdoors they are often keen to take a more active role in the activities.

As a result, Branching Out have recently piloted the provision of environmental training to healthcare workers regularly involved with Branching Out groups.

Two different versions of this training were trialled, but both included skills such as risk assessment outdoors, safe use of tools, and environmental awareness.

Following positive feedback they are now working on rolling out a training programme next year to other interested project partners.

What's next for the project?

Branching Out is in the process of expanding into a further two NHS health boards – NHS Highland and NHS Fife. This will allow them to take the project benefits into new areas. Moving into NHS Fife also means that Branching Out will have a presence across the whole Central Scotland Green Network area.

Some of Branching Out's project partners have a large caseload, or a high turnover of patients, as a result they are keen to have regular Branching Out programmes with new patients.

In the longer term this will allow Branching Out to run some groups with just one Branching Out leader (instead of two) and an HCP in an assistant role. This will both increase workforce skills and reduce programme costs.

Finally, Branching Out are also collecting further data for their economic study and aim to publish their first paper with interim results in 2014.

What is this?

What is it about?

Where is this relevant?

When was this published?

4/7/2014

Lead Contact Name

Hugh McNish

Organisation

Forestry Commission Scotland

Email Address

hugh.mcnish@forestry.gsi.gov.uk

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Copyright 2009 NHS Health Scotland