Social prescribing at Blenheim Palace Estates

Introduction

A large proportion of chronic diseases that plague healthcare systems are preventable or can be brought into remission through lifestyle interventions; indeed, 80% of health outcomes are determined by social factors.

An emerging approach that is trying to address these issues is called social prescribing (social px), which provides ‘a way of linking patients in primary care with sources of support within the community to help improve their health and well-being.’ Social px can address mental and physical health through activities like sports and leisure/arts activities and can address social determinants of health through activities more focused on social issues (for example housing, food), education or skills development.

The Blenheim Palace Heritage Foundation Charity (Blenheim) is a core believer in the importance of stewardship and, to this end, Blenheim aims “... to be the lifeblood of the local economy, to enhance the lives of the people of Oxfordshire, to share this magnificent Palace and to conserve and protect it for future generations.”

Through its role as the good steward, over the next ten years, Blenheim aims to triple its contribution to Oxfordshire and through this Pitch-In project, Blenheim aimed to explore how it could become a social px exemplar in Oxfordshire.

Oxford University brought together and project managed the team that undertook this trial. It built on work of two other Pitch-In projects: ‘How can IoT-enabled social prescriptions deliver value in healthcare Systems?’ (health theme) and ‘Nature sensing’ (cities theme).

Project aims

To explore how Blenheim can become a social px exemplar, we designed two interlinked workstreams the outputs of which could be used for future projects and funding applications to cement Blenheim’s role as a leading social px provider in Oxfordshire.

Workstream one

Blenheim has access to an enormous pool of community assets (such as 2,000 acres of formal gardens, 12,000 acre estate) that could be harnessed to provide social px. In order to more efficiently and effectively navigate and prioritise these assets as well as the social px that could be provided within Woodstock, and Oxfordshire more widely, we held two workshops.

Workshop one: to gain a better understanding of the social needs within the community by leveraging the Oxfordshire Joint Strategic Needs Assessment

Workshop two: to work with Blenheim staff to brainstorm feasible means by which Blenheim can leverage its assets to create social px to meet local social needs.

Workstream two

Based on the results of the workshops, we aimed to design and implement a social px utilising Blenheim’s land and gardens. In particular, we wanted to explore how some of the insights of our previous Pitch-In project exploring how IoT-enabled social px could deliver value to the NHS could be harnessed to design an effective IoT-enabled social px at Blenheim.

What was done?

Workstream one (December 2020 – January 2021)

Workshop one

The first workshop was held with Blenheim staff on 21 January 2021 to first explore areas of social need within Oxfordshire, informed by Oxfordshire’s Joint Strategic Needs Assessment, that Blenheim staff felt they could positively impact as well as some ideas for interventions that could be delivered utilising the assets Blenheim has access to.

Workshop two

The second workshop was held with Blenheim staff and partner VCSE organisations in Oxfordshire on 28 January 2021 to first give an overview of the assets available at Blenheim that could be utilised by partner organisations to deliver social prescriptions and then to brainstorm with partner organisations on the social px that could be delivered at Blenheim.

Workstream two (January–June 2021)

Based on the insights of workstream one, we decided that a walking-based social px would be a great initial social px to test out at Blenheim. Several studies have pointed to the health benefits of walking as an intervention to improve physical and mental health and for our feasibility study, we worked with beneficiaries from Aspire, an Oxford-based social enterprise, that works with disadvantaged people in Oxford specifically aiming to recruit younger people (16–25) who had a history of substance misuse.

For the design of the intervention, we built on insights gained from walking-based social px that have been delivered by the Eden project for several years to inform the design of our walking-based social px. Over a six week period, a two-hour walking session was organised every Thursday morning around Blenheim’s grounds (table 1), where participants were taken on different routes aimed at conveying different interactive experiences that leveraged the diversity of Blenheim’s grounds.

Table 1. Schedule of walks (all from 10am to 12pm).

Week one, Thursday 22/04/21
Churchill Memorial Garden
Blenheim staff: Antonia Keaney – Social History Researcher, Jo Young and Natalie Valentine
Aspire navigator: Cheryl Huntbach

Week two, Thursday 29/04/21
Cascades (with dog)
Blenheim staff: Antonia Keaney – Social History Researcher, Jo Young and Natalie Valentine
Aspire navigator: Cheryl Huntbach

Week three, Thursday 06/05/21
Column of Victory, Avenue of Trees and Lambs
Blenheim staff: Sylvain Richard – Palace Guide, Jo Young and Natalie Valentine
Aspire navigator: Cheryl Huntbach

Week four, Thursday 13/05/21
Inside the Palace
Blenheim Staff: Antonia Keaney – Social History Researcher, Jo Young and Natalie Valentine
Aspire navigator: Cheryl Huntbach

Week five, Thursday 20/05/21
Secret Garden
Blenheim staff: Antonia Keaney – Social History Researcher, Jo Young and Natalie Valentine
Aspire navigator: Cheryl Huntbach

Week six, Thursday 27/05/21
Queen Pool
Blenheim staff: Antonia Keaney – Social History Researcher, Jo Young and Natalie Valentine
Aspire navigator: Cheryl Huntbach

To understand impact, we looked at both mental and physical health.

• Physical health: we utilised the GPS-enabled FitBit Charge 4, an IoT technology that participants wear on their wrist and which collected real-world evidence on physical health (eg activity levels, heart rate, sleep patterns) through remote monitoring.

• Mental health/wellbeing: the ONS4 Wellbeing measure was used to capture information on the general mental health and wellbeing status at the beginning and end of the intervention. Nine participants were also asked what they were interested in achieving from the wellbeing walks before the start of the programme and general feedback was collected at the end of every walk, which was recorded by Aspire’s navigator.

Results

Workstream one (December 2020 – January 2021)

Through the workshops in workstream one, a variety of social needs were highlighted as being of interest to the Blenheim team (such as loneliness, depression and anxiety in adults and those aged 60+, as well as physical and mental health of children and young people) and brainstorming on different types of social px that could be delivered on Blenheim grounds led to the identification of a walking-based social px on Blenheim grounds as being an ideal starting point for the feasibility study in workstream two.

Workstream two (January–June 2021)

Attendance

Over the six-week period, different participants attended the walks as indicated in table 2 below.

Participant attendance ranged from one session (participant 8) to all six sessions (participant 1) with an average of ~4 sessions/attendee and an average of ~7 participants per walk (reasons for non-attendance ranged from illness to hospitalisation).

Physical health

The data we were most interested in was step counts, which have been shown to lead to short and long term increases in walking, and because they are more reliable compared to some of the other measures collected by FitBits (eg heart rate and sleep patterns). Data from the FitBits were captured and analysed using Fitabase, a platform that allows for direct data streaming from FitBits into the Fitabase platform.

Because beneficiary participation in the walks varied with regard to the number and actual sessions attended, we opted to analyse data only for participants who attended at least three consecutive walks to allow for a comparable measure of the physical health impacts on participants.

Full step count data for every day from the week preceding the walk, as well as step count data on the day of the walk itself, was averaged for a given participant to calculate average steps/day for a given week (figure 1). Average daily step counts for a week varied for a given participant between different weeks as well as between different participants ranging from, on average, ~1,700–15,000 steps/day (figure 1).

The difference in average daily step counts for each participant was calculated by subtracting average daily steps from week one from week three for each participant (figure 2). For three participants, average daily steps decreased by week three while for four participants, average daily steps increased. Over the seven participants, there was an increase of ~1,000 average daily steps after three weeks in the wellbeing walks (figure 2).

Mental health and wellbeing

The ONS4 Wellbeing questionnaire was administered to all participants at the start of their participation in the walks as well as at the end of their participation in the feasibility study. Full baseline and post-intervention measures were collected for five participants and the average scores across all participants for the different ONS4 Wellbeing domains are indicated in figure 3.

On average, scores for all measures improved (life satisfaction, worthwhile and happiness increased while anxiety decreased) post-intervention.

Broader impact

In addition to physical and mental health, Aspire aims to support beneficiaries holistically with all aspects of their lives. To this end, the Aspire navigator as well as Blenheim staff regularly interacted with participants during and after the walking sessions to collect feedback on their experiences and their personal reflections on the walks some of which can be seen in table 3 below.

Table 3. Post-intervention plans from participants.

Participant 1 is continuing to engage with Aspire, he needs to gain more confidence before he starts to look at courses.

Participant 2 is volunteering with Aspire and is looking to take part in a mentoring course so he can work with people who have had similar experiences as himself.

Participant 3 is continuing with exercise and has joined a boxfit class and is spending more time outdoors.

Participant 4 was flying to Inverness to walk from John O’Groats to Land’s End as he has found that being outdoors has given him a new lease of life.

Participant 5 has found a lot in common with participant 9; they were going to meet up outside of the group and encourage each other to lose weight and get fitter.

Participant 9 has found a lot in common with participant 5; they were going to meet up outside of the group and encourage each other to lose weight and get fitter.

Participant 10 has grown in confidence and is starting a new business course to be able to set up on his own, his relationship with his parents has improved and he is taking better care of himself.

Direct feedback was also collected from the participants regarding their experience of the walks:

• I made a new friend and found amazing support from keyworkers – I now have more confidence to do new things.

• I feel really honoured and lucky to have experienced this and I have hopefully made new friends.

• This has made me more active and I now want to get out into the countryside more.

• It’s been good for me.

• It’s improved my mental health over the past six weeks. I feel part of something and the staff are lovely, really welcoming and great. I also now know a lot about Blenheim – Johnny’s facts! It’s been amazing.

• This has been great for my mental health, given me more confidence and I know it is ok not to be ok. I have enjoyed meeting people who are the same as me.

• Lovely place, lovely people, perfect timing. Really happy and grateful to be taking part, It’s been a long old shift getting clean again.

• Thanks Aspire and Blenheim for the wicked day it really is good for your mental health walking round there so thank you again from me my wife and kids.

Impact

Overall, the feasibility study has been valuable because it has allowed us to explore the use of IoT to facilitate a social px. Though there were some difficulties with setting up the technology, these difficulties serve to provide lessons for the future.

Furthermore, the study demonstrated how IoT can be used to capture some of the health and wellbeing outcomes that could be attributed to a social px, which is a validation of a previous Pitch-In project on the intersections of IoT and social px.

In addition to the technical aspects, there are the more general benefits of this intervention that were evident, particularly from the feedback from participants (see table 3 and quotes in the ‘Broader impact’ section above). Every individual who attended enjoyed the walks and despite the variable attendance, a healthy group dynamic did evolve. These outcomes led to Blenheim committing to an additional 12 months of running these walks.

Next steps

Blenheim has committed to hosting wellbeing walks for the next 12 months. Aspire will continue to recruit participants for its walks from its own group of beneficiaries and it has also reached out to partner organisations in Oxfordshire, particularly those focused on mental health, to make them aware of the walks.

For as many participants as possible, we will continue distributing Fitbits and collecting information on their step counts. Where possible, we will continue to collect ONS4 Wellbeing measures as well. For participants that are allocated a Fitbit, we will aim to record at least one week of pre-intervention step count data to have a more accurate baseline measurement. Furthermore, we would like to more fully utilise the FitBit’s GPS features to track each walk, measured elevation and fitness relative to the location of the walks.

Finally, we will look to raise funding to conduct a more robust trial in order to better understand the impact delivered by the wellbeing walks at Blenheim.

Lessons learned

All of the organisations worked very well together and were committed to the project and supporting Aspire’s beneficiaries. This was a key lesson – ensuring alignment of interests and motivations of partners to ensure smooth and effective running of a project like this.

Attendance

Attendance was a consistent problem throughout the study (table 2). This is partly understandable because of the challenges some of the participants were facing – some reasons for non-attendance included illness as well as hospitalisation – but the difficulty of having a variable group between weeks was maintaining a healthy and comfortable group dynamic between sessions. Key lessons learned include:

• Stratifying and grouping participants based on their likelihood of attending.

• As a symbolic gesture, it would be useful to get commitment from participants to attend all sessions of the intervention at the start of the programme.

Setting up the technology

An important set of lessons was around the technical aspects of setting up the FitBits as well as supporting individuals to fully and seamlessly utilise the technology. Some key lessons learned from the feasibility study regarding setting up the technology include:

• Having clearer registration and onboarding procedures in place.

• Allowing more time before the start of the walking sessions to help participants set up their FitBits.

• Allowing more time between the sessions to meet participants to help them set up the FitBits.

Impact attribution

Given the small sample size, lack of a control group and inability to control for confounding variables, it is difficult to causally attribute improvements in physical activity, as indicated by increased step counts (figure 2), and improvement in ONS4 Wellbeing domains (figure 3) to the walking intervention alone.

A key lesson learned: set up a more robust and properly controlled trial in the future to better understand the impact of the walking intervention on health and wellbeing as well as the elements of the walking intervention that have the greatest impact on health and wellbeing for different strata of participants.

Recruitment

Recruitment took longer than expected and was also more complex than anticipated. Key lessons learned include:

• Having more robust and informative referral routes so that expectations, on the side of the participants and organisers, can be set at the beginning.

• Having a clearer system for registration and participation.

What has Pitch-In done for you?

Pitch-In’s support was invaluable in allowing us to organise and test out an IoT-enabled social px that was designed from scratch and delivered through the collaborative effort of four organisations (Blenheim, Aspire, Eden Project, University of Oxford).

Partners

Blenheim Estate

Aspire

Eden Project

Health and wellbeing

Developing IoT and ensuring fitness for purpose