The project will build on the findings of the Prescribe Heritage Highland (PHH) work, funded under Phase 1, which examined delivery challenges and conditions for scalability of a cultural and natural heritage intervention to promote rural mental health and well-being. The value of non-clinical interventions is increasingly recognised by health and social care service planners and professionals. Community-based services like exercise groups, outdoor activities, art therapies and peer support are being 'prescribed' to 'treat' mental health conditions, address sedentary lifestyles and reduce health inequalities. Although awareness is increasing about potential benefits, such interventions are not universally available or accessible, particularly to those from disadvantaged rural areas (Morton and Bradley, 2020). Although rural communities can be perceived as tight-knit and resilient, the extent of social isolation and deprivation can remain hidden. Rural deprivation is hard to measure using conventional tools such as the Scottish Index of Multiple Deprivation (SIMD) due to low population densities and rural data is scarce (RSE, 2023). However, a "rural premium" is evident, with living costs generally higher than in urban areas (RSE 2023). Rural areas provide unique challenges for service delivery, particularly at scale, due to the economic and logistical challenges in large geographical areas with dispersed populations. Drawing on PHH findings, the project will develop a replicable rural model for collaborative community working using a co-design approach. The collaboration's aim is to maximise the use of existing community assets (e.g. museums, archive centres, libraries and green spaces) and develop new ways of integrating them with mainstream healthcare in order to inform service commissioning, improve services, increase community resilience and reduce rural health inequalities. The collaborative model will be developed through local stakeholder groups comprising community members with lived experience, healthcare professionals and third sector organisations in six rural mainland and island communities. The groups will be supported by the research team, who have expertise in community engagement and co-production. The groups will share their learning to develop a toolkit for other rural regions experiencing similar logistical and health equity challenges. The toolkit will be of value to rural communities, service planners and policy makers. The project will add to evidence on co-production, community engagement, service design and the value of community assets as well as offer new insights for rural policy. The project will: establish a regional advisory group comprising people with lived experience and third sector representatives (encompassing heritage, health and rural poverty), NHS and Local Authorities. engage community researchers in asset mapping to identify key local resources, health needs and gaps in rural data establish and support community co-design groups to develop new ways to maximise the value of existing assets and facilities to address local needs based on data gathered 4. conduct a policy/literature reviews and data mapping 5. develop a replicable collaborative model by researching barriers and enablers from each member perspective and develop a toolkit for rural communities, service planners and policy makers 6. implement a clear communication, dissemination and impact strategy involving a range of creative and accessible outputs.

The prescription of a medicine to diagnose, treat, cure, and prevent disease is the most common intervention in healthcare - but this activity negatively impacts the environment, and pharmaceutical pollution is now a well-recognised global public health and environmental issue. Antibiotics, anti-inflammatories, antidiabetics, and antidepressants in surface water can negatively affect aquatic organisms, causing feminisation and reproductive failure, physiological and behavioural changes, immunodeficiency, and assistance in the spread of antimicrobial resistance (AMR - a critical public health issue). Healthcare sustainability targets call for improvements to prescribing and medicine selection, as current practices are environmentally, economically, clinically, and socially unsustainable. Improving medicine selection, use, and disposal can reduce pharmaceutical pollution from healthcare. This project seeks to develop and evaluate, for the first time in the UK, an eco-directed prescription framework that incorporates environmental sustainability alongside clinical and cost effectiveness. This proposes that if pharmaceuticals are of comparable medical efficacy, safety, and effectiveness, then the environmental impact (e.g., drug ecotoxicity, predominance towards AMR) should be considered during the formulary process to better inform prescribers, enabling them to make more sustainable prescribing choices. The research investigators (representing NHS Highland, University of Nottingham, and the Environmental Research Institute-University of the Highlands and Islands) have strong track-records and expertise in pharmaceutical public health, formulary development, qualitative health services research, environmental science, and cross-sector collaboration. The project will capitalise on the established networks and resources of national and international partners representing key stakeholders across the healthcare, prescribing, environment, and water sectors, including the Scottish One Health Breakthrough Partnership - a globally unique, cross-sector group which created an interactive visualisation tool comparing environmental pharmaceutical data and prescribing rates in Scotland (a world first) to progress prioritisation of formulary changes. Investigators will: interrogate environmental and prescribing data; evaluate ecotoxicological data for environmental hazard indicators; prioritise criteria through structured consensus and focus group activity; develop a robust decision-making formulary framework through novel application modelling techniques; and, engage with patients, practitioners, and prescribers to assess suitability. The investigators will work with networks/stakeholder groups to disseminate, educate, and develop post project activity for a pilot trial towards implementation. This project will meet the opportunities and challenges of this call, whilst also: enhancing research sustainability and generating innovation; integrating novel research methods; ensuring genuine PPI and cross-sector stakeholder engagement; supporting high-level dissemination and impact; and creating additionality through next-stage project planning of the framework, which can be piloted post-project and adopted at UK- and international-level. This project will be an innovation-first for the UK, identifying novel methods and data required for eco-directed prescribing and leading to new understanding and awareness of the environmental impact of pharmaceutical prescribing. It will create opportunities for a 'step change' in practice that improves the quality of medicine prescribing and use in Scotland, and benefits the NHS, practitioners/prescribers and patients through enabling better informed and more sustainable prescribing and medicine choices. The project will contribute to reduced environmental pollution from medicines, address sustainability targets, address biodiversity loss and AMR, and promote better health now and for the future.

The proposed work builds on a project that aimed to encourage greater use of hospital grounds for health and well-being benefit. It will utilise materials produced within the project such as workshop frameworks, an engagement toolkit and greenspace intervention evaluation guidance to disseminate knolwedge to health services managers, clinical staff, other health care workers, environmental sector professionals and voluntary sector agencies about how to get staff, visitors and patients using healthcare buildings' grounds and adjacent 'public' greensapce for health and well-being benefit. The main activities will be: (i) Combined dissemination and training workshops for health service managers and clinical staff. (ii) Cross-sector (health, environment, public and voluntary) networking and exchange events. Each of these activities will be held at three sites within the NHS Forth Valley region; one in NHS Highalnd and an additional two sites in other Scottish health board areas. We will hold workshops at which NHS staff, environmental sector staff and voluntary sector staff can learn about the knowledge and materials generated in our original project. The workshops will involve training in tools and methods for encouraging greenspace use through participatory planning; leading conservation and other outdoor activities; and monitoring and measuring the benefits of outdoor activities. As a result of the workshops, the stakeholders will devise a plan for activities and small changes that could be made at their healthcare settings (e.g. healthcare centres) to encourage people to use the outdoors for health and well-being benefit. These plans will outline the roles that stakeholders such as the NHS, Forestry Commission, Local Authority and local voluntary sector will play in the future development of greenspace activities. Taking part in the workshops will equip stakeholders with the tools needed to plan and deliver greenspace activities at various types of healthcare setting. This work will help build relationships between the health, environment and community sectors for the management and use of outdoor spaces associated with, or adjacent to, healthcare buildings. The work aims to bring health and well-being benefits to staff, patients and community members through their increased use of such spaces.

Climate change is the biggest global health threat of the 21st century. The more we ignore the climate emergency the bigger the impact will be on health and the need for care with poor environmental health contributing to major diseases, including cardiac problems, asthma and cancer. Many of the actions to mitigate and adapt to climate change and improve environmental sustainability also have positive health benefits; the Lancet Commission has described tackling climate change as "the greatest global health opportunity of the 21st century". The challenges faced present an incredible opportunity to do things differently - to take a design-led approach in designing and making through high-reward demonstrator projects to help transform the health ecosystem. Through wider public engagement we aim to advance societal understanding of design's impact, and the opportunities, barriers, behaviour changes and tools needed to transition to a green approach. This research will unite a wide range of disciplines, research organisations, regional and local industry, and other public sector stakeholders, with policy-makers. The Design HOPES Green Transition Ecosystem (GTE) Hub will sustain a phased long-term investment to embed design-led innovation, circularity, sustainability and impact for the changing market, across product, service, strategy, policy and social drivers to evolve future design outcomes that matter to the people and planet. Our research is organised around seven core Thematic Workstreams, based on the NHS Scotland Climate Emergency and Sustainability Strategy (2022-2026). Design HOPES will be delivered and managed by interdisciplinary teams with significant expertise in design and making, co-creation, health and social care, with professionals with a sustainability remit, and businesses working in the design economy. Design HOPES encompasses a rich disciplinary mix of knowledge, skills, and expertise from a range of design disciplines (i.e., product, textile, interaction, games, architecture etc.) and other disciplines (computer science, health and wellbeing, geography, engineering, etc.) that will be focused on people and planet (including all living things), from the micro to macro, from root cause to hopeful vision, from the present to the future, and from the personal to the wider system. Design HOPES will design and make things and test them to see how they work, which will help more ideas and things emerge. The Hub will be an inclusive, safe, collaborative space that will bring in multiple and marginalised perspectives and view its projects as one part of a wider movement for transformational change whilst not overlooking existing assets and how we can re-use, nurture and develop these sustainably. Design HOPES aims to be an internationally recognised centre of excellence, promoting and embedding best practice through our collaborative design-led thinking and making approaches to build a more equitable and sustainable health and social care system. We will create new opportunities to support both existing services and new design-led health innovations in collaboration with NHS Boards across Scotland, the Scottish Government, patient and public representatives, health and social care partners, the third sector, academia and industry. Our seven Thematic Workstreams and associated projects will deliver a rich mix of tangible outcomes such as new innovative products, services, and policies (e.g., sustainable theatre consumables, packaging, clothing, waste services, etc.) during the funded period. With award-winning commercialisation and entrepreneurial support from the collaborating universities, we will also look to create new "green' enterprises and businesses. We will achieve this internationally recognised centre of excellence using design-led thinking and making to build a more equitable and sustainable health and social care system.

For centuries, human activities have impacted our rivers by shifting the sources and combinations of physical, biological and chemical drivers and pressures. However, our understanding of their impact on ecosystems has been limited by viewing each in isolation and not considering their combined effects. Significant reductions in some regulated pollutants (such as nitrogen and phosphorus) have been achieved in recent decades. However, even with these improvements, we are witnessing declining water quality of our rivers, and the resulting loss of freshwater species and biota. The picture that we see is made evermore complex by the increasing numbers of different types of emerging contaminants of concern (e.g. pharmaceuticals, pesticides, illicit drugs, micro plastics etc.). This means that our freshwater species are being challenged by a bewildering combination of pollutant cocktails (mixtures) whose effects are poorly understood. At the same time, climate-change driven shifts in water quantity (more frequent floods, longer periods of low flow) and warming waters are expected not only to be influencing the function, physiology, abundance and biological timings of freshwater ecological communities directly, but also the delivery and potential toxicity of these cocktails respectively. It is not simply the water pathway that we need to consider, but also the re-mobilisation of contaminants and the changing patterns of exposure that potentially magnify the effects on biota (i.e. organism sensitivity). Our wastewater systems and combined sewer overflows transport these emerging pollutants from our cities and towns into our freshwater environment. Increasing urbanisation and changes in rainfall intensity and its seasonality, different catchment processes all have the potential to increase inputs of these emerging contaminants to the environment and freshwater species that live there. Substantial knowledge gaps remain around the effects of hydro-climatic and land use changes in combination with the different mixtures of chemicals on freshwater species. Our research will address these gaps by embracing the digital revolution through innovative technologies and transformative data analytics to deliver a step change in our knowledge and understanding. Our approach has three strands. The first will turn a spotlight on a typical catchment encompassing rural to urban land uses through rigorous investigations that will deliver high temporal resolution data. This will provide new understanding of acute/event-based impacts on freshwater ecosystems. Secondly, we will use national scale datasets and cutting edge data analytics tools to investigate the impacts of longer-term exposure to pollutant cocktails across the UK on water quality and ecosystem health. This will provide new understanding of chronic/long term impacts on freshwater ecosystems. Thirdly, we will integrate our new evidence base and understanding into a risk-based probabilistic model. The model will allow the exploration of the relationships between environmental change, declining river quality, multiple pollutants and ecosystem impacts. Our research will develop the evidence base to understand changing pollutant sources, delivery pathways and the environmental tolerances and boundaries within which organisms can thrive and flourish (i.e. the ecosystem safe space). Together, MOT4Rivers will inform priorities for policy, regulation and investment to design cost effective programmes of measures to promote and enhance sustainable freshwater ecosystems under a changing climate.