Planning for success: Scottish Prehabilitation

From systemic therapy to surgery, we know that treatment for cancer takes a toll; it is important for patients to be as equipped as possible, both physically and mentally.

In cancer sites from bowel, to breast and lung, evidence is emerging that prehabilitation gives patients better functional status, reduces the length of hospital stays, and might even improve survival outcomes in some patient

With growing recognition of this fact, the offer of ‘prehabilitation’ to patients is entering common practice in cancer care.

The evidence base underpinning prehabilitation is undoubtedly still maturing. Nonetheless, consensus on best practice is emerging. Macmillan’s guidance is representative, describing a multimodal tiered approach, shaped around a patient’s health and support needs.

In many countries, including Wales, talented and motivated teams and individuals have established exemplary services in their areas. Focus is now turning to how prehabilitation can scale, and be consistently available across healthcare systems.

Action in Scotland

One country receiving praise for a more scalable, policy-driven approach to rolling out prehabilitation is Scotland. I spoke with Debbie Provan, ?dietitian and clinical advisor on cancer to the Scottish Government, about their journey over the past few years.

“If we have good prehab, what could that mean? What could safer care mean for patients?”

Getting prehabilitation into cancer services is inherently difficult, Debbie explained to me. Diseases historically regarded as something to ‘live with’ (e.g. diabetes) have health and wellbeing support built in. As a historically acute and radically treated disease, building wellbeing management into cancer is now much more difficult. Pre-2019, Debbie described a similar situation in Scotland as Wales today: pockets of excellent service, maintained by motivated individuals and teams.

The first step in Scotland was to baseline. To understand where services are, how they are supported, and how healthcare providers feel about them. A steering group was formed and a survey (now published) was conducted, with 295 respondents from across the care spectrum reporting prehabilitation practice in their area, and thoughts on how it might be developed.

The survey findings secured support for prehabilitation in Scotland’s Cancer recovery plan in winter 2020. In the plan the Scottish Government set out a series of actions and committed funding to test and evaluate the concept of delivering prehabilitation across Scotland.

Debbie joined the Scottish government in January 2021 to support the delivery of the prehabilitation actions and a new national Cancer Prehabilitation Implementation Steering Group was convened. Importantly, this steering group contained people from across the cancer care spectrum: nurses, AHPs, surgeons, oncologists and cancer charities. ?

This steering group, and commitment in the recovery plan, also secured resource to develop an online resource for prehab – accessible to all patients, giving advice for self-guided care, and signposting for support services.

With funding secured, hard questions began to arise. How do you design prehabilitation for a country, and where do you focus your efforts?

“Do we help make good projects great, or do we try and get something that isn’t there started?”

Another familiar problem was resource: where do you source the professionals, space, and time to deliver a new service?

The Scottish team responded to both problems with flexibility.

Understanding that ideas and services might differ from place to place, they chose to ensure each design was underpinned by a set of key principles, adapted from Macmillan guidelines, and cocreated with Scottish service providers. These principles are available online.

Secondly, they used the funding round to capitalize on and enhance existing resource, in spaces designed to be accessible for patients. Funding went to eight Maggie’s centres in Scotland, who are piloting a universal multimodal prehabilitation workshop for all cancer patients and their supporters, with a by referral and walk-in model.

Scottish ambitions keep developing, with aims of integrating prehabilitation fully with MDT-centred care, and exploring a single point of contact across a patient’s entire prehab-treatment-rehab journey.

A way forward for Wales

With so many experienced and motivated teams and individuals across Wales already delivering service and advocating for more in this space, Scotland could provide valuable lessons for moving forward:

• Baselining is a powerful tool to set the stage for progress.
• If supported by policy and funding, working groups can be a fantastic mechanism for accelerating change and improvement.
• In and outside of direct prehabilitation delivery, every stakeholder you consult and bring onboard can help to smooth the path to prehabilitation, and integrate it better other cancer care.
• With difficulties in design and resource, there is a need for flexible and adaptive problem solving, asking for example ‘what resource do we have available?’.

If anything here sparks any thoughts or ideas, please feel free to reach out for a chat.